Objective Our objective was to develop and validate a prognostic score for predicting mortality at time of extracorporeal membrane oxygenation (ECMO) initiation for children with respiratory failure. Pre-ECMO mortality prediction is important for determining center-specific risk-adjusted outcomes and counseling families. Design Multivariable logistic regression of a large international cohort of pediatric ECMO patients. Setting Multi institutional data. Patients Prognostic score development: 4352 children aged >7 days to <18 years, with an initial ECMO run for respiratory failure reported to the Extracorporeal Life Support Organization’s data registry during 2001–2013 were used for derivation (70%) and validation (30%). Bidirectional stepwise logistic regression was used to identify factors associated with mortality. Retained variables were assigned a score based on the odds of mortality with higher scores indicating greater mortality. External validation was accomplished using 2007 patients from the Pediatric Health Information System dataset. Interventions None Measurements and Main Results The Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction (P-PREP) score included mode of ECMO; pre-ECMO mechanical ventilation > 14 days; pre-ECMO severity of hypoxia; primary pulmonary diagnostic categories including, asthma, aspiration, respiratory syncytial virus, sepsis-induced respiratory failure, pertussis and ‘other’; and pre-ECMO comorbid conditions of cardiac arrest, cancer, renal and liver dysfunction. The area under the receiver operating characteristic curve for internal and external validation data-sets were 0.69 (95% CI, 0.67–0.71) and 0.66 (95% CI, 0.63–0.69). Conclusions P-PREP is a validated tool for predicting in-hospital mortality among children with respiratory failure receiving ECMO support.

Objective Congenital heart disease is commonly a manifestation of Genetic Conditions (GC). Surgery and/or ECMO were withheld in the past from some patients with GC. We hypothesized that surgical care of children with GC has increased over the last decade but their cardiac ECMO use remains lower and mortality greater. Design Retrospective Cohort Study Setting Patients admitted to the Pediatric Health Information System database ≤18 years old with cardiac surgery during 2003–14. GC identified by ICD9 codes were grouped as: Trisomy 21 (T21), Trisomy 13 or 18 (T13/18), 22q11 deletion, and all “other” GC and compared to patients without GC Patients A total of 95,253 patients met study criteria, no GC (85%), T21 (10%), T13/18 (0.2%), 22q11 deletion (1%), and “others” (5%). Interventions None Measurements and Main Results Annual surgical cases did not vary over time. Compared to patients without GC, T21 patient ECMO use was just over half (OR 0.54), but mortality with and without ECMO were similar. In T13/18 patients, ECMO use was similar to those without GC, but all 5 treated with ECMO died. 22q11 patients compared to those without GC had similar ECMO use, but greater odds of ECMO mortality (OR 3.44). “Other” GC had significantly greater ECMO use (OR 1.22), mortality with ECMO (OR 1.42) and even greater mortality odds without (OR 2.62). Conclusions The proportion of children undergoing cardiac surgery who have GC did not increase during the study. Excluding T13/18, all groups of GCs received and benefited from ECMO, although ECMO mortality was greater for those with 22q11 deletion and “other” GC.

There are few data to guide aspirin therapy to prevent shunt thrombosis in infants. We aimed to determine if aspirin administered at conventional dosing in shunted infants resulted in ≥50% arachidonic acid (AA) inhibition in short and midterm follow-up using thromboelastography with platelet mapping (TEG-PM) and to describe bleeding and thrombotic events during follow-up. We performed a prospective observational study of infants on aspirin following Norwood procedure, aortopulmonary shunt alone, or cavopulmonary shunt surgery. We obtained TEG-PM preoperatively, after the third dose of aspirin, at the first postoperative clinic visit, and 2-8 months after surgery. The primary outcome was the proportion of subjects with ≥50% AA inhibition on aspirin. All bleeding and thrombotic events were collected. Of 24 infants analyzed, 13% had ≥50% AA inhibition at all designated time points after aspirin initiation; 38% had ≥50% AA inhibition after the third aspirin dose of aspirin, 60% at the first postoperative clinic visit, and 26% 2-8 months after surgery. Bleeding events occurred in eight subjects, and two had a thrombotic event. Bleeding events were associated with greater AA inhibition just prior to starting aspirin (p = 0.02) and after the third dose of aspirin (p = 0.04), and greater ADP inhibition before surgery (p = 0.03). The majority of infants failed to consistently have ≥50% AA inhibition when checked longitudinally postoperatively. Preoperative TEG-PM may be useful in identifying infants at higher risk of bleeding events on aspirin in the early postoperative period. Further research is needed to guide antiplatelet therapy in this population.

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Adoption of a chylothorax management protocol is feasible, and in our small cohort of patients implementation led to a significant decrease in the duration of chest tube utilisation, while eliminating practice variability among providers.

Objective: To develop a prognostic model for predicting mortality at time of extracorporeal membrane oxygenation (ECMO) initiation for children which is important for determining centerspecific risk-adjusted outcomes.Design: Multivariable logistic regression using a large national cohort of pediatric ECMO patients. Setting:The intensive care units of the eight tertiary care children's hospitals of the Collaborative Pediatric Critical Care Research Network Patients: 514 children (< 19 years), enrolled with an initial ECMO run for any indication between January 2012 and September 2014. Interventions: NoneMeasurements and Main Results: A total of 514 first ECMO runs were analyzed with an overall mortality of 45% (n=232). Weighted logistic regression was used for model selection and internal validation was performed using cross validation. The variables included in the Pediatric ECMO Prediction (PEP) model were age (pre-term neonate, full-term neonate, infant, child, and adolescent), indication for ECMO (extracorporeal cardiopulmonary resuscition, cardiac, or respiratory), meconium aspiration, congenital diaphragmatic hernia, documented blood stream infection, arterial blood pH, partial thromboplastin time, and international normalized ratio. The highest risk of mortality was associated with the presence of a documented blood stream infection (OR 5.26; CI 1.90-14.57) followed by extracorporeal cardiopulmonary resuscitation (OR = 4.36;). The c-statistic was 0.75 (95% CI, 0.70-0.80). Conclusions:The PEP model represents a model for predicting in-hospital mortality among children receiving ECMO support for any indication. Consequently, it holds promise as the first comprehensive pediatric ECMO risk stratification model which is important for benchmarking ECMO outcomes across many centers.

This is the first multicenter study describing extracorporeal membrane oxygenation use and outcomes specific to the cardiac ICU and inclusive of surgical and medical cardiac disease. Mortality remains high, highlighting the importance of identifying levers to improve care. These data provide benchmarks for hospitals to assess their outcomes in extracorporeal membrane oxygenation patients and identify unique high-risk subgroups to target for quality initiatives.

Among neonates, investigation for intraventricular hemorrhage prior to extracorporeal membrane oxygenation and preservation of renal function are important factors for improvement. Earlier initiation of extracorporeal membrane oxygenation and careful attention to preservation of organ function are important to improve survival for children.