Extracorporeal Membrane Oxygenation In Children Research Articles

Early outcomes of moderate-to-high-risk pediatric congenital cardiac surgery and predictors of extracorporeal circulatory life support requirement.

Cardiopulmonary failure refractory to medical management after moderate-to-high-risk congenital cardiac surgery may necessitate mechanical support with veno-arterial extracorporeal membrane oxygenation (ECMO). On the extreme, ECMO can also be initiated in the setting of cardiac arrest (extracorporeal cardiopulmonary resuscitation, ECPR) unresponsive to conventional resuscitative measures. This was a single-center retrospective cohort study of patients (n = 510) aged <3 years old who underwent cardiac surgery with cardiopulmonary bypass with a RACHS-1 score ≥3 between 2011 and 2014. Perioperative factors were reviewed to identify predictors of ECMO initiation and mortality in the operating room (OR) and the intensive care unit (ICU). A total of 510 patients with a mean surgical age of 10.0 ± 13.4 months were included. Among them, 21 (4%) patients received postoperative ECMO-12 were initiated in the OR and 9 in the ICU. ECMO cannulation was associated with cardiopulmonary bypass duration, aortopulmonary shunt, residual severe mitral regurgitation, vaso-inotropic score, and postprocedural lactate (p < 0.001). Of the 32 (6%) total deaths, 7 (22%) were ECMO patients-4 were elective OR cannulations and 3 were ICU ECPR. Prematurity [hazard ratio (HR): 2.61, p < 0.01), Norwood or Damus-Kaye-Stansel procedure (HR: 4.29, p < 0.001), postoperative left ventricular dysfunction (HR: 5.10, p = 0.01), residual severe tricuspid regurgitation (HR: 6.06, p < 0.001), and postoperative ECMO (ECPR: HR: 15.42, p < 0.001 vs. elective: HR: 5.26, p = 0.01) were associated with mortality. The two patients who were electively cannulated in the ICU survived. Although uncommon, postoperative ECMO in children after congenital cardiac surgery is associated with high mortality, especially in cases of ECPR. Patients with long cardiopulmonary bypass time, residual cardiac lesions, or increased vaso-inotropic requirement are at higher risk of receiving ECMO. Pre-emptive or early ECMO initiation before deterioration into cardiac arrest may improve survival.

Extracorporeal membrane oxygenation in children with oncohematological diseases

Extracorporeal membrane oxygenation in children with oncohematological diseases

Admission Functional Status is Associated With Intensivists Perception of Extracorporeal Membrane Oxygenation Candidacy for Pediatric Acute Respiratory Failure.

To determine the association between admission Functional Status Scale (FSS) category and perceived extracorporeal membrane oxygenation (ECMO) candidacy for pediatric acute respiratory failure. Prospective, cross-sectional study. Single-center, quaternary, and ECMO referral academic children's hospital between March 2021 and January 2022. Pediatric intensivists directly caring for patients admitted with acute respiratory failure secondary to shock or respiratory disease. None. Pediatric intensivists were surveyed about current patients within 72 hours of initiation or escalation of invasive mechanical ventilation on whether they would offer ECMO should their patient deteriorate. Baseline functional status was assessed using trichotomized admission FSS: 1) normal/mild dysfunction (6-9), 2) moderate dysfunction (10-15), and 3) severe dysfunction (> 16). Multivariable logistic regression clustered by physician was used to assess the association between admission FSS category with perceived ECMO candidacy. Thirty-seven intensivists participated with 76% (137/180) of survey responses by those with less than 10 years of experience. 81% of patients (146/180) were perceived as ECMO candidates and 19% of patients (34/180) were noncandidates. Noncandidates had worse admission FSS scores than candidates (15.5 vs. 9, p < 0.001). After adjustment for age, admission FSS category of severe dysfunction had lower odds of perceived ECMO candidacy compared with normal to mild dysfunction (odds ratio [OR] 0.18 [95% CI, 0.06-0.56], p < 0.003). Patients with an abnormal communication subscore domain had the lowest odds of being considered a candidate (unadjusted OR 0.44 [95% CI, 0.29-0.68], p < 0.0001). In this prospective, single-center, cross-sectional study, admission FSS category indicating worse baseline functional status impacted pediatric intensivists' perceptions of ECMO candidacy for patients with acute respiratory failure. Abnormal FSS subscores in the neurocognitive domains were the most important considerations. Future studies should better seek to define the decision-making priorities of both parents and medical specialists for the utilization of ECMO in children with acute respiratory failure.

