Pediatric Extracorporeal Cardiopulmonary Resuscitation Research Articles

Outcomes in pediatric extracorporeal cardiopulmonary resuscitation: A single-center retrospective study from 2007 to 2022 in China

ObjectiveWe aimed to investigate the prognostic factors of pediatric extracorporeal cardiopulmonary resuscitation (ECPR). MethodsThe retrospective study included a total of 77 pediatric cases (7 neonates and 70 children) who underwent ECPR after in-hospital and out-of-hospital cardiac arrest between July 2007 and December 2022. Primary endpoints were complications, while secondary endpoints included all-cause in-hospital mortality. ResultsAmong the 45 cases experiencing complications, 4 neonates and 41 children had multiple simultaneous complications, primarily neurological issues in 25 cases. Additionally, organ failure occurred in 11 cases, and immunodeficiency was present in two cases. Furthermore, 9 cases experienced bleeding events, and 13 cases showed thrombosis. Patients with complications had lower weight, shorter ECMO durations, and longer CPR durations. Non-survivors had longer CPR durations and shorter durations of ECMO, ICU stay, and mechanical ventilation compared to survivors. Complications were more prevalent in non-survivors, particularly organ failure and bleeding events. ConclusionWeight, CPR duration, and ECMO duration were associated with complications, suggesting areas for treatment optimization. The higher occurrence of complications in non-survivors underscores the importance of early detection and management to improve survival rates. Our findings suggest clinicians consider these factors in prognostic assessments to enhance the effectiveness of ECPR programs.

High Variability in the Duration of Chest Compression Interruption is Associated With Poor Outcomes in Pediatric Extracorporeal Cardiopulmonary Resuscitation.

To determine the association between chest compression interruption (CCI) patterns and outcomes in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Cardiopulmonary resuscitation (CPR) data were collected using defibrillator-electrode and bedside monitor waveforms from pediatric ECPR cases between 2013 and 2021. Duration and variability of CCI during cannulation for ECPR was determined and compared with survival to discharge using Fishers exact test and logistic regressions with cluster-robust se s for adjusted analyses. Quaternary care children's hospital. Pediatric patients undergoing ECPR. None. Of 41 ECPR events, median age was 0.7 years (Q1, Q3: 0.1, 5.4), 37% (15/41) survived to hospital discharge with 73% (11/15) of survivors having a favorable neurologic outcome. Median duration of CPR from start of ECPR cannulation procedure to initiation of extracorporeal membrane oxygenation (ECMO) flow was 21 minutes (18, 30). Median duration of no-flow times associated with CCI during ECMO cannulation was 11 seconds (5, 28). Following planned adjustment for known confounders, survival to discharge was inversely associated with maximum duration of CCI (odds ratio [OR] 0.91 [0.86-0.95], p = 0.04) as well as the variability in the CCI duration (OR 0.96 [0.93-0.99], p = 0.04). Cases with both above-average CCI duration and higher CCI variability ( sd > 30 s) were associated with lowest survival (12% vs. 54%, p = 0.009). Interaction modeling suggests that lower variability in CCI is associated with improved survival, especially in cases where average CCI durations are higher. Shorter duration of CCI and lower variability in CCI during cannulation for ECPR were associated with survival following refractory pediatric cardiac arrest.

Early Cardiac Arrest Hemodynamics, End-Tidal C o2 , and Outcome in Pediatric Extracorporeal Cardiopulmonary Resuscitation: Secondary Analysis of the ICU-RESUScitation Project Dataset (2016-2021).

