The Incidence of Acute Kidney Injury and Its Effect on Neonatal and Pediatric Extracorporeal Membrane Oxygenation Outcomes: A Multicenter Report From the Kidney Intervention During Extracorporeal Membrane Oxygenation Study Group

Outcomes of Multiple Runs of Extracorporeal Membrane Oxygenation: An analysis of the Extracorporeal Life Support Registry

OBJECTIVE

When patients deteriorate after decannulation from extracorporeal membrane oxygenation (ECMO), a second run of extracorporeal support may be considered. However, repeat cannulation can be difficult and poor outcomes associated with multiple ECMO runs are a concern. The aim of this study was to evaluate outcomes and identify factors associated with survival and mortality in cases of multiple runs of extracorporeal membrane oxygenation.

DESIGN

Retrospective cohort analysis of the Extracorporeal Life Support Organization Registry.

SETTING

The Extracorporeal Life Support Organization's registry was queried for neonates, children, and adults receiving 2 or more runs of ECMO during the same hospitalization, for any indication, from 1998 to 2015.

PATIENTS

1,818 patients from the Extracorporeal Life Support Organization Registry.

RESULTS

Of the 1,818 patients, 1,648 underwent 2 runs and 170 underwent 3 or more runs of ECMO. The survival to discharge rate was 36.7% for 2 runs and 29.4% for 3 or more runs. No significant differences in survival were detected in analysis by decade of ECMO run (p = 0.21). Pediatric patients had less mortality than adults (OR: 0.45, 95%CI: 0.24-0.82). Cardiac support on the first run portrayed worse mortality than pulmonary support regardless of final run indication (OR:1.38, 95%CI: 1.09-1.75). Across all age groups, patients receiving pulmonary support on the last run tended to have higher survival rates regardless of support type on the first run. The only first run complication independently predictive of mortality on the final run was renal complications (OR: 1.60, 95%CI: 1.28-1.99).

CONCLUSIONS

Though the use of multiple runs of ECMO is growing, outcomes remain poor for most cohorts. Survival decreases with each additional run. Patients requiring additional runs for a pulmonary indication should be considered prime candidates. Renal complications on the first run significantly increases the risk of mortality on subsequent runs, and as such, careful consideration should be applied in these cases.

Review of acute kidney injury and continuous renal replacement therapy in pediatric extracorporeal membrane oxygenation

Purpose

To review the relevant literature of acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) as it relates to pediatric extracorporeal membrane oxygenation (ECMO).

Methods

Available online relevant literature.

Results

ECMO is a therapeutic modality utilized to support patients with refractory respiratory and/or cardiac failure. AKI and fluid overload (FO) are frequently observed in this patient population. There are multiple modalities that can be utilized for AKI and FO which include the following: diuretics, in-line hemofiltration, and CRRT. There are multiple considerations when using CRRT with ECMO including access, CRRT flows, hemolysis, anticoagulation, and CRRT termination.

Conclusion

While each ECMO center has its own set of equipment, experiences, and practices, it is imperative that the international ECMO community continues to work together to provide an evidence-based approach to address the morbidity and mortality associated with AKI and FO.

Acute Kidney Injury, Fluid Overload, and Outcomes in Children Supported With Extracorporeal Membrane Oxygenation for a Respiratory Indication

This study seeks to evaluate the association between acute kidney injury (AKI), fluid overload (FO), and mortality in children supported with extracorporeal membrane oxygenation (ECMO) for refractory respiratory failure. This retrospective observational cohort study was performed at six tertiary care children's hospital intensive care units, studying 424 patients < 18 years of age supported with ECMO for ≥ 24 hours for a respiratory indication from January 1, 2007, to December 31, 2011. In a multivariate analysis, FO level at ECMO initiation was not associated with hospital mortality, whereas peak FO level during ECMO was associated with hospital mortality. For every 10% increase in peak FO during ECMO, the odds of hospital mortality were approximately 1.2 times higher. Every 10% increase in peak FO during ECMO resulted in a significant relative change in the duration of ECMO hours by a factor of 1.08. For hospital survivors, every 10% increase in peak FO level during ECMO resulted in a significant relative change in the duration of mechanical ventilation hours by a factor of 1.13. In this patient population, AKI and FO are associated with increased mortality and should be considered targets for medical interventions including judicious fluid management, diuretic use, and renal replacement therapy.

Outcomes and factors associated with early mortality in pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation

Mortality and morbidity of children received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support after cardiac surgery remain high despite remarkable advances in medical management and devices. The purpose of this study was to describe outcomes and risk factors of applying VA-ECMO in the surgical pediatric population. We retrospectively analyzed 85 consecutive pediatric patients (aged <18 years) who received postcardiotomy VA-ECMO from January 2010 to December 2018. Median (IQR) age at ECMO implantation in this cohort was 12.7 (6.4, 43.2) months, median weight was 8.5 (6.0, 12.8) kg, mean ECMO duration was 143.2 ± 81.6 hours and mean hospital length of stay was 48.4 ± 32.4 days. Seventy-five patients (88.2%) were indicated for postcardiotomy cardiogenic shock. The successful ECMO weaning rate was 70.6% and in-hospital mortality was 52.9%. The most common diagnosis was transposition of great arteries (n = 18, 21.2%), while acute kidney injury occurred most often (n = 64, 75.3%). Multivariate logistic regression analysis showed that thrombocytopenia, hemolysis, and nosocomial infection were positively correlated with in-hospital mortality. Multivariate Cox proportional hazard regression analysis presented that thrombocytopenia significantly increased the 180-day mortality in patients with successful weaning. Therefore, multiple factors had adverse effects on prognosis. Patient selection and procedures from ECMO implantation to weaning need to be closely monitored and performed in a timely manner to improve outcome.