Editor’s Choice Articles for May

May 2023–something different for a change: after each of the three Editor’s Choices articles, there is additional material that would normally fall within the educational content found in the section called PCCM Connections for Readers. This month I will use my main highlights as a guide to further read about extracorporeal membrane oxygenation (ECMO), delirium, and organization of PICU rounds. WHAT ABOUT THE NEED FOR ECMO IN CHILDREN WITH COVID-19 OR MULTISYSTEM INFLAMMATORY SYNDROME? Bembea MM, Loftis LL, Thiagarajan RR, et al; Overcoming COVID-19 Investigators: Extracorporeal Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs (1). Sixty-three hospitals in 32 US states collaborated in a registry (during March 2020 through December 2021) and now report their experience of using ECMO in children and adolescents with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related cardiorespiratory failure. The entire cohort included 2,733 patients, of whom 108 were supported with ECMO. In addition to important information about the time course of care, the authors also show data that add to PCCM’s focus on social determinants of health (2,3), with analyses according to race, ethnicity, healthcare insurance status, and social vulnerability index (1). All these themes are discussed in the accompanying editorial (4), and it is also worth rereading PCCM’s approach to SARS-CoV-2-related research (5): we are committed to innovation and new perspectives, and the 2020/2021 US registry satisfies these criteria. “PCCM Connections” for Readers: Please read the systematic review of support with ECMO during SARS-CoV-2-related cardiorespiratory failure (6). The authors have identified 44 studies (18 observational, four case series, and 22 case reports) involving 110 children receiving ECMO in the period up to March 2022. The review is a comprehensive summary of the literature up to PCCM’s latest edition (1), and the accompanying editorial provides a unique assessment of what these data mean in the wider context of the literature in adults (7). WHAT ABOUT FACTORS ASSOCIATED WITH DELIRIUM DURING CRITICAL ILLNESS: REMEDIABLE OR NOT? Ista E, Traube C, de Neef M, et al; Dutch Multidisciplinary Pediatric Delirium Guideline Group: Factors Associated With Delirium in Children: A Systematic Review and Meta-Analysis (8). Clinical research into delirium is a longstanding theme in PCCM. Now, international researchers in this field under the auspices of the Dutch Multidisciplinary Pediatric Delirium Guidelines Group report a systematic review of 1990 to 2022 literature. The authors describe information from 24 studies in which 54 factors were found associated with delirium. In the meta-analysis these findings are reduced to seven factors associated with greater odds of developing delirium during pediatric critical illness (8). In the accompanying editorial our writers propose that it is time to include delirium screening as part of our “vital sign” monitoring (9). “PCCM Connections” for Readers: On a similar theme to delirium prevention, please read the Brief Report describing a single-center, prospective, sleep hygiene quality improvement program in PICU patients eligible for early mobilization (10). There are also interesting details about how the program was organized, which is information that should be read together with the recent practice guideline on prevention and management of delirium (11). WHAT ABOUT ROUNDS AND SETTING AND IMPLEMENTING DAILY GOALS OF CARE? Jones AGR, Friedman S, Vu M, et al: Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project (12). Improved communications between everyone, with a clearly defined plan, is the objective for all PICU patients, families, and the broader healthcare team. My last Editor’s Choice is work carried out in a single-center 12-bedded combined medical and surgical PICU. Here, the authors describe the development and implementation of a low-cost aid, literally writing on a glass door. There is an interesting accompanying editorial, which is both creative and challenging (13). “PCCM Connections” for Readers: We have already discussed an article about organization and goal setting during patient care rounds when considering optimizing sleep hygiene (10). Another article about rounding discussions in this issue examines the impact of unit census and patient acuity on effective discussion (14). Why not enhance your review of the literature on the topic of rounds by looking at similar work in recent issues of PCCM (15–17). Finally, another of this month’s highlights is the narrative essay entitled “Line in the Sand” (18).

