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Shah N, Mathur S, Shanmugham P, Li X, Thiagarajan RR, Natarajan S, Raman L. Neurologic Statistical Prognostication and Risk Assessment for Kids on Extracorporeal Membrane Oxygenation-Neuro SPARK. ASAIO J 2024; 70:305-312. [PMID: 38557687 DOI: 10.1097/mat.0000000000002106] [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: 04/04/2024] Open
Abstract
This study presents Neuro-SPARK, the first scoring system developed to assess the risk of neurologic injury in pediatric and neonatal patients on extracorporeal membrane oxygenation (ECMO). Using the extracorporeal life support organization (ELSO) registry, we applied robust machine learning methodologies and clinical expertise to a 10 years dataset. We produced separate models for veno-venous (V-V ECMO) and veno-arterial (V-A ECMO) configurations due to their different risk factors and prevalence of neurologic injury. Our models identified 14 predictor variables for V-V ECMO and 20 for V-A ECMO, which demonstrated moderate accuracy in predicting neurologic injury as defined by the area under the receiver operating characteristic (AUROC) (V-V = 0.63, V-A = 0.64) and good calibration as measured by the Brier score (V-V = 0.1, V-A = 0.15). Furthermore, our post-hoc analysis identified high- and low-risk groups that may aid clinicians in targeted neuromonitoring and guide future research on ECMO-associated neurologic injury. Despite the inherent limitations, Neuro-SPARK lays the foundation for a risk-assessment tool for neurologic injury in ECMO patients, with potential implications for improved patient outcomes.
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Affiliation(s)
- Neel Shah
- From the Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Saurabh Mathur
- Department of Computer Science, University of Texas at Dallas, Richardson, Texas
| | | | - Xilong Li
- Department of Population and Data Science, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Sriraam Natarajan
- Department of Computer Science, University of Texas at Dallas, Richardson, Texas
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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2
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Wormington SN, Best K, Tumin D, Li X, Desher K, Thiagarajan RR, Raman L. Survival and neurobehavioral outcomes following out-of-hospital cardiac arrest in pediatric patients with pre-existing morbidity: An analysis of the THAPCA out-of-hospital arrest data. Resuscitation 2024; 197:110144. [PMID: 38367829 DOI: 10.1016/j.resuscitation.2024.110144] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
AIM Pre-arrest morbidity in adults who suffer out-of-hospital cardiac arrest (OHCA) is associated with increased mortality and poorer neurologic outcomes. The objective of this study was to determine if a similar association is seen in pediatric patients. METHODS We performed a secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial. Study sites included 36 pediatric intensive care units across the United States and Canada. The study enrolled children between the ages of 48 hours and 18 years following an OHCA between September 1, 2009 and December 31, 2012. For our analysis, patients with (N = 151) and without (N = 142) pre-arrest comorbidities were evaluated to assess morbidity, survival, and neurologic function following OHCA. RESULTS No significant difference in 28-day survival was seen between groups. Dependence on technology and neurobehavioral outcomes were assessed among survivors using the Vineland Adaptive Behavior Scales-Second Edition (VABS-II), Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC). Children with pre-existing comorbidities maintained worse neurobehavioral function at twelve months, evidenced by poorer scores on POPC (p = 0.016), PCPC (p = 0.044), and VABS-II (p = 0.020). They were more likely to have a tracheostomy at hospital discharge (p = 0.034), require supplemental oxygen at three months (p = 0.039) and twelve months (p = 0.034), and be mechanically ventilated at twelve months (p = 0.041). CONCLUSIONS There was no difference in survival to 28 days following OHCA in children with pre-existing comorbidity compared to previously healthy children. The group with pre-existing comorbidity was more reliant on technology following arrest and exhibited worse neurobehavioral outcomes.
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Affiliation(s)
- Sierra N Wormington
- University of Texas Southwestern Medical Center, Department of Anesthesiology, Dallas, TX, USA
| | - Kathryn Best
- East Carolina University, Department of Pediatrics, Greenville, NC, USA
| | - Dmitry Tumin
- East Carolina University, Research Associate Professor, Department of Pediatrics, Greenville, NC, USA
| | - Xilong Li
- University of Texas Southwestern Medical Center, Department of Population and Data Science, Dallas, TX, USA
| | - Kaley Desher
- Emory University, Department of Pediatrics, Atlanta, GA, USA
| | | | - Lakshmi Raman
- University of Texas Southwestern Medical Center, Department of Pediatrics, Dallas, TX, USA.
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3
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Tabet M, Custer C, Khan IR, Sanford E, Sharma J, Choe R, Singh S, Sirsi D, Olson DM, Morriss MC, Raman L, Busch DR. Neuromonitoring of Pediatric and Adult Extracorporeal Membrane Oxygenation Patients: The Importance of Continuous Bedside Tools in Driving Neuroprotective Clinical Care. ASAIO J 2024; 70:167-176. [PMID: 38051987 DOI: 10.1097/mat.0000000000002107] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of temporary cardiopulmonary bypass for patients with acute respiratory or cardiac failure refractory to conventional therapy. Its usage has become increasingly widespread and while reported survival after ECMO has increased in the past 25 years, the incidence of neurological injury has not declined, leading to the pressing question of how to improve time-to-detection and diagnosis of neurological injury. The neurological status of patients on ECMO is clinically difficult to evaluate due to multiple factors including illness, sedation, and pharmacological paralysis. Thus, increasing attention has been focused on developing tools and techniques to measure and monitor the brain of ECMO patients to identify dynamic risk factors and monitor patients' neurophysiological state as a function in time. Such tools may guide neuroprotective interventions and thus prevent or mitigate brain injury. Current means to continuously monitor and prevent neurological injury in ECMO patients are rather limited; most techniques provide indirect or postinsult recognition of irreversible brain injury. This review will explore the indications, advantages, and disadvantages of standard-of-care, emerging, and investigational technologies for neurological monitoring on ECMO, focusing on bedside techniques that provide continuous assessment of neurological health.
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Affiliation(s)
- Margherita Tabet
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Chasity Custer
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Imad R Khan
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ethan Sanford
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Jayesh Sharma
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Regine Choe
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, New York
| | - Sumit Singh
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Deepa Sirsi
- Division of Pediatric Neurology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Department of Pediatrics, The University of Texas Southwestern medical center
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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O'Neil ER, Guner Y, Anders MM, Priest J, Friedman ML, Raman L, Di Nardo M, Alexander P, Tonna JE, Rycus P, Thiagarajan RR, Barbaro R, Sandhu HS. Pediatric Highlights From the Extracorporeal Life Support Organization Registry: 2017-2022. ASAIO J 2024; 70:8-13. [PMID: 37949062 DOI: 10.1097/mat.0000000000002078] [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: 11/12/2023] Open
Abstract
The Extracorporeal Life Support Organization (ELSO) registry which collects data from hundreds of participating centers supports research in ECMO to help improve patient outcomes. The ELSO Scientific Oversight Committee, an international and diverse group of ECMOlogists ( https://www.elso.org/registry/socmembers.aspx ), selected the most impactful and innovative research articles on pediatric ECMO emerging from ELSO data. Here they present brief highlights of these publications.
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Affiliation(s)
- Erika R O'Neil
- From the Department of Pediatrics, United States Air Force, Brooke Army Medical Center, San Antonio, Texas
| | - Yigit Guner
- University of California Irvine Department of Surgery, Children's Hospital of Orange County, California
| | - Marc M Anders
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - John Priest
- Department of Respiratory Care/ECMO Program, Boston Children's Hospital, Boston, Massachusetts
| | - Matthew L Friedman
- Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Lakshmi Raman
- University of Texas Southwestern, UT Southwestern Medical Center, Dallas, Texas
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Peta Alexander
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery and Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Ravi R Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ryan Barbaro
- Division of Pediatric Critical Care Medicine and Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan
| | - Hitesh S Sandhu
- University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
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5
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Custer C, Singh S, Sanford E, Nandy K, Raman L, Busch DR, Morriss MC. Computed Tomography Is Predictive of Significant Neurologic Injury in Children Supported on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:e460-e462. [PMID: 37314831 DOI: 10.1097/mat.0000000000001990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Affiliation(s)
- Chasity Custer
- From the Department of Pediatric Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumit Singh
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ethan Sanford
- From the Department of Pediatric Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Karabi Nandy
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lakshmi Raman
- From the Department of Pediatric Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David R Busch
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, University of Texas Southwestern Medical Center, Dallas, Texas
| | - M Craig Morriss
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
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Pandiyan P, Cvetkovic M, Antonini MV, Shappley RKH, Karmakar SA, Raman L. Clinical Guidelines for Routine Neuromonitoring in Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:895-900. [PMID: 37603797 DOI: 10.1097/mat.0000000000001896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/23/2023] Open
Abstract
DISCLAIMER These guidelines for routine neuromonitoring in neonatal and pediatric patients supported on extracorporeal membrane oxygenation (ECMO) are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS and ECMO but these are not necessarily consensus recommendations. The aim of clinical guidelines was to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or being deemed inclusive of all proper methods of care nor exclusive of other methods of care directed at obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient considering all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Poornima Pandiyan
- From the Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Mirjana Cvetkovic
- Cardiac Critical Care Division, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Rebekah K H Shappley
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Swati A Karmakar
- Department of Pediatrics, Baylor College of Medicine, Neurology and Developmental Neuroscience Section, Texas Children's Hospital, Houston, Texas
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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7
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Shah N, Li X, Shanmugham P, Fan E, Thiagarajan RR, Venkataraman R, Raman L. Early Changes in Arterial Partial Pressure of Carbon Dioxide and Blood Pressure After Starting Extracorporeal Membrane Oxygenation in Children: Extracorporeal Life Support Organization Database Study of Neurologic Complications. Pediatr Crit Care Med 2023; 24:541-550. [PMID: 36877009 DOI: 10.1097/pcc.0000000000003216] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Neurologic complications in pediatric patients supported by extracorporeal membrane oxygenation (ECMO) are common and lead to morbidity and mortality; however, few modifiable factors are known. DESIGN Retrospective study of the Extracorporeal Life Support Organization registry (2010-2019). SETTING Multicenter international database. PATIENTS Pediatric patients receiving ECMO (2010-2019) for all indications and any mode of support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We investigated if early relative change in Pa co2 or mean arterial blood pressure (MAP) soon after starting ECMO was associated with neurologic complications. The primary outcome of neurologic complications was defined as a report of seizures, central nervous system infarction or hemorrhage, or brain death. All-cause mortality (including brain death) was used as a secondary outcome.Out of 7,270 patients, 15.6% had neurologic complications. Neurologic complications increased when the relative Pa co2 decreased by greater than 50% (18.4%) or 30-50% (16.5%) versus those who had a minimal change (13.9%, p < 0.01 and p = 0.046). When the relative MAP increased greater than 50%, the rate of neurologic complications was 16.9% versus 13.1% those with minimal change ( p = 0.007). In a multivariable model adjusting for confounders, a relative decrease in Pa co2 greater than 30% was independently associated with greater odds of neurologic complication (odds ratio [OR], 1.25; 95% CI, 1.07-1.46; p = 0.005). Within this group, with a relative decrease in Pa co2 greater than 30%, the effects of increased relative MAP increased neurologic complications (0.05% per BP Percentile; 95% CI, 0.001-0.11; p = 0.05). CONCLUSIONS In pediatric patients, a large decrease in Pa co2 and increase in MAP following ECMO initiation are both associated with neurologic complications. Future research focusing on managing these issues carefully soon after ECMO deployment can potentially help to reduce neurologic complications.
