Is peripheral venovenous-arterial ECMO a feasible alternative to central cannulation for pediatric refractory septic shock?

Objective: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is recognized as a potential support therapy for pediatric patients with refractory septic shock (RSS). This review aims to report our experience with central VA cannulation in pediatric patients with RSS, and to compare this with peripheral VA ECMO cannulations for this condition at our institution. Design: Retrospective case series. Setting: Pediatric and cardiac intensive care units in an academic pediatric hospital. Patients: All patients 0–18 years old meeting criteria of RSS placed on VA ECMO between January 2011 and December 2018. Interventions: None. Measurements: Demographics, relevant clinical variables, ECMO run details, and outcomes were collected. Results: Between 2011 and 2018, 14 children were placed on VA ECMO for RSS. Nine were cannulated centrally, with the rest placed on peripheral VA ECMO. Overall survival to hospital discharge was 57.1% (8/14), with 66.7% of the central cannulation cohort surviving versus 40% in the peripheral cannulation (p = 0.34). Median ECMO duration was 147.1 hours (IQR: 91.9–178.6 hours), with survivors having a median length of 147.1 (IQR: 138.5–185.7) versus non survivors 114.7 hours (IQR: 63.7–163.5), p = 0.48. Overall median ICU length of stay (LOS) was 19 days (IQR: 10.5–42.2). The median % maximum flow achieved on VA ECMO was higher in the central cannulation group at 179.6% (IQR: 154.4–188.1) versus the peripheral with 133.5% (98.1–149.1), p = 0.01. Functional status scale (FSS) was used to capture morbidity. All survivors had a mean increase in their FSS from baseline. In the centrally cannulated group, 50% (4/8) received mediastinal exploration, but none developed mediastinitis. In terms of blood product utilization, the central cannulation received more platelets compared to the peripherally cannulated group (median 15.6 vs 3.3 mL/kg/day, p = 0.03). Conclusion: A central approach to VA ECMO cannulation is feasible and has potential for good patient outcomes in selected patients.

Download Full-text

Study on the Efficacy and Timing of ECMO Therapy in Children With Refractory Septic Shock

Case Medical Research ◽

10.31525/ct1-nct03948048 ◽

2019 ◽

Author(s):

Keyword(s):

Septic Shock ◽

Refractory Septic Shock ◽

Ecmo Therapy

Download Full-text

Validation of the pediatric refractory septic shock definition: post hoc analysis of a controlled trial

Annals of Intensive Care ◽

10.1186/s13613-021-00822-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Luc Morin ◽

Karthik Narayanan Ramaswamy ◽

Muralidharan Jayashree ◽

Arun Bansal ◽

Karthi Nallasamy ◽

...

Keyword(s):

Septic Shock ◽

Intensive Care ◽

Neonatal Intensive Care ◽

Controlled Trial ◽

Receiver Operating Curve ◽

Double Blind ◽

Post Hoc Analysis ◽

Prognostic Accuracy ◽

Refractory Septic Shock ◽

Post Hoc

Abstract Background The European Society of Pediatric and Neonatal Intensive Care (ESPNIC) developed and validated a definition of pediatric refractory septic shock (RSS), based on two septic shock scores (SSS). Both bedside SSS (bSSS) and computed SSS (cSSS) were found to be strongly associated with mortality. We aimed at assessing the accuracy of the RSS definition on a prospective cohort from India. Methods Post hoc analysis of a cohort issued from a double-blind randomized trial that compared first-line vasoactive drugs in children with septic shock. Sequential bSSS and cSSS from 60 children (single-center study, 53% mortality) were analyzed. The prognostic value of the ESPNIC RSS definition was tested for 28-day all-cause mortality. Results In this septic shock cohort, RSS was diagnosed in 35 patients (58.3%) during the first 24 h. Death occurred in 30 RSS patients (85.7% mortality) and in 2 non-RSS patients (8% mortality), OR = 60.9 [95% CI: 10.5–676.2], p < 0.001 with a median delay from sepsis onset of 3 days [1.0–6.7]. Among patients diagnosed with RSS, the mortality was not significantly different according to vasopressors randomization. Diagnosis of RSS with bSSS and cSSS had a high discrimination for death with an area under the receiver operating curve of 0.916 [95% CI: 0.843–0.990] and 0.925 [95% CI: 0.845–1.000], respectively. High prognostic accuracy of the bSSS was found in the first hours following intensive care admission. The best interval of prognostication occurs after the 12th hour following treatment initiation (AUC 0.973 [95% CI: 0.925–1.000]). Conclusions The ESPNIC refractory septic shock definition accurately identifies, within the first 6 h of septic shock management, children with lethal outcome.