Continuous Renal Replacement Therapy in Pediatric Severe Sepsis: A Propensity Score-Matched Prospective Multicenter Cohort Study in the PICU

Supplemental Digital Content is available in the text.

Continuous renal replacement therapy becomes available utilization for pediatric critically ill, but the impact of mortality rate in severe sepsis remains no consistent conclusion. The aim of the study is to assess the effect of continuous renal replacement therapy in pediatric patients with severe sepsis and the impact this therapy may have on their mortality.

Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy: a multicenter retrospective cohort study

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.

Venoarterial extracorporeal membrane oxygenation in heart surgery post-operative pediatric patients: A retrospective study at Christus Muguerza Hospital, Monterrey, Mexico

Objectives

Extracorporeal membrane oxygenation is a life support procedure developed to offer cardiorespiratory support when conventional therapies have failed. The purpose of this study is to describe the findings during the first years using venoarterial extracorporeal membrane oxygenation in pediatric patients after cardiovascular surgery at Christus Muguerza High Specialty Hospital in Monterrey, Mexico.

Methods

This is a retrospective, observational, and descriptive study. The files of congenital heart surgery post-operative pediatric patients, who were treated with venoarterial extracorporeal membrane oxygenation from January 2013 to December 2015, were reviewed.

Results

A total of 11 patients were reviewed, of which 7 (63.8%) were neonates and 4 (36.7%) were in pediatric age. The most common diagnoses were transposition of great vessels, pulmonary stenosis, and tetralogy of Fallot. Survival rate was 54.5% and average life span was 6.3 days; the main complications were sepsis (36.3%), acute renal failure (36.3%), and severe cerebral hemorrhage (9.1%). The main causes of death were multi-organ dysfunction syndrome (27.3%) and cerebral hemorrhage (18.2%).

Conclusion

The mortality rates found are very similar to those found in a meta-analysis report published in 2013 and the main complication and causes of death are also very similar to the majority of extracorporeal membrane oxygenation reports for these kinds of patients. Although the results are encouraging, early sepsis detection, prevention of cerebral hemorrhage, and renal function monitoring must be improved.

Evaluating Mortality Risk Adjustment Among Children Receiving Extracorporeal Support for Respiratory Failure

This study evaluates whether three commonly used pediatric intensive care unit (PICU) severity of illness scores, pediatric risk of mortality score (PRISM) III, pediatric index of mortality (PIM) 2, and pediatric logistic organ dysfunction (PELOD), are the appropriate tools to discriminate mortality risk in children receiving extracorporeal membrane oxygenation (ECMO) support for respiratory failure. This study also evaluates the ability of the Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS) to discriminate mortality risk in the same population, and whether Ped-RESCUERS' discrimination of mortality is improved by additional clinical and laboratory measures of renal, hepatic, neurologic, and hematologic dysfunction. A multi-institutional retrospective cohort study was conducted on children aged 29 days to 17 years with respiratory failure requiring respiratory ECMO support. Discrimination of mortality was evaluated with the area under the receiver operating curve (AUC); model calibration was measured by the Hosmer-Lemeshow goodness of fit test and Brier score. Admission PRISM-III, PIM-2, and PELOD were found to have poor ability to discriminate mortality with an AUC of 0.56 [0.46-0.66], 0.53 [0.43-0.62], and 0.57 [0.47-0.67], respectively. Alternatively, Ped-RESCUERS performed better with an AUC of 0.68 [0.59-0.77]. Higher alanine aminotransferase, ratio of the arterial partial pressure of oxygen the fraction of inspired oxygen, and lactic acidosis were independently associated with mortality and, when added to Ped-RESCUERS, resulted in an AUC of 0.75 [0.66-0.82]. Admission PRISM-III, PIM-2, and PELOD should not be used for pre-ECMO risk adjustment because they do not discriminate death. Extracorporeal membrane oxygenation population-derived scores should be used to risk adjust ECMO populations as opposed to general PICU population-derived scores.

