Discontinuation Of Extracorporeal Membrane Oxygenation Research Articles

Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital.

To examine characteristics associated with formal ethics consultation (EC) referral in pediatric extracorporeal membrane oxygenation (ECMO) cases, and document ethical issues presented. Retrospective cohort study using mixed methods. Single-center quaternary pediatric hospital. Patients supported on ECMO (January 2012 to December 2021). We compared clinical variables among ECMO patients according to the presence of EC. We defined optimal cutoffs for EC based on run duration, ICU length of stay (LOS), and sum of procedures or complications. To identify independent explanatory variables for EC, we used a forward stepwise selection multivariable logistic regression model. EC records were thematically characterized into ethical issues. Of 601 ECMO patients and 225 patients with EC in 10 years, 27 ECMO patients received EC (4.5% of ECMO patients, 12% of all ECs). On univariate analysis, use of EC vs. not was associated with multiple ECMO runs, more complications/procedures, longer ICU LOS and ECMO duration, cardiac admissions, decannulation outcome, and higher mortality. Cutoffs for EC were ICU LOS >52 days, run duration >160 hours, and >6 complications/procedures. Independent associations with EC included these three cutoffs and older age. The model showed good discrimination (area under the curve 0.88 [0.83, 0.93]) and fit. The most common primary ethical issues were related to end-of-life, ECMO discontinuation, and treatment decision-making. Moral distress was cited in 22 of 27 cases (82%). EC was used in 4.5% of our pediatric ECMO cases, with most ethical issues related to end-of-life care or ECMO discontinuation. Older age, longer ICU LOS, prolonged runs, and multiple procedures/complications were associated with greater odds for EC requests. These data highlight our single-center experience of ECMO-associated ethical dilemmas. Historical referral patterns may guide a supported decision-making framework. Future work will need to include quality improvement projects for timely EC, with evaluation of impacts on relevant endpoints.

Physician communication with families during pediatric ECMO: results from a Delphi study

PurposeTo develop physician recommendations for communicating with families during pediatric extracorporeal membrane oxygenation (ECMO) in Canada and the USA.MethodsWe used the Delphi methodology, which consists of 3 iterative rounds. During Round 1, we conducted semi-structured interviews with each panelist, who were pediatricians from the USA and Canada from the following pediatric specialties: intensive care, cardiac intensive care, and neonatology. We then used content analysis to code the interviews and develop potential recommendations. During Round 2, panelists evaluated each item via a Likert scale as a potential recommendation. Before Round 3, panelists were provided personalized feedback reports of the results of Round 2. During Round 3, panelists re-evaluated items that did not reach consensus during Round 2. Items that reached consensus in Rounds 2 and 3 were translated into the final framework.ResultsConsensus was defined as (1) a median rating ≥ 7 and (2) ≥ 70% of the panelists rating the recommendation ≥ 7. The final framework included 105 recommendations. The recommendations emphasized the importance of clarifying the goal of ECMO, its time-limited nature, and the possibility of its discontinuation resulting in patient death. The recommendations also provide guidance on how to share updates with the family and perform compassionate discontinuation.ConclusionA panel of experts from Canada and the USA developed recommendations for communicating with families during pediatric ECMO therapy. The recommendations offer guidance for communicating during the introduction of ECMO, providing updates throughout the ECMO course, and during the discontinuation of ECMO. There are also points of disagreement on best communication practices which should be further explored.

Death by Neurologic Criteria in Children Undergoing Extracorporeal Cardiopulmonary Resuscitation: Retrospective Extracorporeal Life Support Organization Registry Study, 2017-2021.