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Affiliation(s)
- Neel Shah
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Xilong Li
- Department of Population and Data Science, University of Texas Southwestern Medical Center, Dallas, TX
| | - Prashanth Shanmugham
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada
| | | | | | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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8
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Sanford EL, Akorede R, Miller I, Morriss MC, Nandy K, Raman L, Busch DR. Association Between Disrupted Cerebral Autoregulation and Radiographic Neurologic Injury for Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study. ASAIO J 2023; 69:e315-e321. [PMID: 37172001 DOI: 10.1097/mat.0000000000001970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Validation of a real-time monitoring device to evaluate the risk or occurrence of neurologic injury while on extracorporeal membrane oxygenation (ECMO) may aid clinicians in prevention and treatment. Therefore, we performed a pilot prospective cohort study of children under 18 years old on ECMO to analyze the association between cerebral blood pressure autoregulation as measured by diffuse correlation spectroscopy (DCS) and radiographic neurologic injury. DCS measurements of regional cerebral blood flow were collected on enrolled patients and correlated with mean arterial blood pressure to determine the cerebral autoregulation metric termed DCSx. The primary outcome of interest was radiographic neurologic injury on eligible computed tomography (CT) or magnetic resonance imaging (MRI) scored by a blinded pediatric neuroradiologist utilizing a previously validated scale. Higher DCSx scores, which indicate disruption of cerebral autoregulation, were associated with higher radiographic neurologic injury score (slope, 11.0; 95% confidence interval [CI], 0.29-22). Patients with clinically significant neurologic injury scores of 10 or more had higher median DCSx measures than patients with lower neurologic injury scores (0.48 vs . 0.13; p = 0.01). Our study indicates that obtaining noninvasive DCS measures for children on ECMO is feasible and disruption of cerebral autoregulation determined from DCS is associated with higher radiographic neurologic injury score.
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Affiliation(s)
- Ethan L Sanford
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Rufai Akorede
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Isabel Miller
- UT Southwestern Medical Center Medical School, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Karabi Nandy
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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9
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Sanford EL, Bhaskar P, Li X, Thiagarajan R, Raman L. Hypothermia after Extracorporeal Cardiopulmonary Resuscitation Not Associated with Improved Neurologic Complications or Survival in Children: an Analysis of the ELSO Registry. Resuscitation 2023:109852. [PMID: 37245646 DOI: 10.1016/j.resuscitation.2023.109852] [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] [Received: 03/21/2023] [Revised: 04/26/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023]
Abstract
AIM To analyze the association between hypothermia and neurologic complications among children who were treated with extracorporeal cardiopulmonary resuscitation (ECPR) using the Extracorporeal Life Support Organization (ELSO) international registry METHODS: We conducted a retrospective, multicenter, database study utilizing ELSO data for ECPR encounters from January 1, 2011, through December 31, 2019. Exclusion criteria included multiple ECMO runs and lack of variable data. The primary exposure was hypothermia under 34 degrees Celsius for greater than 24 hours. The primary outcome, determined a priori, was a composite of neurologic complications defined by ELSO registry including brain death, seizures, infarction, hemorrhage, diffuse ischemia. Secondary outcomes were mortality on ECMO and mortality prior to hospital discharge. Multivariable logistic regression determined the odds of neurologic complications, mortality on ECMO or prior to hospital discharge associated with hypothermia after adjustment for available pertinent covariables. RESULTS Of the 2,289 ECPR encounters, no difference in odds of neurologic complications were found between the hypothermia and non-hypothermia groups (AOR 1.10, 95% CI 0.80-1.51). However, hypothermia exposure was associated with decreased odds of mortality on ECMO (AOR 0.76, 95% CI 0.59-0.97), but no difference in mortality prior to hospital discharge (AOR 0.96, 95% CI 0.76-1.21) CONCLUSION: Analysis of a large, multicenter, international dataset demonstrates that hypothermia for greater than 24 hours among children who undergo ECPR is not associated with decreased neurologic complications or mortality benefit at time of hospital discharge.
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Affiliation(s)
- Ethan L Sanford
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA; Outcomes Research Consortium.
| | - Priya Bhaskar
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ravi Thiagarajan
- Division of Cardiovascular Critical Care, Department of Pediatrics, Harvard University, Boston, MA, United States
| | - Lakshmi Raman
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
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10
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Rabie AA, Elhazmi A, Azzam MH, Abdelbary A, Labib A, Combes A, Zakhary B, MacLaren G, Barbaro RP, Peek GJ, Antonini MV, Shekar K, Al-Fares A, Oza P, Mehta Y, Alfoudri H, Ramanathan K, Ogino M, Raman L, Paden M, Brodie D, Bartlett R. Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study. Ann Intensive Care 2023; 13:36. [PMID: 37129771 PMCID: PMC10152433 DOI: 10.1186/s13613-023-01126-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/05/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The high-quality evidence on managing COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support is insufficient. Furthermore, there is little consensus on allocating ECMO resources when scarce. The paucity of evidence and the need for guidance on controversial topics required an international expert consensus statement to understand the role of ECMO in COVID-19 better. Twenty-two international ECMO experts worldwide work together to interpret the most recent findings of the evolving published research, statement formulation, and voting to achieve consensus. OBJECTIVES To guide the next generation of ECMO practitioners during future pandemics on tackling controversial topics pertaining to using ECMO for patients with COVID-19-related severe ARDS. METHODS The scientific committee was assembled of five chairpersons with more than 5 years of ECMO experience and a critical care background. Their roles were modifying and restructuring the panel's questions and, assisting with statement formulation in addition to expert composition and literature review. Experts are identified based on their clinical experience with ECMO (minimum of 5 years) and previous academic activity on a global scale, with a focus on diversity in gender, geography, area of expertise, and level of seniority. We used the modified Delphi technique rounds and the nominal group technique (NGT) through three face-to-face meetings and the voting on the statement was conducted anonymously. The entire process was planned to be carried out in five phases: identifying the gap of knowledge, validation, statement formulation, voting, and drafting, respectively. RESULTS In phase I, the scientific committee obtained 52 questions on controversial topics in ECMO for COVID-19, further reviewed for duplication and redundancy in phase II, resulting in nine domains with 32 questions with a validation rate exceeding 75% (Fig. 1). In phase III, 25 questions were used to formulate 14 statements, and six questions achieved no consensus on the statements. In phase IV, two voting rounds resulted in 14 statements that reached a consensus are included in four domains which are: patient selection, ECMO clinical management, operational and logistics management, and ethics. CONCLUSION Three years after the onset of COVID-19, our understanding of the role of ECMO has evolved. However, it is incomplete. Tota14 statements achieved consensus; included in four domains discussing patient selection, clinical ECMO management, operational and logistic ECMO management and ethics to guide next-generation ECMO providers during future pandemic situations.
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Affiliation(s)
- Ahmed A Rabie
- Critical Care Department-ECMO care Unit (ECU), Riyadh Region Cluster1, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Alyaa Elhazmi
- Internal Medicine Department, King Faisal University, Riyadh, Saudi Arabia
| | - Mohamed H Azzam
- Adult Critical Care Department, Dr. Sulaiman Alhabib Medical Group, Jeddah, Saudi Arabia
| | | | - Ahmed Labib
- Hamad Medical Corporation, Weill Cornell Medical College, Doha, Qatar
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, 75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | | | - Graeme MacLaren
- Cardiothoracic ICU, National University Hospital, Singapore, Singapore
| | - Ryan P Barbaro
- Division of Pediatric Critical Care and Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Giles J Peek
- Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | | | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Ministry of Health, Kuwait City, Kuwait
- Al-Amiri Hospital Center for Respiratory and Cardiac Failure, Kuwait Extracorporeal Life Support Program, Ministry of Health, Kuwait City, Kuwait
| | - Pranay Oza
- Riddhi Vinayak Multispecialty Hospital, Mumbai, India
| | - Yatin Mehta
- Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, 122001, Haryana, India
| | - Huda Alfoudri
- Department of Anaesthesia, Critical Care, and Pain Management, Al-Adan Hospital Ministry of Health, Hadiya, Kuwait
| | | | - Mark Ogino
- Chief Partnership Officer, Nemours Children's Health, Delaware Valley, USA
| | - Lakshmi Raman
- Division of Paediatric Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Paden
- Division of Paediatric Critical Care, Emory University, Atlanta, GA, USA
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian/Columbia University Medical Center, New York, USA
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Yu P, Skinner M, Esangbedo I, Lasa JJ, Li X, Natarajan S, Raman L. Predicting Cardiac Arrest in Children with Heart Disease: A Novel Machine Learning Algorithm. J Clin Med 2023; 12:jcm12072728. [PMID: 37048811 PMCID: PMC10095110 DOI: 10.3390/jcm12072728] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Children with congenital and acquired heart disease are at a higher risk of cardiac arrest compared to those without heart disease. Although the monitoring of cardiopulmonary resuscitation quality and extracorporeal resuscitation technologies have advanced, survival after cardiac arrest in this population has not improved. Cardiac arrest prevention, using predictive algorithms with machine learning, has the potential to reduce cardiac arrest rates. However, few studies have evaluated the use of these algorithms in predicting cardiac arrest in children with heart disease. METHODS We collected demographic, laboratory, and vital sign information from the electronic health records (EHR) of all the patients that were admitted to a single-center pediatric cardiac intensive care unit (CICU), between 2010 and 2019, who had a cardiac arrest during their CICU admission, as well as a comparator group of randomly selected non-cardiac-arrest controls. We compared traditional logistic regression modeling against a novel adaptation of a machine learning algorithm (functional gradient boosting), using time series data to predict the risk of cardiac arrest. RESULTS A total of 160 unique cardiac arrest events were matched to non-cardiac-arrest time periods. Using 11 different variables (vital signs and laboratory values) from the EHR, our algorithm's peak performance for the prediction of cardiac arrest was at one hour prior to the cardiac arrest (AUROC of 0.85 [0.79,0.90]), a performance that was similar to our previously published multivariable logistic regression model. CONCLUSIONS Our novel machine learning predictive algorithm, which was developed using retrospective data that were collected from the EHR and predicted cardiac arrest in the children that were admitted to a single-center pediatric cardiac intensive care unit, demonstrated a performance that was similar to that of a traditional logistic regression model. While these results are encouraging, future research, including prospective validations with multicenter data, is warranted prior to the implementation of this algorithm as a real-time clinical decision support tool.
