Ryan P. Barbaro

Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality: Analysis of the extracorporeal life support organization registry

RATIONALE Recent pediatric studies suggest a survival benefit exists for higher-volume extracorporeal membrane oxygenation (ECMO) centers. OBJECTIVES To determine if higher annual ECMO patient volume is associated with lower case-mix-adjusted hospital mortality rate. METHODS We retrospectively analyzed an international registry of ECMO support from 1989 to 2013. Patients were separated into three age groups: neonatal (0-28 d), pediatric (29 d to <18 yr), and adult (≥18 yr). The measure of hospital ECMO volume was age group-specific and adjusted for patient-level case-mix and hospital-level variance using multivariable hierarchical logistic regression modeling. The primary outcome was death before hospital discharge. A subgroup analysis was conducted for 2008-2013. MEASUREMENTS AND MAIN RESULTS From 1989 to 2013, a total of 290 centers provided ECMO support to 56,222 patients (30,909 neonates, 14,725 children, and 10,588 adults). Annual ECMO mortality rates varied widely across ECMO centers: the interquartile range was 18-50% for neonates, 25-66% for pediatrics, and 33-92% for adults. For 1989-2013, higher age group-specific ECMO volume was associated with lower odds of ECMO mortality for neonates and adults but not for pediatric cases. In 2008-2013, the volume-outcome association remained statistically significant only among adults. Patients receiving ECMO at hospitals with more than 30 adult annual ECMO cases had significantly lower odds of mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.46-0.80) compared with adults receiving ECMO at hospitals with less than six annual cases. CONCLUSIONS In this international, case-mix-adjusted analysis, higher annual hospital ECMO volume was associated with lower mortality in 1989-2013 for neonates and adults; the association among adults persisted in 2008-2013.

Extracorporeal Life Support Organization Registry International Report 2016.

Data on extracorporeal life support (ECLS) use and survival submitted to the Extracorporeal Life Support Organization’s data registry from the inception of the registry in 1989 through July 1, 2016, are summarized in this report. The registry contained information on 78,397 ECLS patients with 58% survival to hospital discharge. Extracorporeal life support use and centers providing ECLS have increased worldwide. Extracorporeal life support use in the support of adults with respiratory and cardiac failure represented the largest growth in the recent time period. Extracorporeal life support indications are expanding, and it is increasingly being used to support cardiopulmonary resuscitation in children and adults. Adverse events during the course of ECLS are common and underscore the need for skilled ECLS management and appropriately trained ECLS personnel and teams.

Pediatric Extracorporeal Life Support Organization Registry International Report 2016

The purpose of this report is to describe the international growth, outcomes, complications, and technology used in pediatric extracorporeal life support (ECLS) from 2009 to 2015 as reported by participating centers in the Extracorporeal Life Support Organization (ELSO). To date, there are 59,969 children who have received ECLS in the ELSO Registry; among those, 21,907 received ECLS since 2009 with an overall survival to hospital discharge rate of 61%. In 2009, 2,409 ECLS cases were performed at 157 centers. By 2015, that number grew to 2,992 cases in 227 centers, reflecting a 24% increase in patients and 55% growth in centers. ECLS delivered to neonates (0–28 days) for respiratory support was the largest subcategory of ECLS among children <18-years old. Overall, 48% of ECLS was delivered for respiratory support and 52% was for cardiac support or extracorporeal life support to support cardiopulmonary resuscitation (ECPR). During the study period, over half of children were supported on ECLS with centrifugal pumps (51%) and polymethylpentene oxygenators (52%). Adverse events including neurologic events were common during ECLS, a fact that underscores the opportunity and need to promote quality improvement work.

Does Extracorporeal Membrane Oxygenation Improve Survival in Pediatric Acute Respiratory Failure

Rationale: Extracorporeal membrane oxygenation (ECMO) has supported gas exchange in children with severe respiratory failure for more than 40 years, without ECMO efficacy studies. Objectives: To compare the mortality and functional status of children with severe acute respiratory failure supported with and without ECMO. Methods: This cohort study compared ECMO‐supported children to pair‐matched non‐ECMO‐supported control subjects with severe acute respiratory distress syndrome (ARDS). Both individual case matching and propensity score matching were used. The study sample was selected from children enrolled in the cluster‐randomized RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) clinical trial. Detailed demographic and daily physiologic data were used to match patients. The primary endpoint was in‐hospital mortality. Secondary outcomes included hospital‐free days, ventilator‐free days, and change in functional status at hospital discharge. Measurements and Main Results: Of 2,449 children in the RESTORE trial, 879 (35.9%) non‐ECMO‐supported patients with severe ARDS were eligible to match to 61 (2.5%) ECMO‐supported children. When individual case matching was used (60 matched pairs), the in‐hospital mortality rate at 90 days was 25% (15 of 60) for both the ECMO‐supported and non‐ECMO‐supported children (P > 0.99). With propensity score matching (61 matched pairs), the ECMO‐supported in‐hospital mortality rate was 15 of 61 (25%), and the non‐ECMO‐supported hospital mortality rate was 18 of 61 (30%) (P = 0.70). There was no difference between ECMO‐supported and non‐ECMO‐supported patients in any secondary outcomes. Conclusions: In children with severe ARDS, our results do not demonstrate that ECMO‐supported children have superior outcomes compared with non‐ECMO‐supported children. Definitive answers will require a rigorous multisite randomized controlled trial.