To determine factors associated with brain death in children treated with extracorporeal cardiopulmonary resuscitation (E-cardiopulmonary resuscitation). Retrospective database study. Data reported to the Extracorporeal Life Support Organization (ELSO), 2017-2021. Children supported with venoarterial extracorporeal membrane oxygenation (ECMO) for E-cardiopulmonary resuscitation. None. Data from the ELSO Registry included patient characteristics, blood gas values, support therapies, and complications. The primary outcome was brain death (i.e., death by neurologic criteria [DNC]). There were 2,209 children (≥ 29 d to < 18 yr of age) included. The reason for ECMO discontinuation was DNC in 138 patients (6%), and other criteria for death occurred in 886 patients (40%). Recovery occurred in 1,109 patients (50%), and the remaining 76 patients (4%) underwent transplantation. Fine and Gray proportional subdistribution hazards' regression analyses were used to examine the association between variables of interest and DNC. Age greater than 1 year ( p < 0.001), arterial blood carbon dioxide tension (Pa co2 ) greater than 82 mm Hg ( p = 0.022), baseline lactate greater than 15 mmol/L ( p = 0.034), and lactate 24 hours after cannulation greater than 3.8 mmol/L ( p < 0.001) were independently associated with greater hazard of subsequent DNC. In contrast, the presence of cardiac disease was associated with a lower hazard of subsequent DNC (subdistribution hazard ratio 0.57 [95% CI, 0.39-0.83] p = 0.004). In children undergoing E-cardiopulmonary resuscitation, older age, pre-event hypercarbia, higher before and during ECMO lactate levels are associated with DNC. Given the association of DNC with hypercarbia following cardiac arrest, the role of Pa co2 management in E-cardiopulmonary resuscitation warrants further studies.

Synergistic association of fluid overload and acute kidney injury on outcomes in pediatric cardiac ECMO: a retrospective analysis of the KIDMO database.

Acute kidney injury (AKI) and fluid overload (FO) are associated with poor outcomes in children receiving extracorporeal membrane oxygenation (ECMO). Our objective is to evaluate the impact of AKI and FO on pediatric patients receiving ECMO for cardiac pathology. We performed a secondary analysis of the six-center Kidney Interventions During Extracorporeal Membrane Oxygenation (KIDMO) database, including only children who underwent ECMO for cardiac pathology. AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. FO was defined as < 10% (FO-) vs. ≥ 10% (FO +) and was evaluated at ECMO initiation, peak during ECMO, and ECMO discontinuation. Primary outcomes were mortality and length of stay (LOS). Data from 191 patients were included. Non-survivors (56%) were more likely to be FO + than survivors at peak ECMO fluid status and ECMO discontinuation. There was a significant interaction between AKI and FO. In the presence of AKI, the adjusted odds of mortality for FO + was 4.79 times greater than FO- (95% CI: 1.52-15.12, p = 0.01). In the presence of FO + , the adjusted odds of mortality for AKI + was 2.7 times higher than AKI- [95%CI: 1.10-6.60; p = 0.03]. Peak FO + was associated with a 55% adjusted relative increase in LOS [95%CI: 1.07-2.26, p = 0.02]. The association of peak FO + with mortality is present only in the presence of AKI + . Similarly, AKI + is associated with mortality only in the presence of peak FO + . FO + was associated with LOS. Studies targeting fluid management have the potential to improve LOS and mortality outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.

Acute Kidney Injury and Fluid Overload in Pediatric Extracorporeal Cardio-Pulmonary Resuscitation: A Multicenter Retrospective Cohort Study.

Acute kidney injury (AKI) and fluid overload (FO) are common complications of extracorporeal membrane oxygenation (ECMO). The purpose of this study was to characterize AKI and FO in children receiving extracorporeal cardiopulmonary resuscitation (eCPR). We performed a multicenter retrospective study of children who received eCPR. AKI was assessed during ECMO and FO defined as <10% [FO-] vs. ≥10% [FO+] evaluated at ECMO initiation and discontinuation. A composite exposure, defined by a four-group discrete phenotypic classification [FO-/AKI-, FO-/AKI+, FO+/AKI-, FO+/AKI+] was also evaluated. Primary outcome was mortality and hospital length of stay (LOS) among survivors. 131 patients (median age 29 days (IQR:9, 242 days); 51% men and 82% with underlying cardiac disease) were included. 45.8% survived hospital discharge. FO+ at ECMO discontinuation, but not AKI was associated with mortality [aOR=2.3; 95% CI: 1.07-4.91]. LOS for FO+ patients was twice as long as FO- patients, irrespective of AKI status [(FO+/AKI+ (60 days; IQR: 49-83) vs. FO-/AKI+ (30 days, IQR: 19-48 days); P = 0.01]. FO+ at ECMO initiation and discontinuation was associated with an adjusted 66% and 50% longer length of stay respectively. Prospective studies that target timing and strategy of fluid management, including its removal in children receiving ECPR are greatly needed.

Measuring the Resting Energy Expenditure in Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study.

