Michael H. Stroud

20-Year Experience of Prolonged Extracorporeal Membrane Oxygenation in Critically Ill Children With Cardiac or Pulmonary Failure

BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for life-threatening respiratory or circulatory failure. Although outcomes are favorable with short-term ECMO therapy, data on the outcomes of prolonged ECMO therapy in children are very limited. This study aimed to study morbidity and mortality associated with prolonged ECMO therapy (≥28 days) in children with refractory cardiac or pulmonary failure. METHODS We conducted a retrospective review of all children≤18 years supported with ECMO for ≥28 days between January 1991 and September 2011 at the Arkansas Childrens Hospital. The data collected in our study included patient demographic information; diagnosis; indication for ECMO; ECMO support details; medical and surgical history; laboratory, microbiologic, and radiographic data; information on organ dysfunction; complications; and patient outcomes. The outcome variables evaluated in this report included survival to ECMO decannulation, survival to hospital discharge, and current survival with emphasis on neurologic, renal, pulmonary, and other end organ function. RESULTS During the study period, 984 events in 951 patients were supported with ECMO with a 30-day survival of 666 events (68%). Only 22 ECMO runs were ≥28 days and were eligible for inclusion in this report. The longest ECMO run in our series was 1,206 hours (50 days). The average length of ECMO run in this cohort was 855±133 hours, with a mean intensive care unit length of stay of 56±27 days. Ten patients (45%) were successfully decannulated from ECMO. Six patients (27%) were alive 30 days after decannulation, and only 4 patients (19%) survived to hospital discharge. Of the 4 survivors, only 3 patients (14%) are living to date. Of the 3 living children, 2 have significant neurologic issues with brain atrophy and developmental delay, and 1 is awaiting renal transplant; all 3 survivors have chronic lung disease. CONCLUSIONS This case series highlights that the prolonged use of ECMO in children with refractory cardiac failure, respiratory failure, or both is associated with low survival. Furthermore, it suggests that the survivors of prolonged ECMO runs have significant long-term sequelae.

Pediatric and Neonatal Interfacility Transport: Results From a National Consensus Conference

The practice of pediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile ICUs capable of delivering state-of-the-art critical care during pediatric and neonatal transport. The most recent document regarding the practice of pediatric/neonatal transport is more than a decade old. The following article details changes in the practice of interfacility transport over the past decade and expresses the consensus views of leaders in the field of transport medicine, including the American Academy of Pediatrics’ Section on Transport Medicine.

Enhanced monitoring improves pediatric transport outcomes: a randomized controlled trial.

BACKGROUND: The “golden-hour” concept has led to emphasis on speed of patient delivery during pediatric interfacility transport. Timely intervention, in addition to enhanced monitoring during transport, is the key to improved outcomes in critically ill patients. Taking the ICU to the patient may be more beneficial than rapid delivery to a tertiary care center. METHODS: The Improved Monitoring During Pediatric Interfacility Transport trial was the first randomized controlled trial in the out-of-hospital pediatric transport environment. It was designed to determine the impact of improved blood pressure monitoring during pediatric interfacility transport and the effect on clinical outcomes in patients with systemic inflammatory response syndrome and moderate-to-severe head trauma. Patients in the control group had their blood pressure monitored intermittently with an oscillometric device; those in the intervention group had their blood pressure monitored every 12 to 15 cardiac contractions with a near-continuous, noninvasive device. RESULTS: Between May 2006 and June 2007, 1995, consecutive transport patients were screened, and 94 were enrolled (48 control, 46 intervention). Patients in the intervention group received more intravenous fluid (19.8 ± 22.2 vs 9.9 ± 9.9 mL/kg; P = .01), had a shorter hospital stay (6.8 ± 7.8 vs 10.9 ± 13.4 days; P = .04), and had less organ dysfunction (18 of 206 vs 32 of 202 PICU days; P = .03). CONCLUSIONS: Improved monitoring during pediatric transport has the potential to improve outcomes of critically ill children. Clinical trials, including randomized controlled trials, can be accomplished during pediatric transport. Future studies should evaluate optimal equipment, protocols, procedures, and interventions during pediatric transport, aimed at improving the clinical and functional outcomes of critically ill patients.

Prolonged extracorporeal membrane oxygenator support among neonates with acute respiratory failure: a review of the Extracorporeal Life Support Organization registry.

The objective of this study was to identify types of neonatal diseases associated with prolonged (≥21 days) extracorporeal membrane oxygenation (ECMO), characteristics of survivors and nonsurvivors among those requiring prolonged ECMO, and factors associated with mortality. Data were obtained from the Extracorporeal Life Support Organization registry over the period from January 1, 1998, through December 31, 2011, for all neonates (age <31 days), with respiratory failure as the indication for ECMO. The primary outcome was survival to hospital discharge. Survivors and nonsurvivors were compared for 1) patient demographics, 2) primary diagnosis, 3) pre-ECMO clinical course and therapies, and 4) ECMO course and associated complications. The most common diagnosis associated with prolonged ECMO support in neonates is congenital diaphragmatic hernia (CDH; 69%). Infants with meconium aspiration syndrome had the highest survival rate (71%) compared with other diagnoses analyzed (26.3%; p < 0.001). Nonsurvivors were more likely to experience complications on ECMO, and multivariate analysis showed that the need for inotropes while on ECMO support (odds ratio, 2.2 [95% confidence interval, 1.3–3.7]; p = 0.003) was independently associated with mortality. Neonates requiring prolonged ECMO support have a 24% survival to discharge. Many of these cases involve CDH. Complications are common with prolonged ECMO, but only receipt of inotropes was shown to be independently associated with mortality. This report may help guide clinical decision making and family counseling for neonates requiring prolonged ECMO support.

