1
|
Linden AF, Howk AA, Billimoria Z, Devine M, DiGeronimo R, Gray B, Hamrick SE, Keene SD, Rintoul N, Mahmood B. Neonatal Carotid Artery and Internal Jugular Vein Management Practices at Extracorporeal Membrane Oxygenation Decannulation: No Standard Approach. J Pediatr Surg 2023; 58:2196-2200. [PMID: 37573253 DOI: 10.1016/j.jpedsurg.2023.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND There are currently no commonly accepted standardized guidelines for management of cervical vessels at neonatal extracorporeal membrane oxygenation (ECMO) decannulation. This study investigates neonatal ECMO decannulation practices regarding management of the carotid artery and internal jugular vein, use of post-repair anticoagulation, and follow-up imaging. METHODS A survey was distributed to the 37 institutions in the Children's Hospitals Neonatal Consortium. Respondents reported their standard approach to carotid artery and internal jugular vein management (ligation or repair) at ECMO decannulation by their pediatric surgery and cardiothoracic (CT) surgery teams as well as post-repair anticoagulation practices and follow-up imaging protocols. RESULTS The response rate was 95%. Pediatric surgeons performed most neonatal respiratory ECMO cannulations (88%) and decannulations (85%), while all neonatal cardiac ECMO cannulations and decannulations were performed by CT surgeons. Pediatric surgeons overwhelmingly ligate both vessels (90%) while CT surgeons typically repair both vessels at decannulation (83%). Of the responding centers that repair, 28% (7) have a standard anticoagulation protocol after neck vessel repair. While 52% (13) of centers routinely image cervical vessel patency at least once post repair, most do not subsequently repeat neck vessel imaging. CONCLUSIONS Significant practice differences exist between pediatric and CT surgeons regarding the approach to cervical vessels at neonatal ECMO decannulation. For those centers that do repair the vessels there is little uniformity in post-repair anticoagulation or imaging protocols. There is a need to develop standardized cervical vessel management guidelines for neonatal ECMO patients and to study their impact on both short- and long-term outcomes. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Allison F Linden
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, GA, 30322, USA.
| | - Amy A Howk
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Zeenia Billimoria
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Matthew Devine
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Brian Gray
- Department of Surgery, Indiana University, 705 Riley Hospital Dr, Bloomington, IN, 46202, USA
| | - Shannon E Hamrick
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Sarah D Keene
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Natalie Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Burhan Mahmood
- UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, Division of Newborn Medicine, University of Pittsburgh School of Medicine, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| |
Collapse
|
2
|
de Vlugt R, Spek B, van de Pol I, Rigter S. Quality of life after extra corporeal life support therapy. Perfusion 2023; 38:1189-1195. [PMID: 35656759 DOI: 10.1177/02676591221106148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extra Corporeal Life Support (ECLS) may be a life-saving treatment for patients with reversible cardiac and/or respiratory failure. ECLS is associated with a high risk of complications and mortality. Because only a small number of studies have been conducted into the long-term effects of ECLS, we investigated the difference in quality of life, anxiety and depressive complaints and PTSD 3 months after ICU discharge. METHOD It is a retrospective case-control study covering the period January 2012 to December 2017. The ECLS patient group was compared to a matched similar patient group in the Intensive Care (IC) that did not have ECLS therapy. Quality of life was measured with the Short-Form-36 (SF-36) questionnaire, anxiety and depression was measured with the Hospital Anxiety and Depression Scale (HADS) questionnaire and for PTSD the Impact of Events Scale (IES) questionnaire was used, comparing sum scores and cut-off points of scores from both groups. RESULTS Included were 19 patients in the ECLS group and 38 in the control group. The mean sum scores on the sub scales of the SF36 questionnaire were the same for both groups. Only the mean score of 66.2 (scale 0-100) on the domain 'general health experience' was statistically significantly different in the ECLS group than in the control group (56.8, p = .02). There was no significant difference between the sum scores of both groups on anxiety and depressive complaints. In the ECLS group 32% of the patients may have a depressive disorder versus 18% from the control group (p = .32). And 26% of the patients from the ECLS group may have an anxiety disorder versus 7% from the control group (p = .51). The incidence of PTSD was 42% in the ECLS group and 24% in the control group (p = .22). CONCLUSION We found no statistically significant difference in quality of life, anxiety and depressive symptoms and PTSD symptoms between ECLS patients and the matched control group - 3 months after the ICU discharge. The incidence of anxiety and depressive symptoms and PTSD in the ECLS group is higher than in the control group, however, this difference is not significant.
Collapse
Affiliation(s)
- Roos de Vlugt
- Intensive Care, St. Antonius hospital, Nieuwegein, Netherlands
| | - Bea Spek
- Department Epidemiology and Data Science, Amsterdam UMC, Amsterdam, Netherlands
| | | | - Sander Rigter
- Department of anesthesiology and ICU, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| |
Collapse
|
3
|
Danzer E, Harting MT, Dahlen A, Mesas Burgos C, Frenckner B, Lally KP, Ebanks AH, van Meurs KP. Impact of Repeat Extracorporeal Life Support on Mortality and Short-term In-hospital Morbidities in Neonates With Congenital Diaphragmatic Hernia. Ann Surg 2023; 278:e605-e613. [PMID: 36102187 DOI: 10.1097/sla.0000000000005706] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of repeat extracorporeal life support (ECLS) on survival and in-hospital outcomes in the congenital diaphragmatic hernia (CDH) neonates. BACKGROUND Despite the widespread use of ECLS, investigations on multiple ECLS courses for CDH neonates are limited. METHODS This is a retrospective cohort study of all ECLS-eligible CDH neonates enrolled in the Congenital Diaphragmatic Hernia Study Group registry between 1995 and 2019. CDH infants with estimated gestational age at birth <32 weeks and a birth weight <1.8 kg and/or with major cardiac or chromosomal anomalies were excluded. The primary outcomes were survival and morbidities during the index hospitalization. RESULTS Of 10,089 ECLS-eligible CDH infants, 3025 (30%) received 1 ECLS course, and 160 (1.6%) received multiple courses. The overall survival rate for patients who underwent no ECLS, 1 ECLS course, and multicourse ECLS were 86.9±0.8%, 53.8±1.8%, and 43.1±7.7%, respectively. Overall ECLS survival rate is increased by 5.1±4.6% ( P =0.03) for CDH neonates treated at centers that conduct repeat ECLS compared with those that do not offer repeat ECLS. This suggests that there would be an overall survival benefit from increased use of multiple ECLS courses. Infants who did not receive ECLS support had the lowest morbidity risk, while survivors of multicourse ECLS had the highest rates of morbidities during the index hospitalization. CONCLUSIONS Although survival is lower for repeat ECLS, the use of multiple ECLS courses has the potential to increase overall survival for CDH neonates. Increased use of repeat ECLS might be associated with improved survival. The potential survival advantage of repeat ECLS must be balanced against the increased risk of morbidities during the index hospitalization.
