Association of Fluid Balance and Survival of Pediatric Patients Treated With Extracorporeal Membrane Oxygenation

The effect of positive fluid balance (FB) on extracorporeal membrane oxygenation (ECMO) outcomes in pediatric patients remains unknown. We sought to evaluate if positive FB in pediatric intensive care unit (PICU) patients with respiratory and/or cardiac failure necessitating ECMO was associated with increased morbidity or mortality. This was a multicenter retrospective cohort study of data from the deidentified PEDiatric ECMO Outcomes Registry (PEDECOR). Patients entered into the database from 2014 to 2017, who received ECMO support, were included. A total of 168 subjects met the study criteria. Univariate analysis showed no significant difference in total FB on ECMO days 1–5 between survivors and non-survivors [median 90 ml/kg (IQR 18–208.5) for survivors vs. median 139.7 ml/kg (IQR 11.2–300.6) for non-survivors, p = 0.334]. There was also no difference in total FB on ECMO days 1–5 in patients with no change in functional outcome as reflected by the Pediatric Outcome Performance Category (POPC) score vs. those who had worsening in POPC score ≥2 at hospital discharge [median 98 ml/kg (IQR 18–267) vs. median 130 ml/kg (IQR 13–252), p = 0.91]. Subjects that required 50 ml/kg or more of blood products over the initial 5 days of ECMO support had an increased rate of mortality with an odds ratio of 5.8 (95% confidence interval of 2.7–12.3; p = 0.048). Our study showed no association of the noted FB with survival after ECMO cannulation. This FB trend was also not associated with POPC at hospital discharge, MV duration, or ECMO duration. The amount of blood product administered was found to be a significant predictor of mortality.

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Extracorporeal Membrane Oxygenation in Postcardiotomy Pediatric Patients—15 Years of Experience Outside Europe and North America

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0037-1608962 ◽

2017 ◽

Vol 67 (01) ◽

pp. 028-036 ◽

Cited By ~ 10

Author(s):

Mohamed Ismail ◽

Tamer Hamouda ◽

Rafik Shaikh ◽

Alaa Mahmoud ◽

Mohammad Shihata ◽

...

Keyword(s):

Renal Failure ◽

Cardiac Surgery ◽

Extracorporeal Membrane Oxygenation ◽

Pediatric Patients ◽

Univariate Analysis ◽

Ecmo Support ◽

Hospital Death ◽

Congenital Cardiac Surgery ◽

Membrane Oxygenation ◽

Cardiopulmonary Support

Background The increasing complexity of congenital cardiac surgery has resulted in the increased use of extracorporeal membrane oxygenation (ECMO) support for children who cannot be weaned from cardiopulmonary bypass. The purpose of this research was to assess the mortality and morbidity in children requiring ECMO support after the repair of congenital heart defects (CHDs). Methods The hospital records of all patients with CHD who required ECMO after a cardiac surgical procedure between January 2001 and December 2016 were retrospectively reviewed. Various outcomes were reported and tested for any association with hospital death. Results A total of 113 children required ECMO for cardiopulmonary support after congenital cardiac surgery; 88 (77.9%) were placed on ECMO in the operating room. Median age of the patients was 3 months (range, 4 days–15 years) and median weight was 3.5 kg (range, 2.2–42.5). Forty-two (37.2%) survived to hospital discharge. In children with single-ventricle physiology, survival to discharge was 37.3% (19/51 patients) and for biventricular physiology, it was 37.1% (23/62 patients). Univariate analysis revealed number of days on ECMO support, renal failure, and stroke as risk factors for hospital mortality, while age and cross-clamp time were found to be statistically nonsignificant. Conclusion Satisfactory results can be achieved in pediatric patients by using ECMO support for postoperative cardiac and pulmonary failure refractory to medical management. Prolonged ECMO support, renal failure, and stroke are risk of mortality.

