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Pettit KA, Selewski DT, Askenazi DJ, Basu RK, Bridges BC, Cooper DS, Fleming GM, Gien J, Gorga SM, Jetton JG, King EC, Steflik HJ, Paden ML, Sahay RD, Zappitelli M, Gist KM. Synergistic association of fluid overload and acute kidney injury on outcomes in pediatric cardiac ECMO: a retrospective analysis of the KIDMO database. Pediatr Nephrol 2023; 38:1343-1353. [PMID: 35943578 DOI: 10.1007/s00467-022-05708-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) and fluid overload (FO) are associated with poor outcomes in children receiving extracorporeal membrane oxygenation (ECMO). Our objective is to evaluate the impact of AKI and FO on pediatric patients receiving ECMO for cardiac pathology. METHODS We performed a secondary analysis of the six-center Kidney Interventions During Extracorporeal Membrane Oxygenation (KIDMO) database, including only children who underwent ECMO for cardiac pathology. AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. FO was defined as < 10% (FO-) vs. ≥ 10% (FO +) and was evaluated at ECMO initiation, peak during ECMO, and ECMO discontinuation. Primary outcomes were mortality and length of stay (LOS). RESULTS Data from 191 patients were included. Non-survivors (56%) were more likely to be FO + than survivors at peak ECMO fluid status and ECMO discontinuation. There was a significant interaction between AKI and FO. In the presence of AKI, the adjusted odds of mortality for FO + was 4.79 times greater than FO- (95% CI: 1.52-15.12, p = 0.01). In the presence of FO + , the adjusted odds of mortality for AKI + was 2.7 times higher than AKI- [95%CI: 1.10-6.60; p = 0.03]. Peak FO + was associated with a 55% adjusted relative increase in LOS [95%CI: 1.07-2.26, p = 0.02]. CONCLUSIONS The association of peak FO + with mortality is present only in the presence of AKI + . Similarly, AKI + is associated with mortality only in the presence of peak FO + . FO + was associated with LOS. Studies targeting fluid management have the potential to improve LOS and mortality outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Kevin A Pettit
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA.
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Rajit K Basu
- Division of Critical Care Medicine, Lurie Children's Hospital, Chicago, IL, USA
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jason Gien
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA
| | - Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer G Jetton
- Divison of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IO, USA
| | - Eileen C King
- Divison of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Heidi J Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Rashmi D Sahay
- Divison of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto Canada and McGill University Health Centre, Montreal, Canada
| | - Katja M Gist
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Gist KM, Misfeldt A, Sahay RD, Gorga SM, Askenazi DJ, Bridges BC, Paden ML, Zappitelli M, Gien J, Basu RK, Jetton JG, Murphy HJ, King E, Fleming GM, Selewski DT, Cooper DS. Acute Kidney Injury and Fluid Overload in Pediatric Extracorporeal Cardio-Pulmonary Resuscitation: A Multicenter Retrospective Cohort Study. ASAIO J 2022; 68:956-963. [PMID: 34643574 DOI: 10.1097/mat.0000000000001601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acute kidney injury (AKI) and fluid overload (FO) are common complications of extracorporeal membrane oxygenation (ECMO). The purpose of this study was to characterize AKI and FO in children receiving extracorporeal cardiopulmonary resuscitation (eCPR). We performed a multicenter retrospective study of children who received eCPR. AKI was assessed during ECMO and FO defined as <10% [FO-] vs. ≥10% [FO+] evaluated at ECMO initiation and discontinuation. A composite exposure, defined by a four-group discrete phenotypic classification [FO-/AKI-, FO-/AKI+, FO+/AKI-, FO+/AKI+] was also evaluated. Primary outcome was mortality and hospital length of stay (LOS) among survivors. 131 patients (median age 29 days (IQR:9, 242 days); 51% men and 82% with underlying cardiac disease) were included. 45.8% survived hospital discharge. FO+ at ECMO discontinuation, but not AKI was associated with mortality [aOR=2.3; 95% CI: 1.07-4.91]. LOS for FO+ patients was twice as long as FO- patients, irrespective of AKI status [(FO+/AKI+ (60 days; IQR: 49-83) vs. FO-/AKI+ (30 days, IQR: 19-48 days); P = 0.01]. FO+ at ECMO initiation and discontinuation was associated with an adjusted 66% and 50% longer length of stay respectively. Prospective studies that target timing and strategy of fluid management, including its removal in children receiving ECPR are greatly needed.
