Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines

Extracorporeal Membrane Oxygenation in Pediatric Patients With Congenital Heart Disease: Surgical Considerations

The use of extracorporeal membrane oxygenation (ECMO) in the paediatric population has increased over time, with the ability to rescue pulmonary and cardiovascular deterioration. ECMO can be utilised by neonates and children with congenital heart disease in both preoperative and postoperative settings to improve survival and minimise morbidity. ECMO cannulation strategy must be tailored to the age, weight, and physiologic state of the patient. Careful patient selection and rapid deployment of ECMO may improve survival and morbidity in patients with congenital heart disease.

Extracorporeal membrane oxygenation (ECMO) in pediatric congenital heart disease: a comprehensive review

BACKGROUND

Extracorporeal membrane oxygenation (ECMO), which provides life-saving assistance in severe cardiac and pulmonary failure cases, has emerged as an important technique in managing children with congenital heart disease (CHD).

MAIN BODY

In this review, we discuss the evolution of ECMO over the years, its clinical uses, and the results in pediatric CHD. ECMO has been utilized as a bridge to recovery, in stabilizing an individual after surgery, and as a bridge to heart transplantation. Cannulation procedures that are adjusted according to the anatomy of an individual have improved outcomes, although bleeding and neurologic concerns remain a matter of concern. In addition, long-term neurodevelopmental disorders and renal failure are also among the alarming outcomes. The use of newer anticoagulant drugs like bivalirudin, which lowers the risk of bleeding, and genomic testing for personalized treatment are examples of recent developments. Furthermore, neuroprotective techniques such as erythropoietin and dexmedetomidine can also enhance the neurocognitive outcomes. Finally, improvements in monitoring systems and pump technology contribute to increased ECMO efficacy and safety.

CONCLUSION

Despite these developments, ECMO's expense and restricted accessibility remain major obstacles, especially in areas with low resources. In this review, the advancements in ECMO technology and care are highlighted, and it also emphasizes future research to address the current challenges.

Conventional Cardiopulmonary Resuscitation Versus Extracorporeal Membrane Oxygenation-Assisted CPR in Children: A Retrospective Analysis of Outcomes and Factors Associated with Conversion from the Former to the Latter

BACKGROUND/OBJECTIVES

Conventional cardiopulmonary resuscitation (CCPR) has been the foundational resuscitation approach for decades. Where CCPR is unsuccessful, extracorporeal membrane oxygenation-assisted CPR (ECPR) may improve outcomes. Predicting failure of CCPR and immediate need for ECPR is difficult, and data are lacking. In this retrospective analysis, we analysed both factors that are associated with conversion from CCPR to ECPR and survival outcomes for each event.

METHODS

Patients having a CPR event that occurred in the PICU between 2016 and 2022 were included. Pre-CPR-event clinical and laboratory data were collected. We recorded whether CPR was converted to ECPR and documented patient outcomes.

RESULTS

201 CPR events occurred in 164 children, with 45 events converted from CCPR to ECPR. Time to ROSC or time to ECMO flow was (median [IQR]) 2 (1.5) min for CCPR events and 37 (21.60) min for ECPR events. The maximum pre-CPR-event lactate values were 1.8 mmol/L for CCPR and 4.5 mmol/L for ECPR events. Respiratory arrest preceded 35.3% of CCPR and 4.4% of ECPR events. PICU mortality was 27.8% for CCPR and 50% for ECPR events. Most deaths occurred because of withdrawal of life-sustaining treatments. In a multivariable analysis, cardiac surgical diagnosis, pre-CPR-event lactate, as well as duration of CPR were associated with conversion from CCPR to ECPR.

CONCLUSIONS

Our study demonstrates that pre-CPR-event lactate concentrations and duration of arrest should alert clinicians to a high likelihood of needing ECPR, while a preceding respiratory arrest may indicate a low likelihood. Mortality post CCPR is significant, mainly due to overall illness severity rather than the consequences of the CPR event.

Perioperative extracorporeal membrane oxygenation in neonates with transposition of the great arteries: 15 years of experience

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) can act as a bridge to recovery in both pre- and postoperative patients with transposition of the great arteries (TGA). However, literature on its use in these patients is scarce.

METHODS

Retrospective single-centre cohort study encompassing all TGA patients who received ECMO between January 2009 and March 2024.

RESULTS

Twenty-two neonates received ECMO during the study period, with an overall median age and weight at time of ECMO cannulation of 6.5 (1.8-10) days and 3.7 (3.3-4.0) kg, respectively. Twelve neonates received ECMO prior to the arterial switch operation because of severe persistent pulmonary hypertension (83%), respiratory failure due to severe pulmonary atelectasis (8%) or hypoxia after pulmonary arterial banding procedure (8%). Postoperative ECMO was used in 11 patients; of these, 1 (9%) had also received ECMO preoperatively. Postoperative indications for the remaining patients included failure to wean from cardiopulmonary bypass (50%), low cardiac output in Intensive Care Unit (20%), or after cardiopulmonary arrest (30%). Overall, median ECMO duration for all TGA patients was 75 (45-171) h, with a survival rate of 59% to hospital discharge. Among the preoperative ECMO patients, 5 patients (42%) died (4 preoperatively, 1 postoperatively performed while on ECMO). In the postoperative ECMO group, survival rate was 60%.

