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Cucchi M, Mariani S, Kawczynski MJ, Shkurka E, Ius F, Comentale G, Hoskote A, Lorusso R. Individual patient data meta-analysis on awake pediatric extracorporeal life support: Feasibility and safety of analgesia, sedation and respiratory support weaning, and physiotherapy. Perfusion 2024:2676591241240377. [PMID: 38652693 DOI: 10.1177/02676591241240377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Awake Extracorporeal Life Support (aECLS) with active mobilization has gained consensus over time, also within the pediatric community. This individual patient data (IPD) meta-analysis summarizes available evidence on pediatric aECLS, its feasibility, and safety regarding sedation weaning, extubation, and physiotherapy. METHODS PubMed/Medline and Cochrane Database were screened until February 2022. Articles reporting on children (≤18 years) undergoing aECLS were selected. IPD were requested, pooled in a single database, and analyzed using descriptive statistics. Primary outcome was survival to hospital discharge. Secondary outcomes included extubation during ECLS, physiotherapy performed, tracheostomy, and complications. RESULTS Nineteen articles and 65 patients (males:n = 30/59,50.8%) were included. Age ranged from 2 days to 17 years. ECLS configurations included veno-venous (n = 42/65, 64.6%), veno-arterial (n = 18/65, 27.7%) and other ECLS settings (n = 5/65, 7.7%). Exclusive neck cannulation was performed in 51/65 (78.5%) patients. Extubation or tracheostomy during ECLS was reported in 66.2% (n = 43/65) and 27.7% (n = 18/65) of patients, respectively. Physiotherapy was reported as unspecified physical activity (n = 34/63, 54%), mobilization in bed (n = 15/63, 23.8%), ambulation (n = 14/63, 22.2%). Complications were reported in 60.3% (n = 35/58) of patients, including hemorrhagic (36.2%), mechanical (17.2%), or pulmonary (17.2%) issues, and need for reintubation (15.5%). Survival at discharge was 81.5% (n = 53/65). CONCLUSION Awake ECLS strategy with active physiotherapy can be applied in children from neonatal age. Ambulation is also possible in selected cases. Complications related to such management were limited. Further studies on aECLS are needed to evaluate safety and efficacy of early physiotherapy and define patient selection.
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Affiliation(s)
- Marta Cucchi
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Pediatric Intensive Care Unit, Queensland Children Hospital, Brisbane, QLD, Australia
| | - Silvia Mariani
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michal J Kawczynski
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Emma Shkurka
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fabio Ius
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Giuseppe Comentale
- IRCCS Policlinico Universitario Sant'Orsola-Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Aparna Hoskote
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Kiskaddon AL, Do NL, Williams P, Betensky M, Goldenberg NA. Anticoagulation with Intravenous Direct Thrombin Inhibitors in Pediatric Extracorporeal Membrane Oxygenation: A Systematic Review of the Literature. Semin Thromb Hemost 2023; 49:756-763. [PMID: 37643746 DOI: 10.1055/s-0043-1772838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Although intravenous (IV) direct thrombin inhibitors (DTI) have gained interest in pediatric extracorporeal membrane oxygenation (ECMO), dosing and safety information is limited. The objective of this systematic review was to characterize DTI types, dosing, monitoring, and outcomes (bleeding and thromboembolic) in pediatric ECMO patients managed with IV DTIs. We conducted searches of MEDLINE (Ovid) and Embase (Elsevier) from inception through December 2022. Case reports, retrospective studies, and prospective studies providing per-patients or summary data for patient(s) <18 years of age receiving IV DTI for ECMO anticoagulation were included. Study selection and data extraction were conducted independently by two reviewers. A total of 28 studies: 14 case reports, 13 retrospective studies, and 1 prospective study were included, totaling 329 patients. Bivalirudin was utilized in 318 (96.7%), argatroban in 9 (2.7%), and lepirudin in 2 (0.6%) patients. Infusion dosing included: bivalirudin 0.14 ± 0.37 mg/kg/h, argatroban 0.69 ± 0.73 µg/kg/min, lepirudin 0.14 ± 0.02 mg/kg/h. Laboratory monitoring tests utilized were the activated clotting time, activated partial thromboplastin time (aPTT), diluted thrombin time, and thromboelastography measures. The aPTT was utilized in most patients (95%). Thromboembolism, bleeding, or death were observed in 17%, 17%, and 23% of bivalirudin, argatroban, and lepirudin patients, respectively. Bivalirudin appears to be the most frequently used DTI in pediatric ECMO. Dosing and laboratory monitoring varied, and bleeding and thromboembolic events were reported in 17% of patients. Prospective studies are warranted to establish dosing, monitoring, safety, and efficacy of bivalirudin and other IV DTI in pediatric ECMO.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Department of Pediatrics, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nhue L Do
- Division of Pediatric Cardiac Surgery, Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Pamela Williams
- Medical Library, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Department of Pediatrics, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida
| | - Neil A Goldenberg
- Department of Pediatrics, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida
- Departments of Pediatrics and Medicine, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, Maryland
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Chiel LE, Winthrop ZA, Fynn-Thompson F, Midyat L. Extracorporeal membrane oxygenation and paracorporeal lung assist devices as a bridge to pediatric lung transplantation. Pediatr Transplant 2022; 26:e14289. [PMID: 35416395 DOI: 10.1111/petr.14289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND "Bridging" is a term used to describe the implementation of various treatment modalities to improve waitlist survival while a patient awaits lung transplantation. ECMO and PLAD are technologies used to bridge patients to lung transplantation. ECMO and PLAD are cardiopulmonary support systems that help move blood forward while using an artificial membrane to remove CO2 from and add O2 to the blood. Recent studies showed that these technologies are increasingly effective in bridging patients to lung transplantation, especially with optimizing patient selection, implementing physical rehabilitation and ambulation goals, standardization of management decisions, and increasing staff experience, among other considerations. We review these technologies, their roles as bridges to pediatric lung transplantation, as well as indications, contraindications, complications, and mortality rates. CONCLUSION Finally, we discuss the existing knowledge gaps and areas for future research to improve patient outcomes and understanding of lung assist devices.
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Affiliation(s)
- Laura E Chiel
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zachary A Winthrop
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Levent Midyat
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Salna M, Naka Y. When to use central mechanical support devices. JTCVS Open 2020; 2:22-26. [PMID: 36003676 PMCID: PMC9390458 DOI: 10.1016/j.xjon.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 10/17/2019] [Accepted: 12/02/2019] [Indexed: 11/19/2022]
Affiliation(s)
| | - Yoshifumi Naka
- Address for reprints: Yoshifumi Naka, MD, PhD, Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, 177 Fort Washington Ave, Milstein Hospital Building, 7GN-435, New York, NY 10032.
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Shudo Y, Wang H, Ha RV, Hayes AD, Woo YJ. Heart transplant after profoundly extended ambulatory central venoarterial extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2018; 156:e7-9. [PMID: 29576264 DOI: 10.1016/j.jtcvs.2018.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/19/2017] [Accepted: 02/04/2018] [Indexed: 11/20/2022]
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Rozencwajg S, Schmidt M. Extracorporeal membrane oxygenation for interstitial lung disease: what is on the other side of the bridge? J Thorac Dis 2016; 8:1918-20. [PMID: 27619972 DOI: 10.21037/jtd.2016.07.50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Sacha Rozencwajg
- Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Schmidt
- Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Abstract
Extracorporeal life support (ECLS) is an important device in the management of children with severe refractory cardiac and or pulmonary failure. Actually, two forms of ECLS are available for neonates and children: extracorporeal membrane oxygenation (ECMO) and use of a ventricular assist device (VAD). Both these techniques have their own advantages and disadvantages. The intra-aortic balloon pump is another ECLS device that has been successfully used in larger children, adolescents, and adults, but has found limited applicability in smaller children. In this review, we will present the "state of art" of ECMO in neonate and children with heart failure. ECMO is commonly used in a variety of settings to provide support to critically ill patients with cardiac disease. However, a strict selection of patients and timing of intervention should be performed to avoid the increase in mortality and morbidity of these patients. Therefore, every attempt should be done to start ECLS "urgently" rather than "emergently," before the presence of dysfunction of end organs or circulatory collapse. Even though exciting progress is being made in the development of VADs for long-term mechanical support in children, ECMO remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation. With the increase in familiarity with ECMO, new indications have been added, such as extracorporeal cardiopulmonary resuscitation (ECPR). The literature supporting ECPR is increasing in children. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Contraindications to ECLS have reduced in the last 5 years and many centers support patients with functionally univentricular circulations. Improved results have been recently achieved in this complex subset of patients.
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Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù , Rome , Italy
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore; Paediatric Intensive Care Unit, Department of Paediatrics, The Royal Children's Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Marco Marano
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù , Rome , Italy
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù , Rome , Italy
| | - Paola Bernaschi
- Microbiology Unit, Children's Hospital Bambino Gesù , Rome , Italy
| | - Antonio Amodeo
- ECMO and VAD Unit, Children's Hospital Bambino Gesù , Rome , Italy
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