Neonatal and pediatric extracorporeal membrane oxygenation in developing Latin American countries

Quality improvement strategies in pediatric ECMO

Pediatric extracorporeal membrane oxygenation is an increasingly utilized, life-saving technology with high mortality and morbidity. A complex technology employed urgently or emergently for some of the sickest children in the hospital by a large multidisciplinary team, ECMO is an ideal area for using quality improvement strategies to reduce the variability in care and improve patient outcomes. We review critical concepts from quality improvement and apply them to patient selection and management, staffing, credentialing and continuing education, and the variability of management among providers and institutions.

Extracorporeal Membrane Oxygenation After Norwood Surgery in Patients With Hypoplastic Left Heart Syndrome: A Retrospective Single-Center Cohort Study From Brazil

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly being used to support patients after the repair of congenital heart disease.

OBJECTIVE

We report our experience with patients with a single functional ventricle who were supported by ECMO after the Norwood procedure, reviewing the outcomes and identifying risk factors for mortality in these patients.

METHODS

In this single-center retrospective cohort study, we enrolled 33 patients with hypoplastic left heart syndrome (HLHS) who received ECMO support after the Norwood procedure between January 2015 and December 2019. The independent variables evaluated in this study were demographic, anatomical, and those directly related to ECMO support (ECMO indication, local of initiation, time under support, and urinary output while on ECMO). The dependent variable was survival. A p < 0.05 was considered statistically significant.

RESULTS

The ECMO support was applied in 33 patients in a group of 120 patients submitted to Norwood procedure (28%). Aortic atresia was present in 72.7% of patients and mitral atresia in 51.5%. For 15% of patients, ECMO was initiated in the operating room; for all other patients, ECMO was initiated in the intensive care unit. The indications for ECMO in the cardiac intensive care unit were cardiac arrest in 22 (79%) of patients, low cardiac output state in 10 (18%), and arrhythmia in 1 patient (3%). The median time under support was 5 (2-25) days. The median follow-up time was 59 (4-150) days. Global survival to Norwood procedure was 90.9% during the 30-day follow-up, being 33.3% for those submitted to ECMO. Longer ECMO support (p = 0.004) was associated with a higher risk of death in the group submitted to ECMO.

CONCLUSIONS

The mortality of patients with HLHS who received ECMO support after stage 1 palliation was high. Patients with low urine output were related to worse survival rates, and longer periods under ECMO support (more than 9 days of ECMO) were associated with 100% mortality. Earlier ECMO initiation before multiorgan damage may improve results.

Clinical Characteristics and Outcomes of Children With Extracorporeal Membrane Oxygenation in a Developing Country: An 11-Year Single-Center Experience

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.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Septic shock in pediatrics: the state-of-the-art

OBJECTIVE

Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock.

SOURCE OF DATA

A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years.

SYNTHESIS OF DATA

Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection.

CONCLUSIONS

The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.

Telemedicine in Pediatric Critical Care: A Retrospective Study in an International Extracorporeal Membrane Oxygenation Program

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is an invaluable rescue technique for critically ill children with imminent or present cardiopulmonary collapse. However, medical team expertise to optimize results and decrease complications is scarce. Telemedicine can be used to enhance the delivery of quality interventions.

MATERIALS AND METHODS

This is a retrospective review of pediatric patients assisted with ECMO in the cardiac intensive care unit (CICU) at Fundación Cardiovascular de Colombia from July 2011 to June 2015 (telemedicine) compared with similar patients from a previous period (pretelemedicine). Collected information included demographic data, cardiac diagnosis, risk adjustment for congenital heart surgery (RACHS-1), hospital mortality, CICU and hospital length of stay (LOS), ECMO type, and ECMO run hours as well as specific telemedicine information.

RESULTS

Fifty-seven patients in the pretelemedicine and 109 in the telemedicine periods were included in the analysis. Forty-nine teleconsulted patients received 218 teleconsultations, with a recommendation for diagnostic or interventional catheterization in 38 patients (77.5%). A surgical procedure for significant residual lesions was recommended in 30 patients (61.2%). Patients in the telemedicine period were older (4.7 months vs. 1.6 months, p = 0.006), more likely to receive operating room ECMO (43.1% vs. 24.6%, p = 0.02), and had a higher proportion of patients with two-ventricle physiology (73.4% vs. 54.4%, p = 0.013). Hospital survival was higher during the telemedicine period (54.1% vs. 29.8%, p = 0.002), with a longer hospital LOS (67 days vs. 28 days, p < 0.001).

CONCLUSION

The implementation of telemedicine-assisted interventions in a pediatric ECMO program delivered valuable diagnostic and therapeutic advice, was associated with significant changes in selection criteria and model of care, and an increased hospital survival.