Extracorporeal membrane oxygenation outcomes in children with hemophagocytic lymphohistiocytosis

Perfusion ◽  
2016 ◽  
Vol 32 (2) ◽  
pp. 151-156 ◽  
Author(s):  
Katherine Cashen ◽  
Roland L Chu ◽  
Justin Klein ◽  
Peter T Rycus ◽  
John M Costello
Keyword(s):  
Risk Factors ◽  
Extracorporeal Membrane Oxygenation ◽  
Cardiac Failure ◽  
Hemophagocytic Lymphohistiocytosis ◽  
Pediatric Patients ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Hemorrhagic Complication ◽  
Membrane Oxygenation ◽  
Va Ecmo

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.

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

2015 ◽  
Vol 81 (3) ◽  
pp. 245-251 ◽  
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.

External validation of the Pediatric Extracorporeal Membrane Oxygenation Prediction model for risk adjusting mortality

Perfusion ◽  
2020 ◽  
pp. 026765912095297
Author(s):  
David K Bailly ◽  
Jamie M Furlong-Dillard ◽  
Melissa Winder ◽  
Mark Lavering ◽  
Ryan P Barbaro ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Prediction Model ◽  
Goodness Of Fit ◽  
Pediatric Patients ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Characteristic Curve ◽  
External Validation ◽  
Group Model ◽  
Membrane Oxygenation

Introduction: The Pediatric Extracorporeal Membrane Oxygenation Prediction (PEP) model was created to provide risk stratification for all pediatric patients requiring extracorporeal life support (ECLS). Our purpose was to externally validate the model using contemporaneous cases submitted to the Extracorporeal Life Support Organization (ELSO) registry. Methods: This multicenter, retrospective analysis included pediatric patients (<19 years) during their initial ECLS run for all indications between January 2012 and September 2014. Median values from the BATE dataset for activated partial thromboplastin time and internationalized normalized ratio were used as surrogates as these were missing in the ELSO group. Model discrimination was evaluated using area under the receiver operating characteristic curve (AUC), and goodness-of-fit was evaluated using the Hosmer-Lemeshow test. Results: A total of 4,342 patients in the ELSO registry were compared to 514 subjects from the bleeding and thrombosis on extracorporeal membrane oxygenation (BATE) dataset used to develop the PEP model. Overall mortality was similar (42% ELSO vs. 45% BATE). The c-statistic after external validation decreased from 0.75 to 0.64 and model calibration decreases most in the highest risk deciles. Conclusion: Discrimination of the PEP model remains modest after external validation using the largest pediatric ECLS cohort. While the model overestimates mortality for the highest risk patients, it remains the only prediction model applicable to both neonates and pediatric patients who require ECLS for any indication and thus maintains potential for application in research and quality benchmarking.

Predictors of Poor Outcomes in Pediatric Venoarterial Extracorporeal Membrane Oxygenation

2018 ◽  
Vol 9 (3) ◽  
pp. 297-304 ◽  
Author(s):  
Maanasi S. Mistry ◽  
Sara M. Trucco ◽  
Timothy Maul ◽  
Mahesh S. Sharma ◽  
Li Wang ◽  
...  
Keyword(s):  
Risk Factors ◽  
Extracorporeal Membrane Oxygenation ◽  
Pediatric Patients ◽  
Ecmo Support ◽  
Cardiorespiratory Failure ◽  
Membrane Oxygenation ◽  
Venoarterial Extracorporeal Membrane Oxygenation ◽  
Poor Outcomes ◽  
Va Ecmo ◽  
Elevated Lactate