Extracorporeal Membrane Oxygenation and Hemolytic Uremic Syndrome in Children: Outcome Review of a Multicenter National Database

AbstractHemolytic uremic syndrome (HUS) is a triad of hemolytic anemia, thrombocytopenia, and acute renal failure. In critically ill children with HUS, extrarenal manifestations may require intensive care unit admission and extracorporeal membrane oxygenation (ECMO) support. Outcomes specific to HUS and ECMO in children have not been well investigated. The primary aim of this project was to query a multicenter database to identify risk factors associated with mortality in HUS patients supported on ECMO. A secondary aim was to identify factors associated with ECMO utilization in children with HUS. Utilizing the Pediatric Health Information System database (January 2004 and September 2018), this retrospective, multicenter cohort study identified the index HUS hospitalization among children aged 0 to 18 years. Univariate analysis was used to compare demographics, clinical characteristics, and procedures to identify risk factors associated with adverse outcomes. Among 4,144 subjects, 37 were supported on ECMO. Survival for those on ECMO support was 54%. Among nonsurvivors, 59% of deaths occurred within 14 days of hospitalization. The mean hospital LOS was 15.9 days in nonsurvivors versus 53.9 days for survivors (p &lt; 0.001). When comparing subjects supported on ECMO to those who were not, patients with ECMO support had statistically longer hospital LOS and higher rates of extrarenal involvement (p &lt; 0.001). This study found a mortality rate of 46% among HUS patients requiring ECMO. The investigated clinical risk factors were not associated with mortality among the ECMO population. The study identifies risk factors associated with ECMO utilization in children with HUS.

Expert consensus on inter-hospital transport of extracorporeal membrane oxygenation in children (version 2022)

危重症患儿由于诊疗的需求，常面对极大的转运风险。与成人相比，儿童危重症院际转运是一项极具挑战性的工作。近年来，体外膜氧合（ECMO）技术广泛应用于常规治疗无效的儿童急性呼吸和（或）循环衰竭，并在院际转运救治中发挥着不可替代的作用，但国内尚无适用于儿童的ECMO院际转运技术规范或共识指南。依据国内开展经验，并结合国外相关研究，从儿童ECMO院际转运的各个环节形成本共识，以指导临床实践，提高ECMO转运安全性。.

Extracorporeal Membrane Oxygenation in Children With COVID-19: A Systematic Review and Meta-Analysis.

The indication, complications, and outcomes of extracorporeal membrane oxygenation (ECMO) in children with COVID-19-related illnesses remain unelucidated. Our study aimed to investigate the characteristics and outcomes of ECMO in children with COVID-19-related illnesses. We searched PubMed and EMBASE databases in March 2022. We retrieved all studies involving children (age ≤ 18 yr) with COVID-19-related illnesses who received ECMO. Two authors independently extracted data and assessed the risk of bias. Mortality, successful weaning rate, and complications while on ECMO were synthesized by a one-group meta-analysis using a random-effect model. Meta-regression was performed to explore the risk factors for mortality. We included 18 observational studies, four case series, and 22 case reports involving 110 children with COVID-19-related illnesses receiving ECMO. The median age was 8 years (range, 10 d to 18 yr), and the median body mass index was 21.4 kg/m 2 (range, 12.3-56.0 kg/m 2 ). The most common comorbidities were obesity (11% [7/63]) and congenital heart disease (11% [7/63]), whereas 48% (30/63) were previously healthy. The most common indications for ECMO were multisystem inflammatory syndrome in children (52% [47/90]) and severe acute respiratory distress syndrome (40% [36/90]). Seventy-one percent (56/79) received venoarterial-ECMO. The median ECMO runtime was 6 days (range, 3-51 d) for venoarterial ECMO and 11 days (range, 3-71 d) for venovenous ECMO. The mortality was 26.6% (95% CI, 15.9-40.9), and the successful weaning rate was 77.0% (95% CI, 55.4-90.1). Complications were seen in 37.0% (95% CI, 23.1-53.5) while on ECMO, including stroke, acute kidney injury, pulmonary edema, and thromboembolism. Corticosteroids and IV immunoglobulin therapies were associated with lower mortality. The mortality of children on ECMO for COVID-19 was relatively low. This invasive treatment can be considered as a treatment option for critically ill children with COVID-19.