CONCLUSIONS

In this single-centre retrospective study, TGA neonates received ECMO preoperatively primarily for severe pulmonary hypertension and postoperatively for failure to wean from cardiopulmonary bypass. This study showed a 58% and 60% survival to hospital discharge in ECMO patients supported preoperatively and those supported postoperatively, respectively.

Extracorporeal cardiopulmonary resuscitation outcomes in pre-Glenn single ventricle infants: Analysis of a ten-year dataset

BACKGROUND

While several studies have reported on outcomes of extracorporeal membrane oxygenation (ECMO) in patients with single ventricle physiology, few studies have described outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) in this unique population. The objective of this study was to determine survival and risk factors for mortality after ECPR in single ventricle patients prior to superior cavopulmonary anastomosis, using a large sample from the Extracorporeal Life Support Organization (ELSO) Registry.

METHODS

We included single ventricle patients who underwent ECPR for in-hospital cardiac arrest (IHCA) between January 2012 and December 2021. We excluded patients who had undergone a superior cavopulmonary anastomosis, inferior cavopulmonary anastomosis, or who were older than 180 days at the time of ECPR. We collected data on mortality, ECMO course and ECMO complications. Subjects who survived to hospital discharge after ECPR were compared to subjects who did not survive to hospital discharge. We then performed univariate logistic regression followed by multivariable logistic regression analysis for associations with survival to hospital discharge.

RESULTS

There were 420 subjects included who had index ECPR events. Median age was 14 (IQR 7,44) days and median weight was 3.14 (IQR 2.8, 3.8) kg.. Hypoplastic left heart syndrome was the most common diagnosis (354/420; 84.2%), and 47.4% of the cohort (199/420) had undergone a Norwood operation. Survival to hospital discharge occurred in 159/420 (37.9%) of subjects. Median number of hours on ECMO (122 vs. 93 h; p < 0.001), presence of seizures by electroencephalography (24% vs. 15%; p = 0.033), and need for renal replacement therapy (45% vs. 34%; p = 0.023) were significantly higher among non-survivors compared to survivors. In the subgroup of Norwood patients, survival was 43.2% after ECPR. Presence of Norwood variable was 54% among ECPR survivors in the overall cohort, compared to 43% among non-survivors (p = 0.032). In a multivariable logistic regression model to test association with survival to discharge, number of ECMO hours and presence of seizures were associated with decreased odds of survival to hospital discharge [adjusted odds ratio 0.95 (95% C.I. 0.92-0.98) and 0.57 (95% C.I. 0.33-0.97) respectively]. The odds ratio for ECMO hours demonstrated a decrease in odds of survival by 5% for every 12 h on ECMO. Presence of Norwood operation pre-arrest was associated with increased odds of survival [adjusted odds ratio 1.53 (95% C.I. 1.01-2.32)].

CONCLUSION

In our cohort of pre-Glenn single ventricle infants, survival after ECPR for in-hospital cardiac arrest was 37.9%. Number of hours on ECMO and seizures post-ECMO cannulation were associated with decreased odds of survival. Single ventricle infants who had undergone Norwood palliation pre-arrest were more likely to survive to hospital discharge.

Plasma brain-related biomarkers and potential therapeutic targets in pediatric ECMO

Extracorporeal membrane oxygenation (ECMO) is a technique used to support severe cardiopulmonary failure. Its potential life-saving benefits are tempered by the significant risk for acute brain injury (ABI), from both primary pathophysiologic factors and ECMO-related complications through central nervous system cellular injury, blood-brain barrier dysfunction (BBB), systemic inflammation and neuroinflammation, and coagulopathy. Plasma biomarkers are an emerging tool used to stratify risk for and diagnose ABI, and prognosticate neurofunctional outcomes. Components of the neurovascular unit have been rational targets for this inquiry in ECMO. Central nervous system (CNS) neuronal and astroglial cellular-derived neuron-specific enolase (NSE), tau, glial fibrillary acidic protein (GFAP) and S100β elevations have been detected in ABI and are associated with poorer outcomes. Evidence of BBB breakdown through peripheral blood detection of CNS cellular components NSE, GFAP, and S100β, as well as evidence of elevated BBB components vWF and PDGFRβ are associated with higher mortality and worse neurofunctional outcomes. Higher concentrations of pro-inflammatory cytokines (IL-1β, IL-6, IFN-γ, TNF-α) are associated with abnormal neuroimaging, and proteomic expression panels reveal different coagulation and inflammatory responses. Abnormal coagulation profiles are common in ECMO with ongoing studies attempting to describe specific abnormalities either being causal or associated with neurologic outcomes; vWF has shown some promise. Understanding these mechanisms of injury through biomarker analysis supports potential neuroprotective strategies such as individualized blood pressure targets, judicious hypercarbia and hypoxemia correction, and immunomodulation (inhaled hydrogen and N-acetylcysteine). Further research continues to elucidate the role of biomarkers as predictors, prognosticators, and therapeutic targets.