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides respiratory and hemodynamic support to pediatric patients in severe cardiac failure. We aim to identify risk factors associated with poorer outcomes in this population. Methods: A retrospective chart review was conducted of pediatric patients requiring VA-ECMO support for cardiac indications at our institution from 2004 to 2015. Data were collected on demographics, indication, markers of cardiac output, ventricular assist device (VAD) insertion, heart transplantation, or left atrial (LA) decompression. Univariate Cox proportional hazards models were used to calculate hazard ratios (HRs) for variables associated with the composite primary outcome of transplant-free survival (TFS). Results: Of the 68 reviewed patients, 65% were male, 84% were white, 38% had a prior surgery, 13% had a prior transplant, 10% had a prior ECMO support, and 87.5% required vasoactive support within six hours of cannulation. The ECMO indications included congenital heart disease repaired >30 days prior (12%), cardiomyopathy (41%), posttransplant rejection (7%), and cardiorespiratory failure (40%). The TFS was 54.5% at discharge and 47.7% at one year. Predictors of transplant and/or death include epinephrine use (hazard ratio [HR] = 2.269, P = .041), elevated lactate (HR = 1.081, P = 0005), and elevated creatinine (HR = 1.081, P = .005) within six hours prior to cannulation. Sixteen (23.6%) patients underwent LA decompression. Placement of VAD occurred in 16 (23.5%) patients, for which nonwhite race (HR = 2.94, P = .034) and prior ECMO (HR = 3.42, P = .053) were the only identified risk factors. Conclusions: Need for VA-ECMO for cardiac support carries high inpatient morbidity and mortality. Epinephrine use and elevated lactate and creatinine were associated with especially poor outcomes. Patients who survived to discharge had good short-term follow-up results.

ECLS for Life-Threatening Complications in Mesothelioma's Surgery: Is It Worthwhile?

2021 ◽  
Author(s):  
Alice Bellini ◽  
Andrea Dell'Amore ◽  
Pia Ferrigno ◽  
Nicolo' Sella ◽  
Paolo Navalesi ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Induction Chemotherapy ◽  
Cardiac Failure ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Perioperative Complications ◽  
Conventional Management ◽  
Membrane Oxygenation ◽  
Oncological Patients ◽  
Life Threatening

AbstractExtracorporeal life support (ECLS) is an effective method for bridging patients to recovery in cases of respiratory and/or cardiac failure that are potentially reversible and unresponsive to conventional management. Nevertheless, there have been only few reports about the use of ECLS in oncological patients with complications due to their neoplasm or its treatment. We report the use of veno-arterial extracorporeal membrane oxygenation in three cases of severe perioperative complications following surgery for mesothelioma after induction chemotherapy at our Institution.

scholarly journals Transfusion-Dependent Anemia and Coagulopathy in a Porcine Model of Pediatric Extracorporeal Membrane Oxygenation (ECMO)

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 1164-1164
Author(s):  
Christopher Robert Reed ◽  
Desiree Bonadonna ◽  
Jeffrey R Everitt ◽  
Victoria Robinson ◽  
James Otto ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Whole Blood ◽  
Porcine Model ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Congenital Defects ◽  
Arterial Line ◽  
Human Infants ◽  
Membrane Oxygenation ◽  
Va Ecmo

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is often required to support infants with congenital defects, congenital heart disease, and other causes of reversible cardiopulmonary insufficiency. Although ECMO can be a life-saving modality, bleeding, inflammation, and thrombosis are well-described complications of ECMO. Adult porcine models of ECMO have been used to recapitulate the physiology and hematologic consequences of ECMO cannulation. However, these models lack the unique physiology and persistence of fetal forms and quantities of coagulation proteins and fibrinogen found in human infants. Furthermore, anticoagulation and hemostatic strategies developed for adults or using adult porcine models are often extrapolated to infants without specific considerations for developmental hemostasis. Therefore, development of an animal model of ECMO that faithfully reproduces both the physiology and coagulation profile of human infants is important to improving anticoagulation strategies and gaining a better mechanistic understanding of hemostatic challenges in infants. We hypothesized that an infant porcine mode (piglets) supported with VA-ECMO would closely recapitulate the physiology and hematology of human infants on ECMO. Methods: Four healthy piglets (5.7-6.4 kg) were cannulated via the jugular vein and carotid artery and supported for 20 hours or until adult whole blood for transfusion was exhausted. Heparin was used with a goal activated clotting time (ACT) of 180-220 seconds. Blood gas (ABG) was performed hourly, and blood was transfused from an adult donor to maintain hematocrit ≥24%. Rotational thromboelastometry (ROTEM) assays were performed at each of seven time points. Specifically, EXTEM, INTEM, and FIBTEM were used to determine the coagulation time (CT) and maximum clot firmness (MCF) of the extrinsically-mediated, intrinsically-mediated, and acellular fibrin clots, respectively. Results: All animals (n=4) had slow but significant hemorrhage at cannulation, arterial line, and bladder catheter sites. All animals required the maximum blood transfusion volume available. All animals became anemic after exhaustion of blood for transfusion, and two required sacrifice before the 20-hour endpoint for critical anemia. ABG showed progressively declining hematocrit and adequate oxygenation. ROTEM demonstrated decreasing FIBTEM clot firmness with preservation of EXTEM and INTEM coagulation times. Histology was overall unremarkable. Conclusion: Our infant porcine model faithfully reproduces the physiology and hematostatic profile of human infants during VA-ECMO, including transfusion dependence and heparin-induced coagulopathy. Weak whole-blood clot firmness by ROTEM suggests defects in fibrinogen. This model serves as an important means to study the complex derangements in hemostasis during VA ECMO in infants, including subtle derangements due to adult blood product transfusions, as well as to investigate novel approaches to anticoagulation and hemostasis during extracorporeal life support. Figure Disclosures Arepally: Veralox Therapeutics: Membership on an entity's Board of Directors or advisory committees; Apotex Pharmaceuticals: Consultancy; Biokit: Patents & Royalties.

