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Fernando SM, Qureshi D, Tanuseputro P, Dhanani S, Guerguerian AM, Shemie SD, Talarico R, Fan E, Munshi L, Rochwerg B, Scales DC, Brodie D, Thavorn K, Kyeremanteng K. Long-term survival and costs following extracorporeal membrane oxygenation in critically ill children-a population-based cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:131. [PMID: 32252807 PMCID: PMC7137509 DOI: 10.1186/s13054-020-02844-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/21/2020] [Indexed: 12/16/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is used to provide temporary cardiorespiratory support to critically ill children. While short-term outcomes and costs have been evaluated in this population, less is known regarding long-term survival and costs. Methods Population-based cohort study from Ontario, Canada (October 1, 2009 to March 31, 2017), of pediatric patients (< 18 years of age) receiving ECMO, identified through the use of an ECMO procedural code. Outcomes were identified through linkage to provincial health databases. Primary outcome was survival, measured to hospital discharge, as well as at 1 year, 2 years, and 5 years following ECMO initiation. We evaluated total patient costs in the first year following ECMO. Results We analyzed 342 pediatric patients. Mean age at ECMO initiation was 2.9 years (standard deviation [SD] = 5.0). Median time from hospital admission to ECMO initiation was 5 days (interquartile range [IQR] = 1–13 days). Overall survival to hospital discharge was 56.4%. Survival at 1 year, 2 years, and 5 years was 51.5%, 50.0%, and 42.1%, respectively. Among survivors, 99.5% were discharged home. Median total costs among all patients in the year following hospital admission were $147,957 (IQR $70,571–$300,295). Of these costs, the large proportion were attributable to the inpatient cost from the index admission (median $119,197, IQR $57,839–$250,675). Conclusions Children requiring ECMO continue to have a significant in-hospital mortality, but reassuringly, there is little decrease in long-term survival at 1 year. Median costs among all patients were substantial, but largely reflect inpatient hospital costs, rather than post-discharge outpatient costs. This information provides value to providers and health systems, allowing for prognostication of short- and long-term outcomes, as well as long-term healthcare-related expenses for pediatric ECMO survivors.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Danial Qureshi
- ICES, Toronto, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sonny Dhanani
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.,Division of Critical Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Anne-Marie Guerguerian
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sam D Shemie
- Department of Pediatrics, McGill University, Montreal, QC, Canada.,Division of Critical Care, Montreal Children's Hospital, Montreal, QC, Canada
| | - Robert Talarico
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Damon C Scales
- ICES, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | - Kednapa Thavorn
- ICES, Toronto, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
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2
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Assy J, Skouri H, Charafeddine L, Majdalani M, Younes K, Bulbul Z, Sfeir P, Bourgi J, Hallal A, Rifai K, Zaatari R, Bitar F, Rassi IE. Establishing an ECMO program in a developing country: challenges and lessons learned. Perfusion 2019; 34:508-515. [DOI: 10.1177/0267659119834489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim: The ECMO (extracorporeal membrane oxygenation) Program at the American University of Beirut Medical Center was established in November 2015 as the first program serving adult and pediatric population in a low-resource setting. The aim of the study is to describe the challenges faced during the establishment of the program and factors leading to its success. Methods: The program establishment is described. The preparation phase, included the strategic, financial, and clinical planning by administration, nursing, and a multidisciplinary team of physicians. The training and education phase included all the involved nurses, perfusionists, and physicians. Concerns were heard from various stakeholders, and the challenges were analyzed and discussed. Results: The preparation committee chose the adequate equipment, responded to the concerns, defined roles and responsibilities through credentialing and privileging, wrote policies and protocols, and established a strategy to decide for the ECMO indication. Selected team of nurses, physicians, and perfusionists are identified and trained locally, and abroad. A full-time ECMO physician was recruited to launch the program. Twelve patients (6 adults, 3 children, and 3 neonates) were supported by ECMO, for cardiac and respiratory indications. Eleven patients were supported by veno-arterial ECMO, and 1 patient (a neonate) with veno-venous ECMO. Overall, 75% survived to decannulation and 41% survived to discharge. Conclusion: With limited human and financial resources, new ECMO centers need to carefully establish selection criteria that may differ from those used in developed countries. Indications should be discussed on a case by case basis, taking into account clinical, social, and financial issues. This experience might help other institutions in developing countries to build their own program despite financial and human limitations.