Should Extracorporeal Membrane Oxygenation Be Offered? An International Survey

Objectives To assess the current attitudes of extracorporeal membrane oxygenation (ECMO) program directors regarding eligibility for ECMO among children with cardiopulmonary failure. Study design Electronic cross‐sectional survey of ECMO program directors at ECMO centers worldwide within the Extracorporeal Life Support Organization directory (October 2015‐December 2015). Results Of 733 eligible respondents, 226 (31%) completed the survey, 65% of whom routinely cared for pediatric patients. There was wide variability in whether respondents would offer ECMO to any of the 5 scenario patients, ranging from 31% who would offer ECMO to a child with trisomy 18 to 76% who would offer ECMO to a child with prolonged cardiac arrest and indeterminate neurologic status. Even physicians practicing the same specialty sometimes held widely divergent opinions, with 50% of pediatric intensivists stating they would offer ECMO to a child with severe developmental delay and 50% stating they would not. Factors such as quality of life and neurologic status influenced decision making and were used to support decisions for and against offering ECMO. Conclusions ECMO program directors vary widely in whether they would offer ECMO to various children with cardiopulmonary failure. This heterogeneity in physician decision making underscores the need for more evidence that could eventually inform interinstitutional guidelines regarding patient selection for ECMO.

Extracorporeal Membrane Oxygenation for Pertussis: Predictors of Outcome Including Pulmonary Hypertension and Leukodepletion

Objective: The recent increase of pertussis cases worldwide has generated questions regarding the utility of extracorporeal membrane oxygenation for children with pertussis. We aimed to evaluate factors associated with extracorporeal membrane oxygenation outcome. Design: The study was designed in two parts: a retrospective analysis of the Extracorporeal Life Support Organization Registry to identify factors independently linked to outcome, and an expanded dataset from individual institutions to examine the association of WBC count, pulmonary hypertension, and leukodepletion with survival. Setting: Extracorporeal Life Support Organization Registry database from 2002 though 2015, and contributions from 19 international centers. Patients: Two hundred infants from the Extracorporeal Life Support Organization Registry and expanded data on 73 children. Interventions: None. Measurements and Main Results: Of the 200 infants who received extracorporeal membrane oxygenation for pertussis, only 56 survived (28%). In a multivariable logistic regression analysis, the following variables were independently associated with increased chance of survival: older age (odds ratio, 1.43 [1.03–1.98]; p = 0.034), higher PaO2/FIO2 ratio (odds ratio, 1.10 [1.03–1.17]; p = 0.003), and longer intubation time prior to the initiation of extracorporeal membrane oxygenation (odds ratio, 2.10 [1.37–3.22]; p = 0.001). The use of vasoactive medications (odds ratio, 0.33 [0.11–0.99]; p = 0.047), and renal neurologic or infectious complications (odds ratio, 0.21 [0.08–0.56]; p = 0.002) were associated with increased mortality. In the expanded dataset (n =73), leukodepletion was independently associated with increased chance of survival (odds ratio, 3.36 [1.13–11.68]; p = 0.03) while the presence of pulmonary hypertension was adverse (odds ratio, 0.06 [0.01–0.55]; p = 0.01). Conclusions: The survival rate for infants with pertussis who received extracorporeal membrane oxygenation support remains poor. Younger age, lower PaO2/FIO2 ratio, vasoactive use, pulmonary hypertension, and a rapidly progressive course were associated with increased mortality. Our results suggest that pre–extracorporeal membrane oxygenation leukodepletion may provide a survival advantage.

The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization

&NA; Extracorporeal life support (ECLS) was developed more than 50 years ago, initially with venoarterial and subsequently with venovenous configurations. As the technique of ECLS significantly improved and newer skills developed, complexity in terminology and advances in cannula design led to some misunderstanding of and inconsistency in definitions, both in clinical practice and in scientific research. This document is a consensus of multispecialty international representatives of the Extracorporeal Life Support Organization, including the North America, Latin America, EuroELSO, South West Asia and Africa, and Asia‐Pacific chapters, imparting a global perspective on ECLS. The goal is to provide a consistent and unambiguous nomenclature for ECLS and to overcome the inconsistent use of abbreviations for ECLS cannulation. Secondary benefits are ease of multicenter collaboration in research, improved registry data quality, and clear communication among practitioners and researchers in the field.

Hospital-level variation in inpatient cost among children receiving extracorporeal membrane oxygenation

Objective: Pediatric extracorporeal membrane oxygenation (ECMO) varies in the way care is provided from hospital to hospital. This variability in hospital ECMO care can be represented by the variation in ECMO costs. We hypothesized that hospitals will demonstrate large variations in case-mix-adjusted ECMO inpatient costs for children requiring ECMO and higher volume hospitals will have lower associated costs. Methods: We retrospectively analyzed the inpatient cost of children receiving ECMO in 2006, 2009 and 2012, using the Healthcare Cost and Utilization Project Kids’ Inpatient Database. We used a hierarchical linear regression model and the intraclass correlation coefficient to quantify how much of the difference in ECMO inpatient costs was associated with the hospital where a child received care. To do this, we adjusted for patient factors, hospital factors and potentially modifiable factors such as complications, procedures and length of stay. Results: The median inflation-adjusted inpatient costs for children requiring ECMO were

Prospective Side by Side Comparison of Outcomes and Complications With a Simple Versus Intensive Anticoagulation Monitoring Strategy in Pediatric Extracorporeal Life Support Patients

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Is there a best approach for extracorporeal life support cannulation: a review of the extracorporeal life support organization

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