scholarly journals Evaluation of Heparin Anti–Factor Xa Levels Following Antithrombin Supplementation in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation

2020 ◽  
Vol 25 (8) ◽  
pp. 717-722
Author(s):  
Sharon E. Gordon ◽  
Travis S. Heath ◽  
Ali B.V. McMichael ◽  
Christoph P. Hornik ◽  
Caroline P. Ozment
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Pediatric Patients ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Tertiary Care ◽  
Factor Xa ◽  
Care Hospital ◽  
Membrane Oxygenation ◽  
Support Organization ◽  
Clinical Benefits

OBJECTIVE Thrombotic events are potential complications in patients receiving extracorporeal membrane oxygenation (ECMO) necessitating the use of systemic anticoagulation with heparin. Heparin works by potentiating the effects of antithrombin (AT), which may be deficient in critically ill patients and can be replaced. The clinical benefits and risks of AT replacement in children on ECMO remain incompletely understood. METHODS This single-center, retrospective study reviewed 28 neonatal and pediatric patients supported on ECMO at a tertiary care hospital between April 1, 2013, and October 31, 2014, who received at least 1 dose of AT during their ECMO course. The primary outcome of the study was the change in anti–factor Xa levels after pooled human AT supplementation. Secondary outcomes included the percentage of anti–factor Xa levels within the therapeutic range surrounding AT administration; survival to decannulation; 30 days after cannulation and discharge; time to first circuit change; and incidence of bleeding and thrombotic events. RESULTS A total of 78 doses of AT were administered during the study period. The mean increase in anti–factor Xa level following AT administration in patients without a ≥10% concurrent change in heparin was 0.075 ± 0.13 international units/mL. A greater percentage of anti–factor Xa levels were therapeutic for the 48 hours following AT administration (64.2% vs 38.6%). Survival and adverse events were similar to Extracorporeal Life Support Organization averages, with the exception of a higher incidence of intracranial hemorrhage. CONCLUSIONS Patients experienced a small but significant increase in anti–factor Xa level and a greater percentage of therapeutic anti–factor Xa levels following AT supplementation.

scholarly journals The use of extracorporeal membrane oxygenation in the setting of postinfarction mechanical complications: outcome analysis of the Extracorporeal Life Support Organization Registry

2020 ◽  
Vol 31 (3) ◽  
pp. 369-374 ◽  
Author(s):  
Matteo Matteucci ◽  
Dario Fina ◽  
Federica Jiritano ◽  
Paolo Meani ◽  
Giuseppe Maria Raffa ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Outcome Analysis ◽  
Ventricular Septal Rupture ◽  
Old Patients ◽  
Patient Cohort ◽  
Membrane Oxygenation ◽  
Mechanical Complications ◽  
Va Ecmo