Collapse
Affiliation(s)
- Enrico Danzer
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
- Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX
| | - Alex Dahlen
- Quantitative Science Unit, Department of Medicine, Stanford University, Stanford, CA
| | - Carmen Mesas Burgos
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Björn Frenckner
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX
| | - Krisa P van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
| |
Collapse
|
4
|
Amodeo A, Stojanovic M, Erdil T, Dave H, Cesnjevar R, Paal S, Kretschmar O, Schweiger M. Risk Factors and Outcomes of Children with Congenital Heart Disease on Extracorporeal Membrane Oxygenation-A Ten-Year Single-Center Report. Life (Basel) 2023; 13:1582. [PMID: 37511957 PMCID: PMC10381661 DOI: 10.3390/life13071582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
For children born with congenital heart defects (CHDs), extracorporeal life support may be necessary. This retrospective single-center study aimed to investigate the outcomes of children with CHDs on extracorporeal membrane oxygenation (ECMO), focusing on various risk factors. Among the 88 patients, 36 (41%) had a single-ventricle heart defect, while 52 (59%) had a biventricular defect. In total, 25 (28%) survived, with 7 (8%) in the first group and 18 (20%) in the latter. A p-value of 0.19 indicated no significant difference in survival rates. Children with biventricular hearts had shorter ECMO durations but longer stays in the intensive care unit. The overall rate of complications on ECMO was higher in children with a single ventricle (odds ratio [OR] 1.57, 95% confidence interval [CI] 0.67-3.7); bleeding was the most common complication in both groups. The occurrence of a second ECMO run was more frequent in patients with a single ventricle (22% vs. 9.6%). ECMO can be effective for children with congenital heart defects, including single-ventricle patients. Bleeding remains a serious complication associated with worse outcomes. Patients requiring a second ECMO run within 30 days have lower survival rates.
Collapse
Affiliation(s)
- Antonio Amodeo
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, 8032 Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| | - Milena Stojanovic
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, 8032 Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| | - Tugba Erdil
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Hitendu Dave
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, 8032 Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| | - Robert Cesnjevar
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, 8032 Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| | - Sebastian Paal
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, 8032 Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| | - Oliver Kretschmar
- Children's Research Center, University Children's Hospital Zurich, 8032 Zurich, Switzerland
- Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, 8032 Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, 8032 Zurich, Switzerland
| |
Collapse
|
5
|
Abdelmohsen G, Al-Ata J, Alkhushi N, Bahaidarah S, Baho H, Abdelsalam M, Bekheet S, Ba-Atiyah W, Alghamdi A, Fawzy A, Elakaby A, Al-Radi O, Jamjoom A, Elassal A, Shihata M, Azhar A, Zaher Z, Maghrabi K, Mashali M, Dohain A. Cardiac Catheterization During Extracorporeal Membrane Oxygenation After Congenital Cardiac Surgery: A Multi-Center Retrospective Study. Pediatr Cardiol 2022; 43:92-103. [PMID: 34328521 DOI: 10.1007/s00246-021-02696-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
Cardiac catheterization can affect clinical outcomes in patients on extracorporeal membrane oxygenation (ECMO) after congenital heart surgery; however, its effect in this group of patients remains unclear. This study aimed to evaluate the safety and outcome of cardiac catheterization in patients undergoing ECMO after congenital cardiac surgery and determine predictors that influence successful weaning. This retrospective cohort study included pediatric patients who underwent cardiac catheterization while on ECMO after congenital heart surgery in two cardiac centers between November 2012 and February 2020. Predictors of successful weaning from ECMO were studied using univariate and multivariate logistic regression analyses. Of 123 patients on ECMO support after congenital cardiac surgery, 60 patients underwent 60 cardiac catheterizations (31 diagnostic and 29 interventional). Thirty-four (56.7%) and 22 patients (36.7%) underwent successful decannulation from ECMO support and survived after hospital discharge, respectively. Patients who underwent earlier catheterization (within 24 h of ECMO initiation) had more successful weaning from ECMO and survival compared to others. Patients who underwent an interventional procedure (interventional catheterization or redo cardiac surgery after cardiac catheterization) had better survival than those who underwent only diagnostic catheterization (P = 0.038). Shorter durations of ECMO was the most important predictor of successful weaning from ECMO. Early cardiac catheterization greatly impacts successful weaning from ECMO and survival. Patients with correctable lesions amenable either by catheterization or redo surgery are more likely to survive. Shorter durations of ECMO could have a significant influence on successful weaning from ECMO and survival.
Collapse
Affiliation(s)
- Gaser Abdelmohsen
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia.
- Paediatric Cardiology Division, Department of Paediatrics, Kasr Al Ainy School of Medicine, Cairo University, 99 El-Manial St., Cairo, 11451, Egypt.
| | - Jameel Al-Ata
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Naif Alkhushi
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Saud Bahaidarah
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Haysam Baho
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Mohamed Abdelsalam
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Cardiology Department, Benha University, Benha, Egypt
| | - Samia Bekheet
- Paediatric Cardiology Division, Department of Paediatrics, Kasr Al Ainy School of Medicine, Cairo University, 99 El-Manial St., Cairo, 11451, Egypt
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Wejdan Ba-Atiyah
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Abdulhadi Alghamdi
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Ahmed Fawzy
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Ahmed Elakaby
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Department, Al -Azhar University, Cairo, Egypt
| | - Osman Al-Radi
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Cardiac Surgery Division, Department of Surgery, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Ahmed Jamjoom
- Cardiac Surgery Division, Department of Surgery, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Ahmed Elassal
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | - Mohammad Shihata
- Cardiac Surgery Division, Department of Surgery, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Ahmed Azhar
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Zaher Zaher
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Khadijah Maghrabi
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Mohamed Mashali
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Cardiology Division, Department of Paediatrics, Kasr Al Ainy School of Medicine, Cairo University, 99 El-Manial St., Cairo, 11451, Egypt
| | - Ahmed Dohain
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Cardiology Division, Department of Paediatrics, Kasr Al Ainy School of Medicine, Cairo University, 99 El-Manial St., Cairo, 11451, Egypt
| |
Collapse
|
6
|
Common carotid artery imaging after vessel sparing decannulation from Extracorporeal Membrane Oxygenation (ECMO) support. J Pediatr Surg 2021; 56:2305-2310. [PMID: 33632514 DOI: 10.1016/j.jpedsurg.2021.01.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/26/2021] [Accepted: 01/30/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In 2008, Children's National Hospital adopted a simple vessel sparing technique (VST) for neck extra corporeal membrane (ECMO) cannulation/decannulation that is technically simple and reproducible. In this study, we review a cohort of patients decannulated from venous-arterial (VA) ECMO using a VST with the goal of understanding flow dynamics and anatomic changes of the common carotid artery (CCA) after repair with a VST. METHODS Patients supported with ECMO at a single, tertiary care center between 2008 and 2019 were identified. Patients were included in the analysis if they survived VA ECMO including VST decannulation and neck vessel imaging was completed with either magnetic resonance angiogram (MRA) or computerized tomography angiogram (CTA) post decannulation. The right CCA was assessed for patency and arteriopathy. Complications and feasibility of repeat ECMO cannulation via the neck vessels were also investigated. RESULTS Three hundred and nineteen patients were identified as having received ECMO support in either the PICU or CICU between 2008 and 2019, of which 76 survived VA ECMO support via neck cannulation. Neck vessel imaging was obtained in 21 patients. Ten had imaging demonstrating a normal right CCA. The CCA was occluded in 3 and stenotic in 5. Vessel wall defects were present in 4. No definitive complication was associated with any of the arterial abnormalities. Repeat right CCA cannulation was achieved in 6/7 patients who needed additional VA ECMO support. CONCLUSIONS Repair of the right CCA with a simple VST can be achieved safely and consistently during VA ECMO support in pediatric patients. Vascular imaging of the right CCA was normal in almost half and repeat cannulation was achieved in most when pursued. Stenosis and vessel wall defects were common, thus neck vessel imaging post decannulation may be warranted for all patients with a right CCA repair after ECMO support.