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Affiliation(s)
- Katja M Gist
- From the Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Colorado
| | - Andrew Misfeldt
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rashmi D Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada and McGill University Health Centre, Montreal, Canada
| | - Jason Gien
- From the Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Colorado
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Deceased
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Barbaro RP, MacLaren G, Boonstra PS, Combes A, Agerstrand C, Annich G, Diaz R, Fan E, Hryniewicz K, Lorusso R, Paden ML, Stead CM, Swol J, Iwashyna TJ, Slutsky AS, Brodie D. Extracorporeal membrane oxygenation for COVID-19: evolving outcomes from the international Extracorporeal Life Support Organization Registry. Lancet 2021; 398:1230-1238. [PMID: 34599878 PMCID: PMC8480964 DOI: 10.1016/s0140-6736(21)01960-7] [Citation(s) in RCA: 222] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Over the course of the COVID-19 pandemic, the care of patients with COVID-19 has changed and the use of extracorporeal membrane oxygenation (ECMO) has increased. We aimed to examine patient selection, treatments, outcomes, and ECMO centre characteristics over the course of the pandemic to date. METHODS We retrospectively analysed the Extracorporeal Life Support Organization Registry and COVID-19 Addendum to compare three groups of ECMO-supported patients with COVID-19 (aged ≥16 years). At early-adopting centres-ie, those using ECMO support for COVID-19 throughout 2020-we compared patients who started ECMO on or before May 1, 2020 (group A1), and between May 2 and Dec 31, 2020 (group A2). Late-adopting centres were those that provided ECMO for COVID-19 only after May 1, 2020 (group B). The primary outcome was in-hospital mortality in a time-to-event analysis assessed 90 days after ECMO initiation. A Cox proportional hazards model was fit to compare the patient and centre-level adjusted relative risk of mortality among the groups. FINDINGS In 2020, 4812 patients with COVID-19 received ECMO across 349 centres within 41 countries. For early-adopting centres, the cumulative incidence of in-hospital mortality 90 days after ECMO initiation was 36·9% (95% CI 34·1-39·7) in patients who started ECMO on or before May 1 (group A1) versus 51·9% (50·0-53·8) after May 1 (group A2); at late-adopting centres (group B), it was 58·9% (55·4-62·3). Relative to patients in group A2, group A1 patients had a lower adjusted relative risk of in-hospital mortality 90 days after ECMO (hazard ratio 0·82 [0·70-0·96]), whereas group B patients had a higher adjusted relative risk (1·42 [1·17-1·73]). INTERPRETATION Mortality after ECMO for patients with COVID-19 worsened during 2020. These findings inform the role of ECMO in COVID-19 for patients, clinicians, and policy makers. FUNDING None.
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Affiliation(s)
- Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic, and Vascular Surgery, National University Health System, Singapore
| | - Philip S Boonstra
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Hôpital Pitié-Salpêtrière, Paris, France
| | - Cara Agerstrand
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Gail Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | | | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Matthew L Paden
- Division of Pediatric Critical Care, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Justyna Swol
- Department of Pneumology, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization. ASAIO J 2021; 67:485-495. [PMID: 33657573 PMCID: PMC8078022 DOI: 10.1097/mat.0000000000001422] [Citation(s) in RCA: 229] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
DISCLAIMER This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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Affiliation(s)
- Jenelle Badulak
- From the Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - M. Velia Antonini
- General ICU, University Hospital of Parma, Parma, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | | | - Lara Shekerdemian
- Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Raman
- Children’s Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew L. Paden
- Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
| | | | - Nicholas Barrett
- Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Mark T. Ogino
- Nemours Children’s Health System, Wilmington, Delaware
| | - Giles Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | | | - Ahmed A. Rabie
- Critical Care ECMO Service, King Saud Medical City, Ministry Of Health (MOH), Riyadh, Saudi Arabia
| | - Leonardo Salazar
- Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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Murphy HJ, Gien J, Sahay R, King E, Selewski DT, Bridges BC, Cooper DS, Fleming GM, Paden ML, Zappitelli M, Gist KM, Basu RK, Jetton JG, Askenazi D. Acute Kidney Injury, Fluid Overload, and Renal Replacement Therapy Differ by Underlying Diagnosis in Neonatal Extracorporeal Support and Impact Mortality Disparately. Blood Purif 2021; 50:808-817. [PMID: 33461205 DOI: 10.1159/000512538] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/23/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to characterize acute kidney injury (AKI), fluid overload (FO), and renal replacement therapy (RRT) utilization by diagnostic categories and examine associations between these complications and mortality by category. METHODS To test our hypotheses, we conducted a retrospective multicenter, cohort study including 446 neonates (categories: 209 with cardiac disease, 114 with congenital diaphragmatic hernia [CDH], 123 with respiratory disease) requiring extracorporeal membrane oxygenation (ECMO) between January 1, 2007, and December 31, 2011. RESULTS AKI, FO, and RRT each varied by diagnostic category. AKI and RRT receipt were most common in those neonates with cardiac disease. Subjects with CDH had highest peak %FO (51% vs. 28% cardiac vs. 32% respiratory; p < 0.01). Hospital survival was 55% and varied by diagnostic category (45% cardiac vs. 48% CDH vs. 79% respiratory; p < 0.001). A significant interaction suggested risk of mortality differed by diagnostic category in the presence or absence of AKI. In its absence, diagnosis of CDH (vs. respiratory disease) (OR 3.04, 95% CL 1.14-8.11) independently predicted mortality. In all categories, peak %FO (OR 1.20, 95% CL 1.11-1.30) and RRT receipt (OR 2.12, 95% CL 1.20-3.73) were independently associated with mortality. DISCUSSION/CONCLUSIONS Physiologically distinct ECMO diagnoses warrant individualized treatment strategies given variable incidence and effects of AKI, FO, and RRT by category on mortality.