Cannulation for extracorporeal membrane oxygenation during active extracorporeal cardiopulmonary resuscitation (ECPR) is a method to rescue patients refractory to standard resuscitation. We hypothesized that early arrest hemodynamics and end-tidal C o2 (ET co2 ) are associated with survival to hospital discharge with favorable neurologic outcome in pediatric ECPR patients. Preplanned, secondary analysis of pediatric Utstein, hemodynamic, and ventilatory data in ECPR patients collected during the 2016-2021 Improving Outcomes from Pediatric Cardiac Arrest study; the ICU-RESUScitation Project (ICU-RESUS; NCT02837497). Eighteen ICUs participated in ICU-RESUS. There were 97 ECPR patients with hemodynamic waveforms during cardiopulmonary resuscitation. None. Overall, 71 of 97 patients (73%) were younger than 1 year old, 82 of 97 (85%) had congenital heart disease, and 62 of 97 (64%) were postoperative cardiac surgical patients. Forty of 97 patients (41%) survived with favorable neurologic outcome. We failed to find differences in diastolic or systolic blood pressure, proportion achieving age-based target diastolic or systolic blood pressure, or chest compression rate during the initial 10 minutes of CPR between patients who survived with favorable neurologic outcome and those who did not. Thirty-five patients had ET co2 data; of 17 survivors with favorable neurologic outcome, four of 17 (24%) had an average ET co2 less than 10 mm Hg and two (12%) had a maximum ET co2 less than 10 mm Hg during the initial 10 minutes of resuscitation. We did not identify an association between early hemodynamics achieved by high-quality CPR and survival to hospital discharge with favorable neurologic outcome after pediatric ECPR. Candidates for ECPR with ET co2 less than 10 mm Hg may survive with favorable neurologic outcome.

Implications of pediatric extracorporeal cardiopulmonary resuscitation simulation for intensive care team confidence and coordination: A pilot study.

Extracorporeal cardiopulmonary resuscitation (ECPR) is associated with improved outcomes in select populations, however, crisis resource management (CRM) in this setting is logistically challenging. This study evaluates the impact of ECPR simulation on self-perceived confidence and collaboration of intensive care unit team members. This is a prospective observational study analyzing data obtained between July 2018-December 2019. This study focused on non-surgical members of critical care team consisting of pediatric intensivists, resident physicians, registered nurses, respiratory therapists. Participants were expected to perform cardiopulmonary resuscitation (CPR) during the ECPR event, participate in code-team responsibilities and provide ancillary support during cannulation. Pre- and post-simulation surveys employed the Likert scale (1 = not at all confident, 5 = highly confident) to assess self-perceived scores in specified clinical competencies. Twenty-nine providers participated in the simulation; 38% had prior ECPR experience. Compared to mean pre-study Likert scores (2.4, 2.4, 2.5), post-simulation scores increased (4.2, 4.4, 4.3) when self-evaluating: confidence in assessing patients needing ECPR, confidence in participating in ECPR workflow and confidence in performing high-quality CPR, respectively. Post-simulation values of >3 were reported by 100% of participants in all domains (p < .0001). All participants indicated the clinical scenario and procedural environment to be realistic and appropriately reflective of situational stress. Additionally, 100% of participants reported the simulation to improve perceived team communication and teamwork skills. This study demonstrated preliminary feasibility of pediatric ECPR simulation in enhancing independent provider confidence and team communication. This self-perceived improvement may establish a foundation for cohesive CRM, in preparation for a real life ECPR encounter.

19: Epinephrine dosing during pediatric extracorporeal cardiopulmonary resuscitation (ECPR): A single center retrospective study assessing adherence to resuscitation guidelines.

19: Epinephrine dosing during pediatric extracorporeal cardiopulmonary resuscitation (ECPR): A single center retrospective study assessing adherence to resuscitation guidelines.

Critical Care Unit Characteristics and Extracorporeal Cardiopulmonary Resuscitation Survival in the Pediatric Cardiac Population: Retrospective Analysis of the Virtual Pediatric System Database.

