Thrombophilia in Pediatric Patients with Multisystem Inflammatory Syndrome in Children Secondary to Coronavirus Disease 2019 Supported on Extracorporeal Membrane Oxygenation

Introduction: Pediatric patients with hemophagocytic lymphohistiocytosis (HLH) may develop refractory respiratory or cardiac failure that warrants consideration for extracorporeal membrane oxygenation (ECMO) support. The purposes of this study were to describe the use and outcomes of ECMO in pediatric HLH patients, to identify risk factors for hospital mortality and to compare their ECMO use and outcomes to the ECMO population as a whole. Methods: Pediatric patients (⩽ 18 years) with a diagnosis of HLH in the Extracorporeal Life Support Organization (ELSO) Registry were included. Results: Between 1983 and 2014, data for 30 children with HLH were available in the ELSO registry and all were included in this study. All cases occurred in the last decade. Of the 30 HLH patients, 24 (80%) had a respiratory indication for ECMO and six (20%) had a cardiac indication (of which 4 were E-CPR and 2 cardiac failure). Of the 24 respiratory ECMO patients, 63% were placed on VA ECMO. Compared with all pediatric patients in the ELSO registry during the study period (n=17,007), HLH patients had worse hospital survival (non-HLH 59% vs HLH 30%, p=0.001). In pediatric HLH patients, no pre-ECMO risk factors for mortality were identified. The development of a hemorrhagic complication on ECMO was associated with decreased mortality (p=0.01). Comparing HLH patients with respiratory failure to patients with other immune compromised conditions, the overall survival rate is similar (HLH 38% vs. non-HLH immune compromised 31%, p=0.64). Conclusions: HLH is an uncommon indication for ECMO and these patients have increased mortality compared to the overall pediatric ECMO population. These data should be factored into decision-making when considering ECMO for pediatric HLH patients.

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The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation

Frontiers in Pediatrics ◽

10.3389/fped.2018.00297 ◽

2018 ◽

Vol 6 ◽

Cited By ~ 4

Author(s):

Carles Bautista-Rodriguez ◽

Joan Sanchez-de-Toledo ◽

Eduardo M. Da Cruz

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Pediatric Patients ◽

Membrane Oxygenation

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Kinetics of Procalcitonin in Pediatric Patients on Extracorporeal Membrane Oxygenation

Biomarker Insights ◽

10.1177/1177271917751900 ◽

2018 ◽

Vol 13 ◽

pp. 117727191775190 ◽

Cited By ~ 5

Author(s):

Sara Bobillo ◽

Javier Rodríguez-Fanjul ◽

Anna Solé ◽

Julio Moreno ◽

Mònica Balaguer ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Prospective Observational Study ◽

Pediatric Patients ◽

Clinical Situation ◽

Multiple Organ ◽

C Reactive Protein ◽

Reactive Protein ◽

Membrane Oxygenation ◽

Neurologic Sequelae ◽

Kinetics Of

Objectives: To assess the kinetics of procalcitonin (PCT) and C-reactive protein (CRP) in pediatric patients who required extracorporeal membrane oxygenation (ECMO) and to analyze its relationship with morbidity and mortality. Patients and methods: Prospective observational study including pediatric patients who required ECMO. Both PCT and CRP were sequentially drawn before ECMO (P0) and until 72 hours after ECMO. Results: A total of 40 patients were recruited. Two cohorts were established based on the value of the P0 PCT (>10 ng/mL). Comparing the kinetics of PCT and CRP in these cohorts, the described curves were the expected for each clinical situation. The cutoff for P0 PCT to predict multiple organ dysfunction syndrome was 2.55 ng/mL (sensibility 83%, specificity 100%). Both PCT and CRP did not predict risk of neurologic sequelae or mortality in any group. Conclusions: Procalcitonin does not seem to be modified by ECMO and could be a good biomarker of evolution.

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Effects of an Ex Vivo Pediatric Extracorporeal Membrane Oxygenation Circuit on the Sequestration of Mycophenolate Mofetil, Tacrolimus, Hydromorphone, and Fentanyl

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-24.4.290 ◽

2019 ◽

Vol 24 (4) ◽

pp. 290-295

Author(s):

Catherine S. Heith ◽

Lizbeth A. Hansen ◽

Rhonda M. Bakken ◽

Sharon L. Ritter ◽

Breeanna R. Long ◽

...