Extracorporeal membrane oxygenation: unmet needs and perspectives

Extracorporeal Membrane Oxygenation (ECMO) has become an essential lifesaving intervention for individuals with severe cardiovascular and respiratory failure. Its application is expanding across several therapeutic contexts, surpassing conventional indications. The COVID-19 pandemic has significantly stressed worldwide health systems to manage acute respiratory failure. ECMO has been employed as a vital intervention, particularly for patients with severe COVID-19-induced acute respiratory distress syndrome (ARDS). ECMO is applicable throughout pregnancy. The principal indications for ECMO in pregnant women align with those in the general population. However, pregnancy complicates issues, necessitating consideration of both mother's and infant's well-being. Patients with systemic rheumatic diseases are prone to experience life-threatening complications. While a majority of these patients respond to immunosuppressive drugs, a small percentage suffer organ failure and may benefit from ECMO as a bridge to recovery. The article addresses coagulation therapies, highlighting the necessity of precise anticoagulation to avert both bleeding and thrombosis, particularly in patients requiring extended ECMO support. Additionally, the pharmacokinetics of antibiotics in ECMO patients are summarized, including the influence of the ECMO circuit on drug metabolism. Survey-based research offers valuable insights into ECMO use, procedures, and challenges. The paper evaluates current survey-based research and ECMO guidelines, highlighting clinical practice, training, and resource availability discrepancies across ECMO centers globally. Particular focus is placed on the rehabilitation requirements of ECMO survivors, acknowledging the importance of early mobilization and post-discharge care in improving long-term outcomes and quality of life.

Outcomes in pediatric extracorporeal cardiopulmonary resuscitation: A single-center retrospective study from 2007 to 2022 in China

OBJECTIVE

We aimed to investigate the prognostic factors of pediatric extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

The retrospective study included a total of 77 pediatric cases (7 neonates and 70 children) who underwent ECPR after in-hospital and out-of-hospital cardiac arrest between July 2007 and December 2022. Primary endpoints were complications, while secondary endpoints included all-cause in-hospital mortality.

RESULTS

Among the 45 cases experiencing complications, 4 neonates and 41 children had multiple simultaneous complications, primarily neurological issues in 25 cases. Additionally, organ failure occurred in 11 cases, and immunodeficiency was present in two cases. Furthermore, 9 cases experienced bleeding events, and 13 cases showed thrombosis. Patients with complications had lower weight, shorter ECMO durations, and longer CPR durations. Non-survivors had longer CPR durations and shorter durations of ECMO, ICU stay, and mechanical ventilation compared to survivors. Complications were more prevalent in non-survivors, particularly organ failure and bleeding events.

CONCLUSION

Weight, CPR duration, and ECMO duration were associated with complications, suggesting areas for treatment optimization. The higher occurrence of complications in non-survivors underscores the importance of early detection and management to improve survival rates. Our findings suggest clinicians consider these factors in prognostic assessments to enhance the effectiveness of ECPR programs.

Extracorporeal cardiopulmonary resuscitation outcomes for children with out-of-hospital and emergency department cardiac arrest

OBJECTIVE

Data suggest extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in adult patients with refractory cardiac arrest; however, ECPR outcomes in pediatric patients with out-of-hospital cardiac arrest (OHCA) is lacking. The primary aim of this study was to characterize pediatric patients who experience OHCA or cardiac arrest in the ED (EDCA). The secondary aim was to examine associations of cardiac arrest and location of ECPR cannulation with mortality.

METHODS

We performed a retrospective analysis of the Extracorporeal Life Support Organization registry. We included pediatric patients (age > 28 days to <18 years) who received ECPR for refractory OHCA or EDCA between 2010 and 2019. Patient, cardiac arrest, and ECPR cannulation characteristics were summarized. We examined associations of location of cardiac arrest and ECPR cannulation with in-hospital mortality using multivariable logistic regression.

RESULTS

We analyzed data from 140 pediatric patients. 66 patients (47%) experienced OHCA and 74 patients (53%) experienced EDCA. Overall survival to hospital discharge was 31% (20% OHCA survival vs. 41% EDCA survival, p = 0.008). In adjusted analyses, OHCA was associated with 3.9 times greater odds of mortality (95% confidence interval [CI] 1.61, 9.81) when compared to compared to EDCA. The location of ECPR cannulation was not associated with mortality (odds ratio 1.8, 95% CI 0.75, 4.3).

