Extracorporeal Membrane Oxygenation in a Patient with Biliary Atresia: Case and Review of Extracorporeal Life Support Organization Data

Is there a role for extracorporeal membrane oxygenation in children with acute liver failure? A retrospective analysis of the Extracorporeal Life Support Organization Registry

Data describing the use of extracorporeal membrane oxygenation (ECMO) in pediatric acute liver failure (PALF) are scarce. Thus, we aimed to describe the use of ECMO in patients with PALF using the data from the Extracorporeal Life Support Organization (ELSO) Registry between January 1, 2010, to December 31, 2022. We described patients' characteristics at ECMO initiation, outcome, and factors associated with mortality. A total of 335 children underwent ECMO support in the context of PALF. Veno-arterial (VA) ECMO was the most prevalent mode (66.6%), followed by veno-venous (VV) ECMO (33.4%). Extracorporeal cardiopulmonary resuscitation (ECPR) was used in 21.5% of the cardiac arrest. In-hospital mortality was 66.6%. Both higher lactate (OR 1.128, CI 1.06-1.209, p < 0.001) and PaCO2 (OR 1.022, CI 1.001-1.047, p 0.05) levels before ECMO reported greater odds of mortality. Low body weight, persistence of hyperlactatemia (OR 0.985, CI 0.973-0.997, p 0.013), and hyperbilirubinemia (OR 2.477, CI 1.042-6.100, p 0.045) after 24 h from ECMO deployment were associated to greater odds of mortality.

CONCLUSIONS

Our results suggest that the use of ECMO for the management of respiratory and cardiac failure in patients with PALF should be considered with caution and that further research is needed to understand its role in this specific high-risk population.

WHAT IS KNOWN

• Pediatric acute liver failure (PALF) is a clinical syndrome associated with significant morbidity and mortality. • Data on the use of extracorporeal membrane oxygenation (ECMO) in the context of PALF are scarce and controversial.

WHAT IS NEW

• ECMO to manage acute respiratory and/or cardiac failure in the context of PALF should be considered with caution. • Bleeding and thrombotic complications in children with acute liver failure receiving ECMO are similar to the ones reported in the general pediatric population.

Extracorporeal Membrane Oxygenation After Liver Transplant in Children: A Review of the ELSO Registry

There are minimal data describing use of extracorporeal membrane oxygenation (ECMO) in pediatric patient after a liver transplantation (LT). This study aimed at describing ECMO run in this specific situation using the data from Extracorporeal Life Support Organization (ELSO) Registry between January 1, 2010, to December 31, 2022. We described patients' characteristics at ECMO initiation, outcome and mortality risk factors. We identified 27 patients with a median age of 2.7 years (interquartile range (IQR) = 1.5-9.9). Main indication for ECMO support was respiratory (14/27 [52%]) followed by extracorporeal cardiopulmonary resuscitation (ECPR) (7/27 [26%]) and cardiac (6/27 [22%]). Overall in-hospital mortality was 63% (17/27). Mortality rate according to ECMO indications was 50% for both respiratory and cardiac failure and reached 100% for ECPR patients. Overall, nonsurvivors experienced significantly more complications under ECMO support ( p = 0.007). Main on-ECMO complications were hemorrhagic (11/27 [41%]) and thrombotic (7/27 [26%]). No clinical or biologic factors was predictive of patients' outcome. Our results suggest that ECMO support is a viable option for cardiac and respiratory indications after pediatric LT. Occurrence of complications while on ECMO are associated with unfavorable outcomes. The extremely high mortality rate in ECPR patients merits further research.

Extracorporeal Membrane Oxygenation in Pediatric Liver Transplantation: A Multicenter Linked Database Analysis and Systematic Review of the Literature

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) can be used to maintain oxygen delivery and provide hemodynamic support in case of circulatory and respiratory failure. Although the role of ECMO has emerged in the setting of adult liver transplantation (LT), data in children are limited. We aimed to describe the characteristics and outcomes of children receiving ECMO support at the time of or following LT.

METHODS

All pediatric LT recipients (≤20 y) requiring ECMO support peri-/post-LT were identified from a linked Pediatric Health Information System/Scientific Registry of Transplant Recipients dataset (2002-2018). The Kaplan-Meier method and Cox regression analysis were used to assess post-ECMO survival. A systematic literature review was conducted in accordance with the PRISMA statement.

RESULTS

Thirty-four children required ECMO peri-/post-LT. The median time from LT to ECMO was 5 d (interquartile range, 0.0-12.3), and the median ECMO duration was 1 d (interquartile range, 1.0-6.3). Children started on ECMO within 1 d of LT exhibited superior survival compared with those started on ECMO later (P = 0.03). When adjusting for recipient weight, increasing time from LT to ECMO initiation was associated with increased risk of mortality (hazard ratio, 1.03; 95% confidence interval, 1.00-1.06; P = 0.049). Overall, 55.9% (n = 19 of 34) of the patients survived. Twenty-two children receiving ECMO in the peri-/post-LT period were systematically reviewed, and 15 of them survived (68.2%).

CONCLUSIONS

With an encouraging >55% patient survival at 6 mo, ECMO should be considered as a viable option in pediatric LT recipients with potentially reversible severe respiratory or cardiovascular failure refractory to conventional treatment.