Both overfeeding and underfeeding critically ill children are problematic. This prospective pilot study evaluated the resting energy expenditure in infants and children requiring extracorporeal membrane oxygenation (ECMO) support. An indirect calorimeter was used to measure oxygen consumption (VO 2 ) and carbon dioxide production (VCO 2 ) from the mechanical ventilator. Blood gases were used to determine VO 2 and VCO 2 from the ECMO circuit. Values from the mechanical ventilator and ECMO circuit were added, and the resting energy expenditure (REE) (Kcal/kg/day) was calculated. Measurements were obtained > 24 hours after ECMO support was initiated (day 2 of ECMO), 1 day before ECMO discontinuation or transfer, and 1 day after decannulation. Data were compared with the predicted energy expenditure. Seven patients aged 3 months to 13 years were included. The REE varied greatly both above and below predicted values, from 26 to 154 KCal/kg/day on day 2 of ECMO support. In patients with septic shock, the REE was > 300% above the predicted value on day 2 of ECMO. Before ECMO discontinuation, two of six (33%) children continued to have a REE > 110% of predicted. Three patients had measurements after decannulation, all with a REE < 90% of predicted. REE measurements can be obtained by indirect calorimetry in children receiving ECMO support. ECMO may not provide metabolic rest for all children as a wide variation in REE was observed. For optimal care, individual testing should be considered to match calories provided with the metabolic demand.

Finishing Well: Compassionate Extracorporeal Membrane Oxygenation Discontinuation

Extracorporeal Membrane Oxygenation (ECMO) is associated with significant mortality. Provision of high-quality end-of-life (EOL) care for patients supported on ECMO entails specific physiological, pharmacological, and technical considerations. Limited guidance exists for clinicians on delivery of optimal EOL care on ECMO. In this article, we review the unique aspects of EOL care as they apply to ECMO support and propose a pragmatic, interdisciplinary framework for compassionate ECMO discontinuation in children and adults.The goal of compassionate ECMO discontinuation (CED) is to allow natural death from the underlying disease process while delivering high-quality EOL care to ensure a good death experience for patients and their families. The CED approach includes: 1) a family meeting to define goal-concordant EOL care and prepare families and patients for the dying process; 2) clinical preparation, including symptom management and discontinuation of other life-sustaining therapies; 3) technical aspects which necessarily vary according to patient factors and the circuit and cannulation strategy; and 4) bereavement support. The proposed CED considerations and checklist may serve as tools aiding provision of comprehensive, quality, individualized patient- and family-centered care for children and adults dying despite ECMO support. A structured CED may enhance EOL experiences for patients, family, and staff by providing a respectful and dignified death experience. Future research is required to determine feasibility and effectiveness of the framework, which must be adapted to the patient and institutional setting.

