Critical Care Unit Characteristics and Extracorporeal Cardiopulmonary Resuscitation Survival in the Pediatric Cardiac Population: Retrospective Analysis of the Virtual Pediatric System Database

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.

Extracorporeal Cardiopulmonary Resuscitation Use Among Children With Cardiac Disease in the ICU: A Meta-Analysis and Meta-Regression of Data Through March 2024

OBJECTIVE

Epidemiologic data on extracorporeal cardiopulmonary resuscitation (ECPR) use in children with cardiac disease after in-hospital cardiac arrest (IHCA) are lacking. We aimed to investigate trends in ECPR use over time in critically ill children with cardiac disease.

DATA SOURCES

We performed a secondary analysis of a recent systematic review (PROSPERO CRD42020156247) to investigate trends in ECPR use in children with cardiac disease. PubMed, Web of Science, Embase, and Cumulative Index to Nursing and Allied Health Literature were screened (inception to September 2021). For completeness of this secondary analysis, PubMed was also rescreened (September 2021 to March 2024).

STUDY SELECTION

Observational studies including epidemiologic data on ECPR use in children with cardiac disease admitted to an ICU.

DATA EXTRACTION

Data were extracted by two independent investigators. The risk of bias was assessed using the National Heart Lung and Blood Institutes Quality Assessment Tools. Random-effects meta-analysis was used to compute a pooled proportion of subjects undergoing ECPR; meta-regression was used to assess trends in ECPR use over time.

DATA SYNTHESIS

Of the 2664 studies identified, 9 (17,669 patients) included data on ECPR use in children with cardiac disease. Eight were cohort studies, 1 was a case-control, 8 were retrospective, 1 was prospective, 6 were single-center, and 3 were multicenter. Seven studies were included in the meta-analysis; all were judged of good quality. By meta-analysis, we found that a pooled proportion of 21% (95% CI, 15-29%) of pediatric patients with cardiac disease experiencing IHCA were supported with ECPR. By meta-regression adjusted for category of patients (surgical vs. general cardiac), we found that the use of ECPR in critically ill children with cardiac disease significantly increased over time ( p = 0 .026).

CONCLUSIONS

About one-fifth of critically ill pediatric cardiac patients experiencing IHCA were supported with ECPR, and its use significantly increased over time. This may partially explain the increased trends in survival demonstrated for this population.

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.

Death by Neurologic Criteria in Children Undergoing Extracorporeal Cardiopulmonary Resuscitation: Retrospective Extracorporeal Life Support Organization Registry Study, 2017-2021

OBJECTIVES

To determine factors associated with brain death in children treated with extracorporeal cardiopulmonary resuscitation (E-cardiopulmonary resuscitation).

DESIGN

Retrospective database study.

SETTINGS

Data reported to the Extracorporeal Life Support Organization (ELSO), 2017-2021.

PATIENTS

Children supported with venoarterial extracorporeal membrane oxygenation (ECMO) for E-cardiopulmonary resuscitation.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Data from the ELSO Registry included patient characteristics, blood gas values, support therapies, and complications. The primary outcome was brain death (i.e., death by neurologic criteria [DNC]). There were 2,209 children (≥ 29 d to < 18 yr of age) included. The reason for ECMO discontinuation was DNC in 138 patients (6%), and other criteria for death occurred in 886 patients (40%). Recovery occurred in 1,109 patients (50%), and the remaining 76 patients (4%) underwent transplantation. Fine and Gray proportional subdistribution hazards' regression analyses were used to examine the association between variables of interest and DNC. Age greater than 1 year ( p < 0.001), arterial blood carbon dioxide tension (Pa co2 ) greater than 82 mm Hg ( p = 0.022), baseline lactate greater than 15 mmol/L ( p = 0.034), and lactate 24 hours after cannulation greater than 3.8 mmol/L ( p < 0.001) were independently associated with greater hazard of subsequent DNC. In contrast, the presence of cardiac disease was associated with a lower hazard of subsequent DNC (subdistribution hazard ratio 0.57 [95% CI, 0.39-0.83] p = 0.004).

CONCLUSIONS

In children undergoing E-cardiopulmonary resuscitation, older age, pre-event hypercarbia, higher before and during ECMO lactate levels are associated with DNC. Given the association of DNC with hypercarbia following cardiac arrest, the role of Pa co2 management in E-cardiopulmonary resuscitation warrants further studies.

Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease

OBJECTIVES

To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease.

DESIGN

Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021).

SETTING

Eighteen PICUs.

PATIENTS

Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups.

CONCLUSIONS

In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.