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Affiliation(s)
- Priscilla Yu
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Michael Skinner
- Department of Computer Science, University of Texas at Dallas, Richardson, TX 75080, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Ivie Esangbedo
- Section of Cardiac Critical Care, Division of Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
| | - Javier J Lasa
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Xilong Li
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Sriraam Natarajan
- Department of Computer Science, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Lakshmi Raman
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
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12
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Lee AE, Munoz E, Al Dabbous T, Harris E, O'Callaghan M, Raman L. Extracorporeal Life Support Organization Guidelines for the Provision and Assessment of Nutritional Support in the Neonatal and Pediatric ECMO Patient. ASAIO J 2022; 68:875-880. [PMID: 35703144 DOI: 10.1097/mat.0000000000001767] [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: 11/26/2022] Open
Abstract
DISCLAIMER This guideline is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/extracorporeal membrane oxygenation (ECMO) and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but Extracorporeal Life Support Organization (ELSO) is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Amy E Lee
- From the Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Tala Al Dabbous
- Bayt Abdullah Children's Hospice, Al-Adan Hospital, NBK Children's Hospital, Kuwait City, Kuwait
| | | | - Maura O'Callaghan
- ECMO Service Team, Great Ormond Street Hospital, London, United Kingdom
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Di Nardo M, Ahmad AH, Merli P, Zinter MS, Lehman LE, Rowan CM, Steiner ME, Hingorani S, Angelo JR, Abdel-Azim H, Khazal SJ, Shoberu B, McArthur J, Bajwa R, Ghafoor S, Shah SH, Sandhu H, Moody K, Brown BD, Mireles ME, Steppan D, Olson T, Raman L, Bridges B, Duncan CN, Choi SW, Swinford R, Paden M, Fortenberry JD, Peek G, Tissieres P, De Luca D, Locatelli F, Corbacioglu S, Kneyber M, Franceschini A, Nadel S, Kumpf M, Loreti A, Wösten-Van Asperen R, Gawronski O, Brierley J, MacLaren G, Mahadeo KM. Extracorporeal membrane oxygenation in children receiving haematopoietic cell transplantation and immune effector cell therapy: an international and multidisciplinary consensus statement. Lancet Child Adolesc Health 2022; 6:116-128. [PMID: 34895512 PMCID: PMC9372796 DOI: 10.1016/s2352-4642(21)00336-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 01/03/2023]
Abstract
Use of extracorporeal membrane oxygenation (ECMO) in children receiving haematopoietic cell transplantation (HCT) and immune effector cell therapy is controversial and evidence-based guidelines have not been established. Remarkable advancements in HCT and immune effector cell therapies have changed expectations around reversibility of organ dysfunction and survival for affected patients. Herein, members of the Extracorporeal Life Support Organization (ELSO), Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network (HCT and cancer immunotherapy subgroup), the Pediatric Diseases Working Party of the European Society for Blood and Marrow Transplantation (EBMT), the supportive care committee of the Pediatric Transplantation and Cellular Therapy Consortium (PTCTC), and the Pediatric Intensive Care Oncology Kids in Europe Research (POKER) group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) provide consensus recommendations on the use of ECMO in children receiving HCT and immune effector cell therapy. These are the first international, multidisciplinary consensus-based recommendations on the use of ECMO in this patient population. This Review provides a clinical decision support tool for paediatric haematologists, oncologists, and critical care physicians during the difficult decision-making process of ECMO candidacy and management. These recommendations can represent a base for future research studies focused on ECMO selection criteria and bedside management.
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Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Ali H Ahmad
- Department of Pediatrics, Pediatric Critical Care, Houston, TX, USA
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matthew S Zinter
- Department of Pediatrics, Divisions of Critical Care and Bone Marrow Transplantation, University of California, San Francisco, CA, USA
| | - Leslie E Lehman
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Courtney M Rowan
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Sangeeta Hingorani
- Department of Pediatrics, Division of Nephrology, University of Washington School of Medicine, and the Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Joseph R Angelo
- Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Transplantation and Cell Therapy Program, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sajad J Khazal
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Basirat Shoberu
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer McArthur
- Division of Critical Care Medicine, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Rajinder Bajwa
- Department of Pediatrics, Division of Blood and Marrow Transplantation, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Saad Ghafoor
- Division of Critical Care Medicine, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Samir H Shah
- Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Hitesh Sandhu
- Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Karen Moody
- CARTOX Program, and Department of Pediatrics, Supportive Care, Houston, TX, USA
| | - Brandon D Brown
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Diana Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Taylor Olson
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Lakshmi Raman
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Brian Bridges
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christine N Duncan
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Sung Won Choi
- University of Michigan, Rogel Cancer Center, Ann Arbor, MI, USA; Department of Pediatrics, Ann Arbor, MI, USA
| | - Rita Swinford
- Department of Pediatrics, Division of Pediatric Nephrology, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Matt Paden
- Pediatric Critical Care, Children's Healthcare of Atlanta, and Emory University School of Medicine, Atlanta, GA, USA
| | - James D Fortenberry
- Pediatric Critical Care, Children's Healthcare of Atlanta, and Emory University School of Medicine, Atlanta, GA, USA
| | - Giles Peek
- Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Pierre Tissieres
- Division of Pediatric Intensive Care and Neonatal Medicine, Paris South University Hospital, Le Kremlin-Bicetre, France; Institute of Integrative Biology of the Cell, CNRS, CEA, Univ. Paris Sud, Paris Saclay University, Paris, France
| | - Daniele De Luca
- Division of Pediatrics, Transportation and Neonatal Critical Care Medicine, APHP, Paris Saclay University Hospital, "A.Beclere" Medical Center and Physiopathology and Therapeutic Innovation Unit-INSERM-U999, Paris Saclay University, Paris, France
| | - Franco Locatelli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Martin Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital Groningen, Groningen, Netherlands; Critical Care, Anesthesiology, Peri-Operative and Emergency Medicine (CAPE), University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Alessio Franceschini
- Department of Cardiosurgery, Cardiology, Heart and Lung Transplant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simon Nadel
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Matthias Kumpf
- Interdisciplinary Pediatric Intensive Care Unit, Universitäetsklinikum Tuebingen, Tuebingen, Germany
| | - Alessandra Loreti
- Medical Library, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roelie Wösten-Van Asperen
- Department of Pediatric Intensive Care, University Medical Center Utrecht/Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Joe Brierley
- Department of Pediatric Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - Graeme MacLaren
- Director of Cardiothoracic ICU, National University Health System, Singapore, Singapore; Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Kris M Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Yu P, Esangbedo I, Li X, Wolovits J, Thiagarajan R, Raman L. Early Changes in Near-Infrared Spectroscopy Are Associated With Cardiac Arrest in Children With Congenital Heart Disease. Front Pediatr 2022; 10:894125. [PMID: 35832576 PMCID: PMC9271890 DOI: 10.3389/fped.2022.894125] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The association of near-infrared spectroscopy (NIRS) with various outcomes after pediatric cardiac surgery has been studied extensively. However, the role of NIRS in the prediction of cardiac arrest (CA) in children with heart disease has yet to be evaluated. We sought to determine if a model utilizing regional cerebral oximetry (rSO2c) and somatic oximetry (rSO2s) could predict CA in children admitted to a single-center pediatric cardiac intensive care unit (CICU). METHODS We retrospectively reviewed 160 index CA events for patients admitted to our pediatric CICU between November 2010 and January 2019. We selected 711 control patients who did not have a cardiac arrest. Hourly data was collected from the electronic health record (EHR). We previously created a machine-learning algorithm to predict the risk of CA using EHR data. Univariable analysis was done on these variables, which we then used to create a multivariable logistic regression model. The outputs from the model were presented by odds ratio (OR) and 95% confidence interval (CI). RESULTS We created a multivariable model to evaluate the association of CA using five variables: arterial saturation (SpO2)- rSO2c difference, SpO2-rSO2s difference, heart rate, diastolic blood pressure, and vasoactive inotrope score. While the SpO2-rSO2c difference was not a significant contributor to the multivariable model, the SpO2-rSO2s difference was. The average SpO2-rSO2s difference cutoff with the best prognostic accuracy for CA was 29% [CI 26-31%]. In the multivariable model, a 10% increase in the SpO2-rSO2s difference was independently associated with increased odds of CA [OR 1.40 (1.18, 1.67), P < 0.001] at 1 h before CA. Our model predicted CA with an AUROC of 0.83 at 1 h before CA. CONCLUSION In this single-center case-control study of children admitted to a pediatric CICU, we created a multivariable model utilizing hourly data from the EHR to predict CA. At 1 h before the event, for every 10% increase in the SpO2-rSO2s difference, the odds of cardiac arrest increased by 40%. These findings are important as the field explores ways to capitalize on the wealth of data at our disposal to improve patient care.
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Affiliation(s)
- Priscilla Yu
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ivie Esangbedo
- Division of Cardiac Critical Care, Department of Pediatrics, University of Washington Seattle, Seattle, WA, United States
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joshua Wolovits
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ravi Thiagarajan
- Division of Cardiovascular Critical Care, Department of Pediatrics, Harvard University, Boston, MA, United States
| | - Lakshmi Raman
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
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15
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Skinner MA, Yu P, Raman L, Natarajan S. An Anytime Querying Algorithm for Predicting Cardiac Arrest in Children: Work-in-Progress. Artif Intell Med 2022. [DOI: 10.1007/978-3-031-09342-5_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization. ASAIO J 2021; 67:485-495. [PMID: 33657573 PMCID: PMC8078022 DOI: 10.1097/mat.0000000000001422] [Citation(s) in RCA: 229] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
DISCLAIMER This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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Affiliation(s)
- Jenelle Badulak
- From the Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - M. Velia Antonini
- General ICU, University Hospital of Parma, Parma, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | | | - Lara Shekerdemian
- Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Raman
- Children’s Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew L. Paden
- Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Cara Agerstrand
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
| | | | - Nicholas Barrett
- Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM, Sorbonne Université, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Mark T. Ogino
- Nemours Children’s Health System, Wilmington, Delaware
| | - Giles Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | | | - Ahmed A. Rabie
- Critical Care ECMO Service, King Saud Medical City, Ministry Of Health (MOH), Riyadh, Saudi Arabia
| | - Leonardo Salazar
- Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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17
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Brown G, Moynihan KM, Deatrick KB, Hoskote A, Sandhu HS, Aganga D, Deshpande SR, Menon AP, Rozen T, Raman L, Alexander PMA. Extracorporeal Life Support Organization (ELSO): Guidelines for Pediatric Cardiac Failure. ASAIO J 2021; 67:463-475. [PMID: 33788796 DOI: 10.1097/mat.0000000000001431] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 01/02/2023] Open
Abstract
These guidelines are applicable to neonates and children with cardiac failure as indication for extracorporeal life support. These guidelines address patient selection, management during extracorporeal membrane oxygenation, and pathways for weaning support or bridging to other therapies. Equally important issues, such as personnel, training, credentialing, resources, follow-up, reporting, and quality assurance, are addressed in other Extracorporeal Life Support Organization documents or are center-specific.