Abstract 9551: Extracorporeal Membrane Oxygenation for Covid-19 in Children: A Systematic Review and Meta-Analysis

Introduction: In the wake of the COVID-19 pandemic, extracorporeal membrane oxygenation (ECMO) has been widely used to treat severe acute respiratory distress syndrome (ARDS) in adults. However, the indications, complications, and outcomes of ECMO in children with COVID-19 remain unelucidated. We conducted a systematic review and meta-analysis to investigate the characteristics and outcomes of ECMO use in children with COVID-19. Methods: PubMed and EMBASE databases were searched in March 2022 without language restrictions, and studies involving children (aged≤18) with COVID-19 who received ECMO were included. Two investigators extracted data and assessed the risk of bias independently. Mortality, successful weaning rate, and complications related to ECMO were synthesized by a one-group meta-analysis using a random-effect model. Results: We included 18 observational studies, 4 case series, and 22 case reports encompassing 110 children with COVID-19 requiring ECMO. The median age was 8 years (range: 10 days to 18 years), and the median body mass index was 21.4 kg/m 2 (range: 12.3-56.0). The most common comorbidities were obesity (11% [7/63]) and congenital heart diseases (11% [7/63]), while 48% (30/63) were previously healthy. The major indications were multisystem inflammatory syndrome in children (52% [47/90]) and ARDS (40% [36/90]). Seventy-one percent (56/79) received venoarterial-ECMO. The median ECMO runtime was 7 days (range: 3-71). The mortality rate was 26.6% (95% confidence interval [CI] 15.9-40.9), and the successful weaning rate was 77.0% (95% CI 55.4-90.1). ECMO-related complications, including stroke, acute kidney injury, pulmonary edema, and thromboembolism, were seen in 37.0% (95% CI 23.1-53.5). Conclusions: This meta-analysis demonstrated relatively favorable outcomes of ECMO for COVID-19 in children. Our findings will contribute to establishing the evidence of ECMO and serve as a guide to managing children with severe COVID-19.

Interpretation of extracorporeal membrane oxygenation in children receiving hematopoietic cell transplantation and immune effector cell therapy: an international and multidisciplinary consensus statement

2022年2月，Lancet Child Adolescent Health发表“接受造血细胞移植或免疫效应细胞治疗患儿实施体外膜氧合（ECMO）的国际多学科共识声明”，是全球首个在该类患儿中使用ECMO的共识，为儿童重症、体外循环和血液肿瘤科医师启动和管理ECMO提供临床决策，本文对该专家共识进行解读。.

Management of Anticoagulation during Extracorporeal Membrane Oxygenation in Children.

Extracorporeal Membrane Oxygenation (ECMO) is often used in critically ill children with severe cardiopulmonary failure. Worldwide, about 3600 children are supported by ECMO each year, with an increase of 10% in cases per year. Although anticoagulation is necessary to prevent circuit thrombosis during ECMO support, bleeding and thrombosis are associated with significantly increased mortality risk. In addition, maintaining balanced hemostasis is a challenging task during ECMO support. While heparin is a standard anticoagulation therapy in ECMO, recently, newer anticoagulant agents are also in use. Currently, there is a wide variation in anticoagulation management and diagnostic monitoring in children receiving ECMO. This review intends to describe the pathophysiology of coagulation during ECMO support, review of literature on current and newer anticoagulant agents, and outline various diagnostic tests used for anticoagulation monitoring. We will also discuss knowledge gaps and future areas of research.

