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Romlin B, Dahlin A, Hallhagen S, Björk K, Wåhlander H, Söderlund F. Clinical course and outcome after treatment with ventricular assist devices in paediatric patients: A single-centre experience. Acta Anaesthesiol Scand 2021; 65:785-791. [PMID: 33616235 DOI: 10.1111/aas.13804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Heart failure is a rare condition in the paediatric population, associated with high morbidity and mortality. When medical therapy is no longer sufficient, mechanical circulatory support such as a ventricular assist device can be used to bridge these children to transplant or recovery. Coagulation-related complications such as thrombi, embolism and bleeding events represent the greatest challenge in paediatric patients on mechanical support. We aimed to describe the outcomes and coagulation-related complications in this patient population at our institution. METHODS A total of 20 patients with either Berlin Heart EXCOR® or HeartWare® implantation were reviewed in this retrospective study. Study endpoints were survival to heart transplant, weaning due to recovery or death. Thrombotic events were defined as thrombus formation in the device or in the patient, or cardioembolic strokes. Bleeding events were defined as events requiring interventional surgery or transfusion of red blood cells. RESULTS The aetiology of heart failure included cardiomyopathy (n = 12), end-stage congenital heart disease (n = 6) and myocarditis (n = 2). Of the 20 patients, 12 were bridged to transplant, 7 recovered and could be weaned and 1 died. The median duration of mechanical support was 84 days (range: 20-524 days). At least one major or minor bleeding event occurred in 45% of the patients. Thrombotic events occurred 21 times in 10 patients. Four of the patients (20%) had no bleeding or thromboembolic event. CONCLUSION In all, 95% of the patients were successfully bridged to transplant or recovery. Bleeding events and thrombotic events were common.
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Affiliation(s)
- Birgitta Romlin
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Anna Dahlin
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
| | - Stefan Hallhagen
- Department of Cardiothoracic Surgery Sahlgrenska University Hospital Gothenburg Sweden
| | - Kerstin Björk
- Department of Cardiothoracic Surgery Sahlgrenska University Hospital Gothenburg Sweden
| | - Håkan Wåhlander
- Paediatric Heart Centre Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Paediatrics Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Fredrik Söderlund
- Department of Paediatric Anaesthesiology and Intensive Care Queen Silvia Children's Hospital Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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Troy L, Su F, Kilbaugh T, Rasmussen L, Kuo T, Jett E, Cornell T, Berg M, Haileselassie B. Characteristics of Pediatric Extracorporeal Membrane Oxygenation Programs in the United States and Canada. ASAIO J 2021; 67:792-797. [PMID: 33181543 DOI: 10.1097/mat.0000000000001311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to evaluate the current infrastructure and practice characteristics of pediatric extracorporeal membrane oxygenation (ECMO) programs. A 40-question survey of center-specific demographics, practice structure, program experience, and support network utilized to cannulate and maintain a pediatric patient on ECMO was designed via a web-based survey tool. The survey was distributed to pediatric ECMO programs in the United States and Canada. Of the 101 centers that were identified to participate, 41 completed the survey. The majority of responding centers are university affiliated (73%) and have an intensive care unit (ICU) with 15-25 beds (58%). Extracorporeal membrane oxygenation has been offered for >10 years in 85% of the centers. The median number of total cannulations per center in 2017 was 15 (interquartile range [IQR] = 5-30), with the majority occurring in the cardiovascular intensive care unit (median = 13, IQR = 5-25). Fifty-seven percent of responding centers offer ECPR, with a median number of four cases per year (IQR = 2-7). Most centers cannulate in an operating room or ICU; 11 centers can cannulate in the pediatric ED. Sixty-three percent of centers have standardized protocols for postcannulation management. The majority of protocols guide anticoagulation, sedation, or ventilator management; left ventricle decompression and reperfusion catheter placement are the least standardized procedures. The majority of pediatric ECMO centers have adopted the infrastructure recommendations from the Extracorporeal Life Support Organization. However, there remains broad variability of practice characteristics and organizational infrastructure for pediatric ECMO centers across the United States and Canada.
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Affiliation(s)
- Lindsey Troy
- From the Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Felice Su
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Todd Kilbaugh
- Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Lindsey Rasmussen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Tony Kuo
- Stanford Children's Health, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Eric Jett
- Stanford Children's Health, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Timothy Cornell
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Marc Berg
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Bereketeab Haileselassie
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
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Lin JC, Barron LM, Vogel AM, Colvin RM, Baltagi SA, Doctor A, Gazit AZ, Mehegan M, O'Connor N, Said AS, Shepard M, Wallendorf M, Spinella PC. Context-Responsive Anticoagulation Reduces Complications in Pediatric Extracorporeal Membrane Oxygenation. Front Cardiovasc Med 2021; 8:637106. [PMID: 34179125 PMCID: PMC8224528 DOI: 10.3389/fcvm.2021.637106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/21/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO). Design: Single-center, observational pre- and post-implementation cohort study. Setting: Academic pediatric hospital. Patients: Patients in the PICU, CICU, and NICU receiving ECMO support. Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline. Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications. Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg. Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.
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Affiliation(s)
- John C. Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Lauren M. Barron
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Adam M. Vogel
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Ryan M. Colvin
- Pediatric Computing Facilities, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Sirine A. Baltagi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Avihu Z. Gazit
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Mary Mehegan
- St. Louis Children's Hospital, St. Louis, MO, United States
| | | | - Ahmed S. Said
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Mark Shepard
- St. Louis Children's Hospital, St. Louis, MO, United States
| | - Michael Wallendorf
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Philip C. Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
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Scott BL, Bonadonna D, Ozment CP, Rehder KJ. Extracorporeal membrane oxygenation in critically ill neonatal and pediatric patients with acute respiratory failure: a guide for the clinician. Expert Rev Respir Med 2021; 15:1281-1291. [PMID: 34010072 DOI: 10.1080/17476348.2021.1932469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Intro: Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure continues to demonstrate improving outcomes, largely due to advances in technology along with refined management strategies despite mounting patient acuity and complexity. Successful use of ECMO requires thoughtful initiation and candidacy strategies, along with reducing the risk of ventilator induced lung injury and the progression to multiorgan failure.Areas Covered: This review describes current ECMO management strategies for neonatal and pediatric patients with acute refractory respiratory failure and summarizes relevant published literature. ECMO initiation and candidacy, along with ventilator and sedation management, are highlighted. Additionally, rapidly expanding areas of interest such as anticoagulation strategies, transfusion thresholds, rehabilitation on ECMO, and drug pharmacokinetics are described.Expert Opinion: Over the last few decades, published studies supporting ECMO use for acute refractory respiratory failure, along with institutional experience, have resulted in increased utilization although more randomized-controlled trials are needed. Future research should focus on filling the knowledge gaps that remain regarding anticoagulation, transfusion thresholds, ventilator strategies, sedation, and approaches to rehabilitation to subsequently implement into clinical practice. Additionally, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations.
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Affiliation(s)
- Briana L Scott
- Division of Pediatric Critical Care Medicine, Duke University Health System, Durham, NC, USA
| | | | - Caroline P Ozment
- Division of Pediatric Critical Care Medicine, Duke University Health System, Durham, NC, USA
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Duke University Health System, Durham, NC, USA
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Alexander PMA, Muszynski JA. Ongoing Variability in Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Practices-Could Consensus Change the Next Survey Results? Pediatr Crit Care Med 2021; 22:581-584. [PMID: 34078845 DOI: 10.1097/pcc.0000000000002762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
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Ozment CP, Scott BL, Bembea MM, Spinella PC. Anticoagulation and Transfusion Management During Neonatal and Pediatric Extracorporeal Membrane Oxygenation: A Survey of Medical Directors in the United States. Pediatr Crit Care Med 2021; 22:530-541. [PMID: 33750092 DOI: 10.1097/pcc.0000000000002696] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare current practices within the United States of anticoagulation management and blood transfusion in neonatal and pediatric extracorporeal membrane oxygenation patients with a 2013 international report. DESIGN Cross-sectional survey distributed between August and December 2019. SETTING Extracorporeal Life Support Organization-registered neonatal and pediatric extracorporeal membrane oxygenation centers in the United States. PARTICIPANTS Extracorporeal membrane oxygenation medical directors. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty-three medical directors at 108 centers responded. After removing four duplicate responses, 79 surveys were analyzed. Seventy-nine percent (n = 62) report a written extracorporeal membrane oxygenation protocol for both anticoagulation and blood product management. Ninety-four percent (n = 74) report unfractionated heparin as their primary anticoagulant; the remaining use the direct thrombin inhibitor, bivalirudin. Ninety percent (n = 71) report measuring antifactor Xa levels. Most centers report using a combination of assays to monitor heparin therapy, either antifactor Xa and activated partial thromboplastin time (54%) or more commonly antifactor Xa and activated clotting time (68%). Forty-one percent use viscoelastic tests to aid management. Goal monitoring levels and interventions generated by out of range values are variable. Fifty-one percent will replace antithrombin. Platelet transfusion thresholds vary by age and center with ranges from 50,000 to 100,000 cells/µL. Eighty-two percent of respondents are willing to participate in a randomized controlled trial comparing anticoagulation strategies for patients receiving extracorporeal membrane oxygenation. CONCLUSIONS Compared with the 2013 pediatric population, extracorporeal membrane oxygenation center anticoagulation and blood transfusion approaches continue to vary widely. Most report continued use of heparin as their primary anticoagulant and follow a combination of monitoring assays with the majority using the antifactor Xa assay in their practices, a significant shift from prior results. Antithrombin activity levels and viscoelastic tests are followed by a growing number of centers. Platelet transfusion thresholds continue to vary widely. Future research is needed to establish optimal anticoagulation and blood transfusion management.