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Affiliation(s)
- Georgia Brown
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Hitesh S Sandhu
- Department of Pediatrics, Critical Care Division, Le Bonheur Children's Hospital, University of Tennessee, Memphis, Tennessee
| | - Devon Aganga
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shriprasad R Deshpande
- Pediatric Cardiology Division, Heart Transplant and Advanced Cardiac Therapies Program, Children's National Heart Institute, Washington, D.C
| | - Anuradha P Menon
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Thomas Rozen
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Lakshmi Raman
- Department of Critical Care, University of Texas Southwestern Medical Center, Texas
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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18
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Farhat A, Ling RR, Jenks CL, Poon WH, Yang IX, Li X, Liu Y, Darnell-Bowens C, Ramanathan K, Thiagarajan RR, Raman L. Outcomes of Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 49:682-692. [PMID: 33591019 DOI: 10.1097/ccm.0000000000004882] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 11/26/2022]
Abstract
OBJECTIVE The goal of this work is to provide insight into survival and neurologic outcomes of pediatric patients supported with extracorporeal cardiopulmonary resuscitation. DATA SOURCES A systematic search of Embase, PubMed, Cochrane, Scopus, Google Scholar, and Web of Science was performed from January 1990 to May 2020. STUDY SELECTION A comprehensive list of nonregistry studies with pediatric patients managed with extracorporeal cardiopulmonary resuscitation was included. DATA EXTRACTION Study characteristics and outcome estimates were extracted from each article. DATA SYNTHESIS Estimates were pooled using random-effects meta-analysis. Differences were estimated using subgroup meta-analysis and meta-regression. The Meta-analyses Of Observational Studies in Epidemiology guideline was followed and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation system. Twenty-eight studies (1,348 patients) were included. There was a steady increase in extracorporeal cardiopulmonary resuscitation occurrence rate from the 1990s until 2020. There were 32, 338, and 1,094 patients' articles published between 1990 and 2000, 2001 and 2010, and 2010 and 2020, respectively. More than 70% were cannulated for a primary cardiac arrest. Pediatric extracorporeal cardiopulmonary resuscitation patients had a 46% (CI 95% = 43-48%; p < 0.01) overall survival rate. The rate of survival with favorable neurologic outcome was 30% (CI 95% = 27-33%; p < 0.01). CONCLUSIONS The use of extracorporeal cardiopulmonary resuscitation is rapidly expanding, particularly for children with underlying cardiac disease. An overall survival of 46% and favorable neurologic outcomes add credence to this emerging therapy.
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Affiliation(s)
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Wynne Hsing Poon
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Xilong Li
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Yulun Liu
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Cindy Darnell-Bowens
- University of Texas Southwestern Medical Center, Dallas, TX
- Pediatric Critical Care Medicine, Children's Medical Center of Dallas, Dallas, TX
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Hospital, National University of Singapore, Singapore
- Bond University, Robina, QLD, Australia
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lakshmi Raman
- University of Texas Southwestern Medical Center, Dallas, TX
- Pediatric Critical Care Medicine, Children's Medical Center of Dallas, Dallas, TX
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Affiliation(s)
- Anne-Marie Guerguerian
- From the Department of Critical Care Medicine, The Hospital for Sick Kids, University of Toronto, Toronto
| | - Minako Sano
- Department of Anesthesiology, Division of Cardiac Anesthesiology, The Hospital for Sick Kids, University of Toronto, Toronto
| | - Mark Todd
- From the Department of Critical Care Medicine, The Hospital for Sick Kids, University of Toronto, Toronto
| | - Osami Honjo
- Department of Surgery, Division of Cardiothoracic Surgery, The Hospital for Sick Kids, University of Toronto, Toronto
| | - Peta Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Lakshmi Raman
- Department of Pediatrics, UTSouthwestern Medical Center, Dallas, Texas
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Richardson ASC, Tonna JE, Nanjayya V, Nixon P, Abrams DC, Raman L, Bernard S, Finney SJ, Grunau B, Youngquist ST, McKellar SH, Shinar Z, Bartos JA, Becker LB, Yannopoulos D, Bˇelohlávek J, Lamhaut L, Pellegrino V. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization. ASAIO J 2021; 67:221-228. [PMID: 33627592 PMCID: PMC7984716 DOI: 10.1097/mat.0000000000001344] [Citation(s) in RCA: 169] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
DISCLAIMER Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available.
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Affiliation(s)
| | | | | | - Paul Nixon
- From the The Alfred Hospital, Melbourne, Australia
| | | | | | | | | | - Brian Grunau
- Vancouver Coastal Health, Vancouver, British Columbia
| | | | | | - Zachary Shinar
- University of Minnesota Medical Center, Minneapolis, Minnesota
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Tonna JE, Barbaro RP, Rycus PT, Wall N, Raman L, Nasr VG, Paden ML, Thiagarajan RR, Dalton H, Conrad SA, Bartlett RH, Toomasian JM, Alexander PMA. On the Academic Value of 30 Years of the Extracorporeal Life Support Organization Registry. ASAIO J 2021; 67:1-3. [PMID: 33196480 PMCID: PMC7748999 DOI: 10.1097/mat.0000000000001318] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Joseph E Tonna
- From the Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Ryan P Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor; Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Peter T Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Natalie Wall
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Lakshmi Raman
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Viviane G Nasr
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matt L Paden
- Division of Pediatric Critical Care, Emory University, Atlanta, Georgia
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Steven A Conrad
- Departments of Medicine, Emergency Medicine and Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Louisiana; and
| | | | - John M Toomasian
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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22
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Ramanathan K, Yeo N, Alexander P, Raman L, Barbaro R, Tan CS, Schlapbach LJ, MacLaren G. Role of extracorporeal membrane oxygenation in children with sepsis: a systematic review and meta-analysis. Crit Care 2020; 24:684. [PMID: 33287861 PMCID: PMC7720382 DOI: 10.1186/s13054-020-03418-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The benefits of extracorporeal membrane oxygenation (ECMO) in children with sepsis remain controversial. Current guidelines on management of septic shock in children recommend consideration of ECMO as salvage therapy. We sought to review peer-reviewed publications on effectiveness of ECMO in children with sepsis. METHODS Studies reporting on mortality in children with sepsis supported with ECMO, published in PubMed, Scopus and Embase from 1972 till February 2020, were included in the review. This study was done in adherence to Preferred Reporting Items for Systematic Review and Meta-Analysis statement after registering the review protocol with PROSPERO. Study eligibility was independently assessed by two authors and disagreements resolved by a third author. Publications were reviewed for quality using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Random-effects meta-analyses (DerSimonian and Laird) were conducted, and 95% confidence intervals were computed using the Clopper-Pearson method. Outliers were identified by the Baujat plot and leave-one-out analysis if there was considerable heterogeneity. The primary outcome measure was survival to discharge. Secondary outcome measures included hospital length of stay, subgroup analysis of neonatal and paediatric groups, types and duration of ECMO and complications . RESULTS Of the 2054 articles screened, we identified 23 original articles for systematic review and meta-analysis. Cumulative estimate of survival (13 studies, 2559 patients) in the cohort was 59% (95%CI: 51-67%). Patients had a median length of hospital stay of 28.8 days, median intensive care unit stay of 13.5 days, and median ECMO duration of 129 h. Children needing venoarterial ECMO (9 studies, 208 patients) showed overall pooled survival of 65% (95%CI: 50-80%). Neonates (< 4 weeks of age) with sepsis needing ECMO (7 studies, 85 neonates) had pooled survival of 73% (95%CI: 56- 87%). Gram positive organisms were the most common pathogens (47%) in septic children supported with ECMO. CONCLUSION Survival rates of children with sepsis needing ECMO was 59%. Neonates had higher survival rates (73%); gram positive organisms accounted for most common infections in children needing ECMO. Despite limitations, pooled survival data from this review indicates consideration of ECMO in refractory septic shock for all pediatric age groups.
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Affiliation(s)
- Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, Department of Cardiothoracic Surgery, National University Hospital, Singapore, 119228, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Nicholas Yeo
- Queen's University Belfast School of Medicine, Belfast, UK
| | - Peta Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Lakshmi Raman
- University of Texas Southwestern Medical Center, Dallas, USA
| | - Ryan Barbaro
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, USA
| | - Chuen Seng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Luregn J Schlapbach
- Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland.,Pediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, Department of Cardiothoracic Surgery, National University Hospital, Singapore, 119228, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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23
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Jenks C, Raman L, Dhar A. Review of acute kidney injury and continuous renal replacement therapy in pediatric extracorporeal membrane oxygenation. Indian J Thorac Cardiovasc Surg 2020; 37:254-260. [PMID: 33967449 DOI: 10.1007/s12055-020-01071-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 10/22/2022] Open
Abstract
Purpose To review the relevant literature of acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) as it relates to pediatric extracorporeal membrane oxygenation (ECMO). Methods Available online relevant literature. Results ECMO is a therapeutic modality utilized to support patients with refractory respiratory and/or cardiac failure. AKI and fluid overload (FO) are frequently observed in this patient population. There are multiple modalities that can be utilized for AKI and FO which include the following: diuretics, in-line hemofiltration, and CRRT. There are multiple considerations when using CRRT with ECMO including access, CRRT flows, hemolysis, anticoagulation, and CRRT termination. Conclusion While each ECMO center has its own set of equipment, experiences, and practices, it is imperative that the international ECMO community continues to work together to provide an evidence-based approach to address the morbidity and mortality associated with AKI and FO.
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Affiliation(s)
- Christopher Jenks
- Blair E Batson Children's Hospital, Department of Pediatrics, Section of Critical Care, University of Mississippi Medical Center, Jackson, MS USA
| | - Lakshmi Raman
- Children's of Dallas, Department of Pediatrics, Section of Critical Care, University of Texas Southwestern Medical Center, Dallas, TX USA.,Children's Health, Dallas, TX USA
| | - Archana Dhar
- Children's of Dallas, Department of Pediatrics, Section of Critical Care, University of Texas Southwestern Medical Center, Dallas, TX USA.,Children's Health, Dallas, TX USA
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24
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Raman L, Dalton HJ. Surveying the Scene: Timing Is Everything. Pediatr Crit Care Med 2020; 21:902-903. [PMID: 33009301 DOI: 10.1097/pcc.0000000000002518] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Lakshmi Raman
- Pediatric Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Heidi J Dalton
- INOVA Fairfax Medical Center; Program Development and Research, ECLS; Pediatrics; and Heart and Vascular Institute Falls Church, VA
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Shah N, Farhat A, Tweed J, Wang Z, Lee J, McBeth R, Skinner M, Tian F, Thiagarajan R, Raman L. Neural Networks to Predict Radiographic Brain Injury in Pediatric Patients Treated with Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:jcm9092718. [PMID: 32842683 PMCID: PMC7565544 DOI: 10.3390/jcm9092718] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/07/2020] [Accepted: 08/19/2020] [Indexed: 01/03/2023] Open
Abstract
Brain injury is a significant source of morbidity and mortality for pediatric patients treated with Extracorporeal Membrane Oxygenation (ECMO). Our objective was to utilize neural networks to predict radiographic evidence of brain injury in pediatric ECMO-supported patients and identify specific variables that can be explored for future research. Data from 174 ECMO-supported patients were collected up to 24 h prior to, and for the duration of, the ECMO course. Thirty-five variables were collected, including physiological data, markers of end-organ perfusion, acid-base homeostasis, vasoactive infusions, markers of coagulation, and ECMO-machine factors. The primary outcome was the presence of radiologic evidence of moderate to severe brain injury as established by brain CT or MRI. This information was analyzed by a neural network, and results were compared to a logistic regression model as well as clinician judgement. The neural network model was able to predict brain injury with an Area Under the Curve (AUC) of 0.76, 73% sensitivity, and 80% specificity. Logistic regression had 62% sensitivity and 61% specificity. Clinician judgment had 39% sensitivity and 69% specificity. Sequential feature group masking demonstrated a relatively greater contribution of physiological data and minor contribution of coagulation factors to the model's performance. These findings lay the foundation for further areas of research directions.