Keyword(s):

Mycophenolate Mofetil ◽

Extracorporeal Membrane Oxygenation ◽

Mycophenolic Acid ◽

Pediatric Patients ◽

Ex Vivo ◽

Centrifugal Pumps ◽

Ecmo Circuit ◽

Binding Characteristics ◽

Membrane Oxygenation ◽

Set Up

OBJECTIVES With the expanding use of extracorporeal membrane oxygenation (ECMO), understanding drug pharmacokinetics has become increasingly important, particularly in pediatric patients. This ex vivo study examines the effect of a pediatric Quadrox-iD ECMO circuit on the sequestration and binding of mycophenolate mofetil (MMF), tacrolimus, and hydromorphone hydrochloride, which have not been extensively studied to date in pediatric ECMO circuits. Fentanyl, which has been well studied, was used as a comparator. METHODS ECMO circuits were set up using Quadrox-iD pediatric oxygenators and centrifugal pumps. The circuit was primed with whole blood and a reservoir was attached to represent a 5-kg patient. Fourteen French venous and 12 French arterial ECMO cannulas were inserted into the sealed reservoir. Temperature, pH, PO2, and PCO2 were monitored and corrected. MMF, tacrolimus, hydromorphone, and fentanyl were injected into the ECMO circuit. Serial blood samples were taken from a postoxygenator site at intervals over 12 hours, and levels were measured. RESULTS Hydromorphone hydrochloride was not as significantly sequestered by the ex vivo pediatric ECMO circuit when compared with fentanyl. Both mycophenolic acid and tacrolimus serum concentrations were stable in the circuit over 12 hours. CONCLUSIONS Hydromorphone may represent a useful medication for pain control for pediatric patients on ECMO due to its minimal sequestration. Mycophenolic acid and tacrolimus also did not show significant sequestration in the circuit, which was unexpected given their lipophilicity and protein-binding characteristics, but may provide insight into unexplored pharmacokinetics of particular medications in ECMO circuits.

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Outcomes of Pediatric Patients with Abdominal Sepsis Requiring Surgery and Extracorporeal Membrane Oxygenation Using the Extracorporeal Life Support Organization Database

The American Surgeon ◽

10.1177/000313481508100325 ◽

2015 ◽

Vol 81 (3) ◽

pp. 245-251 ◽

Cited By ~ 6

Author(s):

Michael R. Phillips ◽

Amal L. Khoury ◽

Briana J. K. Stephenson ◽

Lloyd J. Edwards ◽

Anthony G. Charles ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Pediatric Patients ◽

Clinical Decision Making ◽

Life Support ◽

Extracorporeal Life Support ◽

Abdominal Sepsis ◽

Bleeding Complications ◽

Extracorporeal Life Support Organization ◽

Membrane Oxygenation ◽

Support Organization

No study describes the use of extracorporeal membrane oxygenation (ECMO) in pediatric patients with abdominal sepsis (AS) requiring surgery. A description of outcomes in this patient population would assist clinical decision-making and provide a context for discussions with patients and families. The Extracorporeal Life Support Organization database was queried for pediatric patients (30 days to 18 years) with AS requiring surgery. Forty-five of 61 patients survived (73.8%). Reported bleeding complications (57.1 vs 48.8%), the number of pre-ECMO ventilator hours (208.1 vs 178.9), and the timing of surgery before (50 vs 66.7%) and on-ECMO (50 vs 26.7%) were similar in survivors and nonsurvivors. Decreased pre-ECMO mean pH (7.1 vs 7.3) was associated with increased mortality (odds ratio, 1.49; 95% confidence interval, 1.04 to 2.14). ECMO use for pediatric patients with AS requiring surgery is associated with increased mortality and an increased rate of bleeding complications compared with all pediatric patients receiving ECMO support. Acidemia predicts mortality and provides a potential target of examination for future studies.

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Evaluation of the Effects of Extracorporeal Membrane Oxygenation on Antiepileptic Drug Serum Concentrations in Pediatric Patients

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-22.5.352 ◽

2017 ◽

Vol 22 (5) ◽

pp. 352-357 ◽

Cited By ~ 4

Author(s):

Nicholas O. Dillman ◽

Mindl M. Messinger ◽

Kimberly N. Dinh ◽

Jennifer L. Placencia ◽

Brady S. Moffett ◽

...