Existing literature provides limited data about ICU characteristics and pediatric extracorporeal cardiopulmonary resuscitation (E-CPR) outcomes. We aimed to evaluate the associations between patient and ICU characteristics, and outcomes after E-CPR in the pediatric cardiac population. Retrospective analysis of the Virtual Pediatric System database (VPS, LLC, Los Angeles, CA). PICUs categorized as either cardiac-only versus mixed ICU cohort type. Consecutive cardiac patients less than 18 years old experiencing cardiac arrest in the ICU and resuscitated using E-CPR. None. Event and time-stamp filtering identified E-CPR events. Patient, hospital, and event-related variables were aggregated for independent and multivariable mixed effects logistic regression to assess the association between ICU cohort type and survival. Among ICU admissions in the VPS database, 2010-2018, the prevalence of E-CPR was 0.07%. A total of 671 E-CPR events (650 patients) comprised the final cohort; congenital heart disease (84%) was the most common diagnosis versus acquired heart diseases. The majority of E-CPR events occurred in mixed ICUs (67%, n = 449) and in ICUs with greater than 20 licensed bed capacity (65%, n = 436). Survival to hospital discharge was 51% for the overall cohort. Independent logistic regression failed to reveal any association between survival to hospital discharge and ICU type (ICU type: cardiac ICU, odds ratio [OR], 1.01; 95% CI, 0.71-1.44; p = 0.95). However, multivariable logistic regression revealed an association between cardiac surgical patients and greater odds for survival (OR, 2.03; 95% CI, 1.40-2.95; p < 0.001). Also, there was an association between ICUs with capacity greater than 20 (vs not) and lower survival odds (OR, 0.65; 95% CI, 0.43-0.96). The overall prevalence of E-CPR among critically ill children with cardiac disease observed in the VPS database is low. We failed to identify an association between ICU cohort type and survival. Further investigation into organizational factors is warranted.

Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: A multicenter study utilizing time-stamped epinephrine dosing records

ObjectivesTo describe epinephrine dosing distribution using time-stamped data and assess the impact of dosing strategy on survival after ECPR in children. MethodsThis was a retrospective study at five pediatric hospitals of children <18 years with an in-hospital ECPR event. Mean number of epinephrine doses was calculated for each 10-minute CPR interval and compared between survivors and non-survivors. Patients were also divided by dosing strategy into a frequent epinephrine group (dosing interval of ≤5 min/dose throughout the first 30 minutes of the event), and a limited epinephrine group (dosing interval of ≤5 min/dose for the first 10 minutes then >5 min/dose for the time between 10 and 30 minutes). ResultsA total of 191 patients were included. Epinephrine was not evenly distributed throughout ECPR, with 66% of doses being given during the first half of the event. Mean number of epinephrine doses was similar between survivors and non-survivors the first 10 minutes (2.7 doses). After 10 minutes, survivors received fewer doses than non-survivors during each subsequent 10-minute interval. Adjusted survival was not different between strategy groups [OR of survival for frequent epinephrine strategy: 0.78 (95% CI 0.36–1.69), p = 0.53]. ConclusionsSurvivors received fewer doses than non-survivors after the first 10 minutes of CPR and although there was no statistical difference in survival based on dosing strategy, the findings of this study question the conventional approach to EPCR analysis that assumes dosing is evenly distributed.

Pediatric Extracorporeal Cardiopulmonary Resuscitation: Development of a Porcine Model and the Influence of Cardiopulmonary Resuscitation Duration on Brain Injury.

