Long-Term Follow-Up on Health-Related Quality of Life After Mechanical Circulatory Support in Children

Provider Perceptions of Outcomes in the Pediatric Cardiac Intensive Care Unit

In the pediatric cardiac intensive care unit (PCICU), predicting the complications and long-term impact of extracorporeal membrane oxygenation (ECMO) and cardiopulmonary resuscitation (CPR) is influenced by the providers' perceptions. Little is understood about such perceptions as they relate to provider role and experience. A multi-disciplinary group in the PCICU of a single center was surveyed regarding two patient scenarios: (1) ECMO after cardiac surgery, and (2) cardiac arrest with need for CPR. Respondents indicated their risk tolerance for potential complications of these interventions, and the impact on patient health-related quality of life (HRQoL). Responses were compared based on providers' role and experience. 101 providers were surveyed and were willing to tolerate a 50% risk of death with ECMO or continued CPR but had less tolerance for the risk of other long-term morbidities. For most potential complications, nurses had the lowest risk tolerance and attending physicians the highest. Provider experience had no impact on risk tolerance. All providers underestimated HRQoL scores compared to previously published scores of patients who survived the surveyed scenarios. This survey is one of the first to explore providers' perceptions of ECMO and CPR. PCICU providers are more willing to accept the risk of death than other morbid complications, and poorly predict HRQoL outcomes. Team members have varied risk tolerance for complications and predict their impact differently. Understanding the variability of and influences on perceptions of patient outcomes could help improve communication with patients and families, team dynamics, and decision-making in the PCICU.

Neurologic Outcomes and Quality of Life in Children After Extracorporeal Membrane Oxygenation

RATIONALE

Use of life support with extracorporeal membrane oxygenation (ECMO) is associated with brain injury. However, the consequences of these injuries on subsequent neurologic development and health-related quality of life (HRQoL) are poorly described in children.

OBJECTIVES

The aim of this preliminary study was to describe short- and long-term neurologic outcomes in survivors of ECMO, as well as their HRQoL.

DESIGN

Retrospective identified cohort with contemporary evaluations.

SETTING

Necker Children's Hospital academic PICU.

PATIENTS

Forty survivors who underwent ECMO (October 2014 to January 2020) were included in follow-up assessments in May 2021.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

We first reviewed the outcomes of ECMO at the time of PICU discharge, which included a summary of neurology, radiology, and Pediatric Overall/Cerebral Performance Category (POPC/PCPC) scores. Then, in May 2021, we interviewed parents and patients to assess HRQoL (Pediatric Quality of Life Inventory [PedsQL]) and POPC/PCPC for children 3 years old or older, and Denver II test (DTII) for younger children. An evaluation of DTII in the youngest patients 1 year after ECMO decannulation was also added. Median age at ECMO was 1.4 years (interquartile range [IQR], 0.4-6 yr). Thirty-five children (88%) underwent a venoarterial ECMO. At PICU discharge, 15 of 40 patients (38%) had neurologic impairment. Assessment of HRQoL was carried out at median of 1.6 years (IQR, 0.7-3.3 yr) after PICU discharge. PedsQL scores were over 70 of 100 for all patients (healthy peers mean results: 80/100), and scores were like those published in patients suffering with chronic diseases. In May 2021, seven of 15 patients had a normal DTII, and 36 of 40 patients had a POPC/PCPC score less than or equal to 3.

CONCLUSIONS

None of our patients presented severe disability at long term, and HRQoL evaluation was reassuring. Considering the risk of neurologic impairment after ECMO support, a systematic follow-up of these high-risk survivor patients would be advisable.

Neurocognitive functioning and health-related quality of life of children after pediatric intensive care admission: a systematic review

OBJECTIVE

This study systematically reviewed recent findings on neurocognitive functioning and health-related quality of life (HRQoL) of children after pediatric intensive care unit admission (PICU).

DATA SOURCES

Electronic databases searched included Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar. The search was limited to studies published in the last five years (2015-2019).

STUDY SELECTION

Original studies assessing neurocognitive functioning or HRQoL in children who were previously admitted to the PICU were included in this systematic review.

DATA EXTRACTION

Of the 3649 identified studies, 299 met the inclusion criteria based on title abstract screening. After full-text screening, 75 articles were included in the qualitative data reviewing: 38 on neurocognitive functioning, 33 on HRQoL, and 4 on both outcomes.