CONCLUSIONS

The use of ECPR for pediatric patients with refractory OHCA is associated with poor survival compared to patients with EDCA. Location of ECPR cannulation does not appear to be associated with mortality.

What's new in pediatric critical care?

Pediatric intensive care medicine is a rapidly evolving field of medicine, with recent publication of landmark papers specific for the pediatric population. Progress has been made in modes of mechanical ventilation, including noninvasive ventilation in pediatric ARDS and after extubation failure, with updated guidelines on ventilator liberation. Improved technology and advancements in hemodynamic support allow for better care of our patients with heart disease. Sepsis burden in children remains high and continued efforts are made to improve survival. A nutritional plan with a tailored approach, focusing on individualized needs, could offer benefits for our patients. Sedation practices and guidelines have been updated, focusing on minimizing delirium and facilitating early mobility. This manuscript highlights some of the most recent advances and updates.

Outcomes of protocol-based management for venoarterial extracorporeal membrane oxygenation in congenital heart surgery - A 2-decade experience

Background

Extracorporeal membrane oxygenation (ECMO) is a vital mechanical circulatory support used with increasing frequency in complex congenital cardiac surgeries. This study evaluated the outcomes of a protocol-based venoarterial (VA) ECMO program following congenital heart surgeries.

Methods and Results

This was a retrospective review of 198 patients who underwent VA-ECMO after congenital cardiac surgeries at our institute between 2004 and 2023. Patients were divided into pre-ECMO protocol (2004-2017) and post-ECMO protocol (2018-2023) implementation. There were 107 patients in the preprotocol era and 91 in the postprotocol era. We compared weaning from ECMO and survival to hospital discharge between the two eras. An analysis of the factors influencing survival to hospital discharge was also done. ECMO was initiated through the central cannulation technique through median sternotomy in all patients. The median age and weight at initiation were 4 months (interquartile range [IQR] 1-33.5 months) and 4.4 kg (IQR 3.3-10.1 kg), respectively. The successful weaning of the ECMO (n = 67/91, 73.6%) and survival to discharge (n = 43/91, 47.3%) were higher in patients of the postprotocol era. However, it was not statistically significant. Higher risk adjustment for congenital heart surgery-1 >3 and acute kidney injury were independent predictors of poorer survival to hospital discharge.

Conclusions

A protocol-based ECMO program may improve outcomes of successful weaning and survival to discharge in patients undergoing congenital cardiac surgeries.

The Role of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Intraoperative Cardiac Arrest

Refractory pediatric intraoperative cardiac arrest is a rare but challenging situation for the anesthesiologist. This case describes an intraoperative extracorporeal cardiopulmonary resuscitation (ECPR) in a 16-year-old male who suffered a sudden cardiac arrest during elective thoracolumbar stabilization. The patient recovered to his pre-operative baseline without any neurological sequela secondary to cardiac arrest. Good quality of conventional resuscitation measures, prompt activation of the extracorporeal membrane oxygenation (ECMO) team, and a multidisciplinary coordinated approach were key factors in ECPR success. Despite the lack of robust evidence in pediatrics, case reports like ours outline the life-saving potential of intraoperative ECPR in refractory cardiac arrest scenarios.

The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO

Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.

Outcomes of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest Among Children With Noncardiac Illness Categories

OBJECTIVES

The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years.

DESIGN

Retrospective multicenter cohort study.

SETTING

Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021.

PATIENTS

Children (<18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model estimated the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR utilization. Of 875 patients, 159 received ECPR and 716 received CCPR. The median age was 1.0 [interquartile range: 0.2-7.0] year. Most patients (597/875; 68%) had a primary diagnosis of respiratory insufficiency. Median CPR duration was 45 [35-63] minutes. ECPR use increased over time ( p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis ( p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 [95% CI, 0.84-2.40; p = 0.19]). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge.

CONCLUSIONS

ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability).

Neurological Resilience in Patients With Anorexia Nervosa Following Prolonged Cardiopulmonary Resuscitation

Anorexia nervosa (AN) is a psychiatric disorder with metabolic abnormalities. Prolonged cardiopulmonary resuscitation (CPR) is predicted to result in death and poor neurological outcomes. This report describes the case of a patient with AN who had an unexpectedly favorable outcome after prolonged CPR. A 12-year-old female with AN presented to the emergency department, requiring intubation due to worsening consciousness and respiratory distress. Refractory hypotension led to cardiac arrest. After 135 minutes of CPR, venoarterial extracorporeal membrane oxygenation (EMCO) was started, and the patient was treated for post-resuscitation management, refeeding syndrome, and sepsis. The cardiac function gradually improved, the patient was weaned from EMCO eight days after admission, and the patient was extubated 30 days after admission. The patient maintained a good central nervous system function. AN patients tend to be youngsters and have a lower metabolism, which may be associated with a favorable neurological prognosis after prolonged CPR.

Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification

BACKGROUND

Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics.

METHODS

In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management.

RESULTS

For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication.

CONCLUSION

Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.

Development and assessment of novel assist device for cardiac cannulation

PURPOSE

Congenital heart defects are the most common birth defects in the USA and in 25% of cases need to be treated with cardiovascular interventions. One of such interventions is the postoperative use of an extracorporeal membrane oxygenation (ECMO) machine for the treatment of cardiorespiratory failure. The process of placing the patient on the ECMO is extremely time-critical and requires the use of cardiac cannulation. For the first time, our team developed and evaluated a new quick-connect cannulation system that allows for rapid, easy, and safe ECMO cannulation in the pediatric population. The design should eliminate the need for purse-string sutures that are currently used to secure cannulas, as the cannulas will be inserted through a port that is glued to the cardiovascular tissue.

METHODS

The rapid cannulation assistance device was designed on the SolidWorks computer-aided design software using the dimensions of the commercially available arterial and venous catheters. These designs were then 3D printed, and tensile testing was performed. Then, a flow loop was developed, and cannulation was performed and analyzed on both 3D-printed hearts and porcine hearts.

RESULTS

The rapid cannulation assistance device was designed and 3D printed. Tensile testing found that the parts were strong enough to withstand forces that may be introduced in studies. 3D-printed and porcine heart tests with a flow loop found no leakage with the 3D-printed hearts but minimal leaking with the porcine hearts. However, this leakage was observed at the junction between the device and the heart, leading us to believe that a glue better suited to attach the device to the heart would prevent leakage in the future.

CONCLUSIONS

This project successfully demonstrated how a rapid cannulation assistance device could be developed and tested. Future studies will be conducted that address device adhesion to the cardiovascular tissue so that accurate pressure and flow rates can be measured. Future studies will also include testing the device in a fluid environment to more effectively analyze the device success and comparing the time required to cannulate using our device compared to the standard of care.

Outcome of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Patients Without Congenital Cardiac Disease: Extracorporeal Life Support Organization Registry Study

OBJECTIVES

To describe the use of extracorporeal cardiopulmonary resuscitation (ECPR) in pediatric patients without congenital heart disease (CHD) and identify associations with in-hospital mortality, with a specific focus on initial arrest rhythm.

DESIGN

Retrospective cohort study using data from pediatric patients enrolled in Extracorporeal Life Support Organization (ELSO) registry between January 1, 2017, and December 31, 2019.

SETTING

International, multicenter.

PATIENTS

We included ECPR patients under 18 years old, and excluded those with CHD. Subgroup analysis of patients with initial arrest rhythm.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 567 patients: neonates (12%), infants (27%), children between 1 and 5 years old (25%), and children over 5 years old (36%). The patient cohort included 51% males, 43% of White race, and 89% not obese. Most suffered respiratory disease (26%), followed by acquired cardiac disease (25%) and sepsis (12%). In-hospital mortality was 59%. We found that obesity (adjusted odds ratio [aOR], 2.28; 95% CI, 1.21-4.31) and traumatic injury (aOR, 6.94; 95% CI, 1.55-30.88) were associated with greater odds of in-hospital mortality. We also identified lower odds of death associated with White race (aOR, 0.64; 95% CI, 0.45-0.91), ventricular tachycardia (VT) as an initial arrest rhythm (aOR, 0.36; 95% CI, 0.16-0.78), return of spontaneous circulation before cannulation (aOR, 0.56; 95% CI, 0.35-0.9), and acquired cardiac disease (aOR, 0.43; 95% CI, 0.29-0.64). Respiratory disease was associated with greater odds of severe neurologic complications (aOR, 1.64; 95% CI, 1.06-2.54).

CONCLUSIONS

In children without CHD undergoing ECPR, we found greater odds of in-hospital mortality were associated with either obesity or trauma. The ELSO dataset also showed that other variables were associated with lesser odds of mortality, including VT as an initial arrest rhythm. Prospective studies are needed to elucidate the reasons for these survival differences.

Interprofessional Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation Simulations Aimed at Decreasing Actual Cannulation Times: A Longitudinal Study

BACKGROUND

Since 2013, the cardiac intensive care unit (CICU) at Children's National has conducted annual extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) simulations that focus on team dynamics, room setup, and high-quality CPR. In 2019 and 2020, the simulations were expanded to include the surgical and extracorporeal membrane oxygenation (ECMO) teams in an effort to better understand and improve this process.