Abstract OBJECTIVES Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been recently considered and used for patients with post-acute myocardial infarction mechanical complications (post-AMI MC); however, information in this respect is scarce. The purpose of this study was to evaluate the in-hospital outcomes of patients with post-AMI MC submitted to VA-ECMO, and enrolled in the Extracorporeal Life Support Organizations (ELSO)’s data Registry. METHODS This was a retrospective review of the ELSO Registry to identify adult (&gt;18 years old) patients with post-AMI MC who underwent VA-ECMO support between 2007 and 2018. The primary end point of this study was in-hospital survival. ECMO complications were also evaluated. RESULTS The patient cohort available for this study included 158 patients. The median age was 62.4 years (range 20–80). The most common post-AMI MC was ventricular septal rupture (n = 102; 64.5%), followed by papillary muscle rupture (n = 42; 26.6%) and ventricular free-wall rupture (n = 14; 8.9%). Approximately a quarter of patients (n = 41; 25.9%) had cardiac arrest before VA-ECMO institution. The median duration of VA-ECMO was 5.9 days (range 1 h–40.3 days). ECMO complications occurred in 119 patients (75.3%). Overall, survival to hospital discharge for the entire patient cohort was 37.3%. Patients who had ventricular septal rupture as primary diagnosis had higher in-hospital mortality (n = 66; 64.7%). CONCLUSIONS In patients with post-AMI MC, VA-ECMO provides haemodynamic stabilizations and carries a potential to reverse otherwise lethal course. ECMO complications, however, remain an important limitation. Further investigations are required to better evaluate the efficacy and safety of ECMO in this context.

scholarly journals 1166. Infection Rate in Venous–Venous Extracorporeal Membrane Oxygenation (VV-ECMO)

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S417-S417
Author(s):  
Joseph Wang ◽  
Cason Christensen ◽  
Helenmari Merritt-Genore ◽  
Aleem Siddique ◽  
Kelly Cawcutt ◽  
...  
Keyword(s):  
Escherichia Coli ◽  
Extracorporeal Membrane Oxygenation ◽  
Infection Rate ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Categorical Variables ◽  
Infection Rates ◽  
Membrane Oxygenation ◽  
Va Ecmo ◽  
Vv Ecmo

Abstract Background The Extracorporeal Life Support Organization (ELSO) Infectious Disease Taskforce has identified infection rates as an area requiring further study. We aimed to evaluate our patients on venous–venous extracorporeal membrane oxygenation (VV ECMO) for infection rates, organisms, and specific factors that may alter infection risk. Methods Retrospective data were collected from September 2012 to 2015 for adult patients on VV ECMO. Demographic information as well as type and location of cannulation, antibiotics prior to and during cannulation, and presence of bacteremia were obtained. Counts and percentages are reported for categorical variables. Results 47 patients between 18 and 82 years of age with a median of age of 58 years were included. 76.6% (N = 36) were male. The average number of hospital days until cannulation was 7.8 days. 400 ECMO days were captured with a range of time on ECMO of 1–41 days. 46.8% (N = 22) of patients were alive at the time of discharge. 70.2% (N = 32) of cannulations were in the OR (Figure 1). 55% (N = 26) of patients had a Right Ventricular Assist Device (RVAD) with in-line oxygenator. 66% (N = 31) of all patients were on antibiotics prior to cannulation for other indications while 53% (N = 25) of all patients received perioperative antibiotics (Figure 2). 59% (N = 28) of all patients had blood cultures while on ECMO, with only 8% (N = 4) of all patients returning positive. Of the positive cultures, 2 were true bacteremia resulting in an infection rate of 5 per 1,000 ECMO days (Figure 3). One patient grew Escherichia coli while the other grew Escherichia coli and Streptococcus pneumoniae. Neither patient received antibiotics perioperatively or for other indications (Figure 4). Due to the low number of infected patients, further statistical analysis could not be performed. Conclusion We report a low rate of bloodstream infection amongst our VV-ECMO patients. Further investigation to ascertain trends in infection rate with cannulation location/type as well as association with antibiotic is currently being pursued. Other avenues of research will include a comparison of infection rates between VV and Venous Arterial (VA) ECMO. Information from these investigations will help aid the development of guidelines to minimize the rate of nosocomial infections in ECMO patients. Disclosures All authors: No reported disclosures.

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