AWAKEN-Ing a New Frontier in Neonatal Nephrology

In 2013, literature about the epidemiology of neonatal acute kidney injury (AKI) was limited to primarily retrospective, single center studies that suggested that AKI was common and that those with AKI had higher rates of mortality. We developed a 24-center retrospective cohort of neonates admitted to the NICU between January 1 and March 31, 2014. Analysis of the Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) cohort, has allowed us to describe the prevalence, risk factors and impact of neonatal AKI for different gestational age cohorts. The ample sample size allows us to provide convincing data to show that those with AKI have an increase independent higher odds of death and prolonged hospitalization time (1). This data mirrors similar studies in pediatric (2) and adult (3) critically ill populations which collectively suggest that patients do not just die with AKI, but instead, AKI is directly linked to hard clinical outcomes. This study has allowed us to answer multiple other questions in the field which has expanded our understanding of the risk factors, complications, impact of fluid overload, the definition of neonatal AKI and suggests interventions for improving outcomes. Furthermore, this project brought together neonatologist and nephrologist within and across centers. Finally, the AWAKEN project has enabled us to build relationships and infrastructure that has launched the Neonatal Kidney Collaborative http://babykidney.org/ on its way to accomplish its stated mission to improve the health of newborns with or at risk for kidney disease through multidisciplinary collaborative research, advocacy, and education.

Severe Adenovirus Pneumonia Requiring Extracorporeal Membrane Oxygenation Support in Immunocompetent Children

Objective: To highlight severe adenovirus pneumonia in immunocompetent patients by analysis of severe adenovirus pneumonia associated with acute respiratory distress syndrome in whom extracorporeal membrane oxygenation (ECMO) support is required. Methods:Pediatric patients with adenovirus pneumonia and ECMO supports in our hospital from February 2018 to May 2019 were retrospectively analyzed, and having 100 common adenovirus pneumonia children as a control. Results:A total of 8 patients, including 4 boys (50.0%), were enrolled. They were previously immunocompetent with a median age of 31 months. They were admitted as persistent fever and cough for more than one week. Median time prior to development of respiratory failure requiring intubation and invasive mechanical ventilation was 5 days. Venoarterial ECMO support as rescue ventilation was instituted after a median time of 24.5 h of conventional mechanical ventilator support. The median duration on ECMO support was 9 days and mechanical ventilation was 14 days, respectively. Six patients (75%) were recovered and 2 (25%) died. Median length of stay in ICU and hospital were 27.5 days and 47.5 days, respectively. Conclusion:The promising outcomes of our cases suggested that ECMO support for rescue ventilation may be considered when symptoms deteriorated in adenovirus pneumonia patients, and may improve outcome. However, sequelae of adenovirus pneumonia and ECMO-related complications should also be taken into account.

ECMO for Neonatal Sepsis in 2019

Sepsis and septic shock in newborns causes mortality and morbidity depending on the organism and primary site. ECMO provides cardiorespiratory support to allow adequate organ perfusion during the time for antibiotics and source control surgery (if needed) to occur. ECMO mode and cannulation site vary depending on support required and local preference. Earlier and more aggressive use of ECMO can improve survival.

Case Report: Successful Use of Extracorporeal Therapies After ECMO Resuscitation in a Pediatric Kidney Transplant Recipient

The combination of extracorporeal membrane oxygenation (ECMO) and extracorporeal blood purification in children is rarely used due to small total blood volumes, risks of hemodynamic instability and a negative association between volume of blood transfusion and patient outcome. To our knowledge, this is the first description of a multimodal extracorporeal detoxication in the setting of ECMO in a post-kidney-transplant child on immunosuppression. We describe a case of a 30-months old child, who was extracorporeally resuscitated after cardiac arrest during kidney transplantation surgery and additionally treated with a number of extracorporeal blood purification methods (plasma exchange, CytoSorb, and lipopolysaccharide adsorption) in the setting of immunosuppression therapy. This case report shows the successful use of multimodal extracorporeal therapies for a good patient outcome. The lack of response to CytoSorb therapy might suggest an occult infection and not necessarily failure of treatment.

Acute Kidney Injury in Pediatric Patients on Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-analysis

Background: Acute kidney injury (AKI) is a well-established complication of extra-corporal membrane oxygenation (ECMO) in the adult population. The data in the pediatric and neonatal population is still limited. Moreover, the mortality risk of AKI among pediatric patients requiring ECMO remains unclear. Thus, this meta-analysis aims to assess the incidence of AKI, AKI requiring renal replacement therapy and AKI associated mortality in pediatric/neonatal patients requiring ECMO. Methods: A literature search was performed utilizing MEDLINE, EMBASE, and the Cochrane Database from inception through June 2019. We included studies that evaluated the incidence of AKI, severe AKI requiring renal replacement therapy (RRT) and the risk of mortality among pediatric patients on ECMO with AKI. Random-effects meta-analysis was used to calculate the pooled incidence of AKI and the odds ratios (OR) for mortality. Results: 13 studies with 3523 pediatric patients on ECMO were identified. Pooled incidence of AKI and AKI requiring RRT were 61.9% (95% confidence interval (CI): 39.0-80.4%) and 40.9% (95%CI: 31.2-51.4%), respectively. A meta-analysis limited to studies with standard AKI definitions showed a pooled estimated AKI incidence of 69.2% (95%CI: 59.7-77.3%). Compared with patients without AKI, those with AKI and AKI requiring RRT while on ECMO were associated with increased hospital mortality ORs of 1.70 (95% CI, 1.38-2.10) and 3.64 (95% CI: 2.02-6.55), respectively. Conclusions: The estimated incidence of AKI and severe AKI requiring RRT in pediatric patients receiving ECMO are high at 61.9% and 40.9%, respectively. AKI among pediatric patients on ECMO is significantly associated with reduced patient survival.