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Affiliation(s)
- Jana Assy
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hadi Skouri
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lama Charafeddine
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marianne Majdalani
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Khaled Younes
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad Bulbul
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Pierre Sfeir
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jamil Bourgi
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Hallal
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Khaled Rifai
- Department of Nursing and Perfusion, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rafika Zaatari
- Department of Nursing and Perfusion, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Issam El Rassi
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Padalino MA, Tessari C, Guariento A, Frigo AC, Vida VL, Marcolongo A, Zanella F, Harvey MJ, Thiagarajan RR, Stellin G. The “basic” approach: a single-centre experience with a cost-reducing model for paediatric cardiac extracorporeal membrane oxygenation. Interact Cardiovasc Thorac Surg 2017; 24:590-597. [DOI: 10.1093/icvts/ivw381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/19/2016] [Indexed: 11/12/2022] Open
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Association of Hospital Structure and Complications With Mortality After Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2016; 17:684-91. [PMID: 27099971 DOI: 10.1097/pcc.0000000000000723] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation is increasingly utilized to provide cardiopulmonary support to critically ill children. Although life-saving in many instances, extracorporeal membrane oxygenation support is associated with considerable morbidity and mortality. This study evaluates the effect of extracorporeal membrane oxygenation complications and extracorporeal membrane oxygenation hospital characteristics on mortality in neonates and children supported with extracorporeal membrane oxygenation. DESIGN Retrospective analysis of administrative data. SETTING Data from 31 U.S. states included in 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database. PATIENTS Children treated with extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Study subject were identified using International Classification of Diseases, 9th Edition Clinical Modification code 39.65 and classified into six diagnostic categories: 1) cardiac surgery, 2) non-surgical heart disease, 3) congenital diaphragmatic hernia, 4) neonatal respiratory failure, 5) pediatric respiratory failure, and 6) sepsis. Demographics, hospital characteristics, and outcome information were used in a multivariate logistic regression analysis to determine factors associated with mortality. We identified 1,465 children treated with extracorporeal membrane oxygenation. Overall mortality was 40% (591/1,465). Mortality was independently associated with diagnosis (heart disease: odds ratio, 1.7; p = 0.01; congenital diaphragmatic hernia: odds ratio, 5.1; p < 0.001; and sepsis odds ratio: 2.4; p = 0.003 compared with neonatal respiratory failure) time from hospital admission to extracorporeal membrane oxygenation of more than 10 days (odds ratio, 4.5; p < 0.001) and extracorporeal membrane oxygenation complications (renal [odds ratio: 5; p < 0.001] and neurologic [odds ratio, 1.4; p = 0.03] injury). In addition, hospitals with bed size less than 400 had higher mortality (odds ratio, 1.4; p = 0.02). In patients with any extracorporeal membrane oxygenation complication, probability of mortality was lower for extracorporeal membrane oxygenation patients in larger hospitals, 38% (95% CI, 37-39) versus 44% (95% CI, 43-46) with p value of less than 0.001. CONCLUSIONS Extracorporeal membrane oxygenation mortality was significantly associated with patient diagnosis, time to extracorporeal membrane oxygenation initiation, extracorporeal membrane oxygenation complications, and extracorporeal membrane oxygenation hospital bed size. Improved survival in larger hospitals supports centralization of extracorporeal membrane oxygenation services to larger centers.
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Faraoni D, Nasr VG, DiNardo JA, Thiagarajan RR. Hospital Costs for Neonates and Children Supported with Extracorporeal Membrane Oxygenation. J Pediatr 2016; 169:69-75.e1. [PMID: 26547402 DOI: 10.1016/j.jpeds.2015.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/18/2015] [Accepted: 10/01/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the characteristics associated with high hospital cost for patients receiving extracorporeal membrane oxygenation (ECMO) to identify a cohort of high-resource users. STUDY DESIGN Cost for hospitalization, during which ECMO support was used, was calculated from hospital charges reported in the 2012 Health Care Cost and Use Project Kid's Inpatient Database. Patients were categorized into 6 diagnostic groups: (1) cardiac surgery; (2) nonsurgical heart disease; (3) congenital diaphragmatic hernia; (4) neonatal respiratory failure; (5) pediatric respiratory failure; and (6) sepsis. We categorized cost into 4 groups based on quartiles. We compared ECMO cost with hospital cost for bone marrow, liver, and kidney transplants performed during the same year. RESULTS Median hospital cost for children supported with ECMO (n = 1465) was $230,425 (IQR: $126,599-$420,960). In a multivariable model, lower cost was associated with neonatal respiratory failure (OR: 0.19) and sepsis (OR 0.53) compared with cardiac surgery (OR: 1.88), whereas greater cost was associated with smaller hospital bed-size <99 (OR: 3.49) and 100-399 beds (OR: 3.03) compared with hospitals >400 beds, hospital location (Midwest [OR: 1.74] and West [OR 2.18] compared with North-East), and complications such as renal failure (OR: 3.77) and thromboembolic complications (OR 1.60). Hospital cost per survivor was greater for ECMO ($519,450) than bone marrow transplantation ($207,212), liver ($231,755), or kidney transplantation ($82,008) groups. CONCLUSIONS Hospitalization cost for children supported with ECMO is high. Diagnosis, hospital characteristics, and presence of complications are associated with increased cost.