Collapse
|
7
|
Alsoufi B, Trivedi J, Rycus P, Sinha P, Deshpande S. Repeat Extracorporeal Membrane Oxygenation Support Is Appropriate in Selected Children With Cardiac Disease: An Extracorporeal Life Support Organization Study. World J Pediatr Congenit Heart Surg 2021; 12:597-604. [PMID: 34597210 DOI: 10.1177/21501351211025004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Children requiring multiple consecutive extracorporeal membrane oxygenation (ECMO) runs likely have ongoing cardiac pathology (eg, residual lesions, myocardial dysfunction) and are exposed to increased complications and end-organ failure. Often, repeat back-to-back ECMO is suggested to be futile due to poor reported survival. METHODS Using Extracorporeal Life Support Organization (ELSO) data (2011-2019), we evaluated children (n = 669) who received multiple cardiac ECMO runs (≥2) within 30 days interval. Factors associated with hospital mortality were evaluated using multivariable regression analysis. RESULTS Median ECMO runs was 2 (range: 2-5) including 294 (44%) patients who received extracorporeal cardiopulmonary resuscitation (ECPR). There were 250 (37%) hospital survivors. Survivors were more likely older, Caucasian, and less likely to have hypoplastic left heart syndrome, require >2 runs, receive longer support duration, require inotropes or have acidosis while on ECMO, or develop renal and neurological complications. On multivariable analysis, factors associated with death included neonates (odds ratio [OR] = 3.6, 95% CI = 1.8-7.5, P = .0002), African Americans (OR = 2.7, 95% CI = 1.4-4.9, P = .0307), longer ECMO duration (OR = 1.1, 95% CI = 1.05-1.11, P < .0001, per 10 hours), central cannulation at initial run (OR = 1.7, 95% CI = 1.1-2.8, P = .0285), renal failure (OR = 3.0, 95% CI = 1.9-4.6, P < .0001), and neurological complications (OR = 3.8, 95% CI = 2.2-6.8, P < .0001). CONCLUSIONS In selected children with cardiac pathology, multiple back-to-back ECMO and/or ECPR runs are associated with 37% hospital survival. Although registry data limit the ability to clearly determine selection criteria for repeat ECMO, our findings suggest that in properly selected patients, repeat ECMO support is not futile. Ongoing assessment of support adequacy, end-organ function, and cardiopulmonary recovery is necessary as longer support and emerging complications are associated with poor survival.
Collapse
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville, KY, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville, KY, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Hospital, Washington, DC, USA
| | - Shriprassad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| |
Collapse
|
8
|
Hazekamp MG, Barron DJ, Dangel J, Homfray T, Jongbloed MRM, Voges I. Consensus document on optimal management of patients with common arterial trunk. Eur J Cardiothorac Surg 2021; 60:7-33. [PMID: 34017991 DOI: 10.1093/ejcts/ezaa423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/18/2020] [Accepted: 09/30/2020] [Indexed: 01/12/2023] Open
Affiliation(s)
- Mark G Hazekamp
- Department of Cardiothoracic Surgery, University Hospital Leiden, Leiden, Netherlands
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Joanna Dangel
- Department of Perinatal Cardiology and Congenital Anomalies, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Tessa Homfray
- Department of Medical Genetics, Royal Brompton and Harefield hospitals NHS Trust, London, UK
| | - Monique R M Jongbloed
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Inga Voges
- Department for Congenital Cardiology and Pediatric Cardiology, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | | |
Collapse
|
9
|
|
10
|
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: 2.7] [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.
Collapse
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
| |
Collapse
|
11
|
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: 20] [Impact Index Per Article: 6.7] [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.
Collapse
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
| |
Collapse
|
12
|
Cooper DS, Thiagarajan R, Henry BM, Byrnes JW, Misfeldt A, Frischer J, King E, Gao Z, Rycus P, Marino BS. Outcomes of Multiple Runs of Extracorporeal Membrane Oxygenation: An analysis of the Extracorporeal Life Support Registry. J Intensive Care Med 2020; 37:195-201. [PMID: 33349100 DOI: 10.1177/0885066620981903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE When patients deteriorate after decannulation from extracorporeal membrane oxygenation (ECMO), a second run of extracorporeal support may be considered. However, repeat cannulation can be difficult and poor outcomes associated with multiple ECMO runs are a concern. The aim of this study was to evaluate outcomes and identify factors associated with survival and mortality in cases of multiple runs of extracorporeal membrane oxygenation. DESIGN Retrospective cohort analysis of the Extracorporeal Life Support Organization Registry. SETTING The Extracorporeal Life Support Organization's registry was queried for neonates, children, and adults receiving 2 or more runs of ECMO during the same hospitalization, for any indication, from 1998 to 2015. PATIENTS 1,818 patients from the Extracorporeal Life Support Organization Registry. RESULTS Of the 1,818 patients, 1,648 underwent 2 runs and 170 underwent 3 or more runs of ECMO. The survival to discharge rate was 36.7% for 2 runs and 29.4% for 3 or more runs. No significant differences in survival were detected in analysis by decade of ECMO run (p = 0.21). Pediatric patients had less mortality than adults (OR: 0.45, 95%CI: 0.24-0.82). Cardiac support on the first run portrayed worse mortality than pulmonary support regardless of final run indication (OR:1.38, 95%CI: 1.09-1.75). Across all age groups, patients receiving pulmonary support on the last run tended to have higher survival rates regardless of support type on the first run. The only first run complication independently predictive of mortality on the final run was renal complications (OR: 1.60, 95%CI: 1.28-1.99). CONCLUSIONS Though the use of multiple runs of ECMO is growing, outcomes remain poor for most cohorts. Survival decreases with each additional run. Patients requiring additional runs for a pulmonary indication should be considered prime candidates. Renal complications on the first run significantly increases the risk of mortality on subsequent runs, and as such, careful consideration should be applied in these cases.