USE OF CRESCENT JUGULAR CATHETER IN PATIENTS WITH SEVERE COVID-19 REQUIRING EXTENDED ECMO SUPPORT

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: ECMO has long been used in the ICU as a salvage or bridge therapy for selected ICU patients. There had been a variety of cannulas available in the market. We report 2 cases with positive outcomes associated with the use of jugular dual lumen cannula. CASE PRESENTATION: An obese 42-year-old obese female, with PMH of hypothyroidism and ulcerative colitis, was admitted for acute hypoxic respiratory failure due to COVID-19. Patient underwent conventional treatment at the time (dexamethasone, remdesivir, convalescent plasma and antibiotics) for COVID-19 but was ultimately intubated on day 8 due to profound hypoxia requiring VV ECMO on day 10. She remained on full ECMO support until day 56. Her FiO2 was eventually weaned down to 21% but she continued to require a sweep of 3L secondary to profound muscular weakness and obesity. After transitioning to the jugular dual lumen cannula on day 75 for long-term ECMO, her sedation was weaned down, that allowed participation of physical therapy. She was decannulated on day 94 and was discharged to LTAC on day 100. A 48-year-old female was tested positive for COVID-19 after being exposed 12 days before. Due to worsening symptoms, she eventually sought care at the hospital. Despite the standard treatment, her respiratory status continued to worsen. She was intubated on Day 2 before receiving full support on VV ECMO on day 6. Despite effort to wean down to FiO2 of 21%, she still required a sweep of 1L. After being transitioned to a jugular dual lumen cannula on day 71, she was weaned off of sedation and able to participate in therapy. She was eventually decannulated on day 79, and discharged to a rehab facility on day 85 to continue her recovery. DISCUSSION: Transition from a dual cannula ECMO system to a single cannula ECMO system allowed increased mobility and participation of physical therapy while in the ICU for patients requiring extended time on ECMO. Study has suggested a reduction of up to 35% in muscle mass among ECMO patients by day 20 of their cannulation. In an economic study performing on transplant patients, a 73% reduction in post-transplant ICU cost was reported for those who underwent rehabilitation while being supported on ECMO. Both studies demonstrated the potential benefits with promoting early rehabilitation for ECMO patients. Regarding the technique involved, there was a recent report of a similar transition without any ECMO interruption, allowing the patient uninterrupted time on ECMO while benefiting from early rehab. CONCLUSIONS: We present two cases of severe COVID-19 patients with an extended period of time on VV ECMO became severely debilitated. They were transitioned to a jugular dual lumen cannula, allowing early participation in rehab, resulting in their eventual discharge. These cases demonstrated these cannulas were valuable tool to reduce patients' reliance on support, before being transitioned off of ECMO. REFERENCE #1: Hayes K, Holland AE, Pellegrino VA, Mathur S, Hodgson CL. Acute skeletal muscle wasting and relation to physical function in patients requiring extracorporeal membrane oxygenation (ECMO). J Crit Care. 2018;48:1-8. doi:10.1016/j.jcrc.2018.08.002 REFERENCE #2: Bain JC, Turner DA, Rehder KJ, et al. Economic Outcomes of Extracorporeal Membrane Oxygenation With and Without Ambulation as a Bridge to Lung Transplantation. Respir Care. 2016;61(1):1-7. doi:10.4187/respcare.03729 REFERENCE #3: Chan EG, Chan PG, Harano T, Sanchez PG. Transition of femoral-jugular to dual-stage left subclavian without discontinuation of extracorporeal membrane oxygenation. J Card Surg. 2020;35(10):2794-2797. doi:10.1111/jocs.14881 DISCLOSURES: No relevant relationships by Vernon Chan, source=Web Response No relevant relationships by Marina Dolina, source=Web Response

Decision-Making, Ethics, and End-of-Life Care in Pediatric Extracorporeal Membrane Oxygenation: A Comprehensive Narrative Review.

Pediatric extracorporeal membrane oxygenation is associated with significant morbidity and mortality. We sought to summarize literature on communication and decision-making, end-of-life care, and ethical issues to identify recommended approaches and highlight knowledge gaps. PubMed, Embase, Web of Science, and Cochrane Library. We reviewed published articles (1972-2020) which examined three pediatric extracorporeal membrane oxygenation domains: 1) decision-making or communication between clinicians and patients/families, 2) ethical issues, or 3) end-of-life care. Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Of 2,581 publications screened, we identified one systematic review and 35 descriptive studies. No practical guides exist for communication and decision-making in pediatric extracorporeal membrane oxygenation. Conversation principles and parent/clinician perspectives are described. Ethical issues related to consent, initiation, discontinuation, resource allocation, and research. No patient-level synthesis of ethical issues or end-of-life care in pediatric extracorporeal membrane oxygenation was identified. Despite numerous ethical issues reported surrounding pediatric extracorporeal membrane oxygenation, we found limited patient-level research and no practical guides for communicating with families or managing extracorporeal membrane oxygenation discontinuation.

Extracorporeal membrane oxygenation outcomes in children with Williams syndrome: a review of the ELSO registry.

Williams syndrome (WS) results from a microdeletion that usually involves the elastin gene, leading to generalized arteriopathy. Cardiovascular anomalies are seen in 80% of WS patients, including supravalvular aortic stenosis (SVAS), pulmonary artery stenosis (PAS), and pulmonary stenosis (PS). Sudden death associated with procedural sedation and in the perioperative period in WS children have been reported. This study aims to describe extracorporeal membrane oxygenation (ECMO) use in WS children, identify risk factors for hospital mortality of WS patients, and compare outcomes between WS children and non-WS children with SVAS, PAS, and PS. Children 0-18 years-old in the Extracorporeal Life Support Organization (ELSO) Registry with a primary or secondary diagnosis of WS, SVAS, PAS, or PAS were included. Included were 50 WS children and 1222 non-WS children with similar cardiac diagnoses. ECMO use increased over time in both groups (p = 0.93), with most cases occurring in the current era. WS children were younger (p = 0.004), weighed less (p = 0.048), had a pulmonary indication for ECMO (50% vs 10%, p < 0.001), and were placed more on high frequency ventilation (p < 0.001) than non-WS patients. Despite reporting a respiratory indication, most (84%) WS patients were placed on VA-ECMO. There were no significant differences between the two groups in terms of pre-ECMO cardiac arrest, ECMO duration, or reason for ECMO discontinuation. Both groups had a mortality rate of 48% (p = 1.00). No risk factors for WS mortality were identified.