Updates in Pediatric Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation is an increasingly used mode of life support for patients with cardiac and/or respiratory failure refractory to conventional therapy. This review provides a synopsis of the evolution of extracorporeal life support in neonates, infants, and children and offers a framework for areas in need of research. Specific aspects addressed are the changing epidemiology; technologic advancements in extracorporeal membrane oxygenation circuitry; the current status and future direction of anticoagulation management; sedative and analgesic strategies; and outcomes, with special attention to the lessons learned from neonatal survivors.

Maternal and environmental risk factors for neonatal AKI and its long-term consequences

Acute kidney injury (AKI) is a common and life-threatening complication in critically ill neonates. Gestational risk factors for AKI include premature birth, intrauterine growth restriction and low birthweight, which are associated with poor nephron development and are often the consequence of pre-gestational and gestational factors, such as poor nutritional status. Our understanding of how to best optimize renal development and prevent AKI is in its infancy; however, the identification of pre-gestational and gestational factors that increase the risk of adverse neonatal outcomes and the implementation of interventions, such as improving nutritional status early in pregnancy, have the potential to optimize fetal growth and reduce the risk of preterm birth, thereby improving kidney health. The overall risk of AKI among critically ill and premature neonates is exacerbated postnatally as these infants are often exposed to dehydration, septic shock and potentially nephrotoxic medications. Strategies to improve outcomes - for example, through careful evaluation of nephrotoxic drugs - may reduce the incidence of AKI and its consequences among this population. Management strategies and updated technology that will support neonates with AKI are greatly needed. Extremely premature infants and those who survive an episode of AKI should be screened for chronic kidney disease until early adulthood. Here, we provide an overview of our current understanding of neonatal AKI, focusing on its relationship to preterm birth and growth restriction. We describe factors that prevent optimal nephrogenesis during pregnancy and provide a framework for future explorations designed to maximize outcomes in this vulnerable population.

Higher Flow on Cardiopulmonary Bypass in Pediatrics Is Associated With a Lower Incidence of Acute Kidney Injury

Adequate perfusion is of paramount concern during cardiopulmonary bypass (CPB) and different methodologies are employed to optimize oxygen delivery. Temperature, hematocrit, and cardiac index (CI) are all modulated during CPB to ensure appropriate support. This study examines 2 different perfusion strategies and their impact on various outcome measures including acute kidney injury (AKI), urine output on CPB, ICU length of stay, time to extubation, and mortality. Predicated upon surgeon preference, the study institution employs 2 different perfusion strategies (PS) during congenital cardiac surgery requiring CPB. One method utilizes a targeted 2.4 L/min/m² CI and nadir hematocrit of 28% (PS1), the other a 3.0 L/min/m² CI with a nadir hematocrit of 25% (PS2). This study retrospectively examines CPB cases during which the 2 perfusion strategies were applied to determine potential differences in packed red blood cell administration, urine output during CPB, AKI post-CPB as defined by the KDIGO criteria, and operative survival as defined by the Society of Thoracic Surgeons. Significant differences were found in urine output while on CPB (P < 0.01) and all combined stages of postoperative AKI (P = 0.01) with the PS2 group faring better in both measures. No significant difference was found between the 2 groups for packed red blood cell administration, mortality, time to extubation, or ICU length of stay. Avoiding a nadir hematocrit less than 25% has been well established but maintaining anything greater than that may not be necessary to achieve adequate oxygen delivery on CPB. Our results indicate that higher CI and oxygen delivery on CPB are associated with a lower rate of AKI and this may be achieved with increased flow rather than increasing the hematocrit thus avoiding unnecessary transfusion.

Development of the Pediatric Extracorporeal Membrane Oxygenation Prediction Model for Risk-Adjusting Mortality

OBJECTIVES

To develop a prognostic model for predicting mortality at time of extracorporeal membrane oxygenation initiation for children which is important for determining center-specific risk-adjusted outcomes.

DESIGN

Multivariable logistic regression using a large national cohort of pediatric extracorporeal membrane oxygenation patients.

SETTING

The ICUs of the eight tertiary care children's hospitals of the Collaborative Pediatric Critical Care Research Network.

PATIENTS

Five-hundred fourteen children (< 19 yr old), enrolled with an initial extracorporeal membrane oxygenation run for any indication between January 2012 and September 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 514 first extracorporeal membrane oxygenation runs were analyzed with an overall mortality of 45% (n = 232). Weighted logistic regression was used for model selection and internal validation was performed using cross validation. The variables included in the Pediatric Extracorporeal Membrane Oxygenation Prediction model were age (pre-term neonate, full-term neonate, infant, child, and adolescent), indication for extracorporeal membrane oxygenation (extracorporeal cardiopulmonary resuscitation, cardiac, or respiratory), meconium aspiration, congenital diaphragmatic hernia, documented blood stream infection, arterial blood pH, partial thromboplastin time, and international normalized ratio. The highest risk of mortality was associated with the presence of a documented blood stream infection (odds ratio, 5.26; CI, 1.90-14.57) followed by extracorporeal cardiopulmonary resuscitation (odds ratio, 4.36; CI, 2.23-8.51). The C-statistic was 0.75 (95% CI, 0.70-0.80).