Collapse
Affiliation(s)
- David S Cooper
- Department of Pediatrics, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ravi Thiagarajan
- Department of Cardiology, 1862Boston Children's Hospital, Boston, MA, USA
| | - Brandon Michael Henry
- Department of Pediatrics, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan W Byrnes
- Department of Pediatrics, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew Misfeldt
- Department of Pediatrics, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jason Frischer
- Division of Pediatric General and Thoracic Surgery, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eileen King
- Division of Biostatistics and Epidemiology, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zhiqian Gao
- Division of Biostatistics and Epidemiology, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - Bradley S Marino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
13
|
Carr BD, Kohne J, Ralls MW, Sassalos P, Ohye RG, Odetola FO, Gadepalli SK. Venogram before long-interval repeat cannulation for pediatric extracorporeal membrane oxygenation. Perfusion 2020; 36:204-206. [PMID: 32460608 DOI: 10.1177/0267659120925351] [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] [Indexed: 11/17/2022]
Abstract
It is rare for children to receive more than one course of support with extracorporeal membrane oxygenation, and in those who do undergo multiple episodes, the interval is usually days to weeks between events. Little data exists on re-cannulation years after an initial extracorporeal membrane oxygenation run, and late repeat cannulation can pose unique challenges. We report the case of a 10-year-old male patient with right jugular vein occlusion due to a previous course of extracorporeal membrane oxygenation as a neonate, who was successfully supported via central cannulation. This case demonstrates the importance of adequate imaging of target vasculature prior to attempting re-cannulation of a previously used vessel. Establishing a thoughtful strategy for late repeat cannulation is essential to achieve safe access in unusual and challenging situations.
Collapse
Affiliation(s)
- Benjamin D Carr
- Division of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Joseph Kohne
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Matthew W Ralls
- Division of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Peter Sassalos
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Richard G Ohye
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Folafoluwa O Odetola
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
14
|
Aguilar JM, Garcia E, Melo M, Rojas C, Belda S, Llorente A, Garcia-Maellas M, Boni L. Oxigenación por membrana extracorpórea poscardiotomía en la edad pediátrica: 119 pacientes en 20 años de experiencia. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
15
|
|
16
|
Thompson JL, Griffeth E, Rappa N, Calame C, Letton RW, Burkhart HM. Delaying Decannulation After Extracorporeal Membrane Oxygenation Is Safe and Advantageous. World J Pediatr Congenit Heart Surg 2019; 10:98-100. [PMID: 30799706 DOI: 10.1177/2150135118805061] [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: 11/17/2022]
Abstract
Removal of extracorporeal membrane oxygenation (ECMO) cannulae and discontinuing systemic anticoagulation typically occurs soon after separation from ECMO. We have found, however, that delaying decannulation after terminating ECMO therapy does not predispose to adverse outcomes and may be advantageous. Between January 2014 and June 2016, 36 postcardiotomy patients at the Children's Hospital of Oklahoma required ECMO. In this cohort of 36 patients, there was a need for 42 ECMO runs. Of the 42 ECMO runs, 29 (69%) survived to decannulation. Of those ECMO runs that survived to decannulation, 18 (62%) were cannulated centrally and 11 (38%) were cannulated via the neck. For the runs where the patient survived to decannulation, the mean number of days on ECMO support was 4 ± 2 days. There was an average time interval of 21 ± 14 hours from ECMO termination to decannulation. A single patient failed being separated from ECMO support and required reinstitution of ECMO 18 hours after separation (but did not require recannulation).
Collapse
Affiliation(s)
- Jess L Thompson
- 1 Section of Congenital Heart Surgery, Department of Surgery, University of Oklahoma, Oklahoma City, OK, USA
| | - Elaine Griffeth
- 1 Section of Congenital Heart Surgery, Department of Surgery, University of Oklahoma, Oklahoma City, OK, USA
| | - Nicholas Rappa
- 2 Clinical Perfusion Services, University of Oklahoma, Oklahoma City, OK, USA
| | - Colette Calame
- 2 Clinical Perfusion Services, University of Oklahoma, Oklahoma City, OK, USA
| | - Robert W Letton
- 3 Division of Pediatric Surgery, Department of Surgery, University of Oklahoma, Oklahoma City, OK, USA
| | - Harold M Burkhart
- 1 Section of Congenital Heart Surgery, Department of Surgery, University of Oklahoma, Oklahoma City, OK, USA
| |
Collapse
|
17
|
Okan Y, Sertac H, Erkut O, Taner K, Selen OI, Firat AH, Nihat C, Pelin A, Halime E, Alper G. Initial Clinical Experiences With Novel Diagonal ECLS System in Pediatric Cardiac Patients. Artif Organs 2017; 41:717-726. [DOI: 10.1111/aor.12977] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/03/2017] [Accepted: 05/10/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Yildiz Okan
- Department of Pediatric Cardiovascular Surgery; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Haydin Sertac
- Department of Pediatric Cardiovascular Surgery; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Ozturk Erkut
- Department of Pediatric Cardiology; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Kasar Taner
- Department of Pediatric Cardiology; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Onan I. Selen
- Department of Pediatric Cardiovascular Surgery; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Altin H. Firat
- Department of Pediatric Cardiovascular Surgery; Siyami Ersek Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Cine Nihat
- Department of Pediatric Cardiovascular Surgery; Kartal Koşuyolu Yüksek İhtisas Education and Research Hospital; Istanbul Turkey
| | - Ayyildiz Pelin
- Department of Pediatric Cardiology; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Erkan Halime
- Pediatric Perfusion; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| | - Guzeltas Alper
- Department of Pediatric Cardiology; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital; Istanbul Turkey
| |
Collapse
|
18
|
Association of Extracorporeal Membrane Oxygenation Support Adequacy and Residual Lesions With Outcomes in Neonates Supported After Cardiac Surgery. Pediatr Crit Care Med 2016; 17:1045-1054. [PMID: 27648896 DOI: 10.1097/pcc.0000000000000943] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There is a paucity of data regarding the impact of extracorporeal membrane oxygenation support, adequacy of surgical repair, and timing of intervention for residual structural lesions in neonates cannulated to extracorporeal membrane oxygenation after cardiac surgery. Our goal was to determine how these factors were associated with survival. DESIGN Retrospective study. SETTING Cardiovascular ICU. SUBJECTS Neonates (≤ 28 d old) with congenital heart disease cannulated to extracorporeal membrane oxygenation after cardiac surgery during 2006-2013. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty-four neonates were cannulated to venoarterial extracorporeal membrane oxygenation after cardiac surgery. Survival to discharge was 50%. There was no difference in survival based on surgical complexity and those with single or biventricular congenital heart disease. Prematurity (≤ 36 wk gestation; odds ratio, 2.33; p = 0.01), preextracorporeal membrane oxygenation pH less than or equal to 7.17 (odds ratio, 2.01; p = 0.04), need for inotrope support during extracorporeal membrane oxygenation (odds ratio, 3.99; p = 0.03), and extracorporeal membrane oxygenation duration greater than 168 hours (odds ratio, 2.04; p = 0.04) were all associated with increased mortality. Although preextracorporeal membrane oxygenation lactate was not significantly different between survivors and nonsurvivors, unresolved lactic acidosis greater than or equal to 72 hours after cannulation (odds ratio, 2.77; p = 0.002) was associated with increased mortality. Finally, many patients (n = 70; 83%) were noted to have residual lesions after cardiac surgery, and time to diagnosis or correction of residual lesions was significantly shorter in survivors (1 vs 2 d; p = 0.02). CONCLUSIONS Our data suggest that clearance of lactate is an important therapeutic target for patients cannulated to extracorporeal membrane oxygenation. In addition, timely identification of residual lesions and expedient interventions on those lesions may improve survival.