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Affiliation(s)
- Caroline P Ozment
- Department of Anesthesiology and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Briana L Scott
- Department of Anesthesiology and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Melania M Bembea
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Philip C Spinella
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
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Amodeo I, Di Nardo M, Raffaeli G, Kamel S, Macchini F, Amodeo A, Mosca F, Cavallaro G. Neonatal respiratory and cardiac ECMO in Europe. Eur J Pediatr 2021; 180:1675-1692. [PMID: 33547504 PMCID: PMC7864623 DOI: 10.1007/s00431-020-03898-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Abstract
Neonatal extracorporeal membrane oxygenation (ECMO) is a life-saving procedure for critically ill neonates suffering from a potentially reversible disease, causing severe cardiac and/or respiratory failure and refractory to maximal conventional management. Since the 1970s, technology, management, and clinical applications of neonatal ECMO have changed. Pulmonary diseases still represent the principal neonatal diagnosis, with an overall 74% survival rate, and up to one-third of cases are due to congenital diaphragmatic hernia. The overall survival rate in cardiac ECMO is lower, with congenital heart defect representing the main indication. This review provides an overview of the available evidence in the field of neonatal ECMO. We will address the changing epidemiology, basic principles, technologic advances in circuitry, and monitoring, and deliver a current multidisciplinary management framework, focusing on ECMO applications, complications, and long-term morbidities. Lastly, areas for further research will be highlighted.Conclusions: ECMO is a life support with a potential impact on long-term patients' outcomes. In the next years, advances in knowledge, technology, and expertise may push neonatal ECMO boundaries towards more premature and increasingly complex infants, with the final aim to reduce the burden of ECMO-related complications and improve overall patients' outcomes. What is Known: • ECMO is a life-saving option in newborns with refractory respiratory and/or cardiac failure. • The multidisciplinary ECMO management is challenging and may expose neonates to complications with an impact on long-term outcomes. What is New: • Advances in technology and biomaterials will improve neonatal ECMO management and, eventually, the long-term outcome of these complex patients. • Experimental models of artificial placenta and womb technology are under investigation and may provide clinical translation and future research opportunities.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | | | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Shady Kamel
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Betamed Perfusion Service, Rome, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Amodeo
- ECMO & VAD Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
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159
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Conversion From Activated Clotting Time to Anti-Xa Heparin Activity Assay for Heparin Monitoring During Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 48:e1179-e1184. [PMID: 33009103 DOI: 10.1097/ccm.0000000000004615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Anticoagulation with unfractionated heparin remains the most common therapy used to prevent circuit thrombosis during extracorporeal membrane oxygenation, but no consensus exists on the optimal method or targets for heparin monitoring. From 2015 to 2018, we switched from monitoring heparin during extracorporeal membrane oxygenation using activated clotting times to anti-Xa heparin activity assays. This study describes the transition from activated clotting time to anti-Xa heparin activity assay monitoring and the associated clinical changes. DESIGN Retrospective analysis at single institution. SETTING Referral Children's Hospital. PATIENTS A total of 145 pediatric patients over 152 extracorporeal membrane oxygenation runs using 206 extracorporeal membrane oxygenation circuits. INTERVENTIONS Anticoagulation protocol quality improvement. MEASUREMENTS AND MAIN RESULTS From 2015 to 2018, heparin monitoring during extracorporeal membrane oxygenation changed from hourly activated clotting time to anti-Xa heparin activity assay every 6 hours with an associated 75% reduction in the circuit changes per extracorporeal membrane oxygenation day. Over the 4 years, patients with an average anti-Xa heparin activity assay of at least 0.25 U/mL showed a 59% reduction in circuit changes per extracorporeal membrane oxygenation day compared with less than 0.15 U/mL. In addition to its association with reduced circuit changes, anti-Xa heparin activity assay monitoring was also associated with reduced heparin dose changes per day from 11 ± 4 to 2 ± 1 (p < 0.001), smaller heparin dose changes (less variation in dose), and reduced diagnostic phlebotomy volumes from 41 ± 6 to 25 ± 11 mL/day (p < 0.001). The number of patients with reported bleeding decreased from 69% using activated clotting time to 51% (p = 0.03). Transfusion rates did not change. CONCLUSIONS Over 4 years, we replaced the activated clotting time assay with the anti-Xa heparin activity assay for heparin monitoring during extracorporeal membrane oxygenation. Minimum anti-Xa heparin activity assay levels of 0.25 U/mL were associated with reduced circuit changes. Further studies are needed to determine the optimum anti-Xa heparin activity assay therapeutic range during extracorporeal membrane oxygenation.
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Papadimas E, Leow L, Tan YK, Shen L, Ramanathan K, Choong AMTL, MacLaren G. Centrifugal and Roller Pumps in Neonatal and Pediatric Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis of Clinical Outcomes. ASAIO J 2021; 68:311-317. [PMID: 34347405 DOI: 10.1097/mat.0000000000001475] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an invaluable means of supporting critically ill children with refractory respiratory or cardiac failure. Controversy remains; however, whether roller or centrifugal pumps are superior, particularly in infants. We performed a comprehensive search on PubMed, Embase, and Scopus for studies comparing the use of centrifugal and roller pumps in the pediatric and neonatal population from 1973 until March 1, 2020. All prospective and retrospective comparative studies were screened. Single-arm studies and those that included adult patients were excluded. The primary endpoint was survival to discharge. Secondary endpoints were complications (mechanical, cardiac, pulmonary, neurologic, renal, and hemolytic) and requirements for inotropic support. Random effects meta-analyses across all clinical endpoints were conducted. A total of four studies with 9111 patients were included. There was a statistically significant difference in in-hospital mortality, favoring the groups where roller pumps were used. Roller pumps were associated with fewer episodes of hemolysis, mechanical complications, cardiac complications, renal complications, and less inotropic support. ECMO with roller pumps may be associated with lower mortality in children. Roller pumps were associated with fewer complications, as well as reduced hemolysis and use of inotropes.
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Affiliation(s)
- Evangelos Papadimas
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Lowell Leow
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | | | - Liang Shen
- NUS Medicine Biostatistics Unit, Singapore
| | - Kollengode Ramanathan
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Andrew M T L Choong
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Graeme MacLaren
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, Singapore
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Joint Society of Critical Care Medicine-Extracorporeal Life Support Organization Task Force Position Paper on the Role of the Intensivist in the Initiation and Management of Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 48:838-846. [PMID: 32282350 DOI: 10.1097/ccm.0000000000004330] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation. DESIGN Retrospective review of the literature and expert consensus. SETTING Series of in-person meetings, conference calls, and emails from January 2018 to March 2019. SUBJECTS A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine and the Extracorporeal Life Support Organization. Experts were identified by their respective societies based on reputation, experience, and contribution to the field. INTERVENTIONS A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9. MEASUREMENTS AND MAIN RESULTS The Task Force developed 18 strong and five weak recommendations in five topic areas of extracorporeal membrane oxygenation initiation and management. These recommendations were organized into five areas related to the care of patients on extracorporeal membrane oxygenation: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is extracorporeal membrane oxygenation is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead. CONCLUSIONS The role of the intensivist in the care of patients on extracorporeal membrane oxygenation continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding extracorporeal membrane oxygenation selection, cannulation, and management are applied.
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Morbidity and Mortality in Critically Ill Children. II. A Qualitative Patient-Level Analysis of Pathophysiologies and Potential Therapeutic Solutions. Crit Care Med 2021; 48:799-807. [PMID: 32301845 DOI: 10.1097/ccm.0000000000004332] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe at the individual patient level the pathophysiologic processes contributing to morbidity and mortality in PICUs and therapeutic additions and advances that could potentially prevent or reduce morbidity and mortality. DESIGN Qualitative content analysis of intensivists' conclusions on pathophysiologic processes and needed therapeutic advances formulated by structured medical record review. SETTING Eight children's hospitals affiliated with the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS A randomly selected cohort of critically ill children with a new functional morbidity or mortality at hospital discharge. New morbidity was assessed using the Functional Status Scale and defined as worsening by two or more points in a single domain from preillness baseline. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 292 children, 175 (59.9%) had a new morbidity and 117 (40.1%) died. The most common pathophysiology was impaired substrate delivery (n = 158, 54.1%) manifesting as global or regional hypoxia or ischemia due to low cardiac output or cardiac arrest. Other frequent pathophysiologies were inflammation (n = 104, 35.6%) related to sepsis, respiratory failure, acute respiratory distress syndrome, or multiple organ dysfunction; and direct tissue injury (n = 64, 21.9%) including brain and spinal cord trauma. Chronic conditions were often noted (n = 156, 53.4%) as contributing to adverse outcomes. Drug therapies (n = 149, 51.0%) including chemotherapy, inotropes, vasoactive agents, and sedatives were the most frequently proposed needed therapeutic advances. Other frequently proposed therapies included cell regeneration (n = 115, 39.4%) mainly for treatment of neuronal injury, and improved immune and inflammatory modulation (n = 79, 27.1%). CONCLUSIONS Low cardiac output and cardiac arrest, inflammation-related organ failures, and CNS trauma were the most common pathophysiologies leading to morbidity and mortality in PICUs. A research agenda focused on better understanding and treatment of these conditions may have high potential to directly impact patient outcomes.
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Barbaro RP, Brodie D, MacLaren G. Bridging the Gap Between Intensivists and Primary Care Clinicians in Extracorporeal Membrane Oxygenation for Respiratory Failure in Children: A Review. JAMA Pediatr 2021; 175:510-517. [PMID: 33646287 PMCID: PMC8096690 DOI: 10.1001/jamapediatrics.2020.5921] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Extracorporeal membrane oxygenation (ECMO) is a form of advanced life support that may be used in children with refractory respiratory or cardiac failure. While it is required infrequently, in the US, ECMO is used to support childhood respiratory failure as often as children receive kidney or heart transplants. ECMO is complex, resource intensive, and potentially lifesaving, but it is also associated with risks of short-term complications and long-term adverse effects, most importantly with neurodevelopmental outcomes that are relevant to all pediatric clinicians, even those remote from the child's critical illness. OBSERVATIONS The 2009 influenza A(H1N1) pandemic, along with randomized clinical trials of adult respiratory ECMO support and conventional management, have catalyzed sustained growth in the use of ECMO. The adult trials built on earlier neonatal ECMO randomized clinical trials that demonstrated improved survival in severe perinatal lung disease. For children outside of the neonatal period, there appear to have been no respiratory ECMO clinical trials. Applying evidence from adult respiratory failure or perinatal lung disease to children outside the neonatal period has important potential pitfalls. For these children, the underlying diseases and risks of ECMO are different. Despite these differences, both neonates and older children are at risk of neurologic complications, such as intracranial hemorrhage, ischemic stroke, and seizures, and those complications may contribute to adverse neurodevelopmental outcomes. Without specific screening, subtle neurodevelopmental impairments may be missed, but when they are identified, children have the opportunity to receive therapy to optimize long-term development. CONCLUSIONS AND RELEVANCE All pediatric clinicians should be aware not only of the potential benefits and complications of ECMO but also that survivors need effective screening, support, and follow-up.