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Affiliation(s)
- Heidi J Murphy
- Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA,
| | - Jason Gien
- Pediatrics, University of Colorado, Denver, Colorado, USA
| | - Rashmi Sahay
- Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eileen King
- Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David T Selewski
- Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian C Bridges
- Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - David S Cooper
- Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Geoffrey M Fleming
- Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Michael Zappitelli
- Pediatrics, Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | - Katja M Gist
- Pediatrics, University of Colorado, Denver, Colorado, USA
| | - Rajit K Basu
- Pediatrics, Emory University, Atlanta, Georgia, USA
| | | | - David Askenazi
- Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
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Abstract
Thromboembolism (TE), including venous thromboembolism (VTE), arterial TE, arterial ischemic stroke (AIS), and myocardial infarction (MI), is considered a relatively rare complication in the pediatric population. Yet, the incidence is rising, especially in hospitalized children. The vast majority of pediatric TE occurs in the setting of at least one identifiable risk factor. Most recently, acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have demonstrated an increased risk for TE development. The mainstay for the management pediatric TE has been anticoagulation. Thrombolytic therapy is employed more frequently in adult patients with ample data supporting its use. The data for thrombolysis in pediatric patients is more limited, but the utilization of this therapy is becoming more commonplace in tertiary care pediatric hospitals. Understanding the data on thrombolysis use in pediatric TE and the involved risks is critical before initiating one of these therapies. In this paper, we present the case of an adolescent male with acute fulminant myocarditis and cardiogenic shock likely secondary to MIS-C requiring extracorporeal life support (ECLS) who developed an extensive thrombus burden that was successfully resolved utilizing four simultaneous catheter-directed thrombolysis (CDT) infusions in addition to a review of the literature on the use of thrombolytic therapy in children.
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Affiliation(s)
- Gary M Woods
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Dennis W Kim
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
| | - Heather K Viamonte
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States
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7
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Goldstein SL, Askenazi DJ, Basu RK, Selewski DT, Paden ML, Krallman KA, Kirby CL, Mottes TA, Terrell T, Humes HD. Use of the Selective Cytopheretic Device in Critically Ill Children. Kidney Int Rep 2020; 6:775-784. [PMID: 33732992 PMCID: PMC7938071 DOI: 10.1016/j.ekir.2020.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction Critically ill children with acute kidney injury (AKI) requiring continuous kidney replacement therapy (CKRT) are at increased risk of death. The selective cytopheretic device (SCD) promotes an immunomodulatory effect when circuit ionized calcium (iCa2+) is maintained at <0.40 mmol/l with regional citrate anticoagulation (RCA). In a randomized trial of adult patients on CRRT, those treated with the SCD maintaining an iCa2+ <0.40 mmol/l had improved survival/dialysis independence. We conducted a US Food and Drug Administration (FDA)–sponsored study to evaluate safety and feasibility of the SCD in 16 critically ill children. Methods Four pediatric intensive care units (ICUs) enrolled children with AKI and multiorgan dysfunction receiving CKRT to receive the SCD integrated post-CKRT membrane. RCA was used to achieve a circuit iCa2+ level <0.40 mmol/l. Subjects received SCD treatment for 7 days or CKRT discontinuation, whichever came first. Results The FDA target enrollment of 16 subjects completed the study from December 2016 to February 2020. Mean age was 12.3 ± 5.1 years, weight was 53.8 ± 28.9 kg, and median Pediatric Risk of Mortality II was 7 (range 2–19). Circuit iCa2+ levels were maintained at <0.40 mmol/l for 90.2% of the SCD therapy time. Median SCD duration was 6 days. Fifteen subjects survived SCD therapy; 12 survived to ICU discharge. All ICU survivors were dialysis independent at 60 days. No SCD-related adverse events (AEs) were reported. Conclusion Our data demonstrate that SCD therapy is feasible and safe in children who require CKRT. Although we cannot make efficacy claims, the 75% survival rate and 100% renal recovery rate observed suggest a possible favorable benefit-to-risk ratio.