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Peripheral Extracorporeal Membrane Oxygenation is a safe and effective support modality for pediatric patients with sepsis

Proceedings of IMPRS ◽

10.18060/24793 ◽

2020 ◽

Vol 3 ◽

Author(s):

Brielle Warnock ◽

Joshua Brown ◽

Eamaan Turk ◽

Gail Hocutt ◽

Brian Gray

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Pediatric Patients ◽

Serum Lactate ◽

Ecmo Support ◽

Bleeding Complications ◽

Flow Rates ◽

Membrane Oxygenation ◽

Significant Difference ◽

Septic Group

Background Extracorporeal Membrane Oxygenation (ECMO) can be used as a treatment modality for pediatric patients with refractory septic shock. Previous studies indicate central ECMO, with direct cardiac cannulation, is superior for septic patients. At Riley Hospital for Children, we believe that peripheral ECMO support, through cervical or femoral vessels, is an effective and safe method of supporting pediatric septic patients in a less invasive manner. Methods We reviewed pediatric (30 days to 18 years) patients supported with ECMO for septic shock from 2005-2019 at Riley Hospital for Children and compared them to non-septic respiratory failure patients supported with ECMO. Pre-ECMO data points, demographics, cannulation sites, flow rates, lab values, Vasoactive Ionotropic Score(VIS), P-Prep score, and outcomes were collected and analyzed using t-test and multivariate analyses. We defined a significance as p=0.05. Results 35 of 80 ECMO patients were supported for septic shock. Septic patients were larger (25.1kg vs 11.4kg, p=0.005) and older (85.6 vs 18.8 months, p=0.001). Pre-ECMO VIS and P-Prep were both greater in the septic group (p=0.007 and p<0.001). Pre-ECMO serum lactate level was higher in the septic group (3.7 vs 1.4, p=0.012) , but by 96hrs, lactate normalized in both groups. Flow rates at 24 hours were similar between the two groups (91mL/kg/min vs 88mL/kg/min, p=0.079). No significant difference in bleeding complications or blood product administration was found, but there was a higher incidence of renal failure in septic patients. Survival in the septic group was similar to the comparison group (51.4% vs 62.2%, p-0.37). Hours on ECMO and length of stay were also similar. Conclusion and Potential Impact Despite septic patients appearing more ill prior to ECMO, they had similar mortality, support parameters, and outcomes, showing that septic shock is not a contraindication to peripheral ECMO support in pediatric patients.

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Stroke During Extracorporeal Membrane Oxygenation: Timing, Risk Factors and Clinical Outcomes

10.21203/rs.3.rs-141344/v1 ◽

2021 ◽

Author(s):

Harim Kim ◽

Jeong Hoon Yang ◽

Chi Ryang Chung ◽

Kyeongman Jeon ◽

Gee Young Suh ◽

...

Keyword(s):

Risk Factors ◽

Extracorporeal Membrane Oxygenation ◽

Brain Injuries ◽

Medical Center ◽

Ecmo Support ◽

Membrane Oxygenation ◽

Significant Difference ◽

Stroke Group ◽

Va Ecmo ◽

Vv Ecmo

Abstract Background Among various complications of extracorporeal membrane oxygenation (ECMO), stroke continues to be a major factor that worsens the clinical outcome because it is associated with mortality and adverse neurologic outcomes. Appropriate risk evaluation, screening, and management of neurologic injury under ECMO support has not yet been established and requires further investigation. Thus, this study analyzes the stroke related risk factors and outcomes in order to determine the appropriate intervention to minimize neurologic sequalae while on ECMO. Method Total 1039 patients who underwent ECMO from January 2012 to September 2019 at the Samsung Medical Center were reviewed and 759 subjects were selected for the analysis. The exclusion criteria were age < 18y, failure of successful ECMO initiation, multiple ECMO runs, underlying severe brain injury, and incomplete medical records. Multivariate analysis was performed to identify the risk factors of strokes on ECMO support using cox proportional hazard regression. In order to analyze the timing of stroke after ECMO initiation, the Mann–Whitney U test and Kruskal–Wallis rank sum test were performed.Results Among The overall incidence of stroke was 5.1% (n = 39) without a significant difference between venoarterial (VA) and venovenous(VV) ECMO (5.3% and 4.8%, respectively, p = 0.480). Independent risk factors for stroke were intraaortic balloon pump (IABP, p = 0.0008) and a history of stroke (p = 0.0354). Most hypoxic brain injuries were found in the VA ECMO (93.3%), and 54.5% of intracranial hemorrhage were in the VV ECMO. Most patients with strokes (61.5%) were diagnosed within 72hours after ECMO initiation. The time taken for stroke event from the time of ECMO insertion was shorter in the VA ECMO than in the VV ECMO (median 1.5 vs. 3 days). The stroke group had a higher mortality rate than the non-stroke group (64.1% and 44.7%, respectively, p = 0.014). Conclusion Concurrent ECMO and IABP use may increase the incidence of stroke during ECMO support. Evaluation for stroke that includes CT within 72 hours of ECMO insertion may enable early diagnosis, allowing timely intervention.