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Affiliation(s)
- Ryan P. Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor; Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
| | - 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, Australia
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164
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Heinsar S, Raman S, Suen JY, Cho HJ, Fraser JF. The use of extracorporeal membrane oxygenation in children with acute fulminant myocarditis. Clin Exp Pediatr 2021; 64:188-195. [PMID: 32777915 PMCID: PMC8103038 DOI: 10.3345/cep.2020.00836] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
Acute fulminant myocarditis (AFM) occurs as an inflammatory response to an initial myocardial insult. Its rapid and deadly progression calls for prompt diagnosis with aggressive treatment measures. The demonstration of its excellent recovery potential has led to increasing use of mechanical circulatory support, especially extracorporeal membrane oxygenation (ECMO). Arrhythmias, organ failure, elevated cardiac biomarkers, and decreased ventricular function at presentation predict requirement for ECMO. In these patients, ECMO should be considered earlier as the clinical course of AFM can be unpredictable and can lead to rapid haemodynamic collapse. Key uncertainties that clinicians face when managing children with AFM such as timing of initiation of ECMO and left ventricular decompression need further investigation.
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Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Sainath Raman
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Hwa Jin Cho
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Department of Pediatrics, Chonnam National University Children's Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - John F Fraser
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
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165
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Brown G, Moynihan KM, Deatrick KB, Hoskote A, Sandhu HS, Aganga D, Deshpande SR, Menon AP, Rozen T, Raman L, Alexander PMA. Extracorporeal Life Support Organization (ELSO): Guidelines for Pediatric Cardiac Failure. ASAIO J 2021; 67:463-475. [PMID: 33788796 DOI: 10.1097/mat.0000000000001431] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
These guidelines are applicable to neonates and children with cardiac failure as indication for extracorporeal life support. These guidelines address patient selection, management during extracorporeal membrane oxygenation, and pathways for weaning support or bridging to other therapies. Equally important issues, such as personnel, training, credentialing, resources, follow-up, reporting, and quality assurance, are addressed in other Extracorporeal Life Support Organization documents or are center-specific.
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Affiliation(s)
- Georgia Brown
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Hitesh S Sandhu
- Department of Pediatrics, Critical Care Division, Le Bonheur Children's Hospital, University of Tennessee, Memphis, Tennessee
| | - Devon Aganga
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shriprasad R Deshpande
- Pediatric Cardiology Division, Heart Transplant and Advanced Cardiac Therapies Program, Children's National Heart Institute, Washington, D.C
| | - Anuradha P Menon
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Thomas Rozen
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Lakshmi Raman
- Department of Critical Care, University of Texas Southwestern Medical Center, Texas
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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166
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Crighton GL, Huisman EJ. Pediatric Fibrinogen PART II-Overview of Indications for Fibrinogen Use in Critically Ill Children. Front Pediatr 2021; 9:647680. [PMID: 33968851 PMCID: PMC8097134 DOI: 10.3389/fped.2021.647680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/09/2021] [Indexed: 01/16/2023] Open
Abstract
Bleeding is frequently seen in critically ill children and is associated with increased morbidity and mortality. Fibrinogen is an essential coagulation factor for hemostasis and hypofibrinogenemia is an important risk factor for bleeding in pediatric and adult settings. Cryoprecipitate and fibrinogen concentrate are often given to critically ill children to prevent bleeding and improve fibrinogen levels, especially in the setting of surgery, trauma, leukemia, disseminated intravascular coagulopathy, and liver failure. The theoretical benefit of fibrinogen supplementation to treat hypofibrinogenemia appears obvious, yet the evidence to support fibrinogen supplementation in children is sparce and clinical indications are poorly defined. In addition, it is unknown what the optimal fibrinogen replacement product is in children and neonates or what the targets of treatment should be. As a result, there is considerable variability in practice. In this article we will review the current pediatric and applicable adult literature with regard to the use of fibrinogen replacement in different pediatric critical care contexts. We will discuss the clinical indications for fibrinogen supplementation in critically ill children and the evidence to support their use. We summarize by highlighting current knowledge gaps and areas for future research.
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Affiliation(s)
| | - Elise J. Huisman
- Department of Hematology, Erasmus MC–Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Clinical Chemistry and Blood Transfusion, Erasmus MC, Rotterdam, Netherlands
- Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
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167
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Chiarini G, Cho SM, Whitman G, Rasulo F, Lorusso R. Brain Injury in Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach. Semin Neurol 2021; 41:422-436. [PMID: 33851392 DOI: 10.1055/s-0041-1726284] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents an established technique to provide temporary cardiac and/or pulmonary support. ECMO, in veno-venous, veno-arterial or in extracorporeal carbon dioxide removal modality, is associated with a high rate of brain injuries. These complications have been reported in 7 to 15% of adults and 20% of neonates, and are associated with poor survival. Thromboembolic events, loss of cerebral autoregulation, alteration of the blood-brain barrier, and hemorrhage related to anticoagulation represent the main causes of severe brain injury during ECMO. The most frequent forms of acute neurological injuries in ECMO patients are intracranial hemorrhage (2-21%), ischemic stroke (2-10%), seizures (2-6%), and hypoxic-ischemic brain injury; brain death may also occur in this population. Other frequent complications are infarction (1-8%) and cerebral edema (2-10%), as well as neuropsychological and psychiatric sequelae, including posttraumatic stress disorder.
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Affiliation(s)
- Giovanni Chiarini
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frank Rasulo
- Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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168
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Lv X, Deng M, Wang L, Dong Y, Chen L, Dai X. Low vs standardized dose anticoagulation regimens for extracorporeal membrane oxygenation: A meta-analysis. PLoS One 2021; 16:e0249854. [PMID: 33831104 PMCID: PMC8031334 DOI: 10.1371/journal.pone.0249854] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background To compare the safety and efficacy of low-dose anticoagulation (LA) with that of standardized dose anticoagulation (SA) for patients supported with extracorporeal membrane oxygenation (ECMO). Methods PubMed, MEDLINE, the Cochrane Library, and Web of Science were screened for original articles. Screening was performed using predefined search terms to identify cohort studies reporting the comparison of LA with SA in patients supported with ECMO from Nov 1990 to Jun 2020. The effect size was determined by the odds ratio (OR) with the 95% confidence interval (CI). Results An analysis of 7 studies including a total of 553 patients was performed. LA (Low-heparin group) was administered to 255 patients, whereas the other 298 patients received SA (Full-heparin group). The incidence of gastrointestinal tract hemorrhage (OR 0.36, 95% CI 0.20–0.64) and surgical site hemorrhage (OR 0.43, 95% CI 0.20–0.94) were significantly lower in patients who underwent LA compared with that in those who underwent SA. The rates of hospital mortality (OR 0.81, 95% CI 0.42–1.56), successfully weaning off of ECMO (OR 0.80, 95% CI 0.30–2.14), pulmonary embolism (OR 0.79, 95% CI 0.24–2.65), intracardiac thrombus (OR 0.34, 95% CI 0.09–1.30), intracranial hemorrhage (OR 0.62, 95% CI 0.22–1.74), and pulmonary hemorrhage (OR 0.77, 95% CI 0.30–1.93) were similar between the two groups. Conclusions This meta-analysis confirms that LA is a feasible and safe anticoagulation strategy in patients supported by ECMO. Future studies should focus on the long-term benefits of LA compared with SA.
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Affiliation(s)
- Xiaochai Lv
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Manjun Deng
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fujian, China
| | - Lei Wang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Yi Dong
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
- * E-mail:
| | - Xiaofu Dai
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fujian, China
- Department of Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
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169
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Resch JC, Said SM, Steiner ME, Somani A. Hirudotherapy for neonatal limb ischemia during ECMO support: A word of caution. J Card Surg 2021; 36:2549-2557. [PMID: 33811665 DOI: 10.1111/jocs.15539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/09/2021] [Accepted: 03/13/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Disordered coagulation, clot formation and distal limb ischemia are complications of extracorporeal membrane oxygenation (ECMO) with significant morbidity and mortality. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and orthopedic surgeries to improve venous congestion and salvage ischemic flaps. To our knowledge this has not been reported in pediatric cardiac surgery or during ECMO support. We present a complex neonate whose ECMO course was complicated by distal limb ischemia for whom leech therapy was attempted. PATIENT AND INTERVENTION A 2-week-old 2.7 kg infant required ECMO support secondary to perioperative multiorgan system dysfunction following repair of critical coarctation and ventricular septal defect. Despite systemic anticoagulation, his clinical course was complicated by arterial thrombus, vasopressor-induced vascular spasm and bilateral distal limb ischemia. Medicinal leech therapy was tried after initially failing conventional measures. RESULT Following the third leech application, this patient developed significant hemorrhage from the web space adjacent to the left great toe. An estimated 450 ml of blood loss occurred and more than 300 ml of blood product transfusions were required. He ultimately progressed to irreversible systemic end organ dysfunction and comfort care was provided. CONCLUSION The use of medicinal leech therapy in pediatric cardiac surgery may be considered to minimize the consequences of advanced limb ischemia and venous congestion. However, this should be used with caution while patients are systemically anticoagulated during ECMO support. A directed review is presented here to assist in determining optimal application and potential course of therapy.