Redefining the golden hour in pediatric transport.

Objective: To emphasize the urgent need for research efforts and application of goal-directed therapy in the pediatric transport environment. Design: Review of existing literature and commentary on current pediatric transport practices. Conclusions: Pediatric transport has evolved significantly since its inception >2 decades ago. Advancements in technology and therapeutic interventions now afford an opportunity to extend intensive care into the transport environment. However, misapplication of the concept of the golden hour has led to a focus on speed of transfer to tertiary care facilities, often delaying early, goal-directed therapeutic interventions. If we are to further improve outcomes for critically ill children, we must extend early institution of goal-directed therapy into the pretertiary hospital setting and bring expertise to the child.

Successful use of extracorporeal membrane oxygenation in severe necrotizing pneumonia caused by Staphylococcus aureus

Objective: To report the successful use of extracorporeal membrane oxygenation (ECMO) as rescue therapy for severe necrotizing pneumonia secondary to infection by the Staphylococcus aureus species. Design: Case series. Setting: Pediatric intensive care unit at a freestanding tertiary care childrens hospital. Patients: Two pediatric patients with severe S. aureus-induced necrotizing pneumonia requiring rescue with ECMO. Both patients survived with good neurologic outcomes. One patient required the use of activated factor VII for severe bleeding while on ECMO, with no thrombotic effect on the ECMO circuit. Conclusion: ECMO as rescue support should be considered in a timely fashion for refractory hypoxemic respiratory failure resulting from S. aureus pneumonia, including patients with necrotizing pneumonia. Use of ECMO support in such cases, coupled with aggressive measures aimed at minimizing bleeding, such as the use of activated factor VII, may result in excellent short- and long-term outcomes for such patients.

Effect of altitude on cerebral oxygenation during pediatric interfacility transport.

Objectives The objectives of this study were to determine the usefulness of cerebral oxygenation monitoring during interfacility helicopter transport of pediatric patients and to determine the effect of changes in altitude during transport on cerebral oxygenation readings in pediatric interfacility transport patients. Methods A convenience sample of pediatric interfacility helicopter transport patients were monitored using near-infrared spectroscopy (NIRS) technology. Cerebral oxygenation numbers were collected at baseline and at cruising altitude in patients on room air, supplemental oxygen, and mechanical ventilation. Comparisons among readings were performed to determine the effect of changing altitude during helicopter transport on cerebral oxygenation. Results Seventeen pediatric patients were monitored at various altitudes during interfacility helicopter transport. When compared collectively, there was no difference in NIRS readings at baseline (B) and at altitude (A): B—65.9% (SD, 9.5%) versus A—65.0% (SD, 9.9%) (P = 0.06). In patients transported at greater than 5000 ft above ground level, there was a statistically significant difference in NIRS readings: B—69.2% (SD, 8.9%) versus A—66.3% (SD, 9.8%) (P < 0.001). Patients requiring mechanical ventilator support also had statistically significant differences in NIRS readings above 5000 ft above ground level: B—78.1% (SD, 5.9%) versus A—75.0% (SD, 3.5%) (P = 0.01). Conclusions Cerebral oxygenation monitoring, using NIRS technology, can be used as a monitoring tool during pediatric helicopter transport. Cerebral oxygenation may change with acute changes in altitude, especially in pediatric patients requiring high levels of respiratory support. This technology has the potential to be used to monitor tissue oxygenation and possibly guide therapeutic interventions during pediatric transport.

Acute kidney injury is associated with increased in-hospital mortality in mechanically ventilated children with trauma.

BACKGROUND Acute kidney injury (AKI) is associated with significant morbidity and mortality in patients with critical illness; however, its impact on children with trauma is not fully unexplored. We hypothesized that AKI is associated with increased in-hospital mortality. METHODS A retrospective review of consecutive mechanically ventilated patients aged 0 years to 20 years from 2004 to 2007 with trauma hospitalized at our institution was performed. Univariate and multivariate analyses were performed to identify whether AKI was a risk factor for hospital mortality. RESULTS Eighty-eight patients met inclusion/exclusion criteria. The study cohort included 58 (66%) males with mean (SD) age of 11.6 (5.5) years (median, 13.25; range, 0.083–19.42 years) and mean (SD) Pediatric Expanded Logical Organ Dysfunction score of 24 (11) (median, 22; range 2–51). Mean pediatric intensive care unit length of stay (median, 11; range, 4–43) and duration of mechanical ventilation (median, 9; range, 3–34), was 13.5 (8.2) days and 11.2 (7.2) days, respectively. The mean (SD) Injury Severity Score for the cohort was 28 (14). Pediatric RIFLE identified those at risk (R), those with injury (I), or those with failure (F) in 30 (51%), 10 (17%), and 12 (21%) patients, respectively. There was a 10% (3 of 30 patients) mortality rate in those at risk, 30% (3 of 10 patients) in those with injury, and 33% (4 of 12 patients) in those with failure. AKI (injury and failure groups) was significantly associated with increased in-hospital mortality. CONCLUSION Development of AKI (injury or failure) is a significant risk factor associated with in-hospital mortality. Our study highlights the need to consider both urine output as well as creatinine-based components of the pRIFLE criteria to define AKI. LEVEL OF EVIDENCE Prognostic and epidemiological study, level II.