METHODS

During a 4-week period in 2019, 7 peripheral ECPR simulations were conducted, and through a 3-week period in 2020, 7 central ECPR simulations were conducted. Participants in each session included: 8 to 10 CICU nurses, 1 CICU attending, 1 to 2 ICU or cardiology fellows, 1 cardiovascular surgery fellow or attending, and 1 ECMO specialist. For each session, the scenario continued until the simulated patient was on full cardiopulmonary bypass. An ECMO trainer was used for peripheral simulations and a 3-dimensionally-printed heart was used for central cannulations. An ECMO checklist was used to objectively determine when the patient and room were fully prepared for surgical intervention, and simulated cannulation times were recorded for both groups. A retrospective chart review was conducted to compare actual cannulation times before and after the intervention period, and video was used to review the events and assist in dividing them into medical versus surgical phases. Control charts were used to trend the total ECPR times before and after the intervention period, and mean and P values were calculated for both ECPR times and for all other categorical data.

RESULTS

Mean peripheral ECPR times decreased significantly from 71.7 to 45.1 minutes ( P = 0.036) after the intervention period, and this was reflected by a centerline shift. Although we could not describe a similar decrease in central ECPR times because there were only 6 postintervention events, the times for each of these events were shorter than the historical mean of 37.8 minutes. There was a trend in improved survival, which did not meet significance both among patients undergoing peripheral ECPR (15.4% ± 10% to 43.8% ± 12.4%, P = 0.10) and central ECPR (36.4% ± 8.4% to 50% ± 25%, P = 0.60). The percentage of time dedicated to the medical phases of the actual versus simulated procedures was very consistent among both peripheral (33.0% vs. 31.9%) and central (39.6% vs. 39.8%) cannulations.

CONCLUSIONS

We observed a significant decrease in peripheral cannulation times at our institution after conducting interprofessional ECPR simulations taken to the establishment of full cardiopulmonary bypass. The use of an ECMO trainer and a 3-dimensionally-printed heart allowed for both the medical and surgical phases of the procedure to be studied in detail, providing opportunities to streamline and improve this complex process. Larger multisite studies will be needed in the future to assess the effect of efforts like these on patient survival.

Bivalirudin or heparin for systemic anticoagulation during pediatric extracorporeal membrane oxygenation: Multicenter retrospective study

BACKGROUND

The objective of this study is to evaluate the outcomes of unfractionated heparin (UFH) compared to bivalirudin anticoagulation in pediatric ExtraCorporeal Membrane Oxygenation (ECMO).

METHODS

A multicenter retrospective study, that included pediatric patients <18 years of age, who were supported on ECMO between June 2017 and May 2020. Patients treated with UFH were matched 2:1 by age and type of ECMO support to the bivalirudin group.

RESULTS

The bivalirudin group (75 patients) were matched to 150 patients treated with UFH. Baseline characteristics and comorbidities of the two groups were similar. Veno-Arterial ECMO was the most common mode (141/225 [63 %]) followed by extracorporeal cardiopulmonary resuscitation (48/225 [21 %]). Bivalirudin treatment was associated with lower odds of bleeding events (aOR 0.23, 95%CI 0.12-0.45, p < 0.001) and lower odds of thrombotic events (aOR 0.48, 95%CI 0.23-0.98, p = 0.045). Patients who received bivalirudin had lesser odds for transfusion with fresh frozen plasma, and platelets (aOR 0.26, CI 0.12-0.57, p ≤0.001 and aOR 0.28, CI 0.15-0.53, p < 0.001, respectively). After adjusting for the type of ECMO support and adjusting for age, bivalirudin was associated with a decrease in hospital mortality by 50 % compared to the UFH group (aOR 0.50, 95%CI 0.27-0.93, p = 0.028). Similarly, for neurological disability at time of discharge, bivalirudin was associated with higher odds of intact neurological outcomes compared to UFH (OR 1.99 [95%CI 1.13-3.51], p = 0.017).

CONCLUSIONS

This study demonstrated that effective anticoagulation can be achieved with bivalirudin, which was associated with lesser odds of bleeding events and utilization of blood products. Bivalirudin, in comparison with UFH, was associated with greater odds of hospital survival and intact neurological function at the time of discharge. A prospective randomized trial is required to validate the results of this study.

Rewarming Young Children After Drowning-Associated Hypothermia and Out-of-Hospital Cardiac Arrest: Analysis Using the CAse REport Guideline

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) is recommended in adults with drowning-associated hypothermia and out-of-hospital cardiac arrest (OHCA). Our experience of managing a drowned 2-year-old girl with hypothermia (23°C) and cardiac arrest (58 min) prompted this summary using the CAse REport (CARE) guideline to address the question of optimal rewarming procedure in such patients.

DESIGN/PATIENTS

Following the CARE guideline, we identified 24 reports in the "PubMed database" describing children less than or equal to 6 years old with a temperature less than or equal to 28°C who had been rewarmed using conventional intensive care ± ECMO. Adding our patient, we were able to analyze a total of 57 cases.