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Affiliation(s)
- David Faraoni
- Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Viviane G Nasr
- Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Ravi R Thiagarajan
- Department of Cardiology, Cardiac Intensive Care Unit, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Harvey MJ, Gaies MG, Prosser LA. U.S. and International In-Hospital Costs of Extracorporeal Membrane Oxygenation: a Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:341-57. [PMID: 25894740 DOI: 10.1007/s40258-015-0170-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
CONTEXT The in-hospital costs of extracorporeal membrane oxygenation (ECMO) have not been well established. OBJECTIVE To evaluate the in-hospital costs of ECMO technology in both US and non-US settings for all patient types. DATA SOURCES Systematic review of English-language articles, using the PubMed, Embase, Web of Science and EconLit databases. Searches consisted of the terms 'ECMO' AND 'health expenditures' or 'resource use' or 'costs' or 'cost analysis' or 'cost(-)effectiveness' or 'cost(-)benefit' or 'cost(-)utility' or 'economic(-)evaluation' or 'economic' or 'QALY' or 'cost per quality-adjusted life year'. STUDY SELECTION Only full scientific research articles were included. The exclusion criteria included papers that focused on pumpless ECMO, simulation training or decision support systems; papers that did not include human subjects or were not written in English; papers that did not mention ECMO, costs, economics or resource utilization; and papers that included only outside-hospital, infrastructure capital or device capital costs. DATA EXTRACTION Data extraction was completed by one author, using predefined criteria. RESULTS From the database searches, 1371 results were returned, 226 records underwent a full review and 18 studies were included in the final review. Three papers studied adult populations, two studied adult and paediatric populations, five studied only paediatric populations, one studied a paediatric and neonatal population, and the remaining seven exclusively examined ECMO in neonatal populations. The sample sizes ranged from 8 to 8753 patients. ECMO for respiratory conditions was the most common diagnosis category, followed by congenital diaphragmatic hernia (CDH) and then cardiac conditions. Most papers (n = 14) used retrospective cost collection. Only eight papers stated the perspective of the cost analysis. The results show a large variation in the cost of ECMO over multiple cost categories (e.g., range of total in-hospital costs of treatment: USD 42,554-537,554 [in 2013 values]). In the U.S.A., the reported costs of ECMO were highest for CDH repair, followed by cardiac conditions, and lowest for respiratory conditions. The US charges were highest for cardiac conditions. Outside the U.S.A., the ECMO cost was highest for cardiac conditions, followed by respiratory conditions, and lowest for CDH repair. No non-US studies reported charges. CONCLUSION The current literature shows that a large variation exists in the in-hospital cost estimates for ECMO. Further research is needed to understand how the diagnosis, setting and other factors relate to this variation in the cost of this technology. Reliable costing methodologies and cost information will be critical to inform policymakers and stakeholders wishing to maximize the value of advanced medical technologies such as ECMO.