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Affiliation(s)
- Neel Shah
- Department of Pediatrics, Division of Pediatric Critical Care, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Abdelaziz Farhat
- Department of Pediatrics, Pediatrix Medical Group, Orem, UT 84057, USA;
| | | | - Ziheng Wang
- Department of Mechanical Engineering, The University of Texas at Dallas, Dallas, TX 75080, USA;
| | - Jeon Lee
- Department of Bioinformatics, University of Texas Southwestern, Dallas, TX 75390, USA;
| | - Rafe McBeth
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX 75390, USA;
| | - Michael Skinner
- Department of Computer Science, The University of Texas at Dallas, Dallas, TX 75080, USA;
| | - Fenghua Tian
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX 76019, USA;
| | - Ravi Thiagarajan
- Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Lakshmi Raman
- Children’s Health Dallas, Dallas, TX 75201, USA;
- Department of Pediatrics, Division of Pediatric Critical Care, University of Texas Southwestern, Dallas, TX 75390, USA
- Correspondence:
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26
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Fox J, Jenks CL, Farhat A, Li X, Liu Y, James E, Karasick S, Morriss MC, Sirsi D, Raman L. EEG is A Predictor of Neuroimaging Abnormalities in Pediatric Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:jcm9082512. [PMID: 32759731 PMCID: PMC7463499 DOI: 10.3390/jcm9082512] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 12/31/2022] Open
Abstract
The goal of this project was to evaluate if severity of electroencephalogram (EEG) during or shortly after being placed on extracorporeal membrane oxygenation (ECMO) would correlate with neuroimaging abnormalities, and if that could be used as an early indicator of neurologic injury. This was a retrospective chart review spanning November 2009 to May 2018. Patients who had an EEG recording during ECMO or within 48 hours after being decannulated (early group) or within 3 months of being on ECMO (late group) were included if they also had ECMO-related neuroimaging. In the early EEG group, severity of the EEG findings of mild, moderate, and severe EEG correlated to mild, moderate, and severe neuroimaging scores. Patients on venoarterial (VA) ECMO were noted to have higher EEG and neuroimaging severity; this was statistically significant. There was no association in the late EEG group to neuroimaging abnormalities. Our study highlights that EEG severity can be an early predictor for neuroimaging abnormalities that can be identified by computed tomography (CT) and or magnetic resonance imaging (MRI). This can provide guidance for both the medical team and families, allowing for a better understanding of overall prognosis.
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Affiliation(s)
- Jordana Fox
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA;
| | | | - Abdelaziz Farhat
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA; (A.F.); (D.S.)
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (X.L.); (Y.L.)
| | - Yulun Liu
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (X.L.); (Y.L.)
| | - Ellen James
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
| | - Stephanie Karasick
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
| | - Michael C. Morriss
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Deepa Sirsi
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA; (A.F.); (D.S.)
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA; (A.F.); (D.S.)
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
- Correspondence:
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Shekar K, Badulak J, Peek G, Boeken U, Dalton HJ, Arora L, Zakhary B, Ramanathan K, Starr J, Akkanti B, Antonini MV, Ogino MT, Raman L, Barret N, Brodie D, Combes A, Lorusso R, MacLaren G, Müller T, Paden M, Pellegrino V. Extracorporeal Life Support Organization Coronavirus Disease 2019 Interim Guidelines: A Consensus Document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers. ASAIO J 2020; 66:707-721. [PMID: 32604322 DOI: 10.1097/mat.000000000000119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Disclaimer: The Extracorporeal Life Support Organization (ELSO) Coronavirus Disease 2019 (COVID-19) Guidelines have been developed to assist existing extracorporeal membrane oxygenation (ECMO) centers to prepare and plan provision of ECMO during the ongoing pandemic. The recommendations have been put together by a team of interdisciplinary ECMO providers from around the world. Recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. This is a living document and will be regularly updated when new information becomes available. ELSO is not liable for the accuracy or completeness of the information in this document. These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.
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Affiliation(s)
- Kiran Shekar
- From Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Giles Peek
- University of Florida, Shands Hospital for Children, Gainesville, Florida
| | - Udo Boeken
- Department of Cardiac Surgery, University Hospital, Duesseldorf, Germany
| | | | - Lovkesh Arora
- University of Iowa Hospital & Clinics, Iowa City, Iowa
| | | | | | | | | | - M Velia Antonini
- 1st Intensive Care Unit, University Hospital of Parma, Parma, Italy
| | - Mark T Ogino
- Department of Paediatrics, Division of Neonatology, Nemours Alfred I duPont Hospital for Children, Wilmington, Delaware
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lakshmi Raman
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Daniel Brodie
- Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Alain Combes
- Assitance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Roberto Lorusso
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Matthew Paden
- Department of Pediatrics, Emory University, Atlanta, Georgia
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Raman L, Yahya F, Ng CM, Sockalingam S, Raja Mohamed RJB. SAT0597 EARLY DAMAGE AS MEASURED BY SLICC/ACR DAMAGE INDEX IS A PREDICTOR OF HOSPITALIZATION IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE). Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Hospital admissions and re-admissions in lupus patients are common occurrences that can lead to mortality. The predictive factors influencing hospitalizations and mortality are variable in literature.Objectives:We evaluated the leading causes of hospitalizations and mortality and their predictive factors in the multi-ethnic SLE patients.Methods:A retrospective study was done on SLE patients from University Malaya Medical Centre and diagnosed for at least 1 year. Data were collected from 1988 until 2019. Demographic and disease details, causes of hospital admissions and mortality were reviewed from electronic medical records. Baseline and latest disease activity (SLEDAI 2K) and SLICC/ACR damage index (SDI) scores were evaluated.Results:A total of 300 SLE patients, 285 (95%) of whom were females were included in this study. Majority were of Chinese ethnicity 150 (50%), followed by Malays 108 (36%), Indians 39 (13%) and others 3 (1%). The cohort’s median age was 48 (18-82) years and median disease duration was 14 (1-72) years. Median age at SLE diagnosis was 27.5 (6-72) years. 133 (44.3%) had SDI score of ≥1 at baseline (early damage). 23% had developed new organ damage during this study period.There were 222 (74%) patients ever hospitalized and 12 (5.4%) deaths from this cohort. The main cause of hospitalization was lupus flare which included concurrent infection (n=415 admissions, 46%), followed by elective admissions for procedures and others (n=284 admissions, 31.5%). 17% of admissions were due to infections with concurrent flare (8.7% were due to infection alone). Admissions for treatment and disease related complications were 13.8%. Median length of stay for SLE related cause admissions was longer compared to non-SLE related causes, 10 (range 1-113) vs 7.5 (range 1-130) days. Causes of death included SLE flare without features of infection (25%), concurrent lupus flare and infection (25%), and non-SLE causes (50%). Malignancy (33.3%) was the main cause of death in non-SLE deaths. Independent predictive factors for hospitalization and mortality are shown in Table 1 and Table 2.Table 1.Multivariate logistic regression analysis for the predictors of hospitalizationHOSPITALIZATIONParametersB CoefficientOR (95% C. I)p valueEthnicity Malay2.0057.428 (0.181-226.883)0.26 Chinese1.2873.623 (0.089-106.163)0.47 Indian1.6955.446 (0.126-177.222)0.35Disease Duration- 0.0150.985 (0.953-1.020)0.40Comorbids ≥ 21.6735.328 (0.843-105.481)0.14APLS1.7845.956 (1.883-26.685)0.001*Serology markers Anti-Smith1.8406.298 (1.733-40.638)0.01* Anti-SSA1.2113.360 (1.758-6.640)<0.001*ACR Serositis2.65614.248 (2.555-275.071)0.01* Neurological1.7065.506(1.403-36.834)0.01*SCORES SDI Baseline0.5521.737 (1.062-3.048)0.01*Table 2.Multiple logistic regression analysis of the predictors for mortalityMORTALITYParametersB CoefficientOR (95% C. I)p valueDisease duration0.0951.099 (1.031-1.183)0.001*Comorbids ≥23.16123.618 (1.997-344.533)0.01*APLS2.55612.888 (1.592-136.512)0.01*SDI Renal2.1678.734 (1.385-80.528)0.01* Malignancy3.93651.218 (6.725-616.957)0.001* Pulmonary1.6965.452 (0.684-41.395)0.1SCORES SLEDAI latest0.2751.316 (1.161-1.556)0.001*Conclusion:Early damage in lupus as measured by SDI is of predictive value of hospitalization. Optimization in managing patients with pre-existing damage is crucial to reduce hospitalization risk and subsequent complications.References:[1]GP Rosa,et al. Causes and factors related to hospitalizations in patients with SLE: analysis of a 20-year period (1995–2015) from a single referral centre in Catalonia.Lupus. 2019;28(9):1158-66.[2]P Rahman,et al.Early damage as measured by the SLICC/ACR damage index is a predictor of mortality in SLE.Lupus. 2001;10(2), 93-6.Disclosure of Interests:None declared