Collapse
|
19
|
The Outcome of Patients Requiring Multiple Extracorporeal Membrane Oxygenation: How Many Runs of ECMO is Reasonable? Int J Artif Organs 2016; 39:288-93. [DOI: 10.5301/ijao.5000511] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2016] [Indexed: 11/20/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has been proven effective in life support for patients with refractory cardiopulmonary failure. Deteriorating patients who have removed their first ECMO support and required second or more courses of ECMO support have rarely been discussed. Methods and Results All the records of the patients who experienced at least 2 courses of ECMO during single admission were retrieved. Survival was defined as survival to discharge. Demographic data and clinical information were compared between survival and nonsurvival groups. There were 86 patients who received at least 2 courses of ECMO in the 20-year database, and 27 (31.3%) were <18 years old. Of them, 87.3% received 2 runs of ECMO, 10.4% 3 runs, and 2.3% 4 runs. Overall survival rate was 30.2%. The survival rate for patients with 2 runs of ECMO was 33.3% (25 out of 75), 11.1% (1 out of 9) for 3 runs, and 0% (0 out of 2) for 4 runs. Multivariate analysis revealed that only ARF with hemodialysis was the independent risk factor. Conclusions The decision to perform repeated ECMO implantation is a complex and difficult process. Despite the arguments debating the consumption of resources and increased complications, there are still nearly 1 out of 3 patients who will survive to discharge. More than 2 courses of ECMO may be carefully considered for further rescue.
Collapse
|
20
|
Mian AN, Guillet R, Ruck L, Wang H, Schwartz GJ. Acute Kidney Injury in Premature, Very Low-Birth-Weight Infants. J Pediatr Intensive Care 2015; 5:69-78. [PMID: 31110888 DOI: 10.1055/s-0035-1564797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 05/17/2015] [Indexed: 12/16/2022] Open
Abstract
The epidemiology of neonatal acute kidney injury (AKI) is not well established, partly due to lack of a consensus definition. Preterm neonates are likely especially vulnerable to AKI. We performed a retrospective review to assess the incidence of and risk factors for AKI in very low-birth-weight (VLBW), premature infants admitted to a level 4 NICU (2006-2007). AKI was classified using a standardized definition based on changes in serum creatinine (SCr). AKI incidence varied inversely with gestational age (GA): 65% (22-25 weeks), 25% (26-28 weeks), 9% (29-32 weeks) as did severity (p < 0.001). Stage 1 AKI was most common in each cohort. Stages 2 and 3 AKI comprised approximately 60% of AKI in the 22- to 25-week cohort but 20% or less in the older cohorts. By univariate analysis, factors associated with AKI included younger GA, lower BW, lower Apgar scores, hypotension, more frequent treatment with nephrotoxic antimicrobials, longer-duration mechanical ventilation, and higher incidence of patent ductus arteriosus (PDA) requiring treatment. By multiple logistic regression analysis, only GA, hypotension, PDA, and longer duration of mechanical ventilation were independently associated with AKI. AKI was not independently associated with risk of death. Our study suggests that small increases (≥ 0.3 mg/dL) in SCr occur frequently in premature, VLBW infants, and are associated with increased morbidity but not mortality. AKI incidence and severity were highest in the youngest GA cohort. Understanding the epidemiology, risk factors, and impact of neonatal AKI is crucial as long-term premature infant survival continues to improve.
Collapse
Affiliation(s)
- Ayesa N Mian
- Department of Pediatrics, Division of Nephrology, University of Rochester School of Medicine, Rochester, New York, United States
| | - Ronnie Guillet
- Department of Pediatrics, Division of Neonatology, University of Rochester School of Medicine, Rochester, New York, United States
| | - Lela Ruck
- Department of Medicine, Barnes Jewish Hospital, Washington University in St. Louis, St. Louis, Missouri, United States
| | - Hongyue Wang
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, United States
| | - George J Schwartz
- Department of Pediatrics, Division of Nephrology, University of Rochester School of Medicine, Rochester, New York, United States
| |
Collapse
|
21
|
Abstract
OBJECTIVE To investigate the prevalence and survival to discharge of neonates with kidney disease who received extracorporeal life support. DESIGN We analyzed the Extracorporeal Life Support Organization international registry of neonates (< 30 d old) who received extracorporeal life support from 1989 to 2012. We used International Classification of Diseases and Related Health Problems, 9th Revision, Clinical Modification, codes to identify neonates with kidney disease at time of cannulation for extracorporeal life support. SETTING Participating Extracorporeal Life Support Organization centers. PATIENTS All neonates who received extracorporeal life support at an Extracorporeal Life Support Organization center from 1989 to 2012. INTERVENTIONS We performed bivariate logistic regression to estimate associations between survival and covariates. We used unadjusted and adjusted logistic regression to compare survival to discharge between neonates with and without kidney disease. Odds ratios were estimated separately for three groups based on extracorporeal life support indication: pulmonary indication without congenital diaphragmatic hernia, pulmonary indication with congenital diaphragmatic hernia, and cardiac indication. Adjusted models included covariates identified as significant in bivariate models for each group. MEASUREMENTS AND MAIN RESULTS The primary outcome measure was survival to discharge from hospitalization. Of the 28,755 neonates who received extracorporeal life support, 405 had kidney disease (extracorporeal life support indication: 210 pulmonary indication without congenital diaphragmatic hernia, 65 pulmonary indication with congenital diaphragmatic hernia, and 130 cardiac indication). Survival was lower in neonates with kidney disease than those without (49% vs 82% pulmonary indication without congenital diaphragmatic hernia, 25% vs 51% pulmonary indication with congenital diaphragmatic hernia, 21% vs 41% cardiac indication). Kidney disease was associated with reduced survival in adjusted models (95% CI for odds ratio 0.31-0.59 pulmonary indication without congenital diaphragmatic hernia, 0.27-0.89 pulmonary indication with congenital diaphragmatic hernia, 0.31-0.77 cardiac indication). CONCLUSIONS Neonates with kidney disease who receive extracorporeal life support have poorer survival to discharge compared with other neonates who receive extracorporeal life support, suggesting that kidney disease should be considered when making extracorporeal life support initiation decisions.