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Affiliation(s)
- Michael J Harvey
- Department of Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA,
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The Use of Pediatric Ventricular Assist Devices in Children's Hospitals From 2000 to 2010: Morbidity, Mortality, and Hospital Charges. Pediatr Crit Care Med 2015; 16:522-8. [PMID: 25850863 DOI: 10.1097/pcc.0000000000000401] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The use of ventricular assist devices has increased dramatically in adult heart failure patients. However, the overall use, outcome, comorbidities, and resource utilization of ventricular assist devices in pediatric patients have not been well described. We sought to demonstrate that the use of ventricular assist devices in pediatric patients has increased over time and that mortality has decreased. DESIGN A retrospective study of the Pediatric Health Information System database was performed for patients 20 years old or younger undergoing ventricular assist device placement from 2000 to 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four hundred seventy-five pediatric patients were implanted with ventricular assist devices during the study period: 69 in 2000-2003 (era 1), 135 in 2004-2006 (era 2), and 271 in 2007-2010 (era 3). Median age at ventricular assist device implantation was 6.0 years (interquartile range, 0.5-13.8), and the proportion of children who were 1-12 years old increased from 29% in era 1 to 47% in era 3 (p = 0.002). The majority of patients had a diagnosis of cardiomyopathy; this increased from 52% in era 1 to 72% in era 3 (p = 0.003). Comorbidities included arrhythmias (48%), pulmonary hypertension (16%), acute renal failure (34%), cerebrovascular disease (28%), and sepsis/systemic inflammatory response syndrome (34%). Two hundred forty-seven patients (52%) underwent heart transplantation and 327 (69%) survived to hospital discharge. Hospital mortality decreased from 42% in era 1 to 25% in era 3 (p = 0.004). Median hospital length of stay increased (37 d [interquartile range, 12-64 d] in era 1 vs 69 d [interquartile range, 35-130] in era 3; p < 0.001) and median adjusted hospital charges increased ($630,630 [interquartile range, $227,052-$853,318] in era 1 vs $1,577,983 [interquartile range, $874,463-$2,280,435] in era 3; p < 0.001). Factors associated with increased mortality include age less than 1 year (odds ratio, 2.04; 95% CI, 1.01-3.83), acute renal failure (odds ratio, 2.1; 95% CI, 1.26-3.65), cerebrovascular disease (odds ratio, 2.1; 95% CI, 1.25-3.62), and extracorporeal membrane oxygenation (odds ratio, 3.16; 95% CI, 1.79-5.60). Ventricular assist device placement in era 3 (odds ratio, 0.3; 95% CI, 0.15-0.57) and a diagnosis of cardiomyopathy (odds ratio, 0.5; 95% CI, 0.32-0.84), were associated with decreased mortality. Large-volume centers had lower mortality (odds ratio, 0.55; 95% CI, 0.34-0.88), lower use of extracorporeal membrane oxygenation, and higher charges. CONCLUSIONS The use of ventricular assist devices and survival after ventricular assist device placement in pediatric patients have increased over time, with a concomitant increase in resource utilization. Age under 1 year, certain noncardiac morbidities, and the use of extracorporeal membrane oxygenation are associated with worse outcomes. Lower mortality was seen at larger volume ventricular assist device centers.
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The outcomes of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S118-31. [PMID: 26035362 DOI: 10.1097/pcc.0000000000000438] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To provide additional details and evidence behind the recommendations for outcomes assessment of patients with pediatric acute respiratory distress syndrome from the Pediatric Acute Lung Injury Consensus Conference. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The outcomes subgroup comprised four experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was used. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, seven of which related to outcomes after pediatric acute respiratory distress syndrome. All seven recommendations had strong agreement. Children with acute respiratory distress syndrome continue to have a high mortality, specifically, in relation to certain comorbidities and etiologies related to pediatric acute respiratory distress syndrome. Comorbid conditions, such as an immunocompromised state, increase the risk of mortality even further. Likewise, certain etiologies, such as non-pulmonary sepsis, also place children at a higher risk of mortality. Significant long-term effects were reported in adult survivors of acute respiratory distress syndrome: diminished lung function and exercise tolerance, reduced quality of life, and diminished neurocognitive function. Little knowledge of long-term outcomes exists in children who survive pediatric acute respiratory distress syndrome. Characterization of the longer term consequences of pediatric acute respiratory distress syndrome in children is vital to help identify opportunities for improved therapeutic and rehabilitative strategies that will lessen the long-term burden of pediatric acute respiratory distress syndrome and improve the quality of life in children. CONCLUSIONS The Consensus Conference developed pediatric-specific recommendations for pediatric acute respiratory distress syndrome regarding outcome measures and future research priorities. These recommendations are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.