DATA SYNTHESIS

Studies examining neurocognitive functioning found overall worse scores for general intellectual functioning, attention, processing speed, memory, and executive functioning. Studies investigating HRQoL found overall worse scores for both physical and psychosocial HRQoL. On the short term (≤ 12 months), most studies reported HRQoL impairments, whereas in some long-term studies HRQoL normalized. The effectiveness of the few intervention studies during and after PICU admission on long-term outcomes varied.

CONCLUSIONS

PICU survivors have lower scores for neurocognitive functioning and HRQoL than children from the general population. A structured follow-up program after a PICU admission is needed to identify those children and parents who are at risk. However, more research is needed into testing interventions in randomized controlled trials aiming on preventing or improving impairments in critically ill children during and after PICU admission.

Psychosocial Impact of Congenital Heart Diseases on Patients and Their Families: A Parent's Perspective

BACKGROUND

Currently, over 90% of children with congenital heart disease (CHD) survive into adulthood. As a consequence the psychosocial impact on children and their families has become an important outcome measure. Therefore, the goal of this study was to assess the psychosocial impact from a parent's perspective and to identify possible predictors.

METHODS

We included all parents of children who underwent open-heart surgery in the years 2010 and 2011 at the Department of Cardiothoracic Surgery at University Hospital Heidelberg and invited them to complete standardized questionnaires. Psychosocial outcome was measured via parent self- and proxy reporting of family burden (Family Burden Questionnaire, FaBel), health-related quality of life (KidScreen-10), developmental problems (Five-to-Fifteen, FTF), and mental health problems (Strength and Difficulties Questionnaire, SDQ).

RESULTS

In total, 113 families returned the questionnaires completely (71.5%). The Aristotle Basic Complexity score and the STAT 2020 Score overall did not predict the psychosocial impact, whereas the number of surgical operations did significantly predict psychosocial impact across all domains in this study cohort.

CONCLUSIONS

These data suggest that the number of surgical operations might be a relevant predictor for the long-term psychosocial impact on families suffering from CHD and a potential connecting factor for specialized psychological support. When setting up screening instruments or support programs the entire family must be considered.

Tracheostomy and long-term mechanical ventilation in children after veno-venous extracorporeal membrane oxygenation

OBJECTIVE

Our objective is to characterize the incidence of tracheostomy placement and of new requirement for long-term mechanical ventilation after extracorporeal membrane oxygenation (ECMO) among children with acute respiratory failure. We examine whether an association exists between demographics, pre-ECMO and ECMO clinical factors, and the placement of a tracheostomy or need for long-term mechanical ventilation.

METHODS

A retrospective multicenter cohort study was conducted at 10 quaternary care pediatric academic centers, including children supported with veno-venous (V-V) ECMO from 2011 to 2016.

RESULTS

Among 202 patients, 136 (67%) survived to ICU discharge. All tracheostomies were placed after ECMO decannulation, in 22 patients, with 19 of those surviving to ICU discharge (14% of survivors). Twelve patients (9% of survivors) were discharged on long-term mechanical ventilation. Tracheostomy placement and discharge on home ventilation were not associated with pre-ECMO severity of illness or pre-existing chronic illness. Patients who received a tracheostomy were older and weighed more than patients who did not receive a tracheostomy, although this association did not exist among patients discharged on home ventilation. ECMO duration was longer in those who received a tracheostomy compared with those who did not, as well as for those discharged on home ventilation, compared to those who were not.

CONCLUSION

The 14% rate for tracheostomy placement and 9% rate for discharge on long-term mechanical ventilation after V-V ECMO are important patient-centered findings. This study informs anticipatory guidance provided to families of patients requiring prolonged respiratory ECMO support, and lays the foundation for future research.

Health-Related Quality of Life in Pediatric Cardiac Patients After Extracorporeal Life Support

Extracorporeal Life Support (ECLS) is often considered successful if the child leaves intensive care alive. For the child and family, a major concern is quality of life. Aim of this study is to compare health-related quality of life scores of children following cardiac ECLS to a healthy control group. Cross-sectional prospective study using Pediatric Quality of Life Inventory 4.0 Generic Core Scale questionnaire. Population included consecutive children between two and sixteen years of age who underwent cardiac ECLS from 2005 to 2016 and their parents. Each age groups' mean and standard deviation was analyzed individually with minimal clinically important difference calculated. We then compared the scores to a healthy population group. Cronbach's alpha for reliability was calculated and linear regression assessed for relationships between demographics and quality of life scores. Forty-one (60%) families responded. The ECLS had significantly (statistically and clinically) lower health-related quality of life scores in every domain when compared to the healthy cohort. The lowest mean total score was school functioning for both children (59.79 vs 81.31, p < 0.01) and parents (59.01 vs 78.27, p  < 0.01). Parents had excellent reliability (α = 0.93, 0.95 & 0.90) compared to children with reliability improving with increasing age in children. Improvements in the management of pediatric patients following ECLS are required to improve their health-related quality of life. Further research is warranted to explore the physical and psychological effects of cardiac ECLS on pediatric survivors to establish individual healthcare needs and optimize health-related quality of life.