Intensivists Performed Percutaneous Bicaval Double-Lumen Echo-Guided Extracorporeal Membrane Oxygenation Cannulation at Bedside in Newborns and Children: A Retrospective Analysis.

To describe a single institution experience on echo-guided percutaneous bicaval double lumen extracorporeal membrane oxygenation cannulation performed at the bedside by intensivists. Retrospective observational study. Extracorporeal membrane oxygenation team of a tertiary care children's hospital. All patients 0-14 years old undergoing venovenous extracorporeal membrane oxygenation from January 1, 2013, to January 1, 2018. None. Thirty children underwent 32 extracorporeal membrane oxygenation runs. Median age at enrollment was 2 months (interquartile range, 0-20.5 mo), 65.6% of the runs (21 patients) were performed in newborns (n = 13, 40.6%) or infants (n = 8, 25%). Median preextracorporeal membrane oxygenation index was 66.9 (interquartile range, 50-85.6). Major comorbidities were present in 50% of patients. All patients were cannulated percutaneously. In two cases cannulation occurred from the left internal jugular vein. Extracorporeal membrane oxygenation was effective in increasing pH, arterial oxygen saturation, PaO2, and lowering PaCO2. The overall differences in pre and postextracorporeal membrane oxygenation values were statistically significant, while stratifying patients according to the cannula diameter (mm)/major diameter of the cannulated internal jugular vein (mm) ratio (> 0.67 or ≤ 0.67), statistical significance was reached only for the highest ratio. Complications were observed in three runs: two cannula tip dislocations in the right atrium and one limited flow in the only case in which an Avalon cannula was not used. In 20 cases (62.5% of 32 runs), the cannulated vessel was patent at follow-up or autopsy. A ratio less than or equal to 0.67 or greater than 0.67 did not influence the occurrence rate of complications, nonpatency of the internal jugular vein, death for intracranial bleeding and death at 30 days from extracorporeal membrane oxygenation discontinuation. Overall cumulative survival at 30 days from extracorporeal membrane oxygenation discontinuation was 60% (95% CI, 40-75), with a survival advantage in the case of ratio greater than 0.67 (65%; 95% CI, 44-80 vs 25%; 95% CI, 0-60). The described technique proved to be feasible, safe, and effective. Further investigation is needed.

Outcomes of Weaning Trial from Veno-Arterial Extracorporeal Membrane Oxygenation Using Inflow-Outflow Bridging

Purpose The use of veno-arterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock support is increasing. Because the recovery period differs from patient to patient, a standard protocol for the timing and strategy of ECMO weaning-off is not well established. Inadequate length of ECMO support can critically affect a patient's outcome, so the evaluation of proper ECMO weaning-off is warranted. A longer weaning trial is preferred to rule out delayed cardiogenic shock, however a long low-flow ECMO wean presents the risk of ECMO thrombosis . At our center, an inflow-outflow bridging technique is aggressively used to evaluate hemodynamics and respiratory status while weaning patients off of ECMO. It allows us to simulate an off-ECMO status for an extended period of time, but is reversible and does not require ECMO discontinuation. Here, we analyzed the outcomes of our inflow-outflow bridging technique for ECMO weaning. Methods This is a single-center retrospective study of patients on veno-arterial ECMO from May 2016 to August 2018. 14 patients on whom we used the inflow-outflow bridging technique were analyzed. The pre-ECMO demographics, ECMO weaning success vs. abortion rates, post-ECMO survival to discharge and complications were analyzed. Figure 1 displays the technique. The outflow cannula is clamped, and then intermittently un-clamped to flash the cannula under proper anticoagulation . Results 14 weaning trials were performed on 14 patients. 12 patients had ECMO weaning-off and decannulation (85.7%). 2 patients underwent a weaning trial, but were deemed unsuitable for ECMO discontinuation (14.3%). 0 patients had stroke/distal embolism or bleeding complications due to ECMO weaning trial. Successful wean sensitivity was 100.0%. Conclusion Our ECMO weaning-off trial highlighted satisfactory rates of screening for ECMO wean. Further larger research will help to clarify our weaning sensitivity and develop an adequate protocol.