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Raman L, Marchak KA, Gelman SA. Children’s understanding of food and activities on body size. Cognitive Development 2020. [DOI: 10.1016/j.cogdev.2020.100865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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De Backer G, Jankowski P, Kotseva K, Mirrakhimov E, Reiner Ž, Rydén L, Tokgözoğlu L, Wood D, De Bacquer D, De Backer G, Jankowski P, Kotseva K, Mirrakhimov E, Reiner Z, Rydén L, Tokgözoğlu L, Wood D, De Bacquer D, Kotseva K, De Backer G, Abreu A, Aguiar C, Badariene J, Bruthans J, Castro Conde A, Cifkova R, Crowley J, Davletov K, Bacquer DD, De Smedt D, De Sutter J, Deckers J, Dilic M, Dolzhenko M, Druais H, Dzerve V, Erglis A, Fras Z, Gaita D, Gotcheva N, Grobbee D, Gyberg V, Hasan Ali H, Heuschmann P, Hoes A, Jankowski P, Lalic N, Lehto S, Lovic D, Maggioni A, Mancas S, Marques-Vidal P, Mellbin L, Miličić D, Mirrakhimov E, Oganov R, Pogosova N, Reiner Ž, Rydén L, Stagmo M, Störk S, Sundvall J, Tokgözoğlu L, Tsioufis K, Vulic D, Wood D, Wood D, Kotseva K, Jennings C, Adamska A, Adamska S, Rydén L, Mellbin L, Tuomilehto J, Schnell O, Druais H, Fiorucci E, Glemot M, Larras F, Missiamenou V, Maggioni A, Taylor C, Ferreira T, Lemaitre K, Bacquer DD, De Backer G, Raman L, Sundvall J, DeSmedt D, De Sutter J, Willems A, De Pauw M, Vervaet P, Bollen J, Dekimpe E, Mommen N, Van Genechten G, Dendale P, Bouvier C, Chenu P, Huyberechts D, Persu A, Dilic M, Begic A, Durak Nalbantic A, Dzubur A, Hadzibegic N, Iglica A, Kapidjic S, Osmanagic Bico A, Resic N, Sabanovic Bajramovic N, Zvizdic F, Vulic D, Kovacevic-Preradovic T, Popovic-Pejicic S, Djekic D, Gnjatic T, Knezevic T, Kovacevic-Preradovic T, Kos L, Popovic-Pejicic S, Stanetic B, Topic G, Gotcheva N, Georgiev B, Terziev A, Vladimirov G, Angelov A, Kanazirev B, Nikolaeva S, Tonkova D, Vetkova M, Milicic D, Reiner Ž, Bosnic A, Dubravcic M, Glavina M, Mance M, Pavasovic S, Samardzic J, Batinic T, Crljenko K, Delic-Brkljacic D, Dula K, Golubic K, Klobucar I, Kordic K, Kos N, Nedic M, Olujic D, Sedinic V, Blazevic T, Pasalic A, Percic M, Sikic J, Bruthans J, Cífková R, Hašplová K, Šulc P, Wohlfahrt P, Mayer O, Cvíčela M, Filipovský J, Gelžinský J, Hronová M, Hasan-Ali H, Bakery S, Mosad E, Hamed H, Ibrahim A, Elsharef M, Kholef E, Shehata A, Youssef M, Elhefny E, Farid H, Moustafa T, Sobieh M, Kabil H, Abdelmordy A, Lehto S, Kiljander E, Kiljander P, Koukkunen H, Mustonen J, Cremer C, Frantz S, Haupt A, Hofmann U, Ludwig K, Melnyk H, Noutsias M, Karmann W, Prondzinsky R, Herdeg C, Hövelborn T, Daaboul A, Geisler T, Keller T, Sauerbrunn D, Walz-Ayed M, Ertl G, Leyh R, Störk S, Heuschmann P, Ehlert T, Klocke B, Krapp J, Ludwig T, Käs J, Starke C, Ungethüm K, Wagner M, Wiedmann S, Tsioufis K, Tolis P, Vogiatzi G, Sanidas E, Tsakalis K, Kanakakis J, Koutsoukis A, Vasileiadis K, Zarifis J, Karvounis C, Crowley J, Gibson I, Houlihan A, Kelly C, O'Donnell M, Bennati M, Cosmi F, Mariottoni B, Morganti M, Cherubini A, Di Lenarda A, Radini D, Ramani F, Francese M, Gulizia M, Pericone D, Davletov K, Aigerim K, Zholdin B, Amirov B, Assembekov B, Chernokurova E, Ibragimova F, Kodasbayev A, Markova A, Mirrakhimov E, Asanbaev A, Toktomamatov U, Tursunbaev M, Zakirov U, Abilova S, Arapova R, Bektasheva E, Esenbekova J, Neronova K, Asanbaev A, Baigaziev K, Toktomamatov U, Zakirov U, Baitova G, Zheenbekov T, Erglis A, Andrejeva T, Bajare I, Kucika G, Labuce A, Putane L, Stabulniece M, Dzerve V, Klavins E, Sime I, Badariene J, Gedvilaite L, Pečiuraite D, Sileikienė V, Skiauteryte E, Solovjova S, Sidabraite R, Briedis K, Ceponiene I, Jurenas M, Kersulis J, Martinkute G, Vaitiekiene A, Vasiljevaite K, Veisaite R, Plisienė J, Šiurkaitė V, Vaičiulis Ž, Jankowski P, Czarnecka D, Kozieł P, Podolec P, Nessler J, Gomuła P, Mirek-Bryniarska E, Bogacki P, Wiśniewski A, Pająk A, Wolfshaut-Wolak R, Bućko J, Kamiński K, Łapińska M, Paniczko M, Raczkowski A, Sawicka E, Stachurska Z, Szpakowicz M, Musiał W, Dobrzycki S, Bychowski J, Kosior D, Krzykwa A, Setny M, Kosior D, Rak A, Gąsior Z, Haberka M, Gąsior Z, Haberka M, Szostak-Janiak K, Finik M, Liszka J, Botelho A, Cachulo M, Sousa J, Pais A, Aguiar C, Durazzo A, Matos D, Gouveia R, Rodrigues G, Strong C, Guerreiro R, Aguiar J, Abreu A, Cruz M, Daniel P, Morais L, Moreira R, Rosa S, Rodrigues I, Selas M, Gaita D, Mancas S, Apostu A, Cosor O, Gaita L, Giurgiu L, Hudrea C, Maximov D, Moldovan B, Mosteoru S, Pleava R, Ionescu M, Parepa I, Pogosova N, Arutyunov A, Ausheva A, Isakova S, Karpova A, Salbieva A, Sokolova O, Vasilevsky A, Pozdnyakov Y, Antropova O, Borisova L, Osipova I, Lovic D, Aleksic M, Crnokrak B, Djokic J, Hinic S, Vukasin T, Zdravkovic M, Lalic N, Jotic A, Lalic K, Lukic L, Milicic T, Macesic M, Stanarcic Gajovic J, Stoiljkovic M, Djordjevic D, Kostic S, Tasic I, Vukovic A, Fras Z, Jug B, Juhant A, Krt A, Kugonjič U, Chipayo Gonzales D, Gómez Barrado J, Kounka Z, Marcos Gómez G, Mogollón Jiménez M, Ortiz Cortés C, Perez Espejo P, Porras Ramos Y, Colman R, Delgado J, Otero E, Pérez A, Fernández-Olmo M, Torres-LLergo J, Vasco C, Barreñada E, Botas J, Campuzano R, González Y, Rodrigo M, de Pablo C, Velasco E, Hernández S, Lozano C, González P, Castro A, Dalmau R, Hernández D, Irazusta F, Vélez A, Vindel C, Gómez-Doblas J, García Ruíz V, Gómez L, Gómez García M, Jiménez-Navarro M, Molina Ramos A, Marzal D, Martínez G, Lavado R, Vidal A, Rydén L, Boström-Nilsson V, Kjellström B, Shahim B, Smetana S, Hansen O, Stensgaard-Nake E, Deckers J, Klijn A, Mangus T, Peters R, Scholte op Reimer W, Snaterse M, Aydoğdu S, Ç Erol, Otürk S, Tulunay Kaya C, Ahmetoğlu Y, Ergene O, Akdeniz B, Çırgamış D, Akkoyun H Kültürsay S, Kayıkçıoğlu M, Çatakoğlu A, Çengel A, Koçak A, Ağırbaşlı M, Açıksarı G, Çekin M, Tokgözoğlu L, Kaya E, Koçyiğit D, Öngen Z, Özmen E, Sansoy V, Kaya A, Oktay V, Temizhan A, Ünal S, İ Yakut, Kalkan A, Bozkurt E, Kasapkara H, Dolzhenko M, Faradzh C, Hrubyak L, Konoplianyk L, Kozhuharyova N, Lobach L, Nesukai V, Nudchenko O, Simagina T, Yakovenko L, Azarenko V, Potabashny V, Bazylevych A, Bazylevych M, Kaminska K, Panchenko L, Shershnyova O, Ovrakh T, Serik S, Kolesnik T, Kosova H, Wood D, Adamska A, Adamska S, Jennings C, Kotseva K, Hoye P Atkin A, Fellowes D, Lindsay S, Atkinson C, Kranilla C, Vinod M, Beerachee Y, Bennett C, Broome M, Bwalya A, Caygill L, Dinning L, Gillespie A, Goodfellow R, Guy J, Idress T, Mills C, Morgan C, Oustance N, Singh N, Yare M, Jagoda J, Bowyer H, Christenssen V, Groves A, Jan A, Riaz A, Gill M, Sewell T, Gorog D, Baker M, De Sousa P, Mazenenga T, Porter J, Haines F, Peachey T, Taaffe J, Wells K, Ripley D, Forward H, McKie H, Pick S, Thomas H, Batin P, Exley D, Rank T, Wright J, Kardos A, Sutherland SB, Wren L, Leeson P, Barker D, Moreby B, Sawyer J, Stirrup J, Brunton M, Brodison A, Craig J, Peters S, Kaprielian R, Bucaj A, Mahay K, Oblak M, Gale C, Pye M, McGill Y, Redfearn H, Fearnley M. Management of dyslipidaemia in patients with coronary heart disease: Results from the ESC-EORP EUROASPIRE V survey in 27 countries. Atherosclerosis 2019; 285:135-146. [DOI: 10.1016/j.atherosclerosis.2019.03.014] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/22/2019] [Accepted: 03/19/2019] [Indexed: 12/16/2022]
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Ortega SB, Torres VO, Tian F, Poinsatte K, Tweed J, Greenwell C, Windsor J, Raman L, Miles D, Stowe A. Adaptive immune cell activation in acute pediatric traumatic brain injury. The Journal of Immunology 2019. [DOI: 10.4049/jimmunol.202.supp.182.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Traumatic brain injury (TBI) is mediated by mechanical injury to the brain resulting in tissue shearing, and characterized by neuronal injury and inflammation. We hypothesize that TBI activates brain-targeting immune responses which can induce secondary neuronal injury. Blood and cerebral spinal fluid (external ventricular drain, EVD) were collected from pediatric TBI patients (pTBI, 1–18 yrs.) at days 1, 3 and 5 following TBI and EVD placement. The blood from sick controls (0–18 yrs, no CNS injury) were collected at day 1 post injury. pTBI patients exhibited a higher quantity of leukocytes (CD45+) relative to controls (p=0.01) on day 1 post-TBI, indicating an immediate and robust immune modulation due to CNS injury, that decreased at days 3 and 5, relative to day 1. Major subsets of adaptive immune cells (CD3, CD4, CD8, and CD19) did not exhibit altered cellularity relative to controls but activated adaptive T cells (CD4+CD161+and CD8+CD161+) were substantially higher at day 1 versus controls. Neuronal autoreactivity was evaluated by labeling peripheral blood mononuclear cells with carboxyfluorescein succinimidyl ester (CFSE) and culturing with neuronal and control antigens. Response to antigen was determined by dilution of CFSE (proliferation) and expression of CD25 (activation). Autoreactivity analysis of pTBI patients revealed a decrease in the CD4 T-cell responses to CNS antigens relative to sick control patients. Interestingly, the CD8 T-cell analysis revealed CNS-specific autoimmune responses absent in pTBI patients which were present in sick controls. Based on these initial observations, we hypothesize that the adaptive immune system is activated upon TBI and can potentially target CNS resident cells in young patients.
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Affiliation(s)
| | | | | | | | | | | | - Jana Windsor
- 2University of Texas Southwestern Medical Center
| | | | - Darryl Miles
- 2University of Texas Southwestern Medical Center
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Engelhardt K, Pirolli T, Raman L, Abu-Hijleh M, Hupp S. Successful Use of Pulmonary Cryotherapy for Tracheobronchial Thrombus Extraction and Recanalization of the Tracheobronchial Tree During a Pediatric Venovenous Extracorporeal Membrane Oxygenation Run. Pediatr Allergy Immunol Pulmonol 2019; 32:28-30. [PMID: 31508253 DOI: 10.1089/ped.2018.0911] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/19/2018] [Indexed: 11/13/2022]
Abstract
Impacted pediatric tracheobronchial thrombus is an uncommon diagnosis. There are no clearly proven therapeutic options for airway casts due to a similar process, plastic bronchitis. Cryotherapy, specifically cryoextraction, has shown potential as a therapeutic option in adults with tracheobronchial thrombus and cast. We describe the novel application of this method in a complex pediatric patient.