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Affiliation(s)
- Joseph C Resch
- Department of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Sameh M Said
- Department of Pediatric Cardiac Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Marie E Steiner
- Department of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Arif Somani
- Department of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
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170
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Deshpande SR, Kennedy KF, Vincent RN, Maher KO. Atrial septostomy in patients supported with venoarterial extracorporeal membrane oxygenation: Analysis of the IMPACT registry data. Int J Artif Organs 2021; 44:262-268. [DOI: 10.1177/0391398820953860] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Background: Patients with severe cardiac dysfunction, supported on extra-corporeal membrane oxygenation (ECMO), develop left atrial hypertension and often warrant atrial decompression. The procedural risks and outcomes, however, are not well established. Objective of this study is to understand the utilization, safety, and outcomes of atrial septostomy in children supported on venoarterial ECMO utilizing the IMPACT registry database. Methods: Data from 55 independent sites reporting to the registry was used for this descriptive study. Patients supported with cardiac ECMO that underwent percutaneous atrial septostomy (PAS) were included and data analyzed. Results: Between 2011 and 2018, 223 patients underwent atrial septostomy and were reported to the registry. Mean age was 4.65 years with 52% being males. Diagnoses of heart failure, sepsis, arrhythmia, and renal insufficiency were commonly noted prior to ECMO. The procedure was performed urgently or emergently in most cases (80%). PAS was associated with significant procedural complications such as arrhythmia (6.8%), tamponade (5.4%), and unplanned surgery (3.6%) but no procedural mortality. Overall hospital mortality was 46% (103/223) with 46 of these deaths occurring within 7 days of procedure. Regression analysis showed that African American race (vs Caucasian), race other than Caucasian, chronic lung disease and emergent procedure need were significantly associated with early post-procedural mortality (all p < 0.05). Conclusion: Using a large multicenter cardiac catheterization registry, we found that left atrial decompression can be performed without procedural mortality but is associated with significant morbidity. Impact of race, chronic lung disease and procedural urgency on early mortality warrant further studies.
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Affiliation(s)
- Shriprasad R Deshpande
- Pediatric Cardiology Division, Children’s National Heart Institute, George Washington University, Washington, DC, USA
| | - Kevin F Kennedy
- Department of Cardiovascular Research, Saint Luke’s Hospital, Kansas City, MO, USA
| | - Robert N Vincent
- Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Kevin O Maher
- Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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171
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Lock NE, Sawyer AA, Wise L, Bhatia J, Stansfield BK. Vitamin K and ECMO for neonatal hypoxic respiratory failure. Perfusion 2021; 37:484-492. [PMID: 33761796 DOI: 10.1177/02676591211003870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The objectives of this retrospective cohort study were to examine the effect of vitamin K administration on hemorrhagic and thrombotic complications, blood product utilization, and outcomes in neonatal extracorporeal membrane oxygenation (ECMO). METHODS In the pilot study, complications, blood product use, and outcome data for neonates who received (n = 21) or did not receive (n = 18) a single dose of vitamin K (5 mg) immediately after initiation of ECMO for respiratory failure between 2006 and 2010 were compared. In the validation cohort, complications and outcomes were compared for 74 consecutive neonates supported with ECMO for respiratory failure who received (n = 45) or did not receive (n = 29) additional vitamin K once daily for prothrombin time (PT) ⩾14 seconds during ECMO from 2014 to 2019. RESULTS In the pilot study, vitamin K at ECMO initiation was associated with fewer thrombotic complications and similar hemorrhagic complications. The volume of fresh frozen plasma was higher in neonates who received vitamin K, but total blood product and other component volume did not differ between groups. ECMO run time, survival off ECMO, survival to discharge, and length of stay did not differ between cohorts. In the validation cohort, neonates who received additional vitamin K during ECMO had longer ECMO run time and length of stay, but no difference in mortality was observed. Further, thrombotic and hemorrhagic complications as well as blood product exposure were similar between cohorts. CONCLUSIONS These data suggest that routine vitamin K administration may have limited or no benefit during neonatal ECMO.
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Affiliation(s)
- Nicole E Lock
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Alexandra A Sawyer
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Linda Wise
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Jatinder Bhatia
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Brian K Stansfield
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA, USA
- Vascular Biology Center, Augusta University, Augusta, GA, USA
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172
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Wang S, Griffith BP, Wu ZJ. Device-Induced Hemostatic Disorders in Mechanically Assisted Circulation. Clin Appl Thromb Hemost 2021; 27:1076029620982374. [PMID: 33571008 PMCID: PMC7883139 DOI: 10.1177/1076029620982374] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mechanically assisted circulation (MAC) sustains the blood circulation in the body of a patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) or on ventricular assistance with a ventricular assist device (VAD) or on extracorporeal membrane oxygenation (ECMO) with a pump-oxygenator system. While MAC provides short-term (days to weeks) support and long-term (months to years) for the heart and/or lungs, the blood is inevitably exposed to non-physiological shear stress (NPSS) due to mechanical pumping action and in contact with artificial surfaces. NPSS is well known to cause blood damage and functional alterations of blood cells. In this review, we discussed shear-induced platelet adhesion, platelet aggregation, platelet receptor shedding, and platelet apoptosis, shear-induced acquired von Willebrand syndrome (AVWS), shear-induced hemolysis and microparticle formation during MAC. These alterations are associated with perioperative bleeding and thrombotic events, morbidity and mortality, and quality of life in MCS patients. Understanding the mechanism of shear-induce hemostatic disorders will help us develop low-shear-stress devices and select more effective treatments for better clinical outcomes.
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Affiliation(s)
- Shigang Wang
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
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173
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Solanki S, Haq KF, Jolly G, Chakinala RC, Khan MA, Patel NR, Bhurwal A, Haq KS, Nabors C, Ganatra S, Aronow W. Gastrointestinal haemorrhage in extracorporeal membrane oxygenation: insights from the national inpatient sample. Arch Med Sci 2021; 19:600-607. [PMID: 37313180 PMCID: PMC10259382 DOI: 10.5114/aoms/112199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/06/2019] [Indexed: 09/20/2023] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is associated with gastrointestinal haemorrhage (GIH), which may result from coagulopathy, systemic inflammation, reduced gastric perfusion, and arteriovenous malformation from non-pulsatile blood flow. Data are limited regarding the burden of this complication in the United States. MATERIAL AND METHODS We analysed the National Inpatient Sample (NIS) database for the years 2007 to 2011 to identify hospitalisations in which an ECMO procedure was performed. Hospitalizations complicated by GIH in this cohort were then identified by relevant codes. RESULTS Between 2007 and 2011, ECMO hospitalisations increased from 1869 to 3799 (p < 0.01). The proportion of hospitalisations complicated by GIH increased from 2.12% in 2007 to 7.46% in 2011 (p < 0.01). Gastrointestinal haemorrhage was more common in men (56.7%) and in Caucasians (57.4%). Common comorbidities in this population were renal failure (71%), anaemia (55%), and hypertension (26%). All-cause inpatient mortality showed a numerical but nonsignificant increase from 56.7% to 61.9% (p = 0.49). The average cost of care per hospitalisation with GIH associated with ECMO use increased from $132,420 in 2007 to $215,673 in 2011 (p < 0.01). CONCLUSIONS Gastrointestinal haemorrhage during ECMO hospitalisations occurred in small but significantly increasing proportions. The inpatient mortality rate and costs associated with GIH were substantial and increased significantly during the study period.
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Affiliation(s)
- Shantanu Solanki
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | - Khwaja Fahad Haq
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, United States
| | - George Jolly
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Raja Chandra Chakinala
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | - Muhammad Ali Khan
- Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Neil R. Patel
- Division of Cardiology, The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, NJ, United States
| | - Khwaja Saad Haq
- Department of Medicine, Kingsbrook Jewish Medical Center, Brooklyn, NY, United States
| | - Christopher Nabors
- Department of Medicine, Westchester Medical Center, Valhalla, NY, United States
| | - Sarju Ganatra
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, MA, United States
| | - Wilbert Aronow
- Division of Cardiology, Westchester Medical Center, Valhalla, NY, United States
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174
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Karam O, Nellis ME. Transfusion management for children supported by extracorporeal membrane oxygenation. Transfusion 2021; 61:660-664. [PMID: 33491189 DOI: 10.1111/trf.16272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 11/30/2022]
Abstract
Due to the patients' underlying illness, in combination with circuit-induced coagulopathy, as well as PLT dysfunction, children supported by ECMO are a risk of receiving large volumes of blood components. Given the increasing use of modified blood products and newer biologics, it is unknown whether these products have equal efficacy and safety, in ECMO. The majority of guidance for transfusion therapy is based on expert opinion alone, and research on indications for RBC, plasma, and PLT transfusions for children on ECMO should be a priority.
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Affiliation(s)
- Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital - Weill Cornell Medicine, New York, New York
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175
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Use of extracorporeal membrane oxygenation in postpartum patients with refractory shock or respiratory failure. Sci Rep 2021; 11:887. [PMID: 33441897 PMCID: PMC7806987 DOI: 10.1038/s41598-020-80423-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022] Open
Abstract
Although extracorporeal membrane oxygenation (ECMO) is increasingly utilized, only a limited level of experience has been reported in postpartum cardiopulmonary failure. Ten critically ill postpartum patients who received ECMO were included between January 2010 and December 2018 in this retrospective observational study. The main indication for ECMO support was peripartum cardiomyopathy (n = 5), followed by postpartum hemorrhage (n = 2). Nine patients initially received veno-arterial ECMO, and one patient received veno-venous ECMO. Major bleeding occurred in six patients. The median number of units of red blood cells (RBC) transfused during ECMO was 14.5 units (interquartile range 6.8–37.8 units), and most RBC transfusions occurred on the first day of ECMO. The survival-to-discharge rate was 80%. Compared to the survival outcomes in female patients of similar age who received ECMO, the survival outcomes were significantly better in the study population (56% versus 80%, P = 0.0004). Despite the high risk of major bleeding, ECMO for patients with postpartum cardiac or respiratory failure showed excellent survival outcomes. ECMO is feasible in these patients and can be carried out with good outcomes in an experienced centre.