Successful long-term extracorporeal membrane oxygenation for invasive pulmonary aspergillosis: a case report

BackgroundExtracorporeal membrane oxygenation is an established life-saving procedure for severe acute respiratory failure due to various causes. In general, the duration of extracorporeal membrane oxygenation ranges from 1 to 2 weeks, with withdrawal recommended if no improvement is noted. We report a successful case of long-term extracorporeal membrane oxygenation management for respiratory failure due to invasive pulmonary Aspergillus infection.Case presentationA 64-year-old Asian man with no previous underlying medical conditions was transferred to our hospital for fever and dyspnea. On admission, he presented with bilateral diffuse infiltration shadow on X-ray and chest computed tomography readings, and severe hypoxemia with a partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio of 55. He was intubated and underwent mechanical ventilation. A bronchial-alveolar lavage was performed prior to administration of antibiotics, and as the bacterial culture was positive for Aspergillus fumigatus, antifungal treatment was then initiated. His respiratory status deteriorated on the 11th admission day, with no improvement on any mechanical ventilator settings. Venous-venous extracorporeal membrane oxygenation was introduced. Extracorporeal membrane oxygenation was used for an extended period of time, with respiratory improvement delayed until the 39th admission day. Extracorporeal membrane oxygenation discontinuation was possible on the 44th day, and he was removed from the ventilator on the 64th day.ConclusionsLong-term extracorporeal membrane oxygenation might be considered if the primary causes of respiratory failure necessitating extracorporeal membrane oxygenation can be expected to be resolved, such as in the case of effective antimicrobial therapy for a definite pathogen. Our case indicates that extracorporeal membrane oxygenation can be used during treatment of respiratory failure due to invasive aspergillosis for the recommended treatment duration of 4 to 8 weeks.

Recovery, Risks, and Adverse Health Outcomes in Year 1 After Extracorporeal Membrane Oxygenation.

Cross-sectional studies suggest that patients treated with extracorporeal membrane oxygenation (ECMO) have adverse health outcomes and high risk for mental health problems after discharge. To describe the recovery of discharged patients during the first year after ECMO. In a prospective cohort study, data were collected 3, 6, and 12 months after discontinuation of ECMO and discharge. Postal surveys included the 36-Item Short Form Health Survey, the EuroQol-5-Dimensions-5-Levels health questionnaire, the Hospital Anxiety and Depression Scale, and the Impact of Event Scale-Revised. Telephone interviews were used to track adverse physical outcomes. The Telephone Interview for Cognitive Status questionnaire was administered at the end of each call. Patients in the study experienced more physical than mental adverse health outcomes, and the risk for mental problems was 2 or 3 times the rate expected. Adverse physical outcomes were common. One-quarter of patients remained significantly restricted; some had severe neurological impairments of the lower extremities. On cognitive tests, about half scored inconclusive or mildly impaired. Patients were often admitted to the hospital. Physical health was more severely impaired than was mental health, and both types improved over time. The EuroQol-5-Dimensions-5-Levels instrument was useful for detecting neurological problems of the lower extremities early and may qualify as a core outcome measure for patients treated with ECMO.

Post-cardiotomy Rescue Extracorporeal Cardiopulmonary Resuscitation in Neonates with Single Ventricle After Intractable Cardiac Arrest: Attrition After Hospital Discharge and Predictors of Outcome

Extracorporeal cardiopulmonary resuscitation (ECPR) in children with cardiac arrest refractory to conventional cardiopulmonary resuscitation (CPR) has been reported with encouraging results. We reviewed outcomes of neonates with functional single ventricle (FSV) surviving post-cardiotomy ECPR after hospital discharge. Fifty-eight patients who required post-cardiotomy extracorporeal membrane oxygenation (ECMO) since the introduction of our ECPR protocol (January 2007-December 2011) were identified. Forty-one were neonates. Survival analysis was conducted. Of 41 neonates receiving post-cardiotomy ECMO, 32 had FSV. Twenty-one had ECPR. Fourteen underwent Norwood operation (NO) for hypoplastic left heart syndrome (HLHS). Seven had non-HLHS FSV. Four (of 7) underwent modified NO/DKS with systemic-to-pulmonary shunt (SPS), 2 SPS only and 1 SPS with anomalous pulmonary venous connection repair. Mean age was 6.8±2.1days. ECMO median duration was 7days [interquartile range (IQR25-75: 4-18)]. Survival to ECMO discontinuation was 72% (15 of 21 patients) and at hospital discharge 62% (13 of 21 patients). The most common cause of late attrition was cardiac. At last follow-up (median: 22months; IQR25-75: 3-36), 47% of patients were alive. Duration of ECMO and failure of lactate clearance within 24h from ECMO deployment determined late survival after hospital discharge (p<0.05). Rescue post-cardiotomy ECMO support in neonates with FSV carries significant late attrition. ECMO duration and failure in lactate clearance after deployment are associated with unfavorable outcome. Emphasis on CPR quality, refinement of management directives early during ECMO and aggressive early identification of patients requiring heart transplantation might improve late survival.