Neonatal respiratory and cardiac ECMO in Europe

Neonatal extracorporeal membrane oxygenation (ECMO) is a life-saving procedure for critically ill neonates suffering from a potentially reversible disease, causing severe cardiac and/or respiratory failure and refractory to maximal conventional management. Since the 1970s, technology, management, and clinical applications of neonatal ECMO have changed. Pulmonary diseases still represent the principal neonatal diagnosis, with an overall 74% survival rate, and up to one-third of cases are due to congenital diaphragmatic hernia. The overall survival rate in cardiac ECMO is lower, with congenital heart defect representing the main indication. This review provides an overview of the available evidence in the field of neonatal ECMO. We will address the changing epidemiology, basic principles, technologic advances in circuitry, and monitoring, and deliver a current multidisciplinary management framework, focusing on ECMO applications, complications, and long-term morbidities. Lastly, areas for further research will be highlighted.Conclusions: ECMO is a life support with a potential impact on long-term patients' outcomes. In the next years, advances in knowledge, technology, and expertise may push neonatal ECMO boundaries towards more premature and increasingly complex infants, with the final aim to reduce the burden of ECMO-related complications and improve overall patients' outcomes. What is Known: • ECMO is a life-saving option in newborns with refractory respiratory and/or cardiac failure. • The multidisciplinary ECMO management is challenging and may expose neonates to complications with an impact on long-term outcomes. What is New: • Advances in technology and biomaterials will improve neonatal ECMO management and, eventually, the long-term outcome of these complex patients. • Experimental models of artificial placenta and womb technology are under investigation and may provide clinical translation and future research opportunities.

Psychosocial outcomes in pediatric patients with ventricular assist devices and their families: A systematic review

Ventricular assist device (VAD) therapy has provided pediatric patients with severe heart failure new therapeutic options. However, pediatric patients and families receiving VAD therapy also experience psychosocial challenges. No synthesis of the literature on psychosocial outcomes within the pediatric VAD population has been conducted; thus, the current review sought to systematically investigate the impact of pediatric VAD on patient, parent, and family psychosocial outcomes and assess variables associated with poorer outcomes. Literature searches were conducted in PsycInfo, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases and full texts were assessed according to pre-established inclusion criteria. Main findings and study quality were reviewed. Sixteen studies were included in the present review. Findings highlighted the likelihood for psychological sequelae among pediatric patients and families receiving VAD therapy, including decreased psychological and emotional well-being, elevated stress, and difficulty coping with changes to family dynamics and responsibilities. Health-related quality of life was reported comparable to that of healthy peers and children with other cardiac conditions. Patients and families on VAD therapy experience significant difficulties in psychological well-being and challenges related to adjustment. The current review underscores the importance of ongoing support for families and continued assessment of psychosocial functioning across VAD support. Three critical periods for increased distress were identified: 1) immediately following VAD implantation, 2) discharge home and the weeks following discharge, and 3) long-term VAD therapy.

The quality of life in extracorporeal life support survivors: single-center experience of a long-term follow-up

OBJECTIVE

To evaluate the health-related quality of life on a very long-term follow-up in patients treated with extracorporeal membrane oxygenation (ECMO) during neonatal and pediatric age.

DESIGN

Prospective follow-up study.

SETTING

Pediatric Intensive Care Unit of a tertiary-care University-Hospital.

PATIENTS

Out of 20 neonates and 21 children treated with ECMO in our center, 24 patients underwent short-term neurological follow-up. Twenty of them underwent long-term neurological follow-up.

INTERVENTION

Short-term follow-up was performed at 18 months and consisted in clinical evaluation, electroencephalography, and neuroimaging. Long-term follow-up was performed in 2017, at the mean period 19.72 years from ECMO (median 20.75, range 11.50-24.08) and consisted in a standardized questionnaires self-evaluation (PedsQL 4.0 Generic Core Scale) of health-related quality of life and an interviewed about the presence of organ morbidity, school level, or work position.