MAIN RESULTS

The two groups (ECMO vs non-ECMO) differed with respect to submersion time, pH and potassium but not age, temperature or duration of cardiac arrest. However, 44 of 44 in the ECMO group were pulseless on arrival versus eight of 13 in the non-ECMO group. Regarding survival, 12 of 13 children (92%) undergoing conventional rewarming survived compared with 18 of 44 children (41%) undergoing ECMO. Among survivors, 11 of 12 children (91%) in the conventional group and 14 of 18 (77%) in the ECMO group had favorable outcome. We failed to identify any correlation between "rewarming rate" and "outcome."

CONCLUSIONS

In this summary analysis, we conclude that conventional therapy should be initiated for drowned children with OHCA. However, if this therapy does not result in return of spontaneous circulation, a discussion of withdrawal of intensive care might be prudent when core temperature has reached 34°C. We suggest further work is needed using an international registry.

CPR Quality and Outcomes After Extracorporeal Life Support for Pediatric In-Hospital Cardiac Arrest

AIM

of Study: To determine outcomes in pediatric patients who had an in-hospital cardiac arrest and subsequently received extracorporeal cardiopulmonary resuscitation (ECPR). Our secondary objective was to identify cardiopulmonary resuscitation (CPR) event characteristics and CPR quality metrics associated with survival after ECPR.

METHODS

Multicenter retrospective cohort study of pediatric patients in the pediRES-Q database who received ECPR after in-hospital cardiac arrest between July 1, 2015 and June 2, 2021. Primary outcome was survival to ICU discharge. Secondary outcomes were survival to hospital discharge and favorable neurologic outcome at ICU and hospital discharge.

RESULTS

Among 124 patients included in this study, median age was 0.9 years (IQR 0.2-5) and the majority of patients had primarily cardiac disease (92 patients, 75%). Survival to ICU discharge occurred in 61/120 (51%) patients, 36/61 (59%) of whom had favorable neurologic outcome. No demographic or clinical variables were associated with survival after ECPR.

CONCLUSION

In this multicenter retrospective cohort study of pediatric patients who received ECPR for IHCA we found a high rate of survival to ICU discharge with good neurologic outcome.

Resuscitating the resuscitation: A single-centre experience on extracorporeal cardiopulmonary resuscitation

AIM

Extracorporeal cardiopulmonary resuscitation (ECPR) is the rapid deployment of venoarterial extracorporeal membrane oxygenation (ECMO) during active cardiopulmonary resuscitation or in patients with intermittent return of spontaneous circulation. This study aimed to describe the demographic characteristics and outcomes of patients undergoing ECPR to identify survival-associated factors.

METHODS

The study was conducted in an extracorporeal life support centre of a tertiary hospital in Turkey and included all patients who underwent ECPR for in-hospital cardiac arrest between April 2013 and June 2021. Complications included bleeding, neurological injury, renal failure, hepatic failure, limb ischemia and bloodstream infections. The primary outcomes were survival of ECMO and survival to discharge. Neurological outcomes were assessed using the Pediatric Cerebral Performance Category Scale for children and the Category of Cerebral Performance Scale for adults.

RESULTS

The study included 26 patients (24 paediatric, 2 adults), 22 (85%) of them had cardiac pathology. Bleeding was the most common complication. Twelve (46%) patients survived ECMO, 9 (35%) survived to discharge. Sex, age, primary diagnosis, cardiac arrest rhythm and ECMO duration were not significantly associated with the primary outcomes. Bleeding, neurological injury and renal failure were associated with poorer survival to discharge. The neurological outcomes of all survivors to discharge were good.

CONCLUSIONS

ECPR is not commonly accessible. Sharing the experience of the few treating centres to date is crucial to accumulating sufficient knowledge about its efficiency and raising clinician awareness. This limited single-centre experience demonstrated the utility of ECPR.

Perioperative extracorporeal membrane oxygenation in pediatric congenital heart disease: Chinese expert consensus

BACKGROUND

Congenital heart disease (CHD) is one of the main supportive diseases of extracorporeal membrane oxygenation in children. The management of extracorporeal membrane oxygenation (ECMO) for pediatric CHD faces more severe challenges due to the complex anatomical structure of the heart, special pathophysiology, perioperative complications and various concomitant malformations. The survival rate of ECMO for CHD was significantly lower than other classifications of diseases according to the Extracorporeal Life Support Organization database. This expert consensus aims to improve the survival rate and reduce the morbidity of this patient population by standardizing the clinical strategy.

METHODS

The editing group of this consensus gathered 11 well-known experts in pediatric cardiac surgery and ECMO field in China to develop clinical recommendations formulated on the basis of existing evidences and expert opinions.