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Affiliation(s)
| | | | - Rajit K Basu
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - David T Selewski
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Kelli A Krallman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cassie L Kirby
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Theresa A Mottes
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tara Terrell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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8
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Cho HJ, Ogino MT, Jeong IS, Paden ML, Antonini VM, Marwali EM, Fraser JF, MacLaren G, Belohlavek J, Di Nardo M. Pediatric intensive care preparedness and ECMO availability in children with COVID-19: An international survey. Perfusion 2020; 36:637-639. [PMID: 33342366 DOI: 10.1177/0267659120981810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Hwa-Jin Cho
- Department of Pediatrics, Chonnam National University Children's Hospital, and Medical School, Gwangju, South Korea.,Critical Care Research Group, The Prince Charles Hospital and Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Mark T Ogino
- Division of Neonatology, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - In-Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | | | | | - Eva M Marwali
- Pediatric Cardiac ICU, National Cardiovascular Harapan Kita, Jakarta, Indonesia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore.,Paediatric Intensive Care Unit, Department of Paediatrics, The Royal Children's Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Jan Belohlavek
- Internal Medicine and Cardiology Unit, Charles University Prague, Praha, Czech Republic
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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9
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Gorga SM, Sahay RD, Askenazi DJ, Bridges BC, Cooper DS, Paden ML, Zappitelli M, Gist KM, Gien J, Basu RK, Jetton JG, Murphy HJ, King E, Fleming GM, Selewski DT. Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy: a multicenter retrospective cohort study. Pediatr Nephrol 2020; 35:871-882. [PMID: 31953749 PMCID: PMC7517652 DOI: 10.1007/s00467-019-04468-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 12/09/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to characterize continuous renal replacement therapy (CRRT) utilization on extracorporeal membrane oxygenation (ECMO) and to determine the association of both fluid overload (FO) at CRRT initiation and fluid removal during CRRT with mortality in a large multicenter cohort. METHODS Retrospective chart review of all children < 18 years of age concurrently treated with ECMO and CRRT from January 1, 2007, to December 31, 2011, at six tertiary care children's hospital. Children treated with hemodialysis or peritoneal dialysis were excluded from the FO analysis. MEASUREMENTS AND MAIN RESULTS A total of 756 of the 1009 children supported with ECMO during the study period had complete FO data. Of these, 357 (47.2%) received either CRRT or were treated with an in-line filter and thus entered into the final analysis. Survival to ECMO decannulation was 66.4% and survival to hospital discharge was 44.3%. CRRT initiation occurred at median of 1 day (IQR 0, 2) after ECMO initiation. Median FO at CRRT initiation was 20.1% (IQR 5, 40) and was significantly lower in ECMO survivors vs. non-survivors (15.3% vs. 30.5% p = 0.005) and in hospital survivors vs. non-survivors (13.5% vs. 25.9%, p = 0.004). Median FO at CRRT discontinuation was significantly lower in ECMO survivors (23% vs. 37.6% p = 0.002) and hospital survivors vs. non-survivors (22.6% vs. 36.1%, p = 0.002). In ECMO survivors, after adjusting for pH at CRRT initiation, non-renal complications, ECMO mode, support type, center, patient age and AKI, FO at CRRT initiation (p = 0.01), and FO at CRRT discontinuation (p = 0.0002) were independently associated with duration of ECMO. In a similar multivariable analysis, FO at CRRT initiation (adjusted adds ratio [aOR] 1.09, 95% CI 1.00-1.18, p = 0.045) and at CRRT discontinuation (aOR 1.11, 95% CI 1.03-1.19, p = 0.01) were independently associated with hospital mortality. CONCLUSIONS In a multicenter pediatric ECMO cohort, this study demonstrates that severe FO was very common at CRRT initiation. We found an independent association between the degree of FO at CRRT initiation with adverse outcomes including mortality and increased duration of ECMO support. The results suggest that intervening prior to the development of significant FO may be a clinical therapeutic target and warrants further evaluation.
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Affiliation(s)
- Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rashmi D Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada and McGill University Health Centre, Montreal, Canada
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Aurora, CO, USA
| | - Jason Gien
- Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Aurora, CO, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, IA, USA
| | - Heidi J Murphy
- Department of Pediatric, Medical University of South Carolina, Charleston, SC, USA
| | - Eileen King
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David T Selewski
- Department of Pediatric, Medical University of South Carolina, Charleston, SC, USA.
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Sirignano RM, Paden ML, Fasano R, Meyer EK. Epidemiology of therapeutic apheresis with a multidisciplinary approach at a high volume pediatric center. J Clin Apher 2017; 33:297-302. [PMID: 29139162 DOI: 10.1002/jca.21604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 08/28/2017] [Accepted: 11/01/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Therapeutic apheresis (TA) is used inconsistently in pediatric populations. We seek to define our multidisciplinary institutional practice. METHODS We conducted a retrospective chart review of patients receiving TA from January 1, 2012 through October 31, 2015. Data collected included demographics, American Society of Apheresis (ASFA) indication, complications, and mortality. RESULTS Over 46 months, 1198 TA procedures were conducted on 289 patients ranging in age from 5 months to 21 years with weights ranging from 4.76 to 170.3 kg (16 procedures in patients <10 kg). The procedures were 86% therapeutic plasma exchange, 10% red blood cell exchange, 4% extracorporeal photopheresis, and 5 leukocytapheresis procedures. TA was initiated in different clinical environments: 41% outpatient, 37% intensive care, 15% general inpatient, and 7% operating room. The ASFA category (6th edition) indications for the 1198 procedures included: 44% category I, 25% category II, 23% category III, a single category IV procedure, and the remainder (8%) uncategorized by ASFA. The rate of procedure failure and procedure-related mortality are 1 and 0%, respectively. Case mortality rate was 4%. CONCLUSION At a large volume pediatric hospital, TA is commonly used and can be performed safely in a variety of settings by a multidisciplinary team. This demographic review catalogs the number and type of procedures performed as a second-line therapy or on the basis of limited evidence. Additional collaborative investigation is needed to evaluate unique implications of TA in pediatrics to maximize efficacy while preserving safety.