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St-Onge M, Fan E, Mégarbane B, Hancock-Howard R, Coyte PC. Venoarterial extracorporeal membrane oxygenation for patients in shock or cardiac arrest secondary to cardiotoxicant poisoning: a cost-effectiveness analysis. J Crit Care 2014; 30:437.e7-14. [PMID: 25454073 DOI: 10.1016/j.jcrc.2014.10.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 10/03/2014] [Accepted: 10/10/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE Venoarterial extracorporeal membrane oxygenation represents an emerging and recommended option to treat life-threatening cardiotoxicant poisoning. The objective of this cost-effectiveness analysis was to estimate the incremental cost-effectiveness ratio of using venoarterial extracorporeal membrane oxygenation for adults in cardiotoxicant-induced shock or cardiac arrest compared with standard care. MATERIALS AND METHODS Adults in shock or in cardiac arrest secondary to cardiotoxicant poisoning were studied with a lifetime horizon and a societal perspective. Venoarterial extracorporeal membrane oxygenation cost effectiveness was calculated using a decision analysis tree, with the effect of the intervention and the probabilities used in the model taken from an observational study representing the highest level of evidence available. The costs (2013 Canadian dollars, where $1.00 Canadian = $0.9562 US dollars) were documented with interviews, reviews of official provincial documents, or published articles. A series of one-way sensitivity analyses and a probabilistic sensitivity analysis using Monte Carlo simulation were used to evaluate uncertainty in the decision model. RESULTS The cost per life year (LY) gained in the extracorporeal membrane oxygenation group was $145 931/18 LY compared with $88 450/10 LY in the non-extracorporeal membrane oxygenation group. The incremental cost-effectiveness ratio ($7185/LY but $34 311/LY using a more pessimistic approach) was mainly influenced by the probability of survival. The probabilistic sensitivity analysis identified variability in both cost and effectiveness. CONCLUSION Venoarterial extracorporeal membrane oxygenation may be cost effective in treating cardiotoxicant poisonings.
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Affiliation(s)
- Maude St-Onge
- University of Toronto, Toronto, Ontario, Canada; Ontario Poison Centre, Toronto, Ontario, Canada.
| | - Eddy Fan
- University of Toronto, Toronto, Ontario, Canada; Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM U1144, Paris-Diderot University, Paris, France.
| | - Rebecca Hancock-Howard
- Health System Strategy and Policy Division, Ontario Ministry of Health and Long-Term Care, Toronto, Ontario, Canada.
| | - Peter C Coyte
- University of Toronto, Toronto, Ontario, Canada; Health Economics at the Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada.
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Rambaud J, Guilbert J, Guellec I, Renolleau S. A pilot study comparing two polymethylpentene extracorporeal membrane oxygenators. Perfusion 2012; 28:14-20. [PMID: 22918934 DOI: 10.1177/0267659112457970] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We compared two polymethylpentene oxygenators being used in our unit: the Maquet Quadrox-iD paediatric and the Medos Hilite 800LT. STUDY DESIGN A mono-centric, prospective pilot study was conducted on ten consecutive newborn patients who had been admitted to our hospital service for extracorporeal circulation (EC) treatment. We examined the rate of oxygen transfer, the CO2 removal capacity and the average sweep gas flow required to produce this result. We also assessed the disturbances of haemostasis, the need for labile blood products and the membrane oxygenator lifetime and cost of use. CONCLUSIONS According to our study, it seems to us that Medos Hilite 800LT membrane oxygenators demonstrate greater oxygen transfer and CO2 removal capacity than Maquet Quadrox-iD paediatric membrane oxygenators, at a similar cost. These results lead us to conclude that it is reasonable to continue using Medos Hilite 800LT membrane oxygenators. A broader comparison study would be necessary in order to support these initial results.