Necrotizing pneumonia requiring prolonged extracorporeal membrane oxygenation: Pushing the boundaries in pediatric ECMO

Extracorporeal membrane oxygenation (ECMO) is a life‐saving rescue therapy used in acute respiratory failure refractory to invasive mechanical ventilation. Recent studies on positive outcomes of extended ECMO therapy are promising. We describe a case of a 2‐year 8‐month‐old female child with necrotizing pneumonia secondary to Streptococcus pneumoniae, Influenza A, and Mycoplasma pneumoniae, who survived with intact neurological function and no long‐term adverse outcomes after a prolonged ECMO run of 86 days. To the best of our knowledge, this is one of the longer durations of ECMO with transplant‐free survival in a pediatric patient requiring respiratory support with good recovery and a good functional outcome. Allowing time for native lung recovery is pivotal for optimal recovery, despite significant lung injury due to the underlying disease process. With evolving ECMO experience, clinicians may need to re‐consider the conventional maximum duration of ECMO in children with severe respiratory failure on a case‐by‐case basis.

ECMO for paediatric cardiac arrest caused by bronchial rupture and severe lung injury: a case report about life-threatening rescue at an adult ECMO centre

BackgroundBronchial rupture in children is a rare but dangerous complication after chest trauma and is associated with increased mortality. Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) is reported as one of the treatments for this life-threatening complication.Case presentationA 4-year-old boy with bronchial rupture and traumatic wet lung complicated by cardiac arrest after chest trauma was admitted to an adult ECMO centre. He experienced two cardiac arrests, one before and one during the operation. The total duration of cardiac arrest was 30 min. V-V ECMO was initiated because of severe hypoxia and hypercapnia during the operation. ECMO was performed for 6 days, and mechanical ventilation lasted 11 days. On the 31st day after surgery, he had recovered completely and was discharged without neurological deficit.ConclusionV-V ECMO can be considered for supportive care in children with severe acute respiratory failure after bronchial rupture. In an emergency, V-V ECMO can be carried out effectively in a qualified and experienced adult ECMO centre. However, the application of ECMO in children is different from that in adults and requires more refined management.

Extracorporeal membrane oxygenation in children: An update of a single tertiary center 11-Year experience from Croatia.

Extracorporeal membrane oxygenation (ECMO) is an important treatment option for organ support in respiratory insufficiency, cardiac failure, or as an advanced tool for cardiopulmonary resuscitation. Reports on pediatric ECMO use in our region are lacking. This study is a retrospective review of all pediatric cases that underwent a veno-arterial (VA) or veno-venous (VV) ECMO protocol between November 2009 and August 2020 at the Department of Pediatrics, University Hospital Center Zagreb, Croatia. Fifty-two ECMO runs identified over the period; data were complete for 45 cases, of which 23 (51%) were female, and median age was 8 months. Thirty-eight (84%) patients were treated using the VA-and 7 (16%) using VV-ECMO. The overall survival rate was 51%. Circulatory failure was the most common indication for ECMO (N = 38, 84%), and in 17 patients ECMO was started after cardiopulmonary resuscitation (E-CPR). Among survivors, 74% had no or minor neurological sequelae. Variables associated with poor outcome were renal failure with renal replacement therapy (p < .001) and intracranial injury (p < .001). Overall survival rate in our cohort is comparable to the data published in the literature. The use of hemodialysis was shown to be associated with higher mortality. High rates of full neurological recovery among survivors are a strong case for further ECMO program development in our institution.

Cerebral Infarction During Cervical Veno-Arterial Extracorporeal Membrane Oxygenation in Children: Can it be Predicted?

Veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in children is often established by cannulation of the right carotid artery and the right internal jugular vein. Cerebral infarction which is sometimes seen in such cases may be secondary to an incomplete circle of Willis. We present 3 cases with VA ECMO using cervical cannulation who suffered cerebral infarction which may be attributed to an incomplete circle of Willis.

Extracorporeal Membrane Oxygenation in Congenital Heart Disease.