Keyword(s):

Serum Concentration ◽

Extracorporeal Membrane Oxygenation ◽

Pediatric Patients ◽

Pediatric Population ◽

Volume Of Distribution ◽

Serum Concentrations ◽

Inclusion Criteria ◽

Lower Serum ◽

Membrane Oxygenation ◽

Dosing Strategies

OBJECTIVES Patients supported on extracorporeal membrane oxygenation (ECMO) have an increased incidence of seizures. Phenobarbital (PB) and fosphenytoin (fos-PHT) are common antiepileptic drugs (AEDs) used to manage seizures in the pediatric population; however, it is unknown what effect ECMO has on the serum concentrations of AEDs. The purpose of this study is to evaluate the effect of ECMO on AED serum concentrations. METHODS A retrospective, matched-cohort study was performed in patients younger than 18 years who received ECMO and were treated with intravenous (IV) PB or fos-PHT at Texas Children's Hospital between 2004 and 2014. Patients receiving IV AED therapy and ECMO were matched, based on age, sex, and weight, with patients receiving IV AED therapy without ECMO. The 24-hour cumulative AED dose, serum concentrations, number of doses per serum concentration drawn ratio, volume of distribution, therapeutic serum concentrations, and time to therapeutic serum concentration were compared between both groups. The fos-PHT and PB groups were analyzed in all patients and in neonates only. RESULTS Fourteen patients met inclusion criteria. The fos-PHT neonatal (20.1 vs 11.3 mg/kg/day, p = 0.044), PB composite (33.9 vs 21.6 mg/kg/day, p = 0.012), and PB neonatal (40.3 vs 20 mg/kg/day, p = 0.04) had larger 24-hour cumulative doses compared with non-ECMO patients. Lower serum concentrations were observed in the PB composite ECMO group (19.1 vs 35.4 mg/L, p < 0.001) and the PB neonatal ECMO group (20.5 vs 27.8 mg/L, p = 0.01) compared with non-ECMO patients. CONCLUSION Pediatric patients receiving PB on ECMO and neonatal patients receiving fos-PHT on ECMO required larger doses, and in pediatric patients achieved lower serum concentrations, suggesting the necessity for alternative dosing strategies in these populations.

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Venovenous Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure

The American Surgeon ◽

10.1177/000313481608200937 ◽

2016 ◽

Vol 82 (9) ◽

pp. 787-788 ◽

Cited By ~ 2

Author(s):

P. Benson Ham ◽

Brice Hwang ◽

Linda J. Wise ◽

K. Christian Walters ◽

Walter L. Pipkin ◽

...

Keyword(s):

Respiratory Failure ◽

Extracorporeal Membrane Oxygenation ◽

Pediatric Patients ◽

Oxygenation Index ◽

Lung Damage ◽

Positive Pressure ◽

Membrane Oxygenation ◽

Short Run ◽

Va Ecmo ◽

Vv Ecmo

Conventional treatment of respiratory failure involves positive pressure ventilation that can worsen lung damage. Extracorporeal membrane oxygenation (ECMO) is typically used when conventional therapy fails. In this study, we evaluated the use of venovenous (VV)-ECMO for the treatment of severe pediatric respiratory failure at our institution. A retrospective analysis of pediatric patients (age 1–18) placed on ECMO in the last 15 years (1999–2014) by the pediatric surgery team for respiratory failure was performed. Five pediatric patients underwent ECMO (mean age 10 years; range, 2–16). All underwent VV-ECMO. Diagnoses were status asthmaticus (2), acute respiratory distress syndrome due to septic shock (1), aspergillus pneumonia (1), and respiratory failure due to parainfluenza (1). Two patients had severe barotrauma prior to ECMO initiation. Average oxygenation index (OI) prior to cannulation was 74 (range 23–122). No patients required conversion to VA-ECMO. The average ECMO run time was 4.4 days (range 2–6). The average number of days on the ventilator was 15 (range 4–27). There were no major complications due to the procedure. Survival to discharge was 100%. Average follow up is 4.4 years (range 1–15). A short run of VV-ECMO can be lifesaving for pediatric patients in respiratory failure. Survival is excellent despite severely elevated oxygen indices. VV-ECMO may be well tolerated and can be considered for severe pediatric respiratory failure.

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