Faculty Opinions recommendation of Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality Among Patients With COVID-19 Admitted to the Intensive Care Unit: The INSPIRATION Randomized Clinical Trial.

The therapeutic trial comparing extracorporeal membrane oxygenation with conventional treatment in neonatal respiratory failure reported by Bartlett et al (Pediatrics 1985;76:479-487) uses a method of comparing treatments unlikely to be familiar to most pediatricians. Known as the "randomized play the winner" method, it has thus far been little used in clinical research. Most clinical investigators consider the conventional randomized clinical trial to be the last word in treatment comparisons. But randomized clinical trials are costly, cumbersome, and to some observers less than ideal ethically. The ethical problem arises from the fact that during a "successful" randomized clinical trial (ie, one that demonstrates a significant advantage to one treatment) about half of the trial subjects will receive a treatment which, at the end of the trial, will be known to be inferior.

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Outcomes of pediatric oncology and hematopoietic cell transplant patients receiving extracorporeal membrane oxygenation

Perfusion ◽

10.1177/0267659119842471 ◽

2019 ◽

Vol 34 (7) ◽

pp. 598-604

Author(s):

Danielle K Maue ◽

Michael J Hobson ◽

Matthew L Friedman ◽

Elizabeth AS Moser ◽

Courtney M Rowan

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Extracorporeal Membrane Oxygenation ◽

Pediatric Intensive Care Unit ◽

Pediatric Intensive Care ◽

Hematopoietic Cell ◽

Cell Transplant ◽

Hematopoietic Cell Transplant ◽

Membrane Oxygenation ◽

Transplant Patients

Background/objectives: There is controversy regarding the utilization of extracorporeal membrane oxygenation in pediatric patients with an underlying oncologic diagnosis or who have undergone hematopoietic cell transplant. We hypothesized that these patients have higher mortality, more bleeding complications, more blood product utilization, and a higher rate of new infections than the general pediatric intensive care unit population supported with extracorporeal membrane oxygenation. Design/methods: This is a retrospective chart review at a single center quaternary care pediatric hospital including all pediatric intensive care unit extracorporeal membrane oxygenation patients from 2011 to 2016. Patients were categorized as either oncology/hematopoietic cell transplant or general pediatric intensive care unit. Patients from the cardiovascular intensive care unit or the neonatal intensive care unit were excluded. Results: A total of 38 patients met inclusion criteria of which 7 were oncology/hematopoietic cell transplant patients. The oncology/hematopoietic cell transplant group had lower platelets at the start of extracorporeal membrane oxygenation (p = 0.02) but other pre-extracorporeal membrane oxygenation characteristics were similar. Extracorporeal membrane oxygenation survival was lower in the oncology/hematopoietic cell transplant group (29% vs 77%, p = 0.02). The incidence of bleeding complications and new infections did not differ. The oncology/hematopoietic cell transplant group received more platelets (median of 15.9 mL/kg/day (interquartile range 8.4, 36.6) vs 7.9 mL/kg/day (3.3, 21.9), p = 0.04) and fresh frozen plasma (14.0 mL/kg/day (3, 15.7) vs 1.8 mL/kg/day (0.5, 5.9), p = 0.04). Conclusion: Oncology and hematopoietic cell transplant patients had a higher mortality and received more blood products while on extracorporeal membrane oxygenation than the general pediatric intensive care unit patients despite similar pre-extracorporeal membrane oxygenation characteristics. Physicians should use caution when deciding whether or not to utilize extracorporeal membrane oxygenation in this population.

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Mobile extracorporeal membrane oxygenation service for severe acute respiratory failure – A review of five years of experience

Journal of the Intensive Care Society ◽

10.1177/1751143719855207 ◽

2019 ◽

Vol 21 (2) ◽

pp. 134-139 ◽

Cited By ~ 2

Author(s):

Ada M Krzak ◽

Jo-Anne Fowles ◽

Alain Vuylsteke

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Respiratory Failure ◽

Qualitative Study ◽

Extracorporeal Membrane Oxygenation ◽

Acute Respiratory Failure ◽

Equipment Failure ◽

Quality And Safety ◽

Regular Reflection ◽

Membrane Oxygenation

Provision of extracorporeal membrane oxygenation as part of support escalation in severe refractory acute respiratory failure in England is provided by five specialist centres that operate within a well-defined quality and safety framework. We conducted a qualitative study of the extracorporeal membrane oxygenation retrieval service provided by one of the five centres. We analysed 176 consecutive debrief reports written between October 2013 and April 2018 by the consultant. Main identified issues were short delays in retrieval predominantly due to insufficient communication or equipment failure. All issues were addressed in subsequent practice. Our results suggest a need for improved communication between the referring intensive care unit and retrieving team. Our findings highlight the value of regular reflection-based evaluation to ensure continued provision of safe and efficient service.

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