Background The primary objective was to develop a porcine model of prolonged (30 or 60 minutes) pediatric cardiopulmonary resuscitation (CPR) followed by 22- to 24-hour survival with extracorporeal life support, and secondarily to evaluate differences in neurologic injury. Methods and Results Ten-kilogram, 4-week-old female piglets were used. First, model development established the technique (n=8). Then, a pilot study was conducted (n=15). After 80% survival was achieved in the final 5 pilot animals, a proof-of-concept randomized study was completed (n=11). Shams (n=6) underwent anesthesia only. Severe neurological injury was determined by a composite score of mitochondrial function, neuropathology, and cerebral metabolism: scale of 0-6 (severe: >3). Among 15 piglets in the pilot study, overall survival was 10 (67%); of the final 5, overall survival was 4 (80%). Eleven piglets were then randomized to 60 (CPR60, n=5) or 30 minutes of CPR (CPR30, n=5); 1 animal was excluded from prerandomization for intra-abdominal hemorrhage (10/11, 91% survival). Three of 5 animals in the CPR60 group had severe neurological injury scores versus 1 of 5 in the CPR30 group (P=0.52). During ECMO, CPR60 animals had lower pH (CPR60: 7.4 [IQR 7.4-7.4] versus CPR30: 7.5 [IQR 7.4-7.5], P=0.022), higher lactate (CPR60: 6.8 [IQR 6.8-11] versus CPR30: 4.2 [IQR 4.1-4.3] mmol/L; P=0.012), and higher ICP (CPR60: 19.3 [IQR 11.7-29.3] versus CPR30: 7.9 [IQR 6.7-9.3] mm Hg; P=0.037). Both groups had greater mitochondrial injury than shams (CPR60: P<0.001; CPR30: P<0.001). CPR60 did not differ from CPR30 in mitochondrial respiration, neuropathology, or cerebral metabolism. Conclusions A pediatric porcine model of extracorporeal cardiopulmonary resuscitation after 60 and 30 minutes of CPR consistently resulted in 24-hour survival with more severe lactic acidosis in the 60-minute cohort.

1163: QUALITY IMPROVEMENT INITIATIVES REDUCE CHEST COMPRESSION PAUSES DURING PEDIATRIC ECPR

Introduction: Prolonged chest compression (CC) pauses in cardiopulmonary resuscitation (CPR) are associated with worse survival during in-hospital cardiac arrests. Procedures necessary to gain access for extracorporeal CPR (ECPR) can potentially prolong CC pauses during extracorporeal membrane oxygenation (ECMO) cannulation. Implementation of targeted quality improvement initiatives to improve team communication may reduce CC pauses during pediatric ECPR. Methods: Baseline data from a pediatric intensive care unit (PICU) in a tertiary care children’s hospital demonstrated significantly longer CC pauses and lower CC fraction (CCF) during ECMO cannulation when compared to similar metrics pre-cannulation. An intervention designed to improve CC metrics during ECPR was implemented, including: 1. Sharing of baseline CC data with ECPR stakeholders 2. Standardization of counting CC pauses out loud to improve team awareness of pause length 3. Creation of a reporting aid to assist with ECPR documentation and 4. Interdisciplinary ECPR simulation sessions every other month to practice communication during cannulation. CC pause characteristics were compared pre- and post- intervention using unpaired t-tests. Results: Eleven ECPRs were analyzed pre-intervention and five ECPRs post-intervention. CC pause characteristics (mean duration of pauses, individual longest pause, and CCF) improved in both pre- and during ECMO cannulation epochs post-intervention when compared to their pre-intervention counterparts. During ECMO cannulation, mean length of CC pauses was 30 seconds (pre-intervention) vs 13 seconds (post-intervention) (p < 0.02). The longest CC pause during ECMO cannulation was 337 seconds (pre-intervention) compared with 69 seconds (post-intervention) (p = 0.03). CCF during ECMO cannulation pre-intervention and post-intervention was 68% vs 83% respectively (p = 0.03). Conclusions: CC pause metrics during the cannulation phase of pediatric ECPR improved significantly after quality improvement interventions including baseline CC data review, verbal communication of CC pause length and interdisciplinary ECPR simulations. Future aims include correlating CC pause characteristics with clinical outcomes.

Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience.

Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.

Predictors of survival for pediatric extracorporeal cardiopulmonary resuscitation: A systematic review and meta-analysis.