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Affiliation(s)
- Kevin Engelhardt
- Division of Pediatric Intensive Care, Department of Pediatrics, University of Texas Southwestern, Dallas, Texas.,Children's Health Dallas, Critical Care, Dallas, Texas
| | - Timothy Pirolli
- Department of Cardiothoracic Surgery, University of Texas Southwestern, Dallas, Texas.,Children's Health Dallas, Heart Center, Dallas, Texas
| | - Lakshmi Raman
- Division of Pediatric Intensive Care, Department of Pediatrics, University of Texas Southwestern, Dallas, Texas.,Children's Health Dallas, Critical Care, Dallas, Texas
| | - Muhanned Abu-Hijleh
- Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas
| | - Susan Hupp
- Division of Pediatric Intensive Care, Department of Pediatrics, University of Texas Southwestern, Dallas, Texas.,Children's Health Dallas, Critical Care, Dallas, Texas
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Anton-Martin P, Bhattarai P, Rycus P, Raman L, Potera R. The Use of Extracorporeal Membrane Oxygenation in Life-Threatening Foreign Body Aspiration: Case Series, Review of Extracorporeal Life Support Organization Registry Data, and Systematic Literature Review. J Emerg Med 2019; 56:523-529. [PMID: 30879854 DOI: 10.1016/j.jemermed.2019.01.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 09/17/2018] [Accepted: 01/30/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Foreign body aspiration (FBA) is a common cause of morbidity and mortality in children < 3 years of age. Guidelines recommend performing a bronchoscopy in any suspected or confirmed FBA. Extracorporeal membrane oxygenation (ECMO) can be used as a rescue mode of support in children with life-threatening FBA for stabilization before, during, and after removal. CASE REPORT We present a series of children with life-threatening FBA who were placed on ECMO for stabilization before or after FB removal and a review of the literature and the Extracorporeal Life Support Organization database. Foreign bodies were removed without complications, and all patients survived ECMO support and were promptly discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECMO can be safely used in the stabilization of children with life-threatening FBA before, during, and after bronchoscopic removal. ECMO should be considered in the stabilization of children presenting with FBA to facilitate removal.
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Affiliation(s)
- Pilar Anton-Martin
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center/Children's Health, Dallas, Texas
| | - Pallav Bhattarai
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center/Children's Health, Dallas, Texas
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Lakshmi Raman
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center/Children's Health, Dallas, Texas
| | - Renee Potera
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center/Children's Health, Dallas, Texas
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Dakshina S, Olaru ID, Khan P, Raman L, McHugh G, Bwakura-Dangarembizi M, Nathoo K, Munyati S, Mujuru H, Ferrand RA. Evaluation of weight-based prescription of antiretroviral therapy in children. HIV Med 2019; 20:248-253. [PMID: 30632659 PMCID: PMC6590156 DOI: 10.1111/hiv.12702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2018] [Indexed: 11/30/2022]
Abstract
Objectives The aim of the study was to investigate the extent of and factors associated with incorrect dosing of antiretroviral therapy (ART) in HIV‐infected children in Harare, Zimbabwe. Methods All children aged 0–10 years and children aged 11–17 years who weighed < 35 kg and taking ART were recruited from the paediatric HIV clinic at Harare Hospital. Their current doses of ART drugs were compared against doses recommended by the national guidelines. Results Among 309 children recruited [55% male; median age 7 years (interquartile range (IQR) 5–10 years)], the median CD4 count was 899 cells/μL and the median duration of their current ART regimen was 11.2 months (IQR 4.9–17.1 months). Overall, 110 (35.6%) children were prescribed incorrect doses of at least one drug component within their ART regimen; 64 (20.7%) under‐dosed and 49 (15.9%) over‐dosed on at least one drug. Children receiving a higher than recommended dose of at least one drug were younger compared with correctly dosed children (median 6 versus 7 years, respectively; P = 0.001), had been on their current ART regimen for a shorter time (median 7.2 versus 13 months, respectively; P = 0.003) and were less likely to be receiving a three‐drug fixed‐dose combination (FDC; 42.9 versus 63.3%, respectively; P = 0.009). Those who were under‐dosed were also less likely to be on a three‐drug FDC (25 versus 63.3%, respectively; P < 0.001). Conclusions Over a third of children were prescribed incorrect doses of ART. Children taking triple‐drug FDCs were likely to be correctly dosed. Our study highlights the importance of weight monitoring at each clinical contact, training of health care providers on paediatric drug dosing and the need for wider availability of FDCs for children.
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Affiliation(s)
- S Dakshina
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - I D Olaru
- Biomedical Research and Training Institute, Harare, Zimbabwe.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - P Khan
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,Interactive Research and Development, Karachi, Pakistan
| | - L Raman
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - G McHugh
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - M Bwakura-Dangarembizi
- Department of Paediatrics and Child Health College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - K Nathoo
- Department of Paediatrics and Child Health College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - S Munyati
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - H Mujuru
- Department of Paediatrics and Child Health College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - R A Ferrand
- Biomedical Research and Training Institute, Harare, Zimbabwe.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
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Abstract
Plasma iron tolerance curves of ferrous glycine sulphate (FGS) tablets containing 60 and 120 mg of elemental iron were compared with similar doses of ferrous sulphate (FS) tablets using a double-blind crossover design in six women volunteers. The plasma iron tolerance curves obtained with both doses of FGS were similar to those of doses of FS. The relative bioavailability of FGS was close to 1, identical to that of FS. Thus tablets containing ferrous glycine sulphate as the source of elemental iron for the prophylaxis of iron deficiency do not offer any advantage over the less expensive and more available ferrous sulphate.
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Ortega SB, Pandiyan P, Windsor J, Torres VO, Selvaraj UM, Kong X, Raman L, Stowe AM. Abstract WP385: Altered Adaptive Immune Response Correlates With Brain Injury in Extracorporeal Membrane Oxygenation Treated Pediatric Patients. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is a life-saving procedure that provides short-term cardiac and respiratory support to people whose heart and lungs are dysfunctional. Growing use of ECMO has expanded the indications beyond acute severe respiratory and cardiac failure to include extracorporeal cardiopulmonary resuscitation and as a bridge for lung transplantation. Usage of ECMO within the pediatric population has seen a number of complications including an acute induction of systemic inflammatory response syndrome (SIRS) and long-term developmental neurological deficits, with an increasing number of children exhibiting neurological morbidities. We hypothesized that ECMO may potentiate the induction of a central nervous system (CNS)-targeting adaptive immune response which may lead to neurological injury. Using a single center prospective observational study, we sampled 20 pediatric ECMO patients and 5 aged-match disease control patients. Peripheral blood mononuclear cells were isolated using the Ficoll-Paque method and relative analysis revealed an increase in helper T-cells that correlated with ECMO treatment alone, while NK-T cells were found to be increased in the presence of CNS injury. Interestingly, we did see a decrease in activated peripheral T-helper cells (CD4+CD161+), and cytotoxic T cells (CD8+CD161+), which were preceded by an increase in activated macrophages (CD14
+
CD11b
+
) in ECMO treated patients. Only activated peripheral CD8 T-cells were found to associate with CNS injury. Using the CFSE recall response assay, we tested for CNS specificity by culturing cells with myelin basic protein (MBP), proteolipid lipoprotein (PLP), myelin oligodendrocyte glycoprotein (MOG), NMDA receptor GluN2A, and microtubule associated protein (MAP2) for 7 days and determined a response by measuring CFSE dilution and CD25 expression using flow cytometry. We observed an increased in myelin-targeting B-cells, myelin- and neuronal-targeting CD8 T-cells and no difference in autoreactive CD4 T-cells. In summary, ECMO induces a robust peripheral CNS-targeting adaptive immune response that may predispose a patient to long-term neurological injury.
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Affiliation(s)
| | | | - Jana Windsor
- Neurology & Neurotherapeutics, UT Southwestern, Dallas, TX
| | - Vanessa O Torres
- Neurology & Neurotherapeutics, UT Southwestern Med Cntr, Dallas, TX
| | - Uma M Selvaraj
- Neurology & Neurotherapeutics, UT Southwestern, Dallas, TX
| | - Xiangmei Kong
- Neurology & Neurotherapeutics, UT Southwestern, Dallas, TX
| | - Lakshmi Raman
- Neurology & Neurotherapeutics, UT Southwestern, Dallas, TX
| | - Ann M Stowe
- Neurology & Neurotherapeutics, UT Southwestern, Dallas, TX
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Abstract
Background Injury is the commonest cause of morbidity and mortality amongst the younger age groups. Management of injuries has been identified as one of the major health issues facing our community. The study objective was to define the epidemiology of injury related deaths in Singapore. Methods A nationwide review of all deaths arising as a result of injury in 1995 was conducted. Results There were 913 cases with an injury mortality rate of 27 per 100,000 population. Ninety-seven percent (97%) were due to blunt injury. Falls from heights from deliberate self-harm was the commonest mechanism, followed by motor vehicle collisions (MVC). Fifty-two percent (52%) of MVC deaths were motorcyclists or pillion riders. Sixty-six percent (66%) of all deaths occurred in the prehospital phase. Central nervous system injury was the main cause of hospital deaths. Conclusion Results from this study will help our community focus on the appropriate preventive strategies to reduce mortality and the cost of injuries to our society.
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Affiliation(s)
- MKF Leong
- Singapore General Hospital, Department of Emergency Medicine, Outram Road, S169608, Singapore
| | - S Mujumdar
- Singapore General Hospital, Department of Emergency Medicine, Outram Road, S169608, Singapore
| | - L Raman
- Singapore General Hospital, Department of Emergency Medicine, Outram Road, S169608, Singapore
| | - YH Lim
- Singapore General Hospital, Department of Emergency Medicine, Outram Road, S169608, Singapore
| | - TC Chao
- Institute of Forensic Medicine
| | - V Anantharaman
- Singapore General Hospital, Department of Emergency Medicine, Outram Road, S169608, Singapore
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Tian F, Morriss MC, Chalak L, Venkataraman R, Ahn C, Liu H, Raman L. Impairment of cerebral autoregulation in pediatric extracorporeal membrane oxygenation associated with neuroimaging abnormalities. Neurophotonics 2017; 4:041410. [PMID: 28840161 PMCID: PMC5562949 DOI: 10.1117/1.nph.4.4.041410] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/24/2017] [Indexed: 05/27/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-supporting therapy for critically ill patients with severe respiratory and/or cardiovascular failure. Cerebrovascular impairment can result in hemorrhagic and ischemic complications commonly seen in the patients supported on ECMO. We investigated the degree of cerebral autoregulation impairment during ECMO as well as whether it is predictive of neuroimaging abnormalities. Spontaneous fluctuations of mean arterial pressure (MAP) and cerebral tissue oxygen saturation ([Formula: see text]) were continuously measured during the ECMO run. The dynamic relationship between the MAP and [Formula: see text] fluctuations was assessed based on wavelet transform coherence (WTC). Neuroimaging was conducted during and/or after ECMO as standard of care, and the abnormalities were evaluated based on a scoring system that had been previously validated among ECMO patients. Of the 25 patients, 8 (32%) had normal neuroimaging, 7 (28%) had mild to moderate neuroimaging abnormalities, and the other 10 (40%) had severe neuroimaging abnormalities. The degrees of cerebral autoregulation impairment quantified based on WTC showed significant correlations with the neuroimaging scores ([Formula: see text]; [Formula: see text]). Evidence that cerebral autoregulation impairment during ECMO was related to the patients' neurological outcomes was provided.