Life saving use of ECMO in an obstetric patient with massive hemorrhage following uterine atony: a case report

The aim of this case report is to present the life saving use of extracorporeal membrane oxygenation (ECMO) in an obstetric pa-tient with acute cardiorespiratory collapse following massive bleeding caused by an atonic uterus post partum. A 39-year-old patient, following a spontaneous abor-tion at 21 weeks of pregnancy, developed uterine atony and massive bleeding and was ultimately referred to the operating room for an emergent hysterectomy. Post-operatively, she was referred to the inten-sive care unit (ICU) where she developed severe acute respiratory distress syndrome (ARDS) that was successfully treated by employing ECMO. Following discontinu-ation of ECMO, her treatment was further complicated by a manifest hemolytic trans-fusion reaction. Although extensive testing was done to establish the cause of this reac-tion, we were unable to find it. The patient responded well to treatment with erythro-poietin (EPO) and corticosteroids as well as a restrictive transfusion regime. This treatment pointed to a possible immune reaction to massive transfusions of blood products. This case demonstrated the im-portance of early aggressive treatment us-ing ECMO in reversal of life threatening ARDS, as well as the need for a judicious approach when transfusing blood prod-ucts.

Comparison between clinical indicators of transmembrane oxygenator thrombosis and multidetector computed tomographic analysis

This study aims to assess whether multidetector computed tomography (MDCT) could accurately confirm the clinical suspicion of transmembrane oxygenator thrombosis (MOT) during extracorporeal membrane oxygenation (ECMO). Twenty-seven oxygenators were examined using MDCT at the end of patient treatment. Transmembrane oxygenator thrombosis was suspected in 15 of them according to the presence of at least 2 of the following clinical indicators: (1) increase in d-dimer, (2) decrease in platelet count, (3) decrease in oxygenator performance, and (4) presence of clots on the surface of the oxygenator. Transmembrane oxygenator thrombosis was confirmed by MDCT in 5 (33%) of them. Transmembrane oxygenator thrombosis was unexpectedly found in 5 (41%) of the remaining 12 oxygenators not suspected for MOT. Eight (80%) of these oxygenators had clots accounting for less than 1% of total volume. Clots were mainly detectable at the apical corner of the oxygenator, most likely due to greater blood stasis. We found a significant increase in d-dimer and in membrane oxygenator shunt and a decrease in platelet count from the start to the discontinuation of ECMO. Hemostatic abnormalities significantly reverted 48 hours after oxygenator removal, suggesting the role of ECMO in activation of the coagulation cascade. Multidetector computed tomographic scan could not accurately confirm the clinical suspicion of MOT.

Peritoneal Dialysis: An Alternative Modality of Fluid Removal in Neonates Requiring Extracorporeal Membrane Oxygenation after Cardiac Surgery

Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for patients with cardiopulmonary failure after cardiac surgery. Fluid overload (FO) is associated with increased morbidity and mortality in this population. We present our experience using peritoneal dialysis (PD) as an adjunct for fluid removal in eight consecutive neonates requiring ECMO after cardiac surgery between 2010 and 2012. PD was added to FO management when fluid removal goals were not being met by hemofiltration (HF) or hemodialysis (HD). Percent FO was 36% at ECMO initiation; 88% (seven of eight) achieved negative fluid balance before discontinuation of ECMO. PD removed median 119 mL/kg/day (interquartile range [IQR], 70–166) compared with median 132 mL/kg/day (IQR, 47–231) removed by HF/HD. PD and HF/HD fluid removal were performed concurrently 38% of the time. Unlike HF/HD, PD was never stopped secondary to hemodynamic compromise. Median duration of ECMO was 155 hours (IQR, 118–215). Six of eight patients were successfully decannulated. These results suggest PD safely and effectively removes fluid in neonates on ECMO after cardiac surgery. PD may increase total fluid removal potential when combined with other modalities.