Background:The use of extracorporeal cardiopulmonary resuscitation (ECPR) has improved survival in patients with cardiac arrest; however, factors predicting survival remain poorly characterized. A systematic review and meta-analysis was conducted to examine the predictors of survival of ECPR in pediatric patients.Methods:We searched EMBASE, PubMed, SCOPUS, and the Cochrane Library from 2010 to 2021 for pediatric ECPR studies comparing survivors and non-survivors. Thirty outcomes were analyzed and classified into 5 categories: demographics, pre-ECPR laboratory measurements, pre-ECPR co-morbidities, intra-ECPR characteristics, and post-ECPR complications.Results:Thirty studies (n = 3794) were included. Pooled survival to hospital discharge (SHD) was 44% (95% CI: 40%–47%, I2 = 67%). Significant predictors of survival for pediatric ECPR include the pre-ECPR lab measurements of PaO2, pH, lactate, PaCO2, and creatinine, pre-ECPR comorbidities of single ventricle (SV) physiology, renal failure, sepsis, ECPR characteristics of extracorporeal membrane oxygenation (ECMO) duration, ECMO flow rate at 24 hours, cardiopulmonary resuscitation (CPR) duration, shockable rhythm, intra-ECPR neurological complications, and post-ECPR complications of pulmonary hemorrhage, renal failure, and sepsis.Conclusion:Prior to ECPR initiation, increased CPR duration and lactate levels had among the highest associations with mortality, followed by pH. After ECPR initiation, pulmonary hemorrhage and neurological complications were most predictive for survival. Clinicians should focus on these factors to better inform potential prognosis of patients, advise appropriate patient selection, and improve ECPR program effectiveness.

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.

Compression Device-Assisted Extracorporeal Cardiopulmonary Resuscitation Cannulation in Pediatric Patients-A Simulation Study.

Background: Surgical neck cannulation for pediatric extracorporeal cardiopulmonary resuscitation (ECPR) requires multiple interruptions of manual chest compressions to facilitate the procedure. Effective uninterrupted CPR is essential to prevent neurological injury. We hypothesized that an automated chest compression device can be used to provide effective and uninterrupted chest compressions during pediatric neck ECPR cannulation. The feasibility of surgically cannulating the right carotid artery and right internal jugular vein in an infant during ongoing automated chest compressions was tested in a simulation study. Methods: A working prototype of a pediatric chest compression device was designed to provide automated chest compressions on an infant CPR manikin at the rate of 120 compressions/minute. A feedback device attached to the manikin was used to monitor the effectiveness of CPR. A synthetic artery, vein along with carotid sheath and skin was utilized to simulate surgical neck exploration. ECPR simulation was conducted using the compression device to provide chest compressions. Results: Four ECPR simulations were conducted during which vessel sparing (n = 2) and non-vessel sparing (n = 2) cannulation of the right internal carotid artery and right internal jugular vein were performed during ongoing mechanical chest compressions. All four cannulations were successfully performed without the need to interrupt chest compressions. Conclusions: In a simulated environment, pediatric ECPR neck cannulation with uninterrupted chest compressions may be accomplished using an automated chest compression device. The strategy of compression device-assisted ECPR cannulation requires further study and could potentially reduce the neurological complications of ECPR.

Abstract 13945: Central Cannulation During Pediatric Extracorporeal Cardiopulmonary Resuscitation is Faster Than Peripheral Approaches