Mechanical circulatory support (MCS) is a key therapy in the management of patients with severe cardiac disease or respiratory failure. There are two major forms of MCS commonly employed in the pediatric population—extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD). These modalities have overlapping but distinct roles in the management of pediatric patients with severe cardiopulmonary compromise. The use of ECMO to provide circulatory support arose from the development of the first membrane oxygenator by George Clowes in 1957, and subsequent incorporation into pediatric cardiopulmonary bypass (CPB) by Dorson and colleagues. The first successful application of ECMO in children with congenital heart disease undergoing cardiac surgery was reported by Baffes et al. in 1970. For the ensuing nearly two decades, ECMO was performed sparingly and only in specialized centers with varying degrees of success. The formation of the Extracorporeal Life Support Organization (ELSO) in 1989 allowed for the collation of ECMO-related data across multiple centers for the first time. This facilitated development of consensus guidelines for the use of ECMO in various populations. Coupled with improving ECMO technology, these advances resulted in significant improvements in ECMO utilization, morbidity, and mortality. This article will review the use of ECMO in children with congenital heart disease.

Outcome of Extracorporeal Membrane Oxygenation for Pediatric Patients With Neoplasm: An Extracorporeal Life Support Organization Database Study (2000-2019).

This study update in usage and outcomes of pediatric extracorporeal membrane oxygenation (ECMO) for patients with neoplasm analyzed according to demographics, clinical variables, and complications. Retrospective database review of the Extracorporeal Life Support Organization registry from the last 2 decades (2000-2019). The data were divided between two decades in order to compare patients' backgrounds and outcomes over time. ECMO centers reporting to Extracorporeal Life Support Organization. Patients equal to or younger than 18 years old with International Classification of Diseases, 9th Revision and International Classification of Diseases, 10th Revision codes that referred to neoplasms who were managed with ECMO. None. Demographics, cancer subtype, clinical variables, and ECMO complications were assessed in relation to the primary study outcome of survival to hospital discharge. Nine-hundred two patients met inclusion criteria; 699 patients were in the latest decade, which is more than three times the number from the previous decade (203 patients). On univariate analysis, compared with the previous decade, in the later decade, ECMO was more frequently applied in patients with pre-ECMO cardiac arrest (31.3% vs 17.1%; p < 0.001), and/or lower oxygenation index (38.0 vs 48.1; p < 0.001). We failed to identify a difference in survival between the 2 decades (42.8% vs 37.9%; p = 0.218). On multivariable analysis, diagnosis of hematologic malignancy, post-cardiopulmonary resuscitation support type, hematopoietic stem cell transplant, and age older than seven were each associated with greater odds of mortality. The use of ECMO in children with neoplasm has expanded over the latest decade with changes in patient selection. Mortality remains unchanged. Hence, although the clinician still should stay cautious in its application, ECMO can be considered as an option to rescue pediatric oncologic patients in the setting of worsening cardiopulmonary status in the PICU.

Feasibility of non-invasive neuro-monitoring during extracorporeal membrane oxygenation in children.

Detection of neurological complications during extracorporeal membrane oxygenation (ECMO) may be enhanced with non-invasive neuro-monitoring. We investigated the feasibility of non-invasive neuro-monitoring in a paediatric intensive care (PIC) setting. In a single centre, prospective cohort study we assessed feasibility of recruitment, and neuro-monitoring via somatosensory evoked potentials (SSEP), electroencephalography (EEG) and near infrared spectroscopy (NIRS) during venoarterial (VA) ECMO in paediatric patients (0-15years). Measures were obtained within 24h of cannulation, during an intermediate period, and finally at decannulation or echo stress testing. SSEP/EEG/NIRS measures were correlated with neuro-radiology findings, and clinical outcome assessed via the Pediatric cerebral performance category (PCPC) scale 30days post ECMO cannulation. We recruited 14/20 (70%) eligible patients (median age: 9months; IQR:4-54, 57% male) over an 18-month period, resulting in a total of 42 possible SSEP/EEG/NIRS measurements. Of these, 32/42 (76%) were completed. Missed recordings were due to lack of access/consent within 24h of cannulation (5/42, 12%) or PIC death/discharge (5/42, 12%). In each patient, the majority of SSEP (8/14, 57%), EEG (8/14, 57%) and NIRS (11/14, 79%) test results were within normal limits. All patients with abnormal neuroradiology (4/10, 40%), and 6/7 (86%) with poor outcome (PCPC ≥4) developed indirect SSEP, EEG or NIRS measures of neurological complications prior to decannulation. No study-related adverse events or neuro-monitoring data interpreting issues were experienced. Non-invasive neuro-monitoring (SSEP/EEG/NIRS) during ECMO is feasible and may provide early indication of neurological complications in this high-risk population.