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176
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Ki KK, Millar JE, Langguth D, Passmore MR, McDonald CI, Shekar K, Shankar-Hari M, Cho HJ, Suen JY, Fraser JF. Current Understanding of Leukocyte Phenotypic and Functional Modulation During Extracorporeal Membrane Oxygenation: A Narrative Review. Front Immunol 2021; 11:600684. [PMID: 33488595 PMCID: PMC7821656 DOI: 10.3389/fimmu.2020.600684] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022] Open
Abstract
A plethora of leukocyte modulations have been reported in critically ill patients. Critical illnesses such as acute respiratory distress syndrome and cardiogenic shock, which potentially require extracorporeal membrane oxygenation (ECMO) support, are associated with changes in leukocyte numbers, phenotype, and functions. The changes observed in these illnesses could be compounded by exposure of blood to the non-endothelialized surfaces and non-physiological conditions of ECMO. This can result in further leukocyte activation, increased platelet-leukocyte interplay, pro-inflammatory and pro-coagulant state, alongside features of immunosuppression. However, the effects of ECMO on leukocytes, in particular their phenotypic and functional signatures, remain largely overlooked, including whether these changes have attributable mortality and morbidity. The aim of our narrative review is to highlight the importance of studying leukocyte signatures to better understand the development of complications associated with ECMO. Increased knowledge and appreciation of their probable role in ECMO-related adverse events may assist in guiding the design and establishment of targeted preventative actions.
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Affiliation(s)
- Katrina K Ki
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jonathan E Millar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Daman Langguth
- Clinical Immunology and Allergy, and Sullivan Nicolaides Pathology, Wesley Hospital, Brisbane, QLD, Australia
| | - Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Charles I McDonald
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Kiran Shekar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Manu Shankar-Hari
- Department of Intensive Care Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom.,School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Hwa Jin Cho
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Paediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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177
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Nellis ME, Vasovic LV, Goel R, Karam O. Epidemiology of the Use of Hemostatic Agents in Children Supported by Extracorporeal Membrane Oxygenation: A Pediatric Health Information System Database Study. Front Pediatr 2021; 9:673613. [PMID: 34041211 PMCID: PMC8141845 DOI: 10.3389/fped.2021.673613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives: Children supported by extracorporeal membrane oxygenation (ECMO) are at high risk of bleeding. Though practitioners often prescribe blood components and/or medications to prevent or treat bleeding, the utilization of these hemostatic measures in children is not well-understood. We sought to evaluate the use of hemostatic blood products (platelet, plasma and cryoprecipitate transfusions) and medications [aminocaproic acid, tranexamic acid (TXA) and Factor VIIa] in children supported by ECMO. Design: Retrospective observational study using the Pediatric Health Information System (PHIS) database from 2011-2017. Setting: Fifty-one U.S. children's hospitals. Patients: Children (aged 0-18 years) supported by ECMO. Interventions: None. Measurements and Main Results: ECMO was employed in the care of 7,910 children for a total of 56,079 ECMO days. Fifty-five percent of the patients were male with a median (IQR) age of 0 (0-2) years. The median (IQR) length of ECMO was 5 (2-9) days with a hospital mortality rate of 34%. Platelets were transfused on 49% of ECMO days, plasma on 33% of ECMO days and cryoprecipitate on 17% of ECMO days. Twenty-two percent of children received TXA with the majority receiving it on the first day of ECMO and the use of TXA increased during the 6-year period studied (p < 0.001). Seven percent of children received aminocaproic acid and 3% received Factor VIIa. Conclusions: Children supported by ECMO are exposed to a significant number of hemostatic blood products. Antifibrinolytics, in particular TXA, are being used more frequently. Given the known morbidity and mortality associated with hemostatic blood products, studies are warranted to evaluate the effectiveness of hemostatic strategies.
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Affiliation(s)
- Marianne E Nellis
- Department of Pediatrics, New York Presbyterian Hospital - Weill Cornell Medicine, New York, NY, United States
| | - Ljiljana V Vasovic
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Ruchika Goel
- Division of Hematology, Oncology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States.,Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, United States
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178
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Kersten CM, Hermelijn SM, Wijnen RMH, Tibboel D, Houmes RJM, Schnater JM. Surgery in Neonatal and Pediatric ECMO Patients Other Than Congenital Diaphragmatic Hernia Repair: A 10-Year Experience. Front Pediatr 2021; 9:660647. [PMID: 34017808 PMCID: PMC8129514 DOI: 10.3389/fped.2021.660647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/30/2021] [Indexed: 11/23/2022] Open
Abstract
Aim of Study: The use of extracorporeal membrane oxygenation (ECMO) has increased as a result of technological developments and the expansion of indications. Relatedly, the number of patients undergoing surgery during ECMO is also rising, at least in the adult population. Little is known on surgery in children during ECMO-therapy. We therefore aimed to assess the frequencies and types of surgical interventions in neonatal and pediatric patients on ECMO and to analyze surgery-related morbidity and mortality. Methods: We retrospectively collected information of all patients on ECMO over a 10-year period in a single tertiary and designated ECMO-center, excluding patients undergoing cardiac surgery, and correction of congenital diaphragmatic hernia. Chi-squared test and Mann-Whitney U test were used to analyze data. Main Results: Thirty-two of 221 patients (14%) required surgery when on ECMO. Common interventions were thoracotomy (32%), laparotomy (23%), fasciotomy (17%), and surgical revision of ECMO (15%). Complications occurred in 28 cases (88%), resulting in a 50% in-hospital mortality rate. Surgical patients had a longer ICU stay and longer total hospital stay compared to those not receiving surgery during ECMO. No significant difference in mortality was found when comparing surgical to non-surgical patients (50 vs. 41%). Conclusions: Approximately one in seven neonatal or pediatric patients required surgical intervention during ECMO, of whom almost 90% developed a complication, resulting in a 50% mortality rate. These results should be taken into account in counseling.
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Affiliation(s)
- Casper M Kersten
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Sergei M Hermelijn
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - René M H Wijnen
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Robert J M Houmes
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - J Marco Schnater
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
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179
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Cavallaro G, Di Nardo M, Hoskote A, Tibboel D. Editorial: Neonatal ECMO in 2019: Where Are We Now? Where Next? Front Pediatr 2021; 9:796670. [PMID: 35059363 PMCID: PMC8764394 DOI: 10.3389/fped.2021.796670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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180
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Iamwat W, Samankatiwat P, Lertbunrian R, Anantasit N. Clinical Characteristics and Outcomes of Children With Extracorporeal Membrane Oxygenation in a Developing Country: An 11-Year Single-Center Experience. Front Pediatr 2021; 9:753708. [PMID: 34869109 PMCID: PMC8635152 DOI: 10.3389/fped.2021.753708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a lifesaving procedure for patients with refractory cardiac or respiratory failure. The indications for ECMO are growing, and it is increasingly being used to support cardiopulmonary failure in children. However, the risks and benefits of ECMO should be weighed before deploying it on the patients. The objectives of this study were to identify the mortality risk factors and to determine the ECMO outcomes. Methods: The retrospective chart reviews were done for all patients aged 1 day-20 years old receiving ECMO between January 2010 and December 2020. Results: Seventy patients were enrolled in the study. The median age was 31.3 months. The incidence of VA and VV ECMO was 85.7 and 14.3%, respectively. The most common indication for ECMO was the failure to wean off cardiopulmonary bypass after cardiac surgery. Pre-existing acute kidney injury (OR 4.23; 95% CI 1.34-13.32, p = 0.014) and delayed enteral feeding (OR 3.85, 95% CI 1.23-12.02, p = 0.020), and coagulopathy (OD 12.64; 95% CI 1.13-141.13, p = 0.039) were associated with the higher rate of mortality. The rates of ECMO survival and survival to discharge were 70 and 50%, respectively. Conclusion: ECMO is the lifesaving tool for critically ill pediatric patients. Pre-existing acute kidney injury, delayed enteral feeding, and coagulopathy were the potential risk factors associated with poor outcomes in children receiving ECMO. However, ECMO setup can be done successfully in a developing country.
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Affiliation(s)
- Wirapatra Iamwat
- Division of Pediatric Critical Care, Department of Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piya Samankatiwat
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rojjanee Lertbunrian
- Division of Pediatric Critical Care, Department of Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattachai Anantasit
- Division of Pediatric Critical Care, Department of Pediatric, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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181
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Shukla I, Hanson SJ, Yan K, Zhang J. Vasoactive-Inotropic Score and Vasoactive-Ventilation-Renal Score as Outcome Predictors for Children on Extracorporeal Membrane Oxygenation. Front Pediatr 2021; 9:769932. [PMID: 34917562 PMCID: PMC8669802 DOI: 10.3389/fped.2021.769932] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
We aimed to determine the association of vasoactive-inotropic score (VIS) and vasoactive-ventilation-renal (VVR) score with in-hospital mortality and functional outcomes at discharge of children who receive ECMO. A sub-analysis of the multicenter, prospectively collected data by the Collaborative Pediatric Critical Care Research Network (CPCCRN) for Bleeding and Thrombosis on ECMO (BATE database) was conducted. Of the 514 patients who received ECMO across eight centers from December 2012 to February 2016, 421 were included in the analysis. Patients > 18 years of age, patients placed on ECMO directly from cardiopulmonary bypass or as an exit procedure, or patients with an invalid or missing VIS score were excluded. Higher VIS (OR = 1.008, 95% CI: 1.002-1.014, p = 0.011) and VVR (OR: 1.006, 95% CI: 1.001-1.012, p = 0.023) were associated with increased mortality. VIS was associated with worse Pediatric Cerebral Performance Category (PCPC) (OR = 1.027, 95% CI: 1.010-1.044, p = 0.002) and Pediatric Overall Performance Category (POPC) score (OR = 1.023, 95% CI: 1.009-1.038, p = 0.002) at discharge. No association was found between VIS or VVR and Functional Status Score (FSS) at discharge. Using multivariable analyses, controlling for ECMO mode, ECMO location, ECMO indication, primary diagnosis, and chronic diagnosis, extremely high VIS and VVR were still associated with increased mortality.
