Objectives To determine the prevalence of and risk factors for hemorrhagic complications in children with cardiac disease requiring extracorporeal membrane oxygenation. Design Retrospective review of the Extracorporeal Life Support Organization Registry (2002–2013). Setting Participating Extracorporeal Life Support Organization centers. Patients Patients less than 18 years old on extracorporeal membrane oxygenation. Interventions None. Measurements and Main Results Of 21,845 patients requiring extracorporeal membrane oxygenation during the study period, 8,905 (41%) had cardiac disease, and 79% of whom (6,995) had cardiac surgery. Hemorrhagic complications occurred in 8,480 patients (39% of overall cohort), with higher rates in cardiac versus noncardiac patients (49% vs 32%; p < 0.0001) related to cannulation and surgical site bleeding. Cardiac surgical patients had higher rates of hemorrhage compared with cardiac medical patients (57% vs 38%; p < 0.0001), and cardiac patients with hemorrhage had higher extracorporeal membrane oxygenation mortality compared with those without (42% vs 22% in medical patients and 34% vs 20% in surgical patients; both p < 0.0001). In multivariable analysis in both the cardiac medical and surgical groups, hemorrhage risk was higher in children greater than 1 year old and in patients with longer extracorporeal membrane oxygenation duration. Additional independent risk factors for hemorrhage in cardiac surgical patients included pre-extracorporeal membrane oxygenation mediastinal exploration (odds ratio, 3.6; 95% CI, 2.1–6.3), Society of Thoracic Surgeons morbidity category 4–5 (odds ratio, 1.2; 95% CI, 1.03–1.5), cannulation less than 24 hours after surgery (odds ratio, 1.6; 95% CI, 1.3–1.9), and longer cardiopulmonary bypass time (≥ 282 min [upper quartile]; odds ratio, 1.5; 95% CI, 1.3–1.9). Conclusions In this large, multicenter analysis, hemorrhagic complications occurred in nearly half of children with heart disease on extracorporeal membrane oxygenation and were associated with a significant mortality risk. Several factors were associated with hemorrhagic complications in cardiac surgical patients including pre-extracorporeal membrane oxygenation mediastinal exploration, greater surgical complexity, early postoperative cannulation, and longer bypass times. Whether these risks can be mitigated by modifying or delaying systemic anticoagulation requires further investigation.

Background Stroke is a common complication of extracorporeal membrane oxygenation (ECMO), and pediatric cardiac surgical patients may be at higher risk. Epidemiology and risk factors for stroke in these patients are not well-characterized. Methods We analyzed pediatric (<18 years-old) cardiac ECMO cases in the Extracorporeal Life Support Organization Registry from 2002-2013. Cardiac surgical patients were identified and procedures stratified by Society of Thoracic Surgeons (STS) morbidity categories. The primary outcome was any stroke (hemorrhagic or infarction) identified by neuroimaging. Risk factors were identified through multivariable logistic regression. Results We analyzed 3,517 cardiac surgical patients; 81% with cyanotic disease, and 57% in high-risk STS categories (4-5). Overall, 12% developed stroke on ECMO and those with stroke had greater in-hospital mortality (72% vs. 51%, p<0.0001). In multivariable analysis, neonatal status (adjusted odds ratio 1.8, 95% confidence interval 1.3-2.4), lower weight-for-age z-score (adjusted odds ratio 1.1 for each one-point decrease, 95% confidence interval 1.04-1.25), and longer ECMO duration (upper quartile [≥167 hours] adjusted odds ratio 1.4, 95% confidence interval 1.1-1.8) were independently associated with increased stroke risk, while cyanotic disease, STS category, and bypass time were not. Conclusions This multicenter analysis demonstrates that pediatric cardiac surgical patients on ECMO are at high risk of stroke; younger or underweight patients, and those with longer ECMO duration are at greatest risk, independent of procedural complexity. Future study is necessary to determine how anticoagulation or other clinical practices can be modified to reduce stroke incidence.

OBJECTIVES: Define a set of entrustable professional activities for pediatric cardiac critical care that are recognized as the core activities of the subspecialty by a diverse group of pediatric cardiac critical care physicians and that can be broadly and consistently applied irrespective of training pathway.DESIGN: Mixed methods study with sequential integration of qualitative and quantitative data. SETTING:Structured telephone interviews of pediatric cardiac critical care medical directors at Pediatric Cardiac Critical Care Consortium centers followed by an electronic survey of pediatric cardiac critical care physician members of the Pediatric Cardiac Intensive Care Society from across the United States and internationally. SUBJECTS:Pediatric cardiac intensive care physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:Twenty-four of 26 eligible Pediatric Cardiac Critical Care Consortium medical directors participated in the interviews. Based on qualitative analyses of interview data, we identified an initial set of nine entrustable professional activities. Fifty-eight of 185 eligible physicians completed a subsequent survey asking them to rate their agreement with the entrustable professional activities. It showed consensus (> 80% agreement) with the entire initial set of entrustable professional activities, with greater than 96% agreement in most cases. The feedback from free-text survey responses was incorporated to generate a final set of entrustable professional activities. CONCLUSIONS:We generated a set of nine