Collapse
|
22
|
Abstract
OBJECTIVE Changes in technology and increased reports of successful extracorporeal life support use in patient populations, such as influenza, cardiac arrest, and adults, are leading to expansion of extracorporeal life support. Major limitations to extracorporeal life support expansion remain bleeding and thrombosis. These complications are the most frequent causes of death and morbidity. As a pilot project to provide baseline data for a detailed evaluation of bleeding and thrombosis in the current era, extracorporeal life support patients were analyzed from eight centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. STUDY DESIGN Retrospective analysis of patients (< 19 yr) reported to the Extracorporeal Life Support Organization registry from eight Collaborative Pediatric Critical Care Research Network centers between 2005 and 2011. SETTING Tertiary children's hospitals within the Collaborative Pediatric Critical Care Research Network. SUBJECTS The study cohort consisted of 2,036 patients (13% with congenital diaphragmatic hernia). INTERVENTIONS None. MAIN RESULTS In the cohort of patients without congenital diaphragmatic hernia (n = 1,773), bleeding occurred in 38% of patients, whereas thrombosis was noted in 31%. Bleeding and thrombosis were associated with a decreased survival by 40% (relative risk, 0.59; 95% CI, 0.53-0.66) and 33% (odds ratio, 0.67; 95% CI, 0.60-0.74). Longer duration of extracorporeal life support and use of venoarterial cannulation were also associated with increased risk of bleeding and/or thrombotic complications and lower survival. The most common bleeding events included surgical site bleeding (17%; n = 306), cannulation site bleeding (14%; n = 256), and intracranial hemorrhage (11%; n = 192). Common thrombotic events were clots in the circuit (15%; n = 274) and the oxygenator (12%; n = 212) and hemolysis (plasma-free hemoglobin > 50 mg/dL) (10%; n = 177). Among patients with congenital diaphragmatic hernia, bleeding and thrombosis occurred in, respectively, 45% (n = 118) and 60% (n = 159), Bleeding events were associated with reduced survival (relative risk, 0.62; 95% CI, 0.46-0.86) although thrombotic events were not (relative risk, 0.92; 95% CI, 0.67-1.26). CONCLUSIONS Bleeding and thrombosis remain common complications in patients undergoing extracorporeal life support. Further research to reduce or eliminate bleeding and thrombosis is indicated to help improve patient outcome.
Collapse
|
23
|
Alsoufi B, Wolf M, Botha P, Kogon B, McCracken C, Ehrlich A, Kanter K, Deshpande S. Late Outcomes of Infants Supported by Extracorporeal Membrane Oxygenation Following the Norwood Operation. World J Pediatr Congenit Heart Surg 2014; 6:9-17. [DOI: 10.1177/2150135114558072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Hospital survival for infants who require extracorporeal membrane oxygenation (ECMO) following the Norwood operation is 30% to 60%. However, little is known about late outcomes of hospital survivors and their ability to progress through subsequent palliative stages. Methods: Between 2002 and 2012, 38 (13.4%) of the 284 neonates with hypoplastic left heart syndrome or other single ventricle variants received ECMO support following Norwood. We examined factors affecting hospital death and compared postdischarge events between hospital survivors who received postoperative ECMO (n = 16 of 38) and a control of hospital survivors who did not receive ECMO (220 of 246). Results: Unplanned cardiac reoperation was the only predictor of postoperative ECMO requirement. Overall, 22 (58%) of the 38 patients were weaned from ECMO support and 16 (42%) of the 38 survived to hospital discharge. The ECMO duration was a significant factor for hospital mortality (odds ratio = 1.52 per 1-day increase [1.03-2.24], P = .035). Following discharge, 15 (94%) of the 16 underwent Glenn and 1 (6%) of the 16 had interstage mortality. In the control group, 194 (88%) of the 220 underwent Glenn and 26 (12%) of the 220 had interstage mortality or received transplantation ( P = .499). Following Glenn, 3 (20%) of the 15 patients had interstage mortality or received transplantation and 12 (80%) of the 15 proceeded to Fontan or were alive awaiting Fontan. In the control group, 23 (12%) of the 194 had interstage mortality or received transplantation and 171 (88%) proceeded to Fontan or were alive awaiting Fontan ( P = .357). Overall, 81% of hospital survivors were alive 5 years following discharge in both ECMO and non-ECMO groups. Conclusions: ECMO support following Norwood is associated with high probability of hospital death. Nonetheless, interstage mortality, progression to subsequent palliative stages, intermediate survival, and freedom from heart transplantation are comparable to those in patients who did not require postoperative ECMO support.
Collapse
Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Wolf
- Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Phil Botha
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexandra Ehrlich
- Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Shriprasad Deshpande
- Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
24
|
Papadopoulos N, Martens S, Keller H, El-Sayed Ahmad A, Moritz A, Zierer A. Challenging rescue of a 4 years old boy with H1N1 infection by extracorporeal membrane oxygenator: A case report. World J Clin Cases 2014; 2:578-580. [PMID: 25325070 PMCID: PMC4198412 DOI: 10.12998/wjcc.v2.i10.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/23/2014] [Accepted: 07/29/2014] [Indexed: 02/05/2023] Open
Abstract
Introduction: World Health Organization announced on April 2009 a public health emergency of international concern caused by swine-origin influenza A (H1N1) virus. Acute respiratory distress syndrome (ARDS) has been reported to be the most devastating complications of this pathogen. Extracorporeal membrane oxygenator (ECMO) therapy for patients with H1N1 related ARDS has been described once all other therapeutic options have been exhausted. Here, we report the case of a child (German, male) with H1N1-associated fulminate respiratory and secondary hemodynamic deterioration who was rescued by initial emergent ECMO established through a dialysis catheter and subsequent switch to central cannulation following median sternotomy. This report highlights several important issues. First, it describes a successful use of a dialysis catheter for the establishment of a veno-venous ECMO in an emergency case by child. Second, it highlights the importance of a closely monitoring of clotting parameters during ECMO therapy and third, if severe respiratory failure is complicated by cardiogenic shock, veno-atrial ECMO support via median sternotomy should be considered as a viable treatment option without further delay.
Collapse
|
25
|
Kajimoto M, Ledee DR, Xu C, Kajimoto H, Isern NG, Portman MA. Triiodothyronine Activates Lactate Oxidation Without Impairing Fatty Acid Oxidation and Improves Weaning From Extracorporeal Membrane Oxygenation. Circ J 2014. [DOI: 10.1253/circj.cj-14-0821] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masaki Kajimoto
- Center for Developmental Therapeutics, Seattle Children’s Research Institute
| | - Dolena R. Ledee
- Center for Developmental Therapeutics, Seattle Children’s Research Institute
| | - Chun Xu
- Center for Developmental Therapeutics, Seattle Children’s Research Institute
| | - Hidemi Kajimoto
- Center for Developmental Therapeutics, Seattle Children’s Research Institute
| | - Nancy G. Isern
- Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory
| | - Michael A. Portman
- Center for Developmental Therapeutics, Seattle Children’s Research Institute
- Division of Cardiology, Department of Pediatrics, University of Washington
| |
Collapse
|
26
|
Takeuchi K, Minegishi S, Kobayashi J, Tsuchiya K. Left mammary artery bypass grafting rescued a patient with hypoplastic left heart syndrome with ascending aorta obstruction after norwood stage I procedure. World J Pediatr Congenit Heart Surg 2013; 4:290-2. [PMID: 24327498 DOI: 10.1177/2150135113480220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A three-month-old boy with hypoplastic left heart syndrome (mitral atresia, aortic atresia) and moderate tricuspid regurgitation developed ascending aorta obstruction two months after a Norwood stage I procedure. An emergent left mammary artery bypass grafting to the ascending aorta and extracorporeal membrane oxygenator support resulted in successful salvage. The patient subsequently underwent a bidirectional Glenn procedure and tricuspid valve repair at the age of five months. Follow-up at an outpatient clinic reveals no electrocardiographic evidence of ischemia, and echocardiography shows recovery of ventricular function.