CONCLUSIONS

The Pediatric Extracorporeal Membrane Oxygenation Prediction model represents a model for predicting in-hospital mortality among children receiving extracorporeal membrane oxygenation support for any indication. Consequently, it holds promise as the first comprehensive pediatric extracorporeal membrane oxygenation risk stratification model which is important for benchmarking extracorporeal membrane oxygenation outcomes across many centers.

Population Pharmacokinetic Analysis of Gentamicin in Pediatric Extracorporeal Membrane Oxygenation

BACKGROUND

Gentamicin pharmacokinetics may be altered in pediatric patients undergoing extracorporeal membrane oxygenation (ECMO). Description of gentamicin pharmacokinetics and relevant variables can improve dosing.

METHODS

A retrospective population pharmacokinetic study was designed, and pediatric patients who received gentamicin while undergoing ECMO therapy over a period of 6 1/2 years were included. Data collection included the following: patient demographics, serum creatinine, albumin, hematocrit, gentamicin dosing and serum concentrations, urine output, and ECMO circuit parameters. Descriptive statistics were used to characterize the patient population. Population pharmacokinetic analysis was performed with NONMEM, and simulation was performed to identify empiric doses to achieve therapeutic serum concentrations.

RESULTS

A total of 37 patients met study criteria (75.7% male patients), with a median age of 0.17 [interquartile range (IQR) 0.12-0.82] years. Primary indications for ECMO included the following: congenital diaphragmatic hernia (n = 17), persistent pulmonary hypertension (n = 5), and septic shock (n = 4). Patients received a total of 117 gentamicin doses [median 1.8 (IQR 1.4-2.9) mg/kg/dose] and had 125 serum concentrations measured at a median of 22.8 (IQR 15.8-25.5) hours after a dose. Population pharmacokinetic analysis identified a 2-compartment model with additive error as the best fit. Covariates included the following: allometrically scaled fat-free mass on clearance, central and peripheral volume of distribution (VDcentral and VDperipheral), and intercompartmental clearance; serum creatinine on clearance; ultrafiltration rate on central volume of distribution. Simulation identified dosage of 4-5 mg/kg/dose every 24 hours for neonates and infants as an acceptable empiric dosing regimen. Children and adolescents had elevated trough concentrations when dosed according to traditional dosing methods.

CONCLUSIONS

Fat-free mass should be used to dose gentamicin in pediatric ECMO patients. Serum creatinine is a marker of gentamicin clearance and should be used to adjust gentamicin dosing in pediatric ECMO patients.

Evaluation of Calcium Homeostasis and Dietary Supplementation for Pediatric and Neonatal Patients Receiving Extracorporeal Membrane Oxygenation Support

OBJECTIVES

Although the use of extracorporeal membrane oxygenation (ECMO) significantly improves survival in patients with persistent respiratory or cardiovascular failure, it also induces physiologic stress and disrupts homeostatic mechanisms. Patients undergoing ECMO support at our institution have required widely variable quantities of calcium supplementation for maintenance of normal calcium levels. Our primary objective was to assess the frequency of calcium abnormalities in pediatric and neonatal ECMO patients. Secondary objectives included quantifying electrolyte supplementation provided during ECMO and determining the relationships between calcium abnormalities and ECMO duration, mortality, and intensive care and hospital length of stay.

METHODS

We performed a single-center retrospective chart review of all patients less than 18 years of age who received ECMO support between July 1, 2013, and May 31, 2016. Clinical and laboratory data were reviewed for each patient for the duration of ECMO support, and the incidence of ionized calcium outside the reference range of 1.1 to 1.4 mmol/L beyond the first 24 hours of ECMO was recorded.

RESULTS

Seventy-eight patients were included in the study: 51 patients (65%) experienced at least one reading outside the normal ionized calcium range, while 27 patients (35%) were normocalcemic during their ECMO course. There were no differences between groups in the quantities of calcium, phosphate, or vitamin D administered during ECMO. Abnormal calcium levels were associated with a longer duration of ECMO (median 9 days vs 6 days, p = 0.0054), prolonged ICU length of stay (median 33 vs 18 days, p = 0.0055), and prolonged hospital length of stay (median 52 vs 40 days, p = 0.0239). No significant differences were found in survival to decannulation or survival to hospital discharge.

CONCLUSIONS

Calcium abnormalities occur frequently in pediatric and neonatal patients during ECMO and are associated with worse patient outcomes. The underlying physiology of these changes is thought to be related to ECMO-induced disruption of normal calcium homeostasis.

Optimizing the AKI definition during first postnatal week using Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) cohort

BACKGROUND

Neonates with serum creatinine (SCr) rise ≥0.3 mg/dL and/or ≥50% SCr rise are more likely to die, even when controlling for confounders. These thresholds have not been tested in newborns. We hypothesized that different gestational age (GA) groups require different SCr thresholds.