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Affiliation(s)
- Fenghua Tian
- University of Texas at Arlington, Department of Bioengineering, Arlington, Texas, United States
| | - Michael Craig Morriss
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, Texas, United States
| | - Lina Chalak
- University of Texas Southwestern Medical Center, Department of Pediatrics, Dallas, Texas, United States
| | - Ramgopal Venkataraman
- University of Texas at Arlington, Department of Accounting, Arlington, Texas, United States
| | - Chul Ahn
- University of Texas Southwestern Medical Center, Department of Clinical Science, Dallas, Texas, United States
| | - Hanli Liu
- University of Texas at Arlington, Department of Bioengineering, Arlington, Texas, United States
| | - Lakshmi Raman
- University of Texas Southwestern Medical Center, Department of Pediatrics, Dallas, Texas, United States
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Abstract
Extracorporeal membrane oxygenation (ECMO) is a modified form of cardiopulmonary bypass. Although early trials were plagued by severe bleeding and high rates of death, subsequent experience with neonates found good survival, and ECMO became an important tool in the care of critically ill infants with respiratory failure. Since the 1980s, expansion to other groups (children, patients with cardiac disease, etc) followed as experience was obtained. Today, there is a rapid growth of ECMO, especially in the adult population. To date, >73,000 patients receiving ECMO have been reported to the international Extracorporeal Life Support Organization registry. This rapid growth in the usage of ECMO has made it possible for it to be included in the management algorithm of certain disease processes, such as ARDS, cardiopulmonary arrest, and septic shock. Significant advances in technology have made it possible to support patients on ECMO for weeks or months with success. Reduction in sedative use and experience with "awake" patients has led to ambulatory and mobile ECMO. Changes in ventilator support while on ECMO, even to the point of extubation, are also occurring. This article will review briefly some of the literature related to criteria for severity of illness before ECMO and related to ECMO care and practice. Issues relating to the use of ECMO as a resuscitative tool in cardiac arrest as well as the controversial topic of volume and outcome will also be presented.
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Affiliation(s)
- Lakshmi Raman
- University of Texas Southwestern Medical Center, Dallas, Texas
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Affiliation(s)
- Lakshmi Raman
- Department of Psychology; Oakland University; Rochester Michigan USA
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Jenks CL, Zia A, Venkataraman R, Raman L. High Hemoglobin Is an Independent Risk Factor for the Development of Hemolysis During Pediatric Extracorporeal Life Support. J Intensive Care Med 2017; 34:259-264. [PMID: 28486865 DOI: 10.1177/0885066617708992] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 11/15/2022]
Abstract
OBJECTIVE To evaluate risk factors for hemolysis in pediatric extracorporeal life support. DESIGN Retrospective, single-center study. SETTING Pediatric intensive care unit. PATIENTS Two hundred thirty-six children who received extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Risk factors for hemolysis were retrospectively analyzed from a single center in a total of 236 neonatal and pediatric patients who received extracorporeal membrane oxygenation support (ECMO). There was no difference in the incidence of hemolysis between centrifugal (127 patients) and roller head (109 patients) pump type or between venoarterial and venovenous ECMO. High hemoglobin (Hb) was found to be an independent risk factor for hemolysis in both pump types. The Hb level >12 g/dL was significant in the roller group and the Hb level >13 g/dL was significant in the centrifugal group for the development of hemolysis for the cumulative ECMO run. The presence of high Hb levels on any given day increased the risk of hemolysis for that day of the ECMO run regardless of ECMO pump type. Higher revolutions per minute (RPMs) and higher inlet pressures on any given day increased the risk for the development of hemolysis in the centrifugal pump. Lower inlet venous pressures and RPMs were not associated with hemolysis in the roller group. CONCLUSIONS An Hb level greater than 13 g/dL was associated with an increased risk of hemolysis, and a high Hb on a given day was associated with a significantly higher risk of hemolysis on the same day. Higher RPMs and lower inlet venous pressures were associated with an increased risk of hemolysis in the centrifugal pump only.
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Affiliation(s)
- Christopher L Jenks
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Ayesha Zia
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Medical Center of Dallas, Dallas, TX, USA
| | - Ramgopal Venkataraman
- Department of Accounting, University of Texas at Arlington, Arlington, TX, USA.,*Joint senior authors
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Medical Center of Dallas, Dallas, TX, USA.,*Joint senior authors
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Raman L. Impairment of cerebral autoregulation in pediatric extracorporeal membrane oxygenation. Qatar Med J 2017. [PMCID: PMC5474605 DOI: 10.5339/qmj.2017.swacelso.37] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Lakshmi Raman
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Lim YMJ, Han X, Raman L, Ng TK, Goh THA, Vathsala A, Tiong HY. Outcome of Living Donor Transplant Kidneys With Multiple Arteries. Transplant Proc 2016; 48:848-51. [PMID: 27234750 DOI: 10.1016/j.transproceed.2015.12.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 12/30/2015] [Indexed: 10/21/2022]
Abstract
BACKGROUND Living donor transplantation (LDT) using kidneys with multiple arteries (MA) has previously been reported to be associated with increased complications and poorer outcomes in recipients. The objective of this study was to investigate outcomes of LDT with MA at the National University Hospital of Singapore, an institution with modest kidney transplant volumes. METHODS From 2007 to 2014, a total of 109 consecutive living donor kidney transplantations were performed. Of the nephrectomies, 91% were left sided. A total of 19 cases involved MA, of which 7 with small polar vessels (<2 mm) were ligated and 12 were revascularized. Baseline characteristics and outcomes were comparable between donor-recipient pairs with MA and single artery (SA). Both groups had equivalent induction and maintenance immunosuppressive regimens. RESULTS Mean warm ischemia time (minutes) was similar for kidneys with MA and SA (4.3 ± 3.2 vs 3.9 ± 3.2, P = .38). Operative time (minutes) in the recipients was also equivalent (P > .05) for MA and SA (158 ± 39.2 and 145 ± 57.2, respectively). The MA kidney recipients had a lower estimated glomerular filtration rate (eGFR) on postoperative day 5 compared to SA (56.6 ± 24.2 vs 74.1 ± 35.9 mL/min/1.73 m(2), P = .058). However, eGFR at 1 year was the similar for both groups (64.9 ± 16.2 vs 66.4 ± 18.1 mL/min/1.73 m(2), respectively, P = .76). Delayed graft function rates were 5.6% and 6.6% for MA and SA, respectively (P = .9). There were no surgical complications for LDT recipients within the MA group. Patient and graft survival was 100% in the MA group compared with 98% in the SA group (P > .05). CONCLUSIONS With current surgical techniques, LDT with MA can achieve equally good functional outcomes at 1 year as SA kidneys, with minimal surgical complications.
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Affiliation(s)
- Y M J Lim
- Department of Urology, National University Health System, Singapore
| | - X Han
- Department of Urology, National University Health System, Singapore
| | - L Raman
- Department of Urology, National University Health System, Singapore
| | - T K Ng
- Department of Urology, National University Health System, Singapore
| | - T H A Goh
- Department of Urology, National University Health System, Singapore
| | - A Vathsala
- Department of Urology, National University Health System, Singapore
| | - H Y Tiong
- Department of Urology, National University Health System, Singapore.
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Anton-Martin P, Darnell-Bowens C, Aquino VM, Jones T, Raman L. Successful engraftment after hematopoietic stem cell transplantation with infusion of donor stem cells through the extracorporeal membrane oxygenation circuit. Indian J Crit Care Med 2016; 20:617-619. [PMID: 27829721 PMCID: PMC5073780 DOI: 10.4103/0972-5229.192062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Wiskott–Aldrich syndrome (WAS) is a rare X-linked primary immunodeficiency due to mutations in the WAS gene expressed in hematopoietic cells. Hematopoietic stem cell transplantation (HSCT) is the treatment of choice when an appropriate human leukocyte antigen-matched donor is available. The use of the extracorporeal membrane oxygenation (ECMO) circuit to infuse donor cells for HSCT has not been previously published in the literature. We describe a case of a child who had successful engraftment after HSCT with infusion of the donor stem cells through the ECMO circuit.
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Affiliation(s)
- Pilar Anton-Martin
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern/Children's Health Dallas, TX, USA
| | - Cindy Darnell-Bowens
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern/Children's Health Dallas, TX, USA
| | - Victor M Aquino
- Department of Pediatrics, Division of Hematology-Oncology, University of Texas Southwestern/Children's Health Dallas, TX, USA
| | - Teresa Jones
- Department of Pediatrics, Division of Hematology-Oncology, University of Texas Southwestern/Children's Health Dallas, TX, USA
| | - Lakshmi Raman
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern/Children's Health Dallas, TX, USA
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Ortega SB, Kong X, Venkataraman R, Savedra AM, Kernie SG, Stowe AM, Raman L. Perinatal chronic hypoxia induces cortical inflammation, hypomyelination, and peripheral myelin-specific T cell autoreactivity. J Leukoc Biol 2015; 99:21-9. [PMID: 26038434 DOI: 10.1189/jlb.5hi0914-447r] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 04/28/2015] [Indexed: 11/24/2022] Open
Abstract
pCH is an important risk factor for brain injury and long-term morbidity in children, occurring during the developmental stages of neurogenesis, neuronal migration, and myelination. We show that a rodent model of pCH results in an early decrease in mature myelin. Although pCH does increase progenitor oligodendrocytes in the developing brain, BrdU labeling revealed a loss in dividing progenitor oligodendrocytes, indicating a defect in mature cell replacement and myelinogenesis. Mice continued to exhibited hypomyelination, concomitant with long-term impairment of motor function, weeks after cessation of pCH. The implication of a novel neuroimmunologic interplay, pCH also induced a significant egress of infiltrating CD4 T cells into the developing brain. This pCH-mediated neuroinflammation included oligodendrocyte-directed autoimmunity, with an increase in peripheral myelin-specific CD4 T cells. Thus, both the loss of available, mature, myelin-producing glial cells and an active increase in autoreactive, myelin-specific CD4 T cell infiltration into pCH brains may contribute to early pCH-induced hypomyelination in the developing CNS. The elucidation of potential mechanisms of hypoxia-driven autoimmunity will expand our understanding of the neuroimmune axis during perinatal CNS disease states that may contribute to long-term functional disability.
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Affiliation(s)
- Sterling B Ortega
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Xiagmei Kong
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Ramgopal Venkataraman
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Allen Michael Savedra
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Steven G Kernie
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Ann M Stowe
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
| | - Lakshmi Raman
- Departments of *Neurology and Neurotherapeutics and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Departments of Pediatrics and Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA; and Department of Accounting, School of Business, University of Texas at Arlington, Arlington, Texas, USA
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Chung E, Kong X, Goldberg MP, Stowe AM, Raman L. Erythropoietin-mediated neuroprotection in a pediatric mouse model of chronic hypoxia. Neurosci Lett 2015; 597:54-9. [DOI: 10.1016/j.neulet.2015.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 03/08/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
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Raman L, Rathod KS, Banka R. Chest pain in a young patient: an unusual complication of Epstein-Barr virus. Case Reports 2014; 2014:bcr-2013-201606. [DOI: 10.1136/bcr-2013-201606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Raman L. Children's and adults' understanding of the impact of nutrition on biological and psychological processes. Br J Dev Psychol 2013; 32:78-93. [DOI: 10.1111/bjdp.12024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 09/02/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Lakshmi Raman
- Department of Psychology; Oakland University; Michigan USA
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Abstract
Calcium channel blocker (CCB) toxicity is associated with refractory hypotension and can be fatal. A 13 year old young woman presented to the emergency department(ED) six hours after an intentional overdose of amlodipine, barbiturates, and alcohol. She remained extremely hypotensive despite the administration of normal saline and calcium chloride and despite infusions of norepinephrine, epinephrine, insulin, and dextrose. Due to increasing evidence of end organ dysfunction, Extracorporeal Life Support (ECLS) was initiated 9 hours after presentation to the ED. The patient's blood pressure and end organ function immediately improved after cannulation. She was successfully decannulated after 57 hours of ECLS and was neurologically intact. Patients with calcium channel blocker overdose who are resistant to medical interventions may respond favorably to early ECLS.
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