Collapse
Affiliation(s)
- Koh Takeuchi
- Division of Cardiovascular Surgery, Japanese Red Cross Medical Center, Hiroo Shibuya, Tokyo, Japan
| | | | | | | |
Collapse
|
27
|
Pediatric ECMO outcomes: comparison of centrifugal versus roller blood pumps using propensity score matching. ASAIO J 2013; 59:145-51. [PMID: 23438777 DOI: 10.1097/mat.0b013e31828387cd] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Centrifugal blood pumps are being increasingly utilized in children supported with extracorporeal membrane oxygenation (ECMO). Our aim was to determine if survival and ECMO-related morbidities in children supported with venoarterial (VA) ECMO differed by blood pump type.Children aged less than 18 years who underwent VA ECMO support from 2007 to 2009 and reported to the Extracorporeal Life Support Organization registry were propensity score matched (Greedy 1:1 matching) using pre-ECMO characteristics.A total of 2,656 (centrifugal = 2,231, roller = 425) patients were identified and 548 patients (274 per pump type) were included in the propensity score-matched cohort. Children supported with centrifugal pumps had increased odds of hemolysis (odds ratio [OR], 4.03 95% confidence interval [CI], 2.37-6.87), hyperbilirubinemia (OR, 5.48; 95% CI, 2.62-11.49), need for inotropic support during ECMO (OR, 1.54; 95% CI, 1.09-2.17), metabolic alkalosis (blood pH > 7.6) during ECMO (OR, 3.13; 95% CI, 1.49-6.54), and acute renal failure (OR, 1.61; 95% CI, 1.10-2.39). Survival to hospital discharge did not differ by pump type.In a propensity score-matched cohort of pediatric ECMO patients, children supported with centrifugal pumps had increased odds of ECMO-related complications. There was no difference in survival between groups.
Collapse
|
28
|
Kajimoto M, O'Kelly Priddy CM, Ledee DR, Xu C, Isern N, Olson AK, Des Rosiers C, Portman MA. Myocardial reloading after extracorporeal membrane oxygenation alters substrate metabolism while promoting protein synthesis. J Am Heart Assoc 2013; 2:e000106. [PMID: 23959443 PMCID: PMC3828804 DOI: 10.1161/jaha.113.000106] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) unloads the heart, providing a bridge to recovery in children after myocardial stunning. ECMO also induces stress which can adversely affect the ability to reload or wean the heart from the circuit. Metabolic impairments induced by altered loading and/or stress conditions may impact weaning. However, cardiac substrate and amino acid requirements upon weaning are unknown. We assessed the hypothesis that ventricular reloading with ECMO modulates both substrate entry into the citric acid cycle (CAC) and myocardial protein synthesis. Methods and Results Sixteen immature piglets (7.8 to 15.6 kg) were separated into 2 groups based on ventricular loading status: 8‐hour ECMO (UNLOAD) and postwean from ECMO (RELOAD). We infused into the coronary artery [2‐13C]‐pyruvate as an oxidative substrate and [13C6]‐L‐leucine as an indicator for amino acid oxidation and protein synthesis. Upon RELOAD, each functional parameter, which were decreased substantially by ECMO, recovered to near‐baseline level with the exclusion of minimum dP/dt. Accordingly, myocardial oxygen consumption was also increased, indicating that overall mitochondrial metabolism was reestablished. At the metabolic level, when compared to UNLOAD, RELOAD altered the contribution of various substrates/pathways to tissue pyruvate formation, favoring exogenous pyruvate versus glycolysis, and acetyl‐CoA formation, shifting away from pyruvate decarboxylation to endogenous substrate, presumably fatty acids. Furthermore, there was also a significant increase of tissue concentrations for all CAC intermediates (≈80%), suggesting enhanced anaplerosis, and of fractional protein synthesis rates (>70%). Conclusions RELOAD alters both cytosolic and mitochondrial energy substrate metabolism, while favoring leucine incorporation into protein synthesis rather than oxidation in the CAC. Improved understanding of factors governing these metabolic perturbations may serve as a basis for interventions and thereby improve success rate from weaning from ECMO.
Collapse
Affiliation(s)
- Masaki Kajimoto
- Center for Developmental Therapeutics, Seattle Children's Research Institute, Seattle, WA
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
Remarkable outcomes have been reported after prolonged mechanical circulatory support in the pediatric population, but there is yet no clear delineation of the duration beyond which supporting a child becomes futile. The likelihood of survival in patients supported on extracorporeal membrane oxygenation for respiratory failure decreases with the length of support. However, extracorporeal membrane oxygenation can be successfully used in these patients for long periods (weeks to months) provided adequate support is maintained without complications. This is not the case with cardiac failure and mechanical circulatory support.Extracorporeal membrane oxygenation is usually the initial form of mechanical circulatory support used in patients with primary refractory myocardial dysfunction. There is evidence and consensus that if the patient shows no signs of recovery after a maximum duration of 2 weeks, he or she should be transitioned to a ventricular assist device, which allows prolonged support. In post-cardiac surgery patients, survival is only anecdotal beyond 12 days of extracorporeal membrane oxygenation support, and myocardial recovery is exceptionally rare after this time period unless new diagnoses and management strategies are formulated.Repeat extracorporeal membrane oxygenation should generally not be offered to patients unless it is established that support was withdrawn prematurely or a new intervention is planned. Repeat extracorporeal membrane oxygenation may achieve some improvement in early survival, but the long-term outcomes of survivors are so poor that these attempts cannot be generally recommended unless organ transplantation is an option.