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Affiliation(s)
- Ira Shukla
- Section of Critical Care, Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA, United States
| | - Sheila J Hanson
- Section of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ke Yan
- Section of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jian Zhang
- Section of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
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182
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Mechanical circulatory support in paediatric population. Cardiol Young 2021; 31:31-37. [PMID: 33423709 DOI: 10.1017/s1047951120004849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Extra-corporeal membrane oxygenation is a life-saving modality to support the cardiac and/or pulmonary system as a form of life support in resuscitation, post-cardiotomy, as a bridge to cardiac transplantation and in respiratory failure. Its use in the paediatric and neonatal population has proven incredibly useful. However, extra-corporeal membrane oxygenation is also associated with a greater rate of mortality and complications, particularly in those with co-morbidities. As a result, interventions such as ventricular assist devices have been trialled in these patients. In this review, we provide a comprehensive analysis of the current literature on extra-corporeal membrane oxygenation for cardiac support in the paediatric and neonatal population. We evaluate its effectiveness in comparison to other forms of mechanical circulatory support and focus on areas for future development.
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183
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McMichael ABV, Zimmerman KO, Kumar KR, Ozment CP. Evaluation of effect of scheduled fresh frozen plasma on ECMO circuit life: A randomized pilot trial. Transfusion 2020; 61:42-51. [PMID: 33269487 DOI: 10.1111/trf.16164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/12/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Factor consumption is common during ECMO complicating the balance of pro and anticoagulation factors. This study sought to determine whether transfusion of coagulation factors using fresh frozen plasma (FFP) increased ECMO circuit life and decreased blood product transfusion. Secondly, it analyzed the association between FFP transfusion and hemorrhagic and thrombotic complications. STUDY DESIGN AND METHODS Thirty-one pediatric ECMO patients between October 2013 and January 2016 at a quaternary care institution were included. Patients were randomized to FFP every 48 hours or usual care. The primary outcome was ECMO circuit change. Secondary outcomes included blood product transfusion, survival to decannulation, hemorrhagic and thrombotic complications, and ECMO costs. RESULTS Median (interquartile range [IQR]) number of circuit changes was 0 (0, 1). No difference was seen in percent days without a circuit change between intervention and control group, P = .53. Intervention group patients received median platelets of 15.5 mL/kg/d IQR (3.7, 26.8) vs 24.8 mL/kg/d (12.2, 30.8) for the control group (P = .16), and median packed red blood cells (pRBC) of 7.7 mL/kg/d (3.3, 16.3) vs 5.9 mL/kg/d (3.4, 18.7) for the control group, P = .60. FFP transfusions were similar with 10.2 mL/kg/d (5.0, 13.9) in the intervention group vs 8.8 (2.5, 17.7) for the control group, P = .98. CONCLUSION In this pilot randomized study, scheduled FFP did not increase circuit life. There was no difference in blood product transfusion of platelets, pRBCs, and FFP between groups. Further studies are needed to examine the association of scheduled FFP with blood product transfusion.
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Affiliation(s)
- Ali B V McMichael
- UT Southwestern, Department of Pediatrics, Division of Critical Care, Dallas, Texas, USA
| | - Kanecia O Zimmerman
- Duke University Hospital, Department of Pediatrics, Division of Critical Care, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Karan R Kumar
- Duke University Hospital, Department of Pediatrics, Division of Critical Care, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Caroline P Ozment
- Duke University Hospital, Department of Pediatrics, Division of Critical Care, Durham, North Carolina, USA
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184
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Coagulopathy Characterized by Rotational Thromboelastometry in a Porcine Pediatric ECMO Model. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:203-211. [PMID: 32981958 DOI: 10.1182/ject-2000011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/16/2020] [Indexed: 11/20/2022]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used to support patients with reversible cardiopulmonary insufficiency. Although it is a lifesaving technology, bleeding, inflammation, and thrombosis are well-described complications of ECMO. Adult porcine models of ECMO have been used to recapitulate the physiology and hemostatic consequences of ECMO cannulation in adults. However, these models lack the unique physiology and persistence of fetal forms of coagulation factors and fibrinogen as in human infants. We aimed to describe physiologic and coagulation parameters of piglets cannulated and supported with VA-ECMO. Four healthy piglets (5.7-6.4 kg) were cannulated via jugular vein and carotid artery by cutdown and supported for a maximum of 20 hours. Heparin was used with a goal activated clotting time of 180-220 seconds. Arterial blood gas (ABG) was performed hourly, and blood was transfused from an adult donor to maintain hematocrit (Hct) > 24%. Rotational thromboelastometry (ROTEM) was performed at seven time points. All animals achieved adequate flow with a patent circuit throughout the run (pre- and post-oxygenator pressure gradient <10 mmHg). There was slow but significant hemorrhage at cannulation, arterial line, and bladder catheter sites. All animals required the maximum blood transfusion volume available. All animals became anemic after exhaustion of blood for transfusion. ABG showed progressively declining Hct and adequate oxygenation. ROTEM demonstrated decreasing fibrin-only ROTEM (FIBTEM) clot firmness. Histology was overall unremarkable. Pediatric swine are an important model for the study of pediatric ECMO. We have demonstrated the feasibility of such a model while providing descriptions of physiologic, hematologic, and coagulation parameters throughout. Weak whole-blood clot firmness by ROTEM suggested defects in fibrinogen, and there was a clinical bleeding tendency in all animals studied. This model serves as an important means to study the complex derangements in hemostasis during ECMO.
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185
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Garg M. Intravascular Hemolysis and Complications During Extracorporeal Membrane Oxygenation. Neoreviews 2020; 21:e728-e740. [PMID: 33139510 DOI: 10.1542/neo.21-11-e728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) remains a crucial lifesaving therapy for critically ill neonates with severe cardiorespiratory failure. Both the roller pump as well as the centrifugal pump are safe and efficient systems, and some red blood cell breakdown and hemolysis occurs in all ECMO systems. The roller pump functions by gravity whereas the centrifugal pump promotes the flow of blood by a magnetically driven spinning rotor to generate negative pressure. Extracorporeal Life Support Organization data indicate a significant increase in intravascular hemolysis in neonatal and pediatric patients receiving ECMO when the centrifugal pump is used compared with its use in adults. Risk factors for developing hemolysis during ECMO are small cannula size, high negative inlet pressure in the pump head, and thrombosis in the pump head and oxygenator. Excessive red blood cell breakdown and release of plasma free hemoglobin (pfHb) saturate physiologic neutralizing mechanisms such as haptoglobin and hemopexin. The increase in pro-oxidant and proinflammatory pfHb levels causes endothelial dysfunction in a dose-dependent manner. Hemolysis also increases the risk of in-hospital morbidities such as renal injury, direct hyperbilirubinemia, and thrombosis without an increase in mortality in patients receiving ECMO. Hemolysis is an unavoidable side effect of current ECMO technology and there are no approved treatments or treatment guidelines for the neonatal population. Therefore, increased vigilance, recognition of the severity of the hemolytic process, and prompt management are essential to prevent severe endothelial injury leading to proinflammatory and prothrombotic events.
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Affiliation(s)
- Meena Garg
- Department of Pediatrics, Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA
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186
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Prospective Exploratory Experience With Bivalirudin Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:975-985. [PMID: 32976347 DOI: 10.1097/pcc.0000000000002527] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Objective of this study was to determine if bivalirudin resulted in less circuit interventions than unfractionated heparin. A secondary objective was to examine associations between bivalirudin dose and partial thromboplastin time, international normalized ratio, and activated clotting time. DESIGN Prospective observational. SETTING Medical-surgical and cardiac PICUs. PATIENTS Neonatal and pediatric extracorporeal membrane oxygenation patients who received bivalirudin anticoagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty extracorporeal membrane oxygenation runs in 18 patients used bivalirudin; 90% were venoarterial. Median (interquartile range) age was 4.5 months (1.6-35 mo). Thirteen patients (72%) had an underlying cardiac diagnosis. Of the 20 runs using bivalirudin, 16 (80%) were initially started on unfractionated heparin and transitioned to bivalirudin due to ongoing circuit thrombosis despite therapeutic anti-Xa levels (n = 13), ongoing circuit thrombosis with unfractionated heparin greater than or equal to 40 U/kg/hr (n = 2), or absence of increase in ACT after bolus of 100 U/kg of unfractionated heparin and escalation of unfractionated heparin infusion (n = 1). Initial bivalirudin dose ranged from 0.2 to 0.5 mg/kg/hr; no bolus doses were used. Median (range) bivalirudin dose was 0.9 mg/kg/hr (0.15-1.6 mg/kg/hr). Median (interquartile range) time on extracorporeal membrane oxygenation was 226.5 hours (150.5-393.0 hr) including 84 hours (47-335 hr) on bivalirudin. Nonparametric results are as follows: the rate of circuit intervention was significantly lower in patients on bivalirudin than on unfractionated heparin (median [interquartile range]: 0 [0-1] and 1 [1-2], respectively; Wilcoxon p = 0.0126). Bivalirudin dose was correlated to PTT (rs = 0.4760; p < 0.0001), INR (rs = 0.6833; p < 0.0001), and ACT (rs = 0.6161; p < 0.0001). Four patients had a significant bleeding complication on bivalirudin. Survival to hospital discharge was 56%. CONCLUSIONS Bivalirudin appears to be a viable option for systemic anticoagulation in pediatric extracorporeal membrane oxygenation patients who have failed unfractionated heparin, but questions remain namely its optimal monitoring strategy. This pilot study supports the need for larger prospective studies of bivalirudin in pediatric extracorporeal membrane oxygenation, particularly focusing on meaningful monitoring variables.
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187
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Severe SARS-CoV-2 Infection in a Pediatric Patient Requiring Extracorporeal Membrane Oxygenation. Case Rep Pediatr 2020; 2020:8885022. [PMID: 33062363 PMCID: PMC7547361 DOI: 10.1155/2020/8885022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/05/2020] [Accepted: 09/24/2020] [Indexed: 12/12/2022] Open
Abstract
The overwhelming majority of pediatric cases of SARS-CoV-2 infection are mild or asymptomatic with only a handful of pediatric deaths reported. We present a case of severe COVID-19 infection in a pediatric patient with signs of hyperinflammation and consumptive coagulopathy requiring intubation and extracorporeal membrane oxygenation (ECMO) and eventual death due to ECMO complications.