MEASUREMENTS AND MAIN RESULTS

Sixty-one percent (25/41) of the patients survived within 30 days after ECMO treatment. Short-term follow-up was performed in 24 patients (1 patient but died before the evaluation): 21 patients (87%) showed a normal neurological status, and 3 developed severe disability. Long-term follow-up was performed in 20 long-term survivors (3 patients were not possible to be contacted and considered lost to follow-up): mean age of patients at long-term follow-up was 21.23 (median 20.96, range 13.33-35.58) years; 90% (18/20) of them have no disability with a complete normal quality of life and 95% have no cognitive impairment.

CONCLUSIONS

ECMO represents a life-saving treatment for infants and children with respiratory and/or heart failure; survivors show a good quality of life comparable to healthy peers.

Neonatal Cardiac ECMO in 2019 and Beyond

Worldwide, the use of Extracorporeal Membrane Oxygenation (ECMO) for cardiac failure has been steadily increasing in the neonatal population and has become a widely accepted modality. Especially in centers caring for children with (congenital) heart disease, ECMO is now an essential part of care available for those with severe heart failure as a bridge to recovery, long term mechanical support, or transplantation. Short-term outcomes depend very much on indication. Hospital survival is ~40% for all neonatal cardiac ECMO patients combined. ECMO is being used for pre- and/or post-operative stabilization in neonates with congenital heart disease and in neonates with medical heart disease such as myocarditis, cardiomyopathy or refractory arrhythmias. ECMO use during resuscitation (ECPR) or for sepsis is summarized elsewhere in this special edition of Frontiers in Pediatrics. In this review article, we will discuss the indications for neonatal cardiac ECMO, the difficult process of patients' selection and identifying the right timing to initiate ECMO, as well as outline pros and cons for peripheral vs. central cannulation. We will present predictors of mortality and, very importantly, predictors of survival: what can be done to improve the outcomes for your patients. Furthermore, an overview of current insights regarding supportive care in neonatal cardiac ECMO is given. Additionally, we will address issues specific to neonates with single ventricle physiology on ECMO, for example cannulation strategies and the influence of shunt type (Blalock-Taussig shunt vs. "right ventricle to pulmonary artery" shunt). We will not only focus on short term outcomes, such as hospital survival, but also on the importance of long-term neuro-developmental outcomes, and we will end this review with suggestions for future research.

Extracorporeal membrane oxygenation in congenital heart disease

This review article will discuss the indications for and outcomes of neonates with congenital heart disease who receive extracorporeal membrane oxygenation (ECMO) support. Most commonly, ECMO is used as a perioperative bridge to recovery or temporary support for those after cardiac arrest or near arrest in patients with congenital or acquired heart disease. What had historically been considered a contraindication to ECMO, is evolving and more of the sickest and most complicated babies are cared for on ECMO. Given that, it is imperative for aggressive survellience for long-term morbidity in survivors, particularly neurodevelopmental outcomes.

Improvement in patient-reported outcomes after lung transplantation is not impacted by the use of extracorporeal membrane oxygenation as a bridge to transplantation

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) is increasingly used as a bridge to lung transplantation. The impact of preoperative ECMO on health-related quality of life (HRQL) and depressive symptoms after lung transplantation remains unknown, however.

METHODS

In a single-center prospective cohort study, we assessed HRQL and depressive symptoms before and at 3, 6, and 12 months after lung transplantation using the Short Form 12 Physical and Mental Component Scores (SF12-PCS and SF12-MCS), Airway Questionnaire 20-Revised (AQ20R), EuroQol 5D (EQ5D), and Geriatric Depression Scale (GDS). Changes in HRQL were quantified by segmented linear mixed-effects models controlling for age, sex, diagnosis, preoperative forced expiratory volume in 1 second, 6-minute walk distance, and Lung Allocation Score. We compared changes in HRQL among subjects bridged with ECMO, subjects hospitalized but not on ECMO, and subjects called in for transplantation as outpatients.

RESULTS

Out of 189 subjects, 17 were bridged to transplantation with ECMO. In all groups, improvements in HRQL following lung transplantation exceeded the minimally clinically important difference using the SF12-PCS, AQ20R, EQ5D, and GDS. HRQL defined by SF12-MCS did not change after transplantation. Improvements were generally similar among the groups, except for EQ5D, which showed a trend toward less benefit in the outpatients, possibly due to their better HRQL before lung transplantation.

CONCLUSIONS

Subjects ill enough to require ECMO as a bridge to lung transplantation appear to achieve similar improvements in HRQL and depressive symptoms as those who do not. It is reassuring to both providers and patients that lung transplantation provides substantial improvements in HRQL, even for those patients who are critically ill in the run up to transplantation.