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Affiliation(s)
- J Rambaud
- Paediatric Intensive Care Unit, Armand-Trousseau Children's Hospital APHP (Paris Hospitals Public Assistance) UPMC (Pierre and Marie Curie University, Paris VI) Paris, France
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Peng CC, Wu SJ, Chen MR, Chiu NC, Chi H. Clinical experience of extracorporeal membrane oxygenation for acute respiratory distress syndrome associated with pneumonia in children. J Formos Med Assoc 2012; 111:147-52. [DOI: 10.1016/j.jfma.2011.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Revised: 01/04/2011] [Accepted: 01/14/2011] [Indexed: 11/25/2022] Open
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Raval MV, Wang X, Reynolds M, Fischer AC. Costs of congenital diaphragmatic hernia repair in the United States-extracorporeal membrane oxygenation foots the bill. J Pediatr Surg 2011; 46:617-624. [PMID: 21496527 DOI: 10.1016/j.jpedsurg.2010.09.047] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 09/20/2010] [Accepted: 09/20/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is the costliest noncardiac congenital defect. Extracorporeal membrane oxygenation (ECMO) is a treatment strategy offered to those babies with CDH who would not otherwise survive on conventional therapy. The primary objective of our study was to identify the leading source of expenditures in CDH care. METHODS All patients surviving CDH repair were identified in the Kids' Inpatient Database (KID) from 1997 to 2006, with costs converted to 2006 US dollars. Patients were categorized into groups based on severity of disease for comparison including CDH repair only, prolonged ventilator dependence, and ECMO use. Factors associated with greater expenditures in CDH management were analyzed using a regression model. RESULTS Eight hundred thirty-nine patients from 213 hospitals were studied. Extracorporeal membrane oxygenation use decreased from 18.2% in 1997 to 11.4% in 2006 (P = .002). Congenital diaphragmatic hernia survivors managed with ECMO cost more than 2.4 times as much as CDH survivors requiring only prolonged ventilation postrepair and 3.5 times as much as those with CDH repair only (both P < .001). Age, multiplicity of diagnoses, patient transfer, inhaled nitric oxide use, prolonged ventilation, and ECMO use were all associated with higher costs. Extracorporeal membrane oxygenation use was the single most important factor associated with higher costs, increasing expenditures 2.4-fold (95% confidence interval, 2.1-2.8). Though the CDH repair with ECMO group constituted 12.2% of patients, this group has the highest median costs ($156,499.90/patient) and constitutes 28.5% of national costs based on CDH survivors in the KID. Annual national cost for CDH survivors is $158 million based on the KID, and projected burden for all CDH patients exceeds $250 million/year. CONCLUSIONS Extracorporeal membrane oxygenation use is the largest contributing factor to the economic burden in CDH. With limited health care resources, judicious resource utilization in CDH care merits further study.
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Affiliation(s)
- Mehul V Raval
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL 60611, USA; Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Children's Memorial Hospital, Chicago, IL 60614, USA.
| | - Xue Wang
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL 60611, USA
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Children's Memorial Hospital, Chicago, IL 60614, USA
| | - Anne C Fischer
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Crow S, Fischer AC, Schears RM. Extracorporeal life support: utilization, cost, controversy, and ethics of trying to save lives. Semin Cardiothorac Vasc Anesth 2009; 13:183-91. [PMID: 19713206 DOI: 10.1177/1089253209347385] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Since the first successful application of extracorporeal membrane oxygenation (ECMO) in 1972, ECMO's role in the management of respiratory and circulatory collapse continues to be refined and debated. Randomized clinical trials aimed at establishing efficacy and patient selection criteria have been fraught with ethical challenges. Growing concerns over rising health care costs require that careful evaluations of cost, utilization, and ethical issues surrounding heroic life-saving interventions such as ECMO are undertaken. Continued analyses of ECMO's place in the medical management of respiratory and circulatory failure will help ensure that ECMO is used for not only prolonging life but also for providing a chance for "quality of life" following recovery from near-fatal illnesses.
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Affiliation(s)
- Sheri Crow
- Mayo Clinic, Rochester, Minnesota 55905, USA.
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Stroud MH, Okhuysen-Cawley R, Jaquiss R, Berlinski A, Fiser RT. Successful use of extracorporeal membrane oxygenation in severe necrotizing pneumonia caused by Staphylococcus aureus. Pediatr Crit Care Med 2007; 8:282-7. [PMID: 17417120 DOI: 10.1097/01.pcc.0000262795.11598.56] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report the successful use of extracorporeal membrane oxygenation (ECMO) as rescue therapy for severe necrotizing pneumonia secondary to infection by the Staphylococcus aureus species. DESIGN Case series. SETTING Pediatric intensive care unit at a freestanding tertiary care children's hospital. PATIENTS Two pediatric patients with severe S. aureus-induced necrotizing pneumonia requiring rescue with ECMO. Both patients survived with good neurologic outcomes. One patient required the use of activated factor VII for severe bleeding while on ECMO, with no thrombotic effect on the ECMO circuit. CONCLUSION ECMO as rescue support should be considered in a timely fashion for refractory hypoxemic respiratory failure resulting from S. aureus pneumonia, including patients with necrotizing pneumonia. Use of ECMO support in such cases, coupled with aggressive measures aimed at minimizing bleeding, such as the use of activated factor VII, may result in excellent short- and long-term outcomes for such patients.
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Affiliation(s)
- Michael H Stroud
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR 72202, USA.
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Affiliation(s)
- Desmond Bohn
- University of Toronto, Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8.