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188
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Continuous Monitoring of Cerebral Autoregulation in Children Supported by Extracorporeal Membrane Oxygenation: A Pilot Study. Neurocrit Care 2020; 34:935-945. [PMID: 33029743 DOI: 10.1007/s12028-020-01111-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Cerebral autoregulation (CA) impairment may pose a risk factor for neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Our first objective was to investigate the feasibility of CA continuous monitoring during ECMO treatment and to describe its evolution over time. The second objective was to analyze the association between CA impairment and neurological outcome. DESIGN Observational prospective study. PATIENTS AND SETTING Twenty-nine children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France, and the PICU of the IRCCS Giannina Gaslini Institute in Genoa, Italy. MEASUREMENTS A correlation coefficient between the variations of regional cerebral oxygen saturation and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). A COx > 0.3 was considered as indicative of autoregulation impairment. COx-MAP plots were investigated allowing determining optimal MAP (MAPopt) and limits of autoregulation: lower (LLA) and upper (ULA). Neurological outcome was assessed by the onset of an acute neurological event (ANE) after ECMO start. RESULTS We included 29 children (median age 84 days, weight 4.8 kg). MAPopt, LLA, and ULA were detected in 90.8% (84.3-93.3) of monitoring time. Mean COx was significantly higher during day 1 of ECMO compared to day 2 [0.1 (0.02-0.15) vs. 0.01 (- 0.05 to 0.1), p = 0.002]. Twelve children experienced ANE (34.5%). The mean COx and the percentage of time spent with a COx > 0.3 were significantly higher among ANE+ compared to ANE- patients [0.09 (0.01-0.23) vs. 0.04 (- 0.02 to 0.06), p = 0.04 and 33.3% (24.8-62.1) vs. 20.8% (17.3-23.7) p = 0.001]. ANE+ patients spent significantly more time with MAP below LLA [17.2% (6.5-32.9) vs. 5.6% (3.6-9.9), p = 0.02] and above ULA [13% (5.3-38.4) vs. 4.2% (2.7-7.4), p = 0.004], respectively. CONCLUSION CA assessment is feasible in pediatric ECMO. The first 24 h following ECMO represents the most critical period regarding CA. Impaired autoregulation is significantly more severe among patients who experience ANE.
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189
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Steppan DA, Coleman RD, Viamonte HK, Hanson SJ, Carroll MK, Klein OR, Cooke KR, Spinella PC, Steiner ME, Loftis LL, Bembea MM. Outcomes of pediatric patients with oncologic disease or following hematopoietic stem cell transplant supported on extracorporeal membrane oxygenation: The PEDECOR experience. Pediatr Blood Cancer 2020; 67:e28403. [PMID: 32519430 DOI: 10.1002/pbc.28403] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/10/2020] [Accepted: 04/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Outcomes for patients with oncologic disease and/or after hematopoietic stem cell transplant (HSCT) requiring intensive care unit admission have improved, but indications for and outcomes after extracorporeal membrane oxygenation (ECMO) support in this population are poorly characterized. PROCEDURE We analyzed data from consecutive patients < 18 years with oncologic disease and/or after HSCT reported to a pediatric ECMO registry by nine pediatric centers in the United States between 2011 and 2018. RESULTS We identified 18 ECMO patients with oncologic disease and/or HSCT, and 415 ECMO controls matched with a propensity score algorithm based on age, gender, race, severity of illness at admission, and reason for ECMO. The primary indication for ECMO was respiratory failure in 66.7% in the oncologic disease and/or HSCT group, and in 70.7% in the matched ECMO control group. Eleven of 18 patients survived to hospital discharge (61.1%), similar to the matched control group (60.8%), P = 0.979. Children with oncologic disease and/or HSCT had lower mean platelet counts during ECMO and received higher volumes of platelets compared with the control group, mean 14.6 mL/kg/day (standard deviations [SD], 9.8) versus mean 9.3 mL/kg/day (SD, 10.4), P = 0.001. Of the 11 surviving children with oncologic disease and/or HSCT, five sustained new neurologic disorders (45.5%) versus 45 of 222 (20.3%) in the control group, P = 0.061. Bleeding complications were similar in the two groups. CONCLUSIONS Outcomes of patients with oncologic disease and/or HSCT supported on ECMO in the current era are not significantly different compared with matched ECMO controls and are improved from previously published reports.
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Affiliation(s)
- Diana A Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ryan D Coleman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Sheila J Hanson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Megan K Carroll
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Orly R Klein
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kenneth R Cooke
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Philip C Spinella
- Department of Pediatrics, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Laura L Loftis
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Snyder CW, Goldenberg NA, Nguyen ATH, Smithers CJ, Kays DW. A perioperative bivalirudin anticoagulation protocol for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation. Thromb Res 2020; 193:198-203. [DOI: 10.1016/j.thromres.2020.07.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 11/17/2022]
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192
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Willems A, Roeleveld PP, Labarinas S, Cyrus JW, Muszynski JA, Nellis ME, Karam O. Anti-Xa versus time-guided anticoagulation strategies in extracorporeal membrane oxygenation: a systematic review and meta-analysis. Perfusion 2020; 36:501-512. [PMID: 32862767 PMCID: PMC8216320 DOI: 10.1177/0267659120952982] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The purpose was to compare time-based vs anti-Xa-based anticoagulation strategies in patients on ECMO. We conducted a systematic review and meta-analysis using multiple electronic databases and included studies from inception to July 19, 2019. The proportion of bleeding, thrombosis, and mortality were evaluated. Twenty-six studies (2,086 patients) were included. Bleeding occurred in 34.2% (95%CI 25.1;43.9) of the patients with anti-Xa-based versus 41.6% (95%CI 24.9;59.4) of the patients with time-based anticoagulation strategies. Thrombosis occurred in 32.6% (95%CI 19.1;47.7) of the patients with anti-Xa-based versus 38.4% (95%CI 22.2;56.1) of the patients with time-based anticoagulation strategies. And mortality rate was 35.4% (95%CI 28.9;42.1) of the patients with anti-Xa-based versus 42.9% (95%CI 36.9;48.9) of the patients with time-based anticoagulation strategies. Among the seven studies providing results from both anticoagulation strategies, significantly fewer bleeding events occurred in the anti-Xa-based anticoagulation strategy (adjusted OR 0.49 (95%CI 0.32;0.74), p < 0.001) and a significantly lower mortality rate (adjusted OR 0.61 (95%CI 0.40;0.95), p = 0.03). There was no significant difference in thrombotic events (adjusted OR 0.91 (95%CI 0.56;1.49), p = 0.71). In these seven observational studies, only a small fraction of the patients were adults, and data were insufficient to analyze the effect of the type of ECMO. In this meta-analysis of observational studies of patients on ECMO, an anti-Xa-based anticoagulation strategy, when compared to a time-based strategy, was associated with fewer bleeding events and mortality rate, without an increase in thrombotic events.
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Affiliation(s)
- Ariane Willems
- Pediatric Critical Care Medicine, Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter P Roeleveld
- Pediatric Critical Care Medicine, Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Sonia Labarinas
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - John W Cyrus
- Tompkins-McCaw Library for the Health Sciences, VCU Libraries, Virginia Commonwealth University, Richmond, VA, USA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
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193
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Jin Y, Feng Z, Zhao J, Hu J, Tong Y, Guo S, Zhang P, Bai L, Li Y, Liu J. Outcomes and factors associated with early mortality in pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation. Artif Organs 2020; 45:6-14. [PMID: 32645759 DOI: 10.1111/aor.13773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Yu Jin
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengyi Feng
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ju Zhao
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinxiao Hu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuanyuan Tong
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengwen Guo
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peiyao Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liting Bai
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixuan Li
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Karam O, Goel R, Dalton H, Nellis ME. Epidemiology of Hemostatic Transfusions in Children Supported by Extracorporeal Membrane Oxygenation. Crit Care Med 2020; 48:e698-e705. [PMID: 32697511 DOI: 10.1097/ccm.0000000000004417] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the epidemiology of hemostatic transfusions (plasma, platelet, and cryoprecipitate) in children supported by extracorporeal membrane oxygenation. DESIGN Secondary analysis of a large observational cohort study. SETTING Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network. PATIENTS Critically ill children supported by extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extracorporeal membrane oxygenation was used in the care of 514 consecutive children. Platelets were transfused on 68% of extracorporeal membrane oxygenation days, plasma on 34% of the days on extracorporeal membrane oxygenation, and cryoprecipitate on 14%. Only 24% of the days on extracorporeal membrane oxygenation were free of any hemostatic transfusions. Daily platelet transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.03), and daily set platelet goal (p = 0.009), but not with total platelet count (p = 0.75). Daily plasma transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.01), activated clotting time (p = 0.001), and antithrombin levels (p = 0.02), but not with international normalized ratio (p = 0.99) or activated partial thromboplastin time (p = 0.29). Daily cryoprecipitate transfusion dose was independently associated with younger age (p = 0.009), but not with chest tube bleeding (p = 0.18), other bleeding requiring RBC transfusion (p = 0.75), fibrinogen level (p = 0.67), or daily fibrinogen goal (p = 0.81). CONCLUSIONS Platelets were transfused on two third of the days on extracorporeal membrane oxygenation, plasma on one third, and cryoprecipitate on one sixth of the days. Although most hemostatic transfusions were independently associated with bleeding, they were not independently associated with the majority of hemostatic testing. Further studies are warranted to evaluate the appropriateness of these transfusion strategies.