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Affiliation(s)
- Rachel M Sirignano
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Division of Critical Care, Emory University, Atlanta, Georgia.,Department of Advanced Technology, Children's Healthcare of Atlanta, Georgia
| | - Matthew L Paden
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Division of Critical Care, Emory University, Atlanta, Georgia.,Department of Advanced Technology, Children's Healthcare of Atlanta, Georgia
| | - Ross Fasano
- Department of Pathology, Emory University, Atlanta, Georgia
| | - Erin K Meyer
- Department of Pathology, Emory University, Atlanta, Georgia.,Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
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Thiagarajan RR, Barbaro RP, Rycus PT, Mcmullan DM, Conrad SA, Fortenberry JD, Paden ML. Extracorporeal Life Support Organization Registry International Report 2016. ASAIO J 2017; 63:60-67. [PMID: 27984321 DOI: 10.1097/mat.0000000000000475] [Citation(s) in RCA: 589] [Impact Index Per Article: 84.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Data on extracorporeal life support (ECLS) use and survival submitted to the Extracorporeal Life Support Organization's data registry from the inception of the registry in 1989 through July 1, 2016, are summarized in this report. The registry contained information on 78,397 ECLS patients with 58% survival to hospital discharge. Extracorporeal life support use and centers providing ECLS have increased worldwide. Extracorporeal life support use in the support of adults with respiratory and cardiac failure represented the largest growth in the recent time period. Extracorporeal life support indications are expanding, and it is increasingly being used to support cardiopulmonary resuscitation in children and adults. Adverse events during the course of ECLS are common and underscore the need for skilled ECLS management and appropriately trained ECLS personnel and teams.
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Affiliation(s)
- Ravi R Thiagarajan
- From the *Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; †Department of Pediatrics, C.S. Mott Children's Hospital, Ann Arbor, Michigan; ‡Extracorporeal Life Support Organization, Ann Arbor, Michigan; §Department of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington; ¶Departments of Medicine, Pediatrics and Emergency Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana; and ‖Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
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Barbaro RP, Bartlett RH, Chapman RL, Paden ML, Roberts LA, Gebremariam A, Annich GM, Davis MM. Development and Validation of the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support. J Pediatr 2016; 173:56-61.e3. [PMID: 27004674 PMCID: PMC4884525 DOI: 10.1016/j.jpeds.2016.02.057] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/14/2016] [Accepted: 02/19/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To develop and validate the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support, which estimates the risk of in-hospital death for neonates prior to receiving respiratory extracorporeal membrane oxygenation (ECMO) support. STUDY DESIGN We used an international ECMO registry (2008-2013); neonates receiving ECMO for respiratory support were included. We divided the registry into a derivation sample and internal validation sample, by calendar date. We chose candidate variables a priori based on published evidence of association with mortality; variables independently associated with mortality in logistic regression were included in this parsimonious model of risk adjustment. We evaluated model discrimination with the area under the receiver operating characteristic curve (AUC), and we evaluated calibration with the Hosmer-Lemeshow goodness-of-fit test. RESULTS During 2008-2013, 4592 neonates received ECMO respiratory support with mortality of 31%. The development dataset contained 3139 patients treated in 2008-2011. The Neo-RESCUERS measure had an AUC of 0.78 (95% CI 0.76-0.79). The validation cohort had an AUC = 0.77 (0.75-0.80). Patients in the lowest risk decile had an observed mortality of 7.0% and a predicted mortality of 4.4%, and those in the highest risk decile had an observed mortality of 65.6% and a predicted mortality of 67.5%. CONCLUSIONS Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support offers severity-of-illness adjustment for neonatal patients with respiratory failure receiving ECMO. This score may be used to adjust patient survival to assess hospital-level performance in ECMO-based care.
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Affiliation(s)
- Ryan P Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, MI; Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, Ann Arbor, MI.