Introduction: Favorable survivorship after pediatric extracorporeal cardiopulmonary resuscitation (ECPR) may be limited by prolonged resuscitations. Surgical cannulation metrics for pediatric ECPR have not been widely reported by centers that use time interval benchmarks with a cardiovascular service responding to different hospital locations. Hypothesis: We hypothesize that survival is associated with resuscitation duration, and cannulation duration differs between peripheral and central approaches. Methods: This was a single-center retrospective study of patients 0-18 years with in-hospital ECPR between January 2015 and December 2020. Primary outcome was survival to hospital discharge. Secondary outcomes were odds of favorable neurologic outcome (dichotomized pediatric cerebral performance category), total resuscitation duration defined as cardiac arrest start to ECMO flow start (CA-ECMO), and cannulation duration. Non-parametric and regression methods were used. Results: Of the 92 events that met ECPR criteria, median weight and age were 4 months (IQR 1 month, 16 years) and 4.4 kg (range 1.9-133 kg). Cannulation occurred in the cardiac intensive care unit (ICU) (66%, 61 of 92), followed by operating room (13%, 12 of 92), pediatric ICU (12%, 11 of 92), and catheterization lab (9%, 8 of 92). Central cannulation was performed in 43% (40 of 92), and 21% (19 of 92) had open chests at the time of the event. Median duration of CA-ECMO was 35 min (IQR 26, 45 min); cannulation duration was 11 min (IQR 5, 16.5 min) for central compared to 18.5 min (IQR 12, 23 min) for peripheral approaches (P=0.01). Survival was 40% (37 of 92), and favorable neurologic outcome occurred in 38% (35 of 92). Survival (adjusted OR, 0.94; 95% CI 0.91-0.99, P=0.018) and favorable neurologic outcome (adjusted OR, 0.95; 95% CI 0.917-1.000, P=0.053) were associated with CA-ECMO duration after adjusting for cannulation approach, location, difficulty, shockable rhythm, and weight. Conclusion: In pediatric in-hospital ECPR, total CA-ECMO duration remains a key metric associated with patient outcomes. Central cannulation is faster than peripheral approaches. Since cannulation strategy alters CPR maneuvers, CPR effectiveness with each approach needs further study.

42 Improving Patient Selection in International Pediatric ECPR Cohorts

To examine the efficacy of duration of cardiopulmonary resuscitation (CPR) and duration of extracorporeal membrane oxygenation (ECMO) as predictors of survival in pediatric extracorporeal cardiopulmonary resuscitation (ECPR) patients outside the United States. We searched EMBASE, PubMed, SCOPUS, and the Cochrane Library from the years 2010 to 2020 for pediatric ECPR performed arrest outside the United States comparing survivor data to non-survivor data. Primary outcomes of interest were duration of CPR and duration of ECMO. Secondary outcomes of interest were age, sex, weight, pre-ECPR pH, and pre-ECPR lactate. 17 studies (n = 1848) were included. The average survival rate was 39.9%. In international ECPR cohorts, longer CPR duration (n = 508, 10 studies) was demonstrated to be a significant predictor of survival, with the average survivor having 37.0 ± 28 minutes of CPR and the average non-survivor having 52.6 ± 48 minutes of CPR (Standardized Mean Difference (SMD) = -0.47 [95% CI: -0.77 - -0.17], I2 = 43%). ECMO duration (n = 1563, 12 studies) was not significantly associated with survival, with the average survivor having 98.0 ± 140 minutes and the average non-survivor having 114.3 ± 114 minutes of ECMO (SMD = -0.16 [-0.37 - 0.05], I2 = 49%). Age (p = 0.46) and female sex (p = 0.056) were additionally not significantly associated with survival. Increased weight (p = 0.047), elevated pre-ECPR lactate levels (p = 0.01), and elevated pre- ECPR pH (p < 0.01) were significantly associated with increased mortality. In this cohort of international pediatric ECPR patients from the last ten years, the primary outcome of elevated CPR duration was significantly associated with increased risk of mortality. This suggests ECPR programs should prioritize ECPR initiation earlier in cardiac arrest cases to minimize CPR duration prior to ECPR commencement. In addition, increased weight, elevated, pre-ECPR lactate levels, and elevated pre- ECPR pH were associated with increased risk of mortality. Elevated ECMO duration, age, and sex were not associated with increased risk of mortality. These factors can help provide clinicians with more information on the potential prognosis of patients, appropriate patient selection, and ECPR program effectiveness.