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Volumetric Capnography in Pediatric Extracorporeal Membrane Oxygenation: A Case Series

Journal of Pediatric Intensive Care ◽

10.1055/s-0040-1718375 ◽

2020 ◽

Author(s):

Kim R. Derespina ◽

Shivanand S. Medar ◽

Scott I. Aydin ◽

Shubhi Kaushik ◽

Awni Al-Subu ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Pediatric Patients ◽

Case Series ◽

Blood Gases ◽

Ecmo Support ◽

Optimal Timing ◽

Hemodynamic Stability ◽

Volumetric Capnography ◽

Patient Demographics ◽

Membrane Oxygenation

AbstractThe kinetics of carbon dioxide elimination (VCO2) may be used as a surrogate for pulmonary blood flow. As such, we can apply a novel use of volumetric capnography to assess hemodynamic stability in patients requiring extracorporeal membrane oxygenation (ECMO). We report our experience of pediatric patients requiring ECMO support who were monitored using volumetric capnography. We describe the use of VCO2 and its association with successful decannulation. This is a prospective observational study of pediatric patients requiring ECMO support at The Children's Hospital at Montefiore from 2017 to 2019. A Respironics NM3 monitor was applied to each patient. Demographics, hemodynamic data, blood gases, and VCO2 (mL/min) data were collected. Data were collected immediately prior to and after decannulation. Over the course of the study period, seven patients were included. Predecannulation VCO2 was higher among patients who were successfully decannulated than nonsurvivors (109 [35, 230] vs. 12.4 [7.6, 17.2] mL/min), though not statistically significant. Four patients (57%) survived without further mechanical support; two (29%) died, and one (14%) was decannulated to Berlin. Predecannulation VCO2 appears to correlate with hemodynamic stability following decannulation. This case series adds to the growing literature describing the use of volumetric capnography in critical care medicine, particularly pediatric patients requiring ECMO. Prospective studies are needed to further elucidate the use of volumetric capnography and optimal timing for ECMO decannulation.

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Predictors of Poor Outcomes in Pediatric Venoarterial Extracorporeal Membrane Oxygenation

World Journal for Pediatric and Congenital Heart Surgery ◽

10.1177/2150135118762391 ◽

2018 ◽

Vol 9 (3) ◽

pp. 297-304 ◽

Cited By ~ 2

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.

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Abstract 10: Outcome Of Pediatric In-hospital Cardiac Arrest By Extracorporeal Membrane Oxygenation Implementation During Active Cardiopulmonary Resuscitation

Circulation ◽

10.1161/circ.116.suppl_16.ii_925 ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Enting Wu ◽

Shuchien Huang ◽

Wenje Ko ◽

YihSharng Chen

Keyword(s):