| | | | - Rachel L Chapman
- Department of Pediatrics, University of Southern California, Los Angeles and Center for Fetal and Neonatal Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Matthew L Paden
- Division of Pediatric Critical Care, Emory University, Atlanta, GA
| | - Lloyd A Roberts
- Intensive Care Department, Alfred Hospital, Monash University, Melbourne, Australia; School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, Ann Arbor, MI
| | - Gail M Annich
- Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Matthew M Davis
- Department of Pediatrics, University of Michigan, Ann Arbor, MI; Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Gerald R. Ford School of Public Policy and School of Public Health, University of Michigan, Ann Arbor, MI
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Barbaro RP, Boonstra PS, Paden ML, Roberts LA, Annich GM, Bartlett RH, Moler FW, Davis MM. Development and validation of the pediatric risk estimate score for children using extracorporeal respiratory support (Ped-RESCUERS). Intensive Care Med 2016; 42:879-888. [PMID: 27007109 DOI: 10.1007/s00134-016-4285-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/20/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE To develop and validate the Pediatric Risk Estimation Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS). Ped-RESCUERS is designed to estimate the in-hospital mortality risk for children prior to receiving respiratory extracorporeal membrane oxygenation (ECMO) support. METHODS This study used data from an international registry of patients aged 29 days to less than 18 years who received ECMO support from 2009 to 2014. We divided the registry into development and validation datasets by calendar date. Candidate variables were selected for model inclusion if the variable independently changed the mortality risk by at least 2 % in a Bayesian logistic regression model with in-hospital mortality as the outcome. We characterized the model's ability to discriminate mortality with the area under curve (AUC) of the receiver operating characteristic. RESULTS From 2009 to 2014, 2458 non-neonatal children received ECMO for respiratory support, with a mortality rate of 39.8 %. The development dataset contained 1611 children receiving ECMO support from 2009 to 2012. The model included the following variables: pre-ECMO pH, pre-ECMO arterial partial pressure of carbon dioxide, hours of intubation prior to ECMO support, hours of admission at ECMO center prior to ECMO support, ventilator type, mean airway pressure, pre-ECMO use of milrinone, and a diagnosis of pertussis, asthma, bronchiolitis, or malignancy. The validation dataset included 438 children receiving ECMO support from 2013 to 2014. The Ped-RESCUERS model from the development dataset had an AUC of 0.690, and the validation dataset had an AUC of 0.634. CONCLUSIONS Ped-RESCUERS provides a novel measure of pre-ECMO mortality risk. Future studies should seek external validation and improved discrimination of this mortality prediction tool.
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Affiliation(s)
- Ryan P Barbaro
- Department of Pediatrics, University of Michigan, 1500 East Medical Center Drive, Mott F-6790/Box 5243, Ann Arbor, MI, 48109, USA. .,Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, Ann Arbor, USA.
| | - Philip S Boonstra
- School of Public Health Department of Biostatistics, University of Michigan, Ann Arbor, USA
| | - Matthew L Paden
- Division of Pediatric Critical Care, Emory University, Atlanta, GA, USA
| | - Lloyd A Roberts
- Intensive Care Department, Alfred Hospital and School of Public Health and Preventative Medicine, Monash University Melbourne, Clayton, Australia
| | - Gail M Annich
- Critical Care Medicine, University of Toronto, Toronto, Canada
| | | | - Frank W Moler
- Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, Ann Arbor, USA
| | - Matthew M Davis
- Department of Pediatrics, University of Michigan, 1500 East Medical Center Drive, Mott F-6790/Box 5243, Ann Arbor, MI, 48109, USA.,Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, Ann Arbor, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, USA.,Gerald R. Ford School of Public Policy and Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, USA
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Chandler HK, Teppa B, Johnson KA, McCracken C, Fortenberry JD, Paden ML. Determining comorbidities and quality of life among pediatric survivors of extracorporeal life support. J Crit Care 2015; 30:1085-9. [DOI: 10.1016/j.jcrc.2015.06.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/15/2015] [Accepted: 06/19/2015] [Indexed: 11/28/2022]
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Barbaro RP, Odetola FO, Kidwell KM, Paden ML, Bartlett RH, Davis MM, Annich GM. Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry. Am J Respir Crit Care Med 2015; 191:894-901. [PMID: 25695688 DOI: 10.1164/rccm.201409-1634oc] [Citation(s) in RCA: 462] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Recent pediatric studies suggest a survival benefit exists for higher-volume extracorporeal membrane oxygenation (ECMO) centers. OBJECTIVES To determine if higher annual ECMO patient volume is associated with lower case-mix-adjusted hospital mortality rate. METHODS We retrospectively analyzed an international registry of ECMO support from 1989 to 2013. Patients were separated into three age groups: neonatal (0-28 d), pediatric (29 d to <18 yr), and adult (≥18 yr). The measure of hospital ECMO volume was age group-specific and adjusted for patient-level case-mix and hospital-level variance using multivariable hierarchical logistic regression modeling. The primary outcome was death before hospital discharge. A subgroup analysis was conducted for 2008-2013. MEASUREMENTS AND MAIN RESULTS From 1989 to 2013, a total of 290 centers provided ECMO support to 56,222 patients (30,909 neonates, 14,725 children, and 10,588 adults). Annual ECMO mortality rates varied widely across ECMO centers: the interquartile range was 18-50% for neonates, 25-66% for pediatrics, and 33-92% for adults. For 1989-2013, higher age group-specific ECMO volume was associated with lower odds of ECMO mortality for neonates and adults but not for pediatric cases. In 2008-2013, the volume-outcome association remained statistically significant only among adults. Patients receiving ECMO at hospitals with more than 30 adult annual ECMO cases had significantly lower odds of mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.46-0.80) compared with adults receiving ECMO at hospitals with less than six annual cases. CONCLUSIONS In this international, case-mix-adjusted analysis, higher annual hospital ECMO volume was associated with lower mortality in 1989-2013 for neonates and adults; the association among adults persisted in 2008-2013.