METHODS

Neonates in Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) with ≥1 SCr on postnatal days 1-2 and ≥1 SCr on postnatal days 3-8 were assessed. We compared the mortality predictability of SCr absolute (≥0.3 mg/dL) vs percent (≥50%) rise. Next, we determine usefulness of combining absolute with percent rise. Finally, we determined the optimal absolute, percent, and maximum SCr thresholds that provide the highest mortality area under curve (AUC) and specificity for different GA groups.

RESULTS

The ≥0.3 mg/dL rise outperformed ≥50% SCr rise. Addition of percent rise did not improve mortality predictability. The optimal SCr thresholds to predict AUC and specificity were ≥0.3 and ≥0.6 mg/dL for ≤29 weeks GA, and ≥0.1 and ≥0.3 mg/dL for >29 week GA. The maximum SCr value provides great specificity.

CONCLUSION

Unique SCr rise cutoffs for different GA improves outcome prediction. Percent SCr rise does not add value to the neonatal AKI definition.

Renal dysfunction in the pediatric surgical patient: When to intervene

Renal dysfunction is very common in the pediatric surgical critical care patient, with an estimated incidence of up to 35% in the PICU population. It impacts multiple other organ systems, particularly ventilation, and adds to the morbidity and mortality in children with multisystem organ dysfunction. In this article, we review the definitions and stages of renal failure in the pediatric population, identify which of these are more likely to require renal replacement therapy, and identify the indications for the different types of intervention. In addition, the complications of each form of therapy, along with management options, will be discussed. Finally, we will discuss the immediate and long-term outcomes for pediatric patients from neonates to adolescents.

Survival analysis of extracorporeal membrane oxygenation in neonatal and pediatric patients - A nationwide cohort study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) provides short-term cardiopulmonary support for patients with acute cardiac and respiratory failure. This study reported the survival rate for pediatric patients from Taiwan's national cohort.

METHODS

Patients under the age of 18 who received ECMO from January 1, 2002 to December 31, 2012 were identified from the Taiwan National Health Insurance Research Database. The underlying etiology for ECMO use was categorized into post-operative (n = 410), cardiac (245), pulmonary (146) groups, and others (120). A Cox regression model was used to determine hazard ratios and to compare 30-day and 1-year survival rates using post-operative group as a reference.

RESULTS

The average age of all 921 patients was 4.83 ± 5.84 years, and 59.1% were male. The overall mortality rate was 29.2% at 1 month, and 46.9% at 1 year. The cardiac origin group, consisting mostly of congenital heart disease without surgical intervention, myocarditis, and heart failure had a better outcome with an adjusted hazard ratio of 0.69 (95% CI 0.49-0.96, p = 0.008) at 30 days and 0.50 (95% CI 0.38-0.66, p < 0.001) at 1 year, as compared to the post-operative group.

CONCLUSION

In contrast to the widespread use of ECMO in respiratory distress syndrome in western countries, pediatric ECMO in Taiwan was more often applied to patients with underlying cardiovascular diseases. Mortality rates varied according to age groups and various etiologies. The results of this large pediatric cohort provides a different prospective in critical care outcomes in medical environments where ECMO is more widely available.

Impact of Hemolysis on Acute Kidney Injury and Mortality in Children Supported with Cardiac Extracorporeal Membrane Oxygenation

Intravascular hemolysis with elevated plasma-free hemoglobin (PFH) complicates extracorporeal membrane oxygenation (ECMO). In 50 consecutive pediatric cardiac patients requiring ECMO, we sought to describe the relationship between PFH and clinical outcomes; primary outcomes were acute kidney injury (AKI) and prolonged (>14 days) renal replacement therapy (RRT). Median age was 35 days, median weight 3.9 kg, and median ECMO duration 4.2 days. Seventy-eight percent (39/50) weaned off ECMO; survival to discharge was 50% (25/50). Seventy percent (35/50) had AKI on ECMO. Seventy-seven percent (30/39) required RRT post-ECMO; median duration was 5.2 days (0, 14.2). Prolonged RRT was associated with higher daily PFH (67.5 mg/dL [54.1, 102.5] vs. 46.7 mg/dL [40, 72.6], p = .025) and higher peak PFH (120 mg/dL [90, 200] vs. 60 mg/dL [40, 135], p = .016). After adjusting for ECMO duration and oliguria/elevated creatinine on ECMO day 0, peak PFH >90 mg/dL was associated with prolonged RRT (operating room [OR] = 18, confidence interval [CI] 1.9-167.8). Patients who died had higher daily PFH (65 mg/dL [51.6, 111.7] vs. 42.5 mg/dL [37.5, 60], p = .0040). Adjusting for ECMO duration and blood product administration, daily PFH >53 mg/dL was associated with mortality (OR 4.8, CI 1.01-23.3). Elevated PFH during pediatric cardiac ECMO is associated with prolonged RRT and non-survival to discharge. Initiatives to decrease PFH burden may improve clinical outcomes.

Management of Fluid Overload in the Pediatric ICU

The implications and management of fluid overload in pediatric critical care remain areas of ongoing controversy. Consensus definitions and methods of quantitating fluid overload continue to evolve, paralleling our growing understanding of fluid dynamics in critically ill patients. Fluid overload has been associated with adverse outcomes in some patient populations; guidelines for fluid management therapies are sparse and have little supporting data. Conflicting data for efficacy of therapies such as diuretic medications and renal replacement therapy are likely reflective of an incomplete understanding of the dynamic relationship between critical illness and fluid overload. Although some guidance regarding diuresis, continuous renal replacement therapy, and fluid balance goals is elucidated in the following chapters, it is important to recognize that further research into these management strategies is required before standardized approaches to management can be established.