Renal Failure ◽

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Discharge ◽

Pediatric Patients ◽

Secondary Outcome ◽

Neurological Outcomes ◽

Membrane Oxygenation ◽

Hospital Cardiac Arrest

Background: To achieve intact neurological survival is a challange for pediatric cardiac arrest. Here we describe the outcome and identify the factors associated with survival among pediatric patients following extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital pediatric cardiac arrest. Method: Retrospective study of 27 pediatric in-hospital cardiac arrest who received extracorporeal membrane oxygenation during active cardiopulmonary resuscitation-.The primary outcome was survival to hospital discharge. The secondary outcome was neurological status after ECPR at hospital discharge and late follow-up. Continuous variables were expressed as medians (inter-quartile range) Results: . We identified 27 ECPR events. The survival rate to hospital discharge was 41% (11/27). The non-survivors had higher serum lactate levels (14 [10.2–19.6] mmol/L vs 8.5 [4.4 –12.6] mmol/L, p < 0.01), longer durations of cardiopulmonary resuscitation (CPR) (60 [37– 81] minutes vs 45 [25–50] minutes, p < 0.05) with longer activating time for ECMO (12.5 [7.5–33.8] minutes vs 5 [0 –10] minutes, p<0.01),and more renal failure after ECPR (68% 11 / 16 vs 9% 1 / 11 , p < 0.01). By multivariate analysis, the earlier cohort and renal failure after ECPR were independent risk factors for mortality. Among the11 survivors, 10 of them had good neurological outcomes. Conclusions: ECPR successfully rescued some pediatric patients who failed rescue with conventional in-hospital CPR. Good neurological outcomes were achieved in the majority of the survivors. Early cohort and post-ECPR renal failure were associated with poor outcomes. Early activation of the ECMO team could possibly shorten the CPR duration and improve the ECPR results.

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Outcomes among Patients Treated with Renal Replacement Therapy during Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Study

Blood Purification ◽

10.1159/000504287 ◽

2019 ◽

Vol 49 (3) ◽

pp. 341-347

Author(s):

David N. Dado ◽

Craig R. Ainsworth ◽

Sarah B. Thomas ◽

Benjamin Huang ◽

Lydia C. Piper ◽

...

Keyword(s):

Renal Replacement Therapy ◽

Extracorporeal Membrane Oxygenation ◽

Replacement Therapy ◽

Hospital Discharge ◽

Fluid Balance ◽

Linear Regression Analysis ◽

Multivariate Linear Regression Analysis ◽

Single Center ◽

Membrane Oxygenation ◽

The Impact

Background: Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are modalities used in critically ill patients suffering organ failure and metabolic derangements. Although the effects of CRRT have been extensively studied, the impact of simultaneous CRRT and ECMO is less well described. The purpose of this study is to evaluate the incidence and the impact of CRRT on outcomes of patients receiving ECMO. Methods: A single center, retrospective chart review was conducted for patients receiving ECMO therapy over a 6-year period. Patients who underwent combined ECMO and CRRT were compared to those who underwent ECMO alone. Intergroup statistical comparisons were performed using Wilcoxon/Kruskal-Wallis and chi-square tests. Logistic regression was performed to identify independent risk factors for mortality. Results: The demographic and clinical data of 92 patients who underwent ECMO at our center were reviewed including primary diagnosis, indications for and mode of ECMO support, illness severity, oxygenation index, vasopressor requirement, and presence of acute kidney injury. In those patients that required ECMO with CRRT, we reviewed urine output prior to initiation, modality used, prescribed dose, net fluid balance after 72 h, requirement of renal replacement therapy (RRT) at discharge, and use of diuretics prior to RRT initiation. Our primary endpoint was survival to hospital discharge. During the study period, 48 patients required the combination of ECMO with CRRT. Twenty-nine of these patients survived to hospital discharge. Of the 29 survivors, 6 were dialysis dependent at hospital discharge. The mortality rate was 39.5% with combined ECMO/CRRT compared to 31.4% among those receiving ECMO alone (p = 0.074). Of those receiving combined therapy, nonsurvivors were more likely to have a significantly positive net fluid balance at 72 h (p = 0.001). A multivariate linear regression analysis showed net positive fluid balance and increased age were independently associated with mortality. Conclusions: Use of CRRT is prevalent among patients undergoing ECMO, with over 50% of our patient population receiving combination therapy. Fluid balance appears to be an important variable associated with outcomes in this cohort. Rates of renal recovery and overall survival were higher compared to previously published reports among those requiring combined ECMO/CRRT.

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