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Abstract
The Extracorporeal Life Support Organization Registry has collected outcome data of almost 56,000 patients receiving extracorporeal life support (ECLS) over the last 24 years. The use of neonatal respiratory ECLS declined from a peak of 1516 cases in 1992 to 750-865 cases from 2008 to 2012. The 26,583 cases of neonatal respiratory ECLS (75% survival) represent the largest patient population in the registry. Indicating the rapid growth in other patient populations, 2013 marks the first year where the number of neonatal respiratory ECLS cases is less than 50% of the registry. Stagnant at ~200 cases/year from 1993 to 2004, growth is occurring in the use of pediatric respiratory ECLS with 331-448 cases/year from 2008 to 2012 (58% survival). Similarly, adult respiratory ECLS use increases have been seen from ~100 cases/year from 1996 to 2007 to 480-846 cases/year from 2009 to 2012 (58% survival). Just over 15,000 cardiac ECLS patients have survival rates of 40%, 49%, and 40% for neonates, pediatric, and adults, respectively.
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Affiliation(s)
- Matthew L Paden
- Division of Critical Care, Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA.
| | - Peter T Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI
| | - Ravi R Thiagarajan
- Department of Cardiology, Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Abstract
The concept and definition of acute kidney injury (AKI) in adults and children has undergone significant change in recent years. Biomarker assessment is aiding in description, defining and understanding timing of AKI. AKI demonstrates unique characteristics in association with sepsis and septic shock, organ dysfunction, and fluid overload. Treatment remains problematic, but growing experience with pediatric continuous renal replacement therapies has improved the delivery of care in children. Increasingly, continuous renal replacement therapy is provided in combination with other extracorporeal technologies, and approaches are advancing to improve combined therapy use.
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Affiliation(s)
- James D Fortenberry
- Critical Care Division, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA 30322, USA.
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Askenazi DJ, Selewski DT, Paden ML, Cooper DS, Bridges BC, Zappitelli M, Fleming GM. Renal replacement therapy in critically ill patients receiving extracorporeal membrane oxygenation. Clin J Am Soc Nephrol 2012; 7:1328-36. [PMID: 22498496 DOI: 10.2215/cjn.12731211] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure used in neonates, children, and adults with severe, reversible, cardiopulmonary failure. On the basis of single-center studies, the incidence of AKI occurs in 70%-85% of ECMO patients. Those with AKI and those who require renal replacement therapy (RRT) are at high risk for mortality, independent of potentially confounding variables. Fluid overload is common in ECMO patients, and is one of the main indications for RRT. RRT to maintain fluid balance and metabolic control is common in some but not all centers. RRT on ECMO can be performed via an in-line hemofilter or by incorporating a standard continuous renal replacement machine into the ECMO circuit. Both of these methods require specific technical considerations to provide safe and effective RRT. This review summarizes available epidemiologic data and how they apply to our understanding of AKI pathophysiology during ECMO, identifies indications for RRT while on ECMO, reviews technical elements for RRT application in the setting of ECMO, and finally identifies specific research-focused questions that need to be addressed to improve outcomes in this at-risk population.
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Affiliation(s)
- David J Askenazi
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, Alabama 35233, USA.
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Santhanakrishnan A, Nestle T, Moore BL, Yoganathan AP, Paden ML. Design, Development, and Validation of KIDS-CRRT - a Safe and Accurate Pediatric Continuous and Renal Replacement Device. J Med Device 2012. [DOI: 10.1115/1.4026754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Trent Nestle
- Department of Biomedical Engineering Georgia Institute of Technology & Emory University
| | | | - Ajit P. Yoganathan
- Department of Biomedical Engineering Georgia Institute of Technology & Emory University
| | - Matthew L. Paden
- Division of Pediatric Critical Care Emory University & Children's Healthcare of Atlanta
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Skinner SC, Iocono JA, Ballard HO, Turner MD, Ward AN, Davenport DL, Paden ML, Zwischenberger JB. Improved survival in venovenous vs venoarterial extracorporeal membrane oxygenation for pediatric noncardiac sepsis patients: a study of the Extracorporeal Life Support Organization registry. J Pediatr Surg 2012; 47:63-7. [PMID: 22244394 DOI: 10.1016/j.jpedsurg.2011.10.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/06/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND/PURPOSE There are few studies comparing venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) in pediatric noncardiac sepsis patients. METHODS Following approval, we reviewed the Extracorporeal Life Support Organization registry data from 1990 to 2008 for patients 0 to 18 years with a diagnosis of sepsis and without diagnosis of congenital heart disease. Survival to discharge was compared between VA and VV ECMO using χ(2) analysis and multivariable logistic regression. RESULTS Four thousand three hundred thirty-two ECMO runs were reviewed, 3256 VA (75%) and 1076 VV (25%). A majority of VA modality was noted in each decade studied. Overall survival was 68% and was higher in VV (79%) than in VA ECMO (64%, P < .001). Survival decreased with increasing age (73% in newborns ≤ 1 month, 40% in children 1 month to 12 years, and 32% in adolescents >12 years, P < .001). VA ECMO had increased mortality risk after adjustment for age, use of vasoactive agents, and advanced respiratory support (odds ratio, 2.06; 95% confidence interval, 1.74-2.44; P < .001). CONCLUSIONS These data demonstrate improved survival in VV vs. VA ECMO in select pediatric septic patients without congenital heart disease. When technically feasible, physicians should consider VV ECMO as first therapeutic choice in this patient population.