Download Full-text

Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis

Critical Care ◽

10.1186/s13054-021-03668-5 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Ryan Ruiyang Ling ◽

Kollengode Ramanathan ◽

Wynne Hsing Poon ◽

Chuen Seng Tan ◽

Nicolas Brechot ◽

...

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Meta Analysis ◽

Left Ventricular ◽

Adult Patients ◽

Circulatory Support ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Septic Shock ◽

Va Ecmo

Abstract Background While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA ECMO, and identify factors associated with survival. Methods We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st June 2021, and included all relevant publications reporting on > 5 adult patients requiring VA ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted. Data synthesis We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI]: 23.6%–50.1%). Survival among patients with left ventricular ejection fraction (LVEF) < 20% (62.0%, 95%-CI: 51.6%–72.0%) was significantly higher than those with LVEF > 35% (32.1%, 95%-CI: 8.69%–60.7%, p = 0.05). Survival reported in studies from Asia (19.5%, 95%-CI: 13.0%–26.8%) was notably lower than those from Europe (61.0%, 95%-CI: 48.4%–73.0%) and North America (45.5%, 95%-CI: 16.7%–75.8%). GRADE assessment indicated high certainty of evidence for pooled survival. Conclusions When treated with VA ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock without severe left ventricular depression. VA ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock.

Download Full-text

Venoarterial extracorporeal membrane oxygenation support for neonatal and pediatric refractory septic shock: more than 15 years of learning

European Journal of Pediatrics ◽

10.1007/s00431-018-3174-2 ◽

2018 ◽

Vol 177 (8) ◽

pp. 1191-1200 ◽

Cited By ~ 10

Author(s):

Anna Solé ◽

Iolanda Jordan ◽

Sara Bobillo ◽

Julio Moreno ◽

Monica Balaguer ◽

...

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Septic Shock

Download Full-text

“All In” For a Huge Pot: The PROWESS-SHOCK Trial for Refractory Septic Shock

Surgical Infections ◽

10.1089/sur.2007.9980 ◽

2007 ◽

Vol 8 (5) ◽

pp. 491-494 ◽

Cited By ~ 15

Author(s):

Philip S. Barie

Keyword(s):

Septic Shock ◽

Shock Trial ◽

Refractory Septic Shock

Download Full-text

Improving the therapy of generalized forms of Meningococcal infection in children using extracorporeal hemocorrection

CHILDREN INFECTIONS ◽

10.22627/2072-8107-2021-20-2-49-56 ◽

2021 ◽

Vol 20 (2) ◽

pp. 49-56

Author(s):

K. V. Markova ◽

E. Yu. Skripchenko ◽

K. V. Serednyakov ◽

Yu. V. Lobzin ◽

N. V. Skripchenko ◽

...

Keyword(s):

Septic Shock ◽

Multiple Organ Failure ◽

Organ Failure ◽

Multiple Organ ◽

Meningococcal Infection ◽

Basic Drug ◽

Inflammatory Reactions ◽

Clinical Center ◽

Refractory Septic Shock ◽

Group 2

Invasive meningococcal infection is a significant cause of death, reaching 80% in septic shock. The Pediatric Research and Clinical Center for Infectious Diseases (PRCCID) has developed an algorithm for the treatment of children with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome, which includes basic drug therapy with polymyxin hemoperfusion in combination with extended methods of extracorporeal hemocorrection.Purpose: to evaluate the effectiveness of extracorporeal hemocorrection operations in children with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome.Materials and research methods: to the intensive care unit of the PRCCID for the analyzed period 2006—2020 34 children were hospitalized with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome. Two groups were formed: Group 1 — children admitted to the PRCCID in the period 2014—2020 (n = 23), who underwent polymyxin hemoperfusion simultaneously with extended methods of extracorporeal hemocorrection, group 2 — children hospitalized in 2006—201 3 (n = 1 1), methods of extracorporeal hemocorrection were not performed. The Mann-Whitney U-test and ANOVA were used to evaluate the results.Results and discussion: the use of extracorporeal hemocorrection operations in the complex therapy of invasive forms of meningococcal infection with refractory septic shock and multiple organ failure syndrome in children provides stabilization of central hemodynamics, reduces clinical and laboratory inflammatory reactions, helps to reduce the dose of vasopressor drugs and parameters of respiratory support, and also increases patient survival rate by 82.6%.

Download Full-text