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Affiliation(s)
- Oliver Karam
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Ruchika Goel
- Division of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine, Springfield, IL
- Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Heidi Dalton
- Adult and Pediatric ECLS, INOVA Fairfax Hospital, Falls Church, VA
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY
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195
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Extracorporeal Membrane Oxygenation for Group B Streptococcal Sepsis in Neonates: A Retrospective Study of the Extracorporeal Life Support Organization Registry. Pediatr Crit Care Med 2020; 21:e505-e512. [PMID: 32168303 DOI: 10.1097/pcc.0000000000002320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Neonatal group B streptococcal sepsis remains a leading cause of neonatal sepsis globally and is characterized by unique epidemiologic features. Extracorporeal membrane oxygenation has been recommended for neonatal septic shock refractory to conventional management, but data on extracorporeal membrane oxygenation in group B streptococcal sepsis are scarce. We aimed to assess outcomes of extracorporeal membrane oxygenation in neonates with group B streptococcal sepsis. DESIGN Retrospective study of the international registry of the Extracorporeal Life Support Organization. SETTING Extracorporeal membrane oxygenation centers contributing to Extracorporeal Life Support Organization registry. PATIENTS Patients less than or equal to 30 days treated with extracorporeal membrane oxygenation and a diagnostic code of group B streptococcal sepsis between January 1, 2007, and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In-hospital mortality was the primary outcome. Univariable and multivariable logistic regression models to predict mortality were established. One hundred ninety-two runs in 191 neonates were identified meeting eligibility criteria, of which 55 of 191 (29%) died. One hundred thirty-seven (71%) were treated with venoarterial extracorporeal membrane oxygenation. One hundred sixty-nine runs (88%) occurred during the first week of life for early-onset sepsis and 23 (12%) after 7 days of life. The in-hospital mortality for extracorporeal membrane oxygenation used after 7 days of life was significantly higher compared with early-onset sepsis (65% vs 24%; p < 0.01). In addition, lower weight, lower pH, lower bicarbonate, and surfactant administration precannulation were significantly associated with mortality (p < 0.05). Adjusted analyses confirmed that age greater than 7 days, lower weight, and lower pH were associated with higher mortality (p < 0.05). One hundred fifty-one of 192 runs (79%) experienced a major complication. The number of major complications during extracorporeal membrane oxygenation was associated significantly with mortality (p < 0.001; adjusted odds ratio, 1.27 [1.08-1.49; p = 0.004]). CONCLUSIONS This large registry-based study indicates that treatment with extracorporeal membrane oxygenation for neonatal group B streptococcal sepsis is associated with survival in the majority of patients. Future quality improvement interventions should aim to reduce the burden of major extracorporeal membrane oxygenation-associated complications which affected four out of five neonatal group B streptococcal sepsis extracorporeal membrane oxygenation patients.
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196
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Bartfay SE, Dellgren G, Hallhagen S, Wåhlander H, Dahlberg P, Redfors B, Ekelund J, Karason K. Durable circulatory support with a paracorporeal device as an option for pediatric and adult heart failure patients. J Thorac Cardiovasc Surg 2020; 161:1453-1464.e4. [PMID: 32653285 DOI: 10.1016/j.jtcvs.2020.04.163] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Not all patients in need of durable mechanical circulatory support are suitable for a continuous-flow left ventricular assist device. We describe patient populations who were treated with the paracorporeal EXCOR, including children with small body sizes, adolescents with complex congenital heart diseases, and adults with biventricular failure. METHODS Information on clinical data, echocardiography, invasive hemodynamic measurements, and surgical procedures were collected retrospectively. Differences between various groups were compared. RESULTS Between 2008 and 2018, a total of 50 patients (21 children and 29 adults) received an EXCOR as bridge to heart transplantation or myocardial recovery. The majority of patients had heart failure compatible with Interagency Registry for Mechanically Assisted Circulatory Support profile 1. At year 5, the overall survival probability for children was 90%, and for adults 75% (P = .3). After we pooled data from children and adults, the survival probability between patients supported by a biventricular assist device was similar to those treated with a left ventricular assist device/ right ventricular assist device (94% vs 75%, respectively, P = .2). Patients with dilated cardiomyopathy had a trend toward better survival than those with other heart failure etiologies (92% vs 70%, P = .05) and a greater survival free from stroke (92% vs 64%, P = .01). Pump house exchange was performed in nine patients due to chamber thrombosis (n = 7) and partial membrane rupture (n = 2). There were 14 cases of stroke in eleven patients. CONCLUSIONS Despite severe illness, patient survival on EXCOR was high, and the long-term overall survival probability following heart transplantation and recovery was advantageous. Treatment safety was satisfactory, although still hampered by thromboembolism, mechanical problems, and infections.
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Affiliation(s)
- Sven-Erik Bartfay
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Göran Dellgren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Hallhagen
- Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Håkan Wåhlander
- Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pia Dahlberg
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bengt Redfors
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Ekelund
- Centre of Registers Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Aiello SR, Flores S, Coughlin M, Villarreal EG, Loomba RS. Antithrombin use during pediatric cardiac extracorporeal membrane oxygenation admission: insights from a national database. Perfusion 2020; 36:138-145. [PMID: 32650697 DOI: 10.1177/0267659120939758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The frequency of extracorporeal membrane oxygenation in pediatric patients continues to increase, especially in patients with complex congenital heart disease. Providing adequate anticoagulation is necessary for patients on extracorporeal membrane oxygenation and is achieved with adequate heparin administration. Antithrombin is administered to potentiate heparin's effects. However, the efficacy of antithrombin supplementation is unclear and a clear clinical benefit has not been established. We present a large retrospective study examining the effects of antithrombin on pediatric patients receiving extracorporeal membrane oxygenation. METHODS Data for this study were obtained from the Pediatric Health Information System and Pediatric Health Information System+ databases from 2004 to 2015. Pediatric patients receiving extracorporeal membrane oxygenation with a congenital heart disease diagnosis were included and divided into groups that did or did not utilize antithrombin. For all admissions, the following were captured: age of admission, gender, year of admission, length of stay, billed charges, inpatient mortality, the presence of specific congenital malformations of the heart, specific cardiac surgeries, and comorbidities. RESULTS A total of 9,193 admissions were included and 865 (9.4%) utilized antithrombin. Between groups, there were significantly different frequencies of co-morbidities, cardiac lesion types and antithrombin usage over the study period. There were significantly lower odds in the antithrombin group of venous thrombosis. Antithrombin was not significantly associated with hemorrhage; however, antithrombin was associated with increased inpatient mortality and a decrease in length of stay and billed charges. CONCLUSION Antithrombin administration is associated with increased mortality, a shorter length of stay, and decreased billing cost. Recently, antithrombin usage has been decreasing-potentially due to the reported lack of clinical benefit. Together, these results reinforce that antithrombin may not be indicated for all pediatric extracorporeal membrane oxygenation patients.
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Affiliation(s)
- Salvatore R Aiello
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
| | - Saul Flores
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Megan Coughlin
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Enrique G Villarreal
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
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Neurological Monitoring and Complications of Pediatric Extracorporeal Membrane Oxygenation Support. Pediatr Neurol 2020; 108:31-39. [PMID: 32299748 PMCID: PMC7698354 DOI: 10.1016/j.pediatrneurol.2020.03.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation is extracorporeal life support for life-threatening cardiopulmonary failure. Since its introduction, the use of extracorporeal membrane oxygenation has expanded to patients with more complex comorbidities without change in patient mortality rates. Although many patients survive, significant neurological complications like seizures, ischemic strokes, and intracranial hemorrhage can occur during extracorporeal membrane oxygenation care. The risks of these complications often add to the complexity of decision-making surrounding extracorporeal membrane oxygenation support. In this review, we discuss the pathophysiology and incidence of neurological complications in children supported on extracorporeal membrane oxygenation, factors influencing the incidence of these complications, commonly used neurological monitoring modalities, and outcomes for this complex patient population. We discuss the current literature on the use of electroencephalography for both seizure detection and monitoring of background electroencephalographic changes, in addition to the use of less commonly used imaging modalities like transcranial Doppler. We summarize the knowledge gaps and the lack of clinical consensus guidelines for managing these potentially life-changing neurological complications. Finally, we discuss future work to further understand the pathophysiology of extracorporeal membrane oxygenation-related neurological complications.
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199
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Anticoagulation and Antithrombin in Veno-venous Extracorporeal Membrane Oxygenation. Anesthesiology 2020; 132:421-423. [PMID: 31899708 DOI: 10.1097/aln.0000000000003098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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200
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Hospital-Associated Venous Thromboembolism in a Pediatric Cardiac ICU: A Multivariable Predictive Algorithm to Identify Children at High Risk. Pediatr Crit Care Med 2020; 21:e362-e368. [PMID: 32343105 DOI: 10.1097/pcc.0000000000002293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Critically ill children with cardiac disease are at significant risk for hospital-associated venous thromboembolism, which is associated with increased morbidity, hospital length of stay, and cost. Currently, there are no widely accepted guidelines for prevention of hospital-associated venous thromboembolism in pediatrics. We aimed to develop a predictive algorithm for identifying critically ill children with cardiac disease who are at increased risk for hospital-associated venous thromboembolism as a first step to reducing hospital-associated venous thromboembolism in this population. DESIGN This is a prospective observational single-center study. SETTING Tertiary care referral children's hospital cardiac ICU. PATIENTS Children less than or equal to18 years old admitted to the cardiac ICU who developed a hospital-associated venous thromboembolism from December 2013 to June 2017 were included. Odds ratios and 95% CIs are reported for multivariable predictors. MEASUREMENTS AND MAIN RESULTS A total of 2,204 separate cardiac ICU encounters were evaluated with 56 hospital-associated venous thromboembolisms identified in 52 unique patients, yielding an overall prevalence of 25 hospital-associated venous thromboembolism per 1,000 cardiac ICU encounters. We were able to create a predictive algorithm with good internal validity that performs well at predicting hospital-associated venous thromboembolism. The presence of a central venous catheter (odds ratio, 4.76; 95% CI, 2.0-11.1), sepsis (odds ratio, 3.5; 95% CI, 1.5-8.0), single ventricle disease (odds ratio, 2.2; 95% CI, 1.2-3.9), and extracorporeal membrane oxygenation support (odds ratio, 2.7; 95% CI, 1.2-5.7) were independent risk factors for hospital-associated venous thromboembolism. Encounters with hospital-associated venous thromboembolism were associated with a higher rate of stroke (17% vs 1.2%; p < 0.001). CONCLUSIONS We developed a multivariable predictive algorithm to help identify children who may be at high risk of hospital-associated venous thromboembolism in the pediatric cardiac ICU.
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