Pediatric extracorporeal cardiopulmonary resuscitation: single-center study

Background/aimExtracorporeal cardiopulmonary resuscitation (ECPR) is defined as the venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in a patient who experienced a sudden pulseless condition attributable to cessation of cardiac mechanical activity and circulation. We aimed to evaluate the clinical outcomes of our ECPR experience in a pediatric patient population.Materials and methodsBetween September 2014 and November 2017, 15 children were supported with ECPR following in-hospital cardiac arrest (IHCA) in our hospitals. VA-ECMO setting was established for all patients. Pediatric cerebral performance category (PCPC) scales and long-term neurological prognosis of the survivors were assessed.ResultsThe median age of the study population was 60 (4–156) months. The median weight was 18 (4.8–145) kg, height was 115 (63–172) cm, and body surface area was 0.73 (0.27–2.49) m2. The cause of cardiac arrest was a cardiac and circulatory failure in 12 patients (80%) and noncardiac causes in 20%. Dysrhythmia was present in 46%, septic shock in 13%, bleeding in 6%, low cardiac output syndrome in 13%, and airway disease in 6% of the study population. Median low-flow time was 95 (range 20–320) min. Central VA-ECMO cannulation was placed in only 2 (13.3%) cases. However, the return of spontaneous circulation (ROSC) was obtained in 10 (66.6%) patients, and 5 (50%) of them survived. Overall, 5 patients were discharged from the hospital. Finally, survival following ECPR was 33.3%, and all survivors were neurologically intact at hospital-discharge.ConclusionECPR can be a life-saving therapeutic strategy using a promising technology in the pediatric IHCA population. Early initiation and a well-coordinated, skilled, and dedicated ECMO team are the mainstay for better survival rates.

Factors Associated With Initiation of Extracorporeal Cardiopulmonary Resuscitation in the Pediatric Population: An International Survey.

Although extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly utilized in the pediatric critical care environment, our understanding regarding pediatric candidacy for ECPR remains unknown. Our objective is to explore current practice and indications for pediatric ECPR. Scenario-based, self-administered, online survey, evaluating clinical determinants that may impact pediatric ECPR initiation with respect to four scenarios: postoperative cardiac surgery, cardiac failure secondary to myocarditis, septic shock, and chronic respiratory failure in a former preterm child. Responders are pediatric critical care physicians from four societies. 249 physicians, mostly from North America, answered the survey. In cardiac scenarios, 40% of the responders would initiate ECPR, irrespective of CPR duration, compared with less than 20% in noncardiac scenarios. Nearly 33% of responders would consider ECPR if CPR duration was less than 60 minutes in noncardiac scenarios. Factors strongly decreasing the likelihood to initiate ECPR were out-of-hospital unwitnessed cardiac arrest and blood pH <6.60. Additional factors reducing this likelihood were multiple organ failure, pre-existing neurologic delay, >10 doses of adrenaline, poor CPR quality, and lactate >18 mmol/l. Pediatric intensive care unit location for cardiac arrest, good CPR quality, 24/7 in-house extracorporeal membrane oxygenation (ECMO) team moderately increase the likelihood of initiating ECPR. This international survey of pediatric ECPR initiation practices reveals significant differences regarding ECPR candidacy based on patient category, location of arrest, duration of CPR, witness status, and last blood pH. Further research identifying prognostic factors measurable before ECMO initiation should help define the optimal ECPR initiation strategy.

Outcomes of Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis.