Ultrasound-guided percutaneous cannulation for extracorporeal membrane oxygenation in children

Objective: To evaluate the effectiveness and safety of ultrasound-guided percutaneous cannulation for extracorporeal membrane oxygenation (ECMO) in children. Methods: In this retrospective observational study, 66 cases who underwent non-cardiac surgery ECMO in pediatric intensive care unit (PICU) of Shanghai Children's Hospital from May 2016 to April 2021 were collected. The demographics, model of ECMO support, type and size of arteriovenous cannulas, way of catheterization and complications were recorded and summarized. Patients were divided into percutaneous cannulation group and surgical cannulation group according to catheterization strategies. The demographics, duration of cannulation and ECMO support, ECMO weaning rate and hospital survival rate were compared among two groups. χ2 and nonparametric rank sum test were used for comparison. Results: Among the 66 patients who received ECMO, 38 were male and 28 were female, with age 44.5 (12.0, 83.5) months and weight 15.0 (10.0, 25.0) kg; 21 patients underwent percutaneous cannulation, with a success rate of 95% (20 cases). Point-of-care ultrasound was performed for all percutaneous cannulation cases. The duration of percutaneous cannulation was significantly shorter than that of surgical cannulation (26.0 (23.3, 30.3) vs. 57.0 (53.8, 64.0) min, Z=6.31, P<0.001). Successful percutaneous cannulation cases were aged 70.5 (23.8, 109.5) months, and their weight was 23.2 (13.6, 37.0) kg. Ten cases were initially given veno-venous (VV) ECMO support, and 10 cases were given veno-arterial (VA) ECMO support. ECMO arterial cannulas were sized from 8 F to 17 F, and venous cannulas sized from 10 F to 19 F. For VV-ECMO, the right internal jugular and femoral veins were used as vascular access, while VA-ECMO used right internal jugular vein-femoral artery or right femoral vein-left femoral artery approach. Only one patient suffered severe complication (superior vena cava perforation). There was no catheter-related bloodstream infection. Conclusion: Ultrasound-guided percutaneous cannulation for ECMO can be performed with a high rate of success and safety in children.