Collapse
|
30
|
Extended survival and re-hospitalisation among paediatric patients requiring extracorporeal membrane oxygenation for primary cardiac dysfunction. Cardiol Young 2013; 23:258-64. [PMID: 22694830 DOI: 10.1017/s1047951112000777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although survival to hospital discharge among children requiring extracorporeal membrane oxygenation support for medical and surgical cardio-circulatory failure has been reported in international registries, extended survival and re-hospitalisation rates have not been well described in the literature. MATERIAL AND METHODS This is a single-institution, retrospective review of all paediatric patients receiving extracorporeal membrane oxygenation for primary cardiac dysfunction over a 5-year period. RESULTS A total of 74 extracorporeal membrane oxygenation runs in 68 patients were identified, with a median follow-up of 5.4 years from hospital discharge. Overall, 66% of patients were decannulated alive and 25 patients (37%) survived to discharge. There were three late deaths at 5 months, 20 months, and 6.8 years from discharge. Of the hospital survivors, 88% required re-hospitalisation, with 63% of re-admissions for cardiac indications. The median number of hospitalisations per patient per year was 0.62, with the first re-admission occurring at a mean time of 9 months after discharge from the index hospitalisation. In all, 38% of patients required further cardiac surgery. CONCLUSIONS Extended survival rates for paediatric hospital survivors of cardiac extracorporeal membrane oxygenation support for medical and post-surgical indications are encouraging. However, re-hospitalisation within the first year following hospital discharge is common, and many patients require further cardiac surgery. Although re-admission hospital mortality is low, longer-term follow-up of quality-of-life indicators is required
Collapse
|
31
|
Abstract
INTRODUCTION The field of extracorporeal life support, which has focused predominantly on extracorporeal membrane oxygenation in the past, is undergoing rapid expansion following years of stagnation as newer devices and improved technology have become available. Additionally, new cannulae and cannulation techniques have allowed extracorporeal life support to be expanded to many groups who would have been excluded from support in the past. REVIEW This update will review the current state of the art since Rogers' Textbook of Pediatric Intensive Care (Fourth Edition) was published several years ago. The changing environment of extracorporeal support in terms of patient populations, technological advances, patient management, and outcome will be discussed. CONCLUSIONS Continued examination of the criteria and circumstances where extracorporeal life support is applied as well as outcomes which include morbidity, cost effectiveness, and quality of life are needed areas of continued research. Increasing collaborations between all centers performing extracorporeal life support throughout the world should remain a priority to further research and understanding of this complex field.
Collapse
|
32
|
Schlingmann TR, Thiagarajan RR, Gauvreau K, Lofgren KC, Zaplin M, Connor JA, del Nido PJ, Lock JE, Jenkins KJ. Cardiac Medical Conditions Have Become the Leading Cause of Death in Children with Heart Disease. CONGENIT HEART DIS 2012; 7:551-8. [DOI: 10.1111/j.1747-0803.2012.00674.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
33
|
Almond CS. The FDA Review Process for Cardiac Medical Devices in Children: A Review for the Clinician. PROGRESS IN PEDIATRIC CARDIOLOGY 2012; 33:105-109. [PMID: 22661882 PMCID: PMC3363973 DOI: 10.1016/j.ppedcard.2012.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pediatric medical devices play a vital role in the treatment of children with cardiovascular disease. Most cardiac medical devices used in children today are used off-label where the risk-benefit of devices has not been well characterized. Pediatric medical devices face a variety of challenges to FDA approval related in large part to the small target population, heterogeneity of the patient population and ethical considerations of device testing in children. While relatively few cardiac devices have received FDA approval in children, the number of devices navigating the approval process successfully is growing. Most pediatric device approvals are being granted through the humanitarian device exemption (HDE) pathway, which is designed for rare diseases making it suitable for devices treating congenital heart disease. This review summarizes the FDA review process for pediatric medical devices as it continues to evolve in response to the unique challenges of understanding device performance in the pediatric population.
Collapse
Affiliation(s)
- Christopher S Almond
- Department of Cardiology, Children's Hospital Boston; Department of Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
34
|
Vida VL, Lo Rito M, Padalino MA, Stellin G. Extracorporeal membrane oxygenation: The simplified weaning bridge. J Thorac Cardiovasc Surg 2012; 143:e27-8. [DOI: 10.1016/j.jtcvs.2011.12.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 11/22/2011] [Accepted: 12/08/2011] [Indexed: 10/14/2022]
|
35
|
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is associated with increased risk of morbidity and mortality in critically ill children and adults. Neonates remain an understudied group, although previous evidence suggests that this association holds true for them as well. RECENT FINDINGS Attention to the issue of neonatal AKI is increasing. New studies in very low-birthweight infants, infants with congenital heart disease who undergo cardiopulmonary bypass, those who receive extracorporeal membrane oxygenation and infants with perinatal depression continue to demonstrate that AKI is common in neonates and associated with increased risk of morbidity and mortality. Additional advances in the field of neonatal AKI include adaptation of modern, categorical AKI definitions, as well as further evaluation of novel urinary biomarkers (e.g., neutrophil gelatinase-associated lipocalin) in this patient group. SUMMARY AKI is an independent risk factor for poor outcomes in critically ill neonates. Our ability to improve outcomes for these patients depends on heightened awareness of this issue both at the bedside as well as in research, commitment to using standardized AKI definitions in order to pool and compare data more effectively and improvement in our diagnostic methods with better AKI biomarkers so that we can identify AKI and intervene much earlier in the disease course.
Collapse
|
36
|
20-year experience of prolonged extracorporeal membrane oxygenation in critically ill children with cardiac or pulmonary failure. Ann Thorac Surg 2012; 93:1584-90. [PMID: 22421589 DOI: 10.1016/j.athoracsur.2012.01.008] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 01/03/2012] [Accepted: 01/06/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for life-threatening respiratory or circulatory failure. Although outcomes are favorable with short-term ECMO therapy, data on the outcomes of prolonged ECMO therapy in children are very limited. This study aimed to study morbidity and mortality associated with prolonged ECMO therapy (≥28 days) in children with refractory cardiac or pulmonary failure. METHODS We conducted a retrospective review of all children≤18 years supported with ECMO for ≥28 days between January 1991 and September 2011 at the Arkansas Children's Hospital. The data collected in our study included patient demographic information; diagnosis; indication for ECMO; ECMO support details; medical and surgical history; laboratory, microbiologic, and radiographic data; information on organ dysfunction; complications; and patient outcomes. The outcome variables evaluated in this report included survival to ECMO decannulation, survival to hospital discharge, and current survival with emphasis on neurologic, renal, pulmonary, and other end organ function. RESULTS During the study period, 984 events in 951 patients were supported with ECMO with a 30-day survival of 666 events (68%). Only 22 ECMO runs were ≥28 days and were eligible for inclusion in this report. The longest ECMO run in our series was 1,206 hours (50 days). The average length of ECMO run in this cohort was 855±133 hours, with a mean intensive care unit length of stay of 56±27 days. Ten patients (45%) were successfully decannulated from ECMO. Six patients (27%) were alive 30 days after decannulation, and only 4 patients (19%) survived to hospital discharge. Of the 4 survivors, only 3 patients (14%) are living to date. Of the 3 living children, 2 have significant neurologic issues with brain atrophy and developmental delay, and 1 is awaiting renal transplant; all 3 survivors have chronic lung disease. CONCLUSIONS This case series highlights that the prolonged use of ECMO in children with refractory cardiac failure, respiratory failure, or both is associated with low survival. Furthermore, it suggests that the survivors of prolonged ECMO runs have significant long-term sequelae.
Collapse
|