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Mahle WT, Forbess JM, Kirshbom PM, Cuadrado AR, Simsic JM, Kanter KR. Cost-utility analysis of salvage cardiac extracorporeal membrane oxygenation in children. J Thorac Cardiovasc Surg 2005; 129:1084-90. [PMID: 15867784 DOI: 10.1016/j.jtcvs.2004.08.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Indications for extracorporeal membrane oxygenation therapy have expanded to include cardiopulmonary arrest and support after congenital heart surgery. Data from a national registry have reported that cardiac patients have the poorest survival of all extracorporeal membrane oxygenation recipients. Concerns have been raised about the appropriateness of such an aggressive strategy, especially in light of the high costs and potential for long-term neurologic disability. We reviewed our experience with salvage cardiac extracorporeal membrane oxygenation to determine the cost-utility, which accounts for both costs and quality of life. METHODS Medical records of patients with congenital heart disease receiving salvage cardiac extracorporeal membrane oxygenation between January 2000 and May 2004 were reviewed. Charges for all medical care after the institution of extracorporeal membrane oxygenation were determined and converted to costs by published standards. The quality-of-life status of survivors was determined with the Health Utilities Index Mark II. RESULTS Salvage cardiac extracorporeal membrane oxygenation was instituted in 32 patients (18 for cardiopulmonary arrest and 14 for cardiac failure after heart surgery) at a median age of 2.0 months (range, 4 days to 5.1 years). Congenital heart disease was present in 27 (84%). The mean duration of extracorporeal membrane oxygenation support was 5.1 +/- 4.1 days. Survival to hospital discharge was 50%, including 1 patient bridged to heart transplantation. Survival to 1 year was 47%. The mean score of the Health Utilities Index for the survivors was 0.75 +/- 0.19 (range, 0.41-1.0). The median cost for hospital stay after the institution of extracorporeal membrane oxygenation was USD 156,324 per patient. The calculated cost-utility for salvage extracorporeal membrane oxygenation in this population was USD 24,386 per quality-adjusted life-year saved, which would be considered within the range of accepted cost-efficacy (< USD 50,000 per quality-adjusted life-year saved). CONCLUSIONS Salvage cardiac extracorporeal membrane oxygenation results in reasonable survival and is justified on a cost-utility basis.
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Affiliation(s)
- William T Mahle
- Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, 52 Executive Park S., Suite 523, Atlanta, GA 30329, USA.
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Abstract
Extracorporeal membrane oxygenation (ECMO) is the utilization of a modified heart-lung machine to provide temporary support for patients with severe respiratory or cardiac failure. In contrast to patients managed with traditional cardiopulmonary bypass, patients on ECMO undergo cannulation of relatively accessible blood vessels, are maintained at normal body temperature, and only require partial anticoagulation with heparin. Although first developed for use in adults, ECMO has been most successful in the treatment of newborn infants with life-threatening pulmonary failure. Since 1974, over 17,000 infants have received ECMO with a 78% survival rate. There is a 15%-20% incidence of neurodevelopmental disabilities among ECMO survivors.
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Affiliation(s)
- Philip J Wolfson
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Fortenberry JD, Meier AH, Pettignano R, Heard M, Chambliss CR, Wulkan M. Extracorporeal life support for posttraumatic acute respiratory distress syndrome at a children's medical center. J Pediatr Surg 2003; 38:1221-6. [PMID: 12891497 DOI: 10.1016/s0022-3468(03)00272-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Primary traumatic injury was considered previously a contraindication for institution of extracorporeal life support because of high risk for persistent or new bleeding. Published experience in adults suggests that extracorporeal membrane oxygenation (ECMO) can successfully support trauma victims with pulmonary failure. The authors reviewed their experience with the use of ECMO in pediatric and adult trauma patients with acute respiratory distress syndrome (ARDS) at a children's medical center. METHODS ECMO Center records from 1991 through 2001 (76 children, 8 adults) were reviewed to identify all patients with a primary or secondary ICD-9 diagnostic code of posttraumatic ARDS in addition to documented trauma. RESULTS Five children and 3 adults with traumatic injury and ARDS received ECMO support. Seven patients were injured in motor vehicle collisions; one patient suffered a gunshot wound to the chest. Patient ages ranged from 21 months to 29 years (pediatric median, 4 years; range, 21 months to 18 years). Four patients had pre-ECMO laparotomies, including 3 who required splenectomy. Four patients had liver lacerations, 3 had pulmonary contusions, and 1 had a renal contusion. Median ventilation before ECMO was 6 days (range, 2 to 10). Seven of 8 patients were placed on venovenous (VV) ECMO. Seven patients had significant bleeding on ECMO. Patients were treated with blood product replacement, epsilon-aminocaproic acid (EACA), and aprotinin infusions. Surgical intervention was not required for bleeding. Six patients received hemofiltration. Median time on ECMO was 653 hours (range, 190 to 921 hours). Six of 8 patients overall survived (75%). Four of 5 pediatric patients survived. CONCLUSIONS Children and adults with severe posttraumatic ARDS can be treated successfully on VV extracorporeal support. Hemorrhage occurs frequently but is manageable.