RESULTS

The primary concern of ECMO management in the perioperative period of CHD are patient selection, cannulation strategy, pump flow/ventilator parameters/vasoactive drug dosage setting, anticoagulation management, residual lesion screening, fluid and wound management and weaning or transition strategy. Prevention and treatment of complications of bleeding, thromboembolism and brain injury are emphatically discussed here. Special conditions of ECMO management related to the cardiovascular anatomy, haemodynamics and the surgical procedures of common complex CHD should be considered.

CONCLUSIONS

The consensus could provide a reference for patient selection, management and risk identification of perioperative ECMO in children with CHD. Video abstract (MP4 104726 kb).

Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience

Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.

Extracorporeal Membrane Oxygenation Outcomes in Children With Preexisting Neurologic Disorders or Neurofunctional Disability

OBJECTIVE

Patient selection for pediatric extracorporeal membrane oxygenation (ECMO) support has broadened over the years to include children with pre-existing neurologic morbidities. We aimed to determine the prevalence and nature of pre-ECMO neurologic disorders or disability and investigate the association between pre-ECMO neurologic disorders or disability and mortality and unfavorable neurologic outcome.

DESIGN

Multicenter retrospective observational cohort study.

SETTING

Eight hospitals reporting to the Pediatric ECMO Outcomes Registry between October 2011 and June 2019.

PATIENTS

Children younger than 18 years supported with venoarterial or venovenous ECMO.

INTERVENTIONS

The primary exposure was presence of pre-ECMO neurologic disorders or moderate-to-severe disability, defined as Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) 3-5. The primary outcome was unfavorable outcome at hospital discharge, defined as in-hospital mortality or survival with moderate-to-severe disability (discharge PCPC 3-5 with deterioration from baseline).

MEASUREMENTS AND MAIN RESULTS

Of 598 children included in the final cohort, 68 of 598 (11%) had a pre-ECMO neurologic disorder, 70 of 595 (12%) had a baseline PCPC 3-5, and 189 of 592 (32%) had a baseline POPC 3-5. The primary outcome of in-hospital mortality ( n = 267) or survival with PCPC 3-5 with deterioration from baseline ( n = 39) was observed in 306 of 598 (51%). Overall, one or more pre-ECMO neurologic disorders or disability were present in 226 of 598 children (38%) but, after adjustment for age, sex, diagnostic category, pre-ECMO cardiac arrest, and ECMO mode, were not independently associated with increased odds of unfavorable outcome (unadjusted odds ratio [OR], 1.34; 95% CI, 1.07-1.69; multivariable adjusted OR, 1.30; 95% CI, 0.92-1.82).

CONCLUSIONS

In this exploratory study using a multicenter pediatric ECMO registry, more than one third of children requiring ECMO support had pre-ECMO neurologic disorders or disability. However, pre-existing morbidities were not independently associated with mortality or unfavorable neurologic outcomes at hospital discharge after adjustment for diagnostic category and other covariates.

Child requiring tracheostomy for removal of an airway foreign body at the tracheal bifurcation

Airway foreign bodies are typically removed orally using a rigid bronchoscope. We present a rare case of a foreign body at the tracheal bifurcation that required removal via tracheostomy. A child turned pale while eating nuts and was suspected to have choked on a foreign body. CT revealed a foreign body at the tracheal bifurcation. As his respiratory condition was unstable, tracheal intubation and removal were attempted using a rigid bronchoscope. Tracheal obstruction during oral removal resulted in respiratory failure and bradycardia. Following emergency tracheostomy, the foreign body was removed via the tracheal stoma after his respiratory condition stabilised. The patient was discharged 21 days later without neurological sequelae. To avoid hypoxaemia during airway foreign body removal, as in this case, assessing the size of the upper airway and foreign body is necessary. Tracheostomy and foreign body removal through the tracheal opening should be considered proactively.

Extracorporeal Membrane Oxygenation in Congenital Heart Disease

Mechanical circulatory support (MCS) is a key therapy in the management of patients with severe cardiac disease or respiratory failure. There are two major forms of MCS commonly employed in the pediatric population—extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD). These modalities have overlapping but distinct roles in the management of pediatric patients with severe cardiopulmonary compromise. The use of ECMO to provide circulatory support arose from the development of the first membrane oxygenator by George Clowes in 1957, and subsequent incorporation into pediatric cardiopulmonary bypass (CPB) by Dorson and colleagues. The first successful application of ECMO in children with congenital heart disease undergoing cardiac surgery was reported by Baffes et al. in 1970. For the ensuing nearly two decades, ECMO was performed sparingly and only in specialized centers with varying degrees of success. The formation of the Extracorporeal Life Support Organization (ELSO) in 1989 allowed for the collation of ECMO-related data across multiple centers for the first time. This facilitated development of consensus guidelines for the use of ECMO in various populations. Coupled with improving ECMO technology, these advances resulted in significant improvements in ECMO utilization, morbidity, and mortality. This article will review the use of ECMO in children with congenital heart disease.

The horizon of pediatric cardiac critical care

Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.