Implementing a practice change: early initiation of continuous renal replacement therapy during neonatal extracorporeal life support standardizes care and improves short-term outcomes

PURPOSE

We hypothesized that a standardized approach to early continuous renal replacement therapy (CRRT) during neonatal extracorporeal life support (ECLS) results in greater homogeneity of CRRT initiation times with improvements in fluid balance and outcomes.

METHODS

Retrospective analysis of data (2007-2015) obtained from neonates treated prior to (E1; n = 32) and after (E2; n = 31) a 2011 practice change: CRRT initiation within 48 h of ECLS.

RESULTS

Birthweight, gestational age, ECLS mode, and age at ECLS initiation were similar to each epoch. Survival [E1: median 75%, E2: 71%] and length of ECLS [E1: median 221 h, E2: 180 h] were comparable. During E2, 100% of infants received CRRT (vs. E1: 37%; p < 0.001) and 97% of infants initiated CRRT within 48 h of ECLS (vs. E1: 13%; p < 0.001). Control charts demonstrate reduced practice variation. Elapsed time from ECLS to CRRT differed between Epochs [E1: median 105 h, E2: 9 h; p < 0.001] as did weight at CRRT initiation [E1: 4.13 kg (29% above baseline), E2: 3.19 kg (0%); p < 0.001]. Significant differences in weight change were noted on days 6 and 7 (E1: 14%, E2: 2%; raw data comparison yielded p < 0.05) and curves were different (p < 0.05).

CONCLUSIONS

We successfully implemented a practice change, initiating CRRT within 48 h of ECLS cannulation, leading to decreased practice variation and improved short-term outcomes including decreased weight gain at CRRT initiation and faster return to baseline weight during the first 7 days of ECLS. We did not demonstrate changes in duration of ECLS, invasive ventilation, or survival.

An overview of medical ECMO for neonates

Extracorporeal membrane oxygenation (ECMO), a life-saving therapy for respiratory and cardiac failure, was first used in neonates in the 1970s. The indications and criteria for ECMO have changed over the years, but it continues to be an important option for those who have failed other medical therapies. Since the Extracorporeal Life Support Organization (ELSO) Registry was established in 1989, more than 29,900 neonates have been placed on ECMO for respiratory failure, with 84% surviving their ECMO course, and 73% surviving to discharge or transfer. In this chapter, we will review the basics of ECMO, patient characteristics and criteria, patient management, ECMO complications, special uses of neonatal ECMO, and patient outcomes.

Adjunctive Therapies During Extracorporeal Membrane Oxygenation to Enhance Multiple Organ Support in Critically Ill Children

Since the advent of extracorporeal membrane oxygenation (ECMO) over 40 years ago, there has been increasing interest in the use of the extracorporeal circuit as a platform for providing multiple organ support. In this review, we will examine the evidence for the use of continuous renal replacement therapy, therapeutic plasma exchange, leukopheresis, adsorptive therapies, and extracorporeal liver support in conjunction with ECMO.

The Impact of Fluid Overload on Outcomes in Children Treated With Extracorporeal Membrane Oxygenation: A Multicenter Retrospective Cohort Study

OBJECTIVE

To characterize the epidemiology of fluid overload and its association with mortality and duration of extracorporeal membrane oxygenation in children treated with extracorporeal membrane oxygenation.

DESIGN

Retrospective cohort study.

SETTING

Six tertiary children's hospital ICUs.

PATIENTS

Seven hundred fifty-six children younger than 18 years old treated with extracorporeal membrane oxygenation for greater than or equal to 24 hours from January 1, 2007, to December 31, 2011.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Overall survival to extracorporeal membrane oxygenation decannulation and hospital discharge was 74.9% (n = 566) and 57.7% (n = 436), respectively. Median fluid overload at extracorporeal membrane oxygenation initiation was 8.8% (interquartile range, 0.3-19.2), and it differed between hospital survivors and non survival, though not between extracorporeal membrane oxygenation survivors and non survivors. Median peak fluid overload on extracorporeal membrane oxygenation was 30.9% (interquartile range, 15.4-54.8). During extracorporeal membrane oxygenation, 84.8% had a peak fluid overload greater than or equal to 10%; 67.2% of patients had a peak fluid overload of greater than or equal to 20% and 29% of patients had a peak fluid overload of greater than or equal to 50%. The median peak fluid overload was lower in patients who survived on extracorporeal membrane oxygenation (27.2% vs 44.4%; p < 0.0001) and survived to hospital discharge (24.8% vs 43.3%; p < 0.0001). After adjusting for acute kidney injury, pH at extracorporeal membrane oxygenation initiation, nonrenal complications, extracorporeal membrane oxygenation mode, support type, center and patient age, the degree of fluid overload at extracorporeal membrane oxygenation initiation (p = 0.05), and the peak fluid overload on extracorporeal membrane oxygenation (p < 0.0001) predicted duration of extracorporeal membrane oxygenation in survivors. Multivariable analysis showed that peak fluid overload on extracorporeal membrane oxygenation (adjusted odds ratio, 1.09; 95% CI, 1.04-1.15) predicted mortality on extracorporeal membrane oxygenation; fluid overload at extracorporeal membrane oxygenation initiation (adjusted odds ratio, 1.13; 95% CI, 1.05-1.22) and peak fluid overload (adjusted odds ratio, 1.18; 95% CI, 1.12-1.24) both predicted hospital morality.