The goal of this work is to provide insight into survival and neurologic outcomes of pediatric patients supported with extracorporeal cardiopulmonary resuscitation. A systematic search of Embase, PubMed, Cochrane, Scopus, Google Scholar, and Web of Science was performed from January 1990 to May 2020. A comprehensive list of nonregistry studies with pediatric patients managed with extracorporeal cardiopulmonary resuscitation was included. Study characteristics and outcome estimates were extracted from each article. Estimates were pooled using random-effects meta-analysis. Differences were estimated using subgroup meta-analysis and meta-regression. The Meta-analyses Of Observational Studies in Epidemiology guideline was followed and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation system. Twenty-eight studies (1,348 patients) were included. There was a steady increase in extracorporeal cardiopulmonary resuscitation occurrence rate from the 1990s until 2020. There were 32, 338, and 1,094 patients' articles published between 1990 and 2000, 2001 and 2010, and 2010 and 2020, respectively. More than 70% were cannulated for a primary cardiac arrest. Pediatric extracorporeal cardiopulmonary resuscitation patients had a 46% (CI 95% = 43-48%; p < 0.01) overall survival rate. The rate of survival with favorable neurologic outcome was 30% (CI 95% = 27-33%; p < 0.01). The use of extracorporeal cardiopulmonary resuscitation is rapidly expanding, particularly for children with underlying cardiac disease. An overall survival of 46% and favorable neurologic outcomes add credence to this emerging therapy.

Abstract 266: Quantifying the Effect of Technological Advancements and Guidelines on Pediatric Extracorporeal Cardiopulmonary Resuscitation Survival Outcomes

Introduction: The 2009 H1N1 pandemic resulted in a substantial increase in the use of extracorporeal cardiopulmonary resuscitation (ECPR). The concurrent release of guidelines by the French Ministry of Health also led to the standardization of ECPR protocol. We conducted a systematic review and meta-analysis to examine if the simultaneous development of guidelines and expanded usage led to an increase in survival to hospital discharge (SHD) in pediatric ECPR and to investigate if predictors of survival have changed since 2009. Methods: PubMed, SCOPUS, Google Scholar, Cochrane, and EMBASE were searched to identify studies examining survival outcome and predictors of survival for pediatric ECPR. A random-effects model was applied. Additional pre-specified subgroup analysis was performed using a fixed-effects model. A univariate meta-regression analysis was conducted. Results: The meta-analysis included 3,454 patients from 30 studies. Total survival rates have not improved in pediatric ECPR between subgroups (Mann-Whitney U test: p &gt; 0.05). Extracorporeal membrane oxygenation (ECMO) duration for survivors was not significantly different than nonsurvivors before 2009 RR -0.02 [95% CI: -0.19 - 0.14], but was significantly lower than nonsurvivors after 2009 RR -0.32 [-0.48 - -0.15, p &lt; 0.05]. Meta-regression analysis revealed the ratio of ECMO duration for survivors compared to non-survivors has significantly decreased from 1998 to 2020 (p &lt; 0.05). Patient age was a significant predictor of survival pre-2009 RR but is not correlated with survival post-2009 (p &gt; 0.05). PaO2 was significantly higher in survivors than nonsurvivors pre-2009 RR 0.15 [0.12 - 0.18, p &lt; 0.05] but was not significantly different post-2009 (p &gt; 0.05). End-tidal CO2, CPR duration, pre-CPR serum lactate, and pre-CPR creatinine were not significantly different (p &gt; 0.05) between survivors and non-survivors in either pre-2009 or post-2009. Conclusion: Pediatric ECPR did not see major improvement in survival rates since 2009. In addition, predictors of survival for pediatric ECPR cases have changed over the last 10 years. As such, clinicians may be advised to rely much more heavily on recent research regarding predictors of survival in pediatric ECPR cases.

Simulation Training in Extracorporeal Cardiopulmonary Resuscitation (ECPR).

Extracorporeal cardiopulmonary resuscitation (ECPR) is the rapid deployment of extracorporeal membrane oxygenation (ECMO) to provide circulatory support to patients in whom conventional CPR is unsuccessful in achieving the return of spontaneous circulation.1 ECPR is a complex, resource-intense, and multidisciplinary therapy.1 Training is essential to perform ECPR well. In “Impacts of a Pediatric Extracorporeal Cardiopulmonary Resuscitation (ECPR) Simulation Training Program”,2 we used a mixed-method, time-series design to examine the impact of high-fidelity ECPR simulations in a tertiary children's hospital.