Extracorporeal membrane oxygenation: The simplified weaning bridge

FIGURE 1. The simplified weaning bridge: (A) heparin infusion lines; (B) Extracorporeal membrane oxygenation (ECMO) is commonly used in children to allow recovery from post–cardiac surgical heart failure that is refractory to medical therapy or resuscitation. The overall survival after ECMO has been reported to be between 35% and 51% in institutions where a dedicated 24-hour in-house ECMO team is part of the surgical program. In pediatric cardiac centers with average volumes, however, a specialized ECMO team is often not available and a greater effort must be made to provide the best outcome for patients requiring mechanical circulatory support. We describe an easy and reproducible technical solution for weaning patients from ECMO support. This method proved to be a safe and an effective solution in our institution, where a dedicated 24-hour in-house ECMO team is lacking. extracorporeal membrane oxygenation (ECMO) bridge; (C) arterial line flushed by heparin infusion; (D) venous line flushed by heparin infusion; (E) straight connector with Luer locks; (F) tubing clamps for separating the extracorporeal membrane oxygenation circuit from the patient. THE SIMPLIFIED WEANING BRIDGE After ECMO weaning criteria have been reached, the simplified weaning bridge (a bridging tube 50 cm long and 2.5 mm in diameter) is placed between the patient and the ECMO circuit to allow flow recirculation (Figure 1). Heparin infusion (20 IU/kg/h, diluted to obtain an infusion rate of 5 mL/h for each cannula) is then started to flush continuously both the arterial and the venous cannulas. A tubing clamp is then placed between the simplified weaning bridge and the heparin infusion lines, separating the patient’s circulation from the ECMO circuit (Figure 1). ECMO circuit heparinization is accomplished with a bolus of heparin (1000 U) and monitored every 3 hours to maintain an activated clotting time greater than 250 seconds. Patients are routinely monitored for the 24 hours after ECMO discontinuation, maintaining the ECMO recirculating next to the bed space in case of need, and then decannulated.

Post-cardiotomy extracorporeal cardiopulmonary resuscitation in neonates with complex single ventricle: analysis of outcomes

Extracorporeal cardiopulmonary resuscitation (ECPR) in children with cardiac arrest refractory to conventional cardiopulmonary resuscitation (CPR) has been reported with encouraging results. We sought to review outcomes of neonates with functional single ventricle (FSV) receiving post-cardiotomy ECPR. Forty-eight patients who required post-cardiotomy extracorporeal membrane oxygenation (ECMO) since the introduction of our ECPR protocol (January 2007-December 2009) were identified. Twenty-seven were neonates. Review of records and survival analysis were conducted. Of 27 neonates receiving post-cardiotomy ECMO 20 had FSV. Fourteen had ECPR. Ten underwent Norwood operation (NO) for hypoplastic left heart syndrome (HLHS). Four had FSV other than HLHS. Three underwent Damus-Kay-Stansel or modified NO with systemic-to-pulmonary shunt (SPS) and one SPS with anomalous pulmonary venous connection repair. Mean age and weight were 7.8 ± 2.9 days and 3.44 ± 1.78 kg, respectively. ECMO median duration was 6 days (interquartile range (IQR) 3-14). Survival to ECMO discontinuation was 79% (11 of 14 patients) and at hospital discharge was 57% (8 of 14 patients). The most common cause of death was multi-organ failure (four of six deaths). At last follow-up (median: 11 months (1-34)) 43% of patients were alive. CPR mean duration for patients with favorable versus unfavorable outcome was 38.6 ± 6.3 versus 42.1 ± 7.7 min (p = 0.12). Previously reported determinants for poorer prognosis in conventional non-rescue ECMO (such as pre-ECMO pH<7.2, renal, neurological or pulmonary hemorrhage complications, and pre- and post-vasoactive inotropic score) did not influence outcome between survivors and non-survivors (p>0.05). ECMO support in neonates with FSV requiring ECPR can result in favorable outcome in more than half of patients at hospital discharge. Aggressive strategy toward timely application of ECPR is justified. Expeditious ECPR deployment after proper patients' selection, refinement of CPR quality and use of adjunctive neuroprotective interventions, such as induced hypothermia, might further improve outcomes.