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Affiliation(s)
- Sean C Skinner
- Division of Pediatric Surgery, University of Kentucky, Lexington, Kentucky 40536-0298, USA.
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Sucosky P, Dasi LP, Paden ML, Fortenberry JD, Yoganathan AP. Assessment of Current Continuous Hemofiltration Systems and Development of a Novel Accurate Fluid Management System for Use in Extracorporeal Membrane Oxygenation. J Med Device 2008. [DOI: 10.1115/1.2952818] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) with a renal replacement therapy such as continuous venovenous hemofiltration (CVVH) provides life-saving temporary heart and lung, and renal support in pediatric and neonatal intensive care units. However, studies have shown that this approach may be hampered due to the potentially inaccurate fluid delivery∕drainage of current intravenous (IV) fluid pumps, creating potential for excessive fluid removal and undesired degrees of dehydration. We present a simple and novel accurate fluid management system capable of working against the high volume flow and pressures typically seen in patients on ECMO. The accuracy of the in-line system implemented at Children’s Healthcare of Atlanta at Egleston was assessed experimentally. The data assisted in the development of a novel automated and accurate fluid management system that functions based on a conservation of volume approach to limit the inaccuracies observed in typical clinical implementations of CVVH. IV pump accuracy measurements demonstrated a standard error in net ultrafiltrate volume removed from the patient of up to 848.5±156ml over a period of 24h, supporting previous observations of patient’s dehydration during the course of a combined ECMO-CVVH treatment and justifying the need for a new fluid management system. The innovative design of the new device is expected to achieve either a perfect or controlled negative fluid balance between the ultrafiltrate and replacement fluid flow rates. Perfect fluid balance is achieved by imposing an identical displacement on two pistons, one delivering replacement fluid to the circuit and the other draining ultrafiltrate from the hemofilter. Fluid removal is managed via a second syringe-pump system that reduces the net replacement fluid flow rate with respect to the ultrafiltration flow rate. The novel fluid management system described in this paper is expected to provide an effective method to control precisely fluid flow rates in patients on ECMO. Therefore, this device could potentially improve the efficacy of ECMO therapy and constitute a safe and effective way of reducing fluid overload in patients with cardiorespiratory failure.
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Affiliation(s)
- Philippe Sucosky
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Parker H. Petit Biotechnology Building, 315 Ferst Drive, Atlanta, GA 30332-0363
| | - Lakshmi P. Dasi
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Parker H. Petit Biotechnology Building, 315 Ferst Drive, Atlanta, GA 30332-0363
| | - Matthew L. Paden
- Division of Pediatric Critical Care, Children’s Healthcare of Atlanta at Egleston, Emory University School of Medicine, 1405 Clifton Road, NE, Atlanta, GA 30322
| | - James D. Fortenberry
- Division of Pediatric Critical Care, Children’s Healthcare of Atlanta at Egleston, Emory University School of Medicine, 1405 Clifton Road, NE, Atlanta, GA 30322
| | - Ajit P. Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, U.A. Whitaker Building, 313 Ferst Drive, Room 2119, Atlanta, GA 30332-0535
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Hoover NG, Heard M, Reid C, Wagoner S, Rogers K, Foland J, Paden ML, Fortenberry JD. Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support. Intensive Care Med 2008; 34:2241-7. [DOI: 10.1007/s00134-008-1200-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Accepted: 06/14/2008] [Indexed: 01/11/2023]
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Abstract
Desire to restore the balance of body elements has enamored physicians since the ancient practice of bloodletting. More recently, extracorporeal techniques have been employed in both adults and children in treating sepsis. Extracorporeal therapies include continuous renal replacement (CRRT), plasma-based removal techniques, and extracorporeal membrane oxygenation (ECMO). These treatments could theoretically 1) provide immunohomeostasis of pro- and anti-inflammatory cytokines and other sepsis mediators, 2) decrease organ microthrombosis through removal of pro-coagulant factors and modulating the impaired septic coagulation response in sepsis, and 3) provide mechanical support of organ perfusion during the acute septic episode to allow time for response to traditional sepsis therapies and antimicrobials. CRRT is beneficial in managing fluid overload and acute renal failure in sepsis. Removal of sepsis mediators through the technique is variable, and the outcome impact of CRRT on sepsis has not been definitively determined. High-flow CRRT has demonstrated benefit in septic adults. Intriguing early results suggest that plasma exchange could improve outcomes in both adults and children. Based on experience, ECMO is recommended for refractory septic shock in neonates and should be considered for use in children. Ongoing trials may help determine whether the promise of extracorporeal therapies translates into outcome improvement in septic children.
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Affiliation(s)
- James D Fortenberry
- Critical Care Division, Children's Healthcare of Atlanta at Egleston, Atlanta, GA 30322, USA.
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