Goal-Directed Resuscitative Interventions During Pediatric Interfacility Transport.

Objectives:This article reports results of the first National Institutes of Health-funded prospective interfacility transport study to determine the effect of goal-directed therapy administered by a specialized pediatric team to critically ill children with the systemic inflammatory response syndrome. We hypothesized that goal-directed therapy during interfacility transport would decrease hospital length of stay, prevent multiple organ dysfunction, and reduce subsequent ICU interventions. Design:Before-and-after intervention trial. Setting:During interfacility transport of critically ill patients by a specialized pediatric transport team, back to a tertiary care children’s hospital. Patients:Before-and-after intervention trial. Design:Interfacility pediatric transport patients, age 1 month to 17 years, with systemic inflammatory response syndrome. Interventions:Prospective data were collected on all pediatric interfacility transport patients with systemic inflammatory response syndrome transported by the Angel One Transport team at Arkansas Children’s Hospital. A 10-month data collection period was followed by institution of a goal-directed resuscitation protocol. Data were subsequently collected for 10 additional months followed by comparison of pre- and postintervention groups. All transport personnel underwent training with didactics and high-fidelity simulation until mastery with goal-directed resuscitation was achieved. Measurements and Main Results:All transport patients were screened for systemic inflammatory response syndrome using established variables and 235 (123 preintervention and 112 postintervention) were enrolled. Univariate analysis revealed shorter hospital stay (11 ± 15 d vs 7 ± 10 d; p = 0.02) and fewer required therapeutic ICU interventions in the postintervention group (Therapeutic Intervention Scoring System-28 Scores, 19.4 ± 6.8 vs 17.3 ± 6.6; p = 0.04). ICU stay and prevalence of organ dysfunction were not statistically different. Multivariable analysis showed a 1.6-day (95% CI, 1.3–2.03; p = 0.02) decrease in hospital stay in the postintervention group. Conclusions:This study suggests that goal-directed therapy administered by a specialized pediatric transport team has the potential to impact the outcomes of critically ill children. Findings from this study should be confirmed across multiple institutions, but have the potential to impact the clinical outcomes of critically ill children with systemic inflammatory response syndrome.

Extracorporeal membrane oxygenation support among children with adenovirus infection: a review of the Extracorporeal Life Support Organization registry.

Overwhelming adenovirus infection requiring extracorporeal membrane oxygenation (ECMO) support carries a high mortality in pediatric patients. The objective of this study was to retrospectively review data from the Extracorporeal Life Support Organization (ELSO) registry for pediatric patients with adenovirus infection and define for this patient cohort: 1) clinical characteristics, 2) survival to hospital discharge, and 3) factors associated with mortality before hospital discharge. In this retrospective registry study, pediatric patients with adenovirus infection requiring ECMO support identified in an international ECMO registry from 1998 to 2009 were compared for clinical characteristics (demographics, pre-ECMO variables, and complications on ECMO) between survivors and nonsurvivors to hospital discharge. Descriptive statistics and univariate and multivariate logistic analysis were used to compare clinical characteristics among survivors and nonsurvivors. For children requiring ECMO support for adenovirus, the survival at hospital discharge is 38% (62/163). Among neonates (<31 days of age), the survival at hospital discharge was only 11% (6/54). Among patient factors, neonatal age (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.62–10.87), a decrease of 0.1 unit in pre-ECMO pH (OR, 1.77; 95% CI, 1.3–2.42), the presence of sepsis (OR, 4.55; 95% CI, 1.47–14.15), and increased peak inspiratory pressures (OR, 1.04; 95% CI, 1.01–1.08) were all independently associated with in-hospital mortality. ECMO complications independently associated with in-hospital mortality were presence of pneumothorax (OR, 3.57; 95% CI, 1.19–10.7), pH less than 7.2 (OR, 5.94; 95% CI, 1.04–34.1), and central nervous system hemorrhage (OR, 25.36; 95% CI, 1.47–436.7). In this retrospective cohort study of pediatric patients with adenovirus infection supported on ECMO, survival to hospital discharge was 38% but was much lower in neonates. Neonatal presentation, degree of acidosis, sepsis, and increased PIP are factors present before decisions are made regarding a trial of ECMO, whereas pneumothorax and brain hemorrhage were ECMO-related complications independently associated with mortality.