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Affiliation(s)
- James D Fortenberry
- Center for ECMO and Advanced Technologies and Critical Care Division, Children's Healthcare of Atlanta at Egleston, Atlanta, GA 30322, USA
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Jacobs P, Finer NN, Fassbender K, Hall E, Robertson CMT. Cost-effectiveness of inhaled nitric oxide in near-term and term infants with respiratory failure: eighteen- to 24-month follow-up for Canadian patients. Crit Care Med 2002; 30:2330-4. [PMID: 12394963 DOI: 10.1097/00003246-200210000-00023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this article is to conduct a cost-effectiveness analysis, based on data up to 18-24 months of follow-up, of the use of inhaled nitrogen oxide vs. oxygen, administered to near-term and term infants with severe respiratory failure who were referred for consideration for extracorporeal membrane oxygenation. DESIGN The cost-effectiveness analysis was conducted alongside a randomized controlled trial conducted by the Canadian Inhaled Nitric Oxide Study Group for patients with severe respiratory distress. SETTING Patients were cared for in Canadian regional neonatal intensive care units; follow-up treatment was based on standard care. PATIENTS Term and near-term neonates with severe respiratory failure determined by at least two oxygenation indexes (oxygenation index = mean arterial pressure x Fio2/Pao2) >/=25 at least 15 mins apart. INTERVENTIONS Patients were randomized to inhaled nitrogen oxide or oxygen. If conditions deteriorated, they qualified for extracorporeal membrane oxygenation. Not all who qualified received extracorporeal membrane oxygenation. Standard care followed after hospital discharge. MEASUREMENTS AND MAIN RESULTS Timelines of analysis were from randomization until the follow-up, which occurred between 18 and 24 months after randomization. Costs included those for initial hospitalization (neonatal intensive care, medications, extracorporeal membrane oxygenation, transport) and standard medical services above routine care and developmental services received until follow-up. Outcomes included mortality rate, clinical outcomes, and a variety of neurodevelopmental indicators. Costs were not significantly different between interventions. While infants who received inhaled nitrogen oxide generally did better than those who received oxygen, the only variable that was significant was the number of seizure disorders. On economic grounds, inhaled nitrogen oxide was the preferred intervention.
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Affiliation(s)
- Philip Jacobs
- Department of Public Health, University of Alberta and the Institute of Health Economics, Edmonton, Canada.
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Abstract
Physicians are in the beginning of an era in intensive care medicine in which they finally are starting to see improved outcomes in patients with AHRF. At the same time, intensivists are presented with a bewildering choice of ventilator options and adjunctive therapies. Trying to sort out which are "cosmetic," that is, improve the blood gases as opposed to influencing the outcome, remains a challenge and will be resolved only with additional RCTs. Principles of ventilator management that are driven by mimicking normal physiology are inappropriate and must be rethought.
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Affiliation(s)
- D Bohn
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Vats A, Pettignano R, Culler S, Wright J. Extracorporeal life support in pediatric acute respiratory failure: we can afford it AND need it. Crit Care Med 2000; 28:1690-1. [PMID: 10834756 DOI: 10.1097/00003246-200005000-00094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jones GD, Hatherill M, Murdoch IA. Excessive predicted mortality in acute hypoxemic respiratory failure? Crit Care Med 2000; 28:600-1. [PMID: 10708221 DOI: 10.1097/00003246-200002000-00068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Excessive Predicted Mortality in Acute Hypoxemic Respiratory Failure? Crit Care Med 2000. [DOI: 10.1097/00003246-200002000-00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Spear RM, Fackler JC. Extracorporeal membrane oxygenation and pediatric acute respiratory distress syndrome: we can afford it, but we don't need it. Crit Care Med 1998; 26:1486-7. [PMID: 9751582 DOI: 10.1097/00003246-199809000-00012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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