Editor’s Choice Articles for December

For December 2021 I draw your attention to three articles as my Editor’s Choices: long-term mental health disorder diagnoses after mechanical ventilation for severe respiratory disease (1); left heart decompression on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for dilated cardiomyopathy and myocarditis (2); and socioeconomic disadvantage and distance to pediatric critical care services in the United States (3). All three research reports have accompanying articles (4−7), and all items will be openly available for the next few months. WHAT IS THE RELATIONSHIP BETWEEN INVASIVE MECHANICAL VENTILATION FOR SEVERE RESPIRATORY DISEASE AND LONG-TERM “MENTAL DISORDER” DIAGNOSES? Geneslaw AS, Lu Y, Miles CH, et al: Long-Term Increase in Mental Disorder Diagnoses After Invasive Mechanical Ventilation for Severe Childhood Respiratory Disease: A Propensity Matched Observational Cohort Study (1). A propensity matching study to learn so much from: the dataset, Texas Medicaid (1999 to 2012); the outcome measure, long-term mental disorder diagnoses; and the comparisons, 1,351 invasively ventilated children matched to 6,755 general inpatients and 7,780 children in the PICU matched to 38,900 general inpatients. For the answer, please read the authors’ transparent analysis of this complex material and their important observations. We all need to understand these data, research this field, and not allow any distortion of fact. Here, we are first helped by an insightful editorial on causal inference from observational data (4). Second, we have an accompanying article in the “PCCM Notes, Methods, and Statistics” section about learning from an association analysis using propensity scores (5). For many reasons, all three of these items are a benchmark for such work in PCCM. WHAT ABOUT LEFT HEART DECOMPRESSION ON VA-ECMO? Choudhury TA, Ofori-Amanfo G, Choi J, et al: Left Heart Decompression on Veno-Arterial Extracorporeal Membrane Oxygenation in Children With Dilated Cardiomyopathy and Myocarditis: An Extracorporeal Life Support Organization Registry Review (2). This database study used the Extracorporeal Life Support Organization (ELSO) registry (2000 to 2016) to review two cohorts of patients supported with VA-ECMO: 532 with myocarditis and 906 with dilated cardiomyopathy. In all, 274 patients had left heart decompression and the authors present an analysis of associated outcomes. There is no editorial with this article. Instead, I am pleased to announce that the accompanying material is the first item in a new section called “PCCM Concise Clinical Physiology Review”. The purpose of this material is to provide an update on some aspect of clinical physiology that applies to pediatric critical illness. This month, Puri and Adachi not only discuss the new ELSO report in the context of other studies, but also treat us to an update of left heart physiology and simulated left ventricle pressure-volume loops on VA-ECMO and cardiopulmonary bypass (6). WHAT IS THE RELATIONSHIP BETWEEN POVERTY AND DISTANCE TO PEDIATRIC CRITICAL CARE SERVICES ACROSS THE UNITED STATES? Brown LE, Franca UL, McManus ML: Socioeconomic Disadvantage and Distance to Pediatric Critical Care (3). My third highlighted article is an epidemiological study using the 2016 American Community Survey that examines access to 319 PICUs within 170 metropolitan statistical areas across the continental United States. Our editorialists provide helpful discussion of the findings and challenge us with their discourse as they argue that unequal access to pediatric critical care services constitutes injustice (7). “PCCM CONNECTIONS” FOR READERS Perhaps you will consider December 2021 as the time to review what is new on the topic of overall health outcomes following pediatric critical illness, which is certainly pertinent given the discussion above about mechanical ventilation and long-term mental disorder diagnoses (1,4,5). Regular readers of PCCM will be able to cross reference to another article in the December 2021 issue, a scoping review of post-PICU discharge methods and instruments used to measure overall health (8). Also consider our other research articles looking at early- to long-term functional outcome and/or quality-of-life of PICU patients reported in the January (9,10), May (11), and October (12) issues of PCCM. Please use all eight articles as a means of quick topic review on how and what others have used in assessing PICU patient outcomes.

Outcomes of extracorporeal life support for respiratory failure in children with primary immunodeficiencies.

Extracorporeal Membrane Oxygenation (ECMO) may serve as a life-saving rescue therapy in critically ill children with respiratory failure. While survival rates of ECMO in children with secondary immunodeficiency is considered relatively poor, survival rates in children with primary immunodeficiencies (PID) has yet to be thoroughly investigated. Retrospective analysis of prospectively collected data from children (29 days-18 years old). PID patients were identified by using International Classification of Diseases (ICD) codes. Data were retrieved from Extracorporeal Life Support Organization Registry (1989-2018). ECMO for a pulmonary support indication. The survival-to-discharge rate was calculated and factors influencing outcomes were compared between survivors and non-survivors. A total of 73 eligible ECMO runs were included. The survival-to-discharge rate in pediatric PID patients was 45.2%. No differences were noted in survival based on type of immunodeficiency (p = 0.42) or decade of support (p = 0.98). There was no difference in the rate of pre-ECMO infection in survivors versus non-survivors (p = 0.69). The survival-to-discharge rate in patients with a culture positive infection during the ECMO run was 45.0% versus 45.3% in those with no infection (p = 0.98). In multivariate analysis, only cardiac complications (OR 5.09, 95% CI: 1.15-22.53), pulmonary complications (OR: 13.00, 95% CI: 1.20-141.25), and neurologic complications (OR: 9.86, 95% CI: 1.64-59.21) were independently associated with increased mortality. Children with a PID who require extracorporeal life support due to respiratory failure have a reasonable chance of survival and should be considered candidates for ECMO. The presence of a pre-ECMO infection should not be considered an ECMO contraindication.