CONCLUSIONS

Fluid overload occurs commonly and is independently associated with adverse outcomes including increased mortality and increased duration of extracorporeal membrane oxygenation in a broad pediatric extracorporeal membrane oxygenation population. These results suggest that fluid overload is a potential target for intervention to improve outcomes in children on extracorporeal membrane oxygenation.

Multicenter Experience With Mechanical Circulatory Support Using a New Diagonal Pump in 233 Children

Technological innovations in pediatric extracorporeal life support circuits can reduce system-related complications and may improve patients' outcome. The Deltastream DP3 (Medos Medizintechnik AG, Stolberg, Germany) is a novel rotational pump with a diagonally streamed impeller that can be used over a broad range of flows. We collected patient data from seven pediatric centers to conduct a retrospective cohort study. We examined 233 patients whose median age was 1.9 (0-201) months. The DP3 system was used for cardiopulmonary support as veno-arterial extracorporeal membrane oxygenation (ECMO) in 162 patients. Respiratory support via veno-venous ECMO was provided in 63 patients. The pump was used as a ventricular assist device in eight patients. Median supporting time was 5.5 (0.2-69) days and the weaning rate was 72.5%. The discharge home rate was 62% in the pulmonary group versus 55% in the cardiac group. Extracorporeal cardiopulmonary resuscitation was carried out in 24 patients (10%) with a survival to discharge of rate of 37.5%. About 106 (47%) children experienced no complications, while 33% suffered bleeding requiring blood transfusion or surgical intervention. Three patients suffered a fatal cerebral event. Renal replacement therapy was performed in 28% and pump or oxygenator exchange in 26%. Multivariable analysis identified system exchange (OR 1.94), kidney failure (OR 3.43), and complications on support (OR 2.56) as risk factors for dismal outcome. This novel diagonal pump has demonstrated its efficacy in all kinds of mechanical circulatory and respiratory support, revealing good survival rates.

Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study

Background

Single-center studies suggest that neonatal acute kidney injury (AKI) is associated with poor outcomes. However, inferences regarding the association between AKI, mortality, and hospital length of stay are limited due to the small sample size of those studies. In order to determine whether neonatal AKI is independently associated with increased mortality and longer hospital stay, we analyzed the Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) database.

Methods

All neonates admitted to 24 participating neonatal intensive care units from four countries (Australia, Canada, India, United States) between January 1 and March 31, 2014, were screened. Of 4273 neonates screened, 2022 (47·3%) met study criteria. Exclusion criteria included: no intravenous fluids ≥48 hours, admission ≥14 days of life, congenital heart disease requiring surgical repair at <7 days of life, lethal chromosomal anomaly, death within 48 hours, inability to determine AKI status or severe congenital kidney abnormalities. AKI was defined using a standardized definition —i.e., serum creatinine rise of ≥0.3 mg/dL (26.5 mcmol/L) or ≥50% from previous lowest value, and/or if urine output was <1 mL/kg/h on postnatal days 2 to 7.

Findings

Incidence of AKI was 605/2022 (29·9%). Rates varied by gestational age groups (i.e., ≥22 to <29 weeks =47·9%; ≥29 to <36 weeks =18·3%; and ≥36 weeks =36·7%). Even after adjusting for multiple potential confounding factors, infants with AKI had higher mortality compared to those without AKI [(59/605 (9·7%) vs. 20/1417 (1·4%); p< 0.001; adjusted OR=4·6 (95% CI=2·5–8·3); p=<0·0001], and longer hospital stay [adjusted parameter estimate 8·8 days (95% CI=6·1–11·5); p<0·0001].

Interpretation

Neonatal AKI is a common and independent risk factor for mortality and longer hospital stay. These data suggest that neonates may be impacted by AKI in a manner similar to pediatric and adult patients.

Funding

US National Institutes of Health, University of Alabama at Birmingham, Cincinnati Children’s, University of New Mexico.

Pediatric Extracorporeal Membrane Oxygenation

Extracorporeal life support is a modified form of cardiopulmonary bypass. Experience in extracorporeal membrane oxygenation (ECMO) has come largely from the neonatal population. Most centers have transitioned the ECMO pumps from roller pumps to centrifugal technology. Modes of support include venovenous for respiratory support and venoarterial for cardiac support. "Awake" ECMO is the trend with extubation and tracheostomy on the rise. Fluid overload is common and managed with diuretics or hemofiltration. Nutrition is important and provided enterally or via total parenteral nutrition. Overall survival for pediatric cardiac and respiratory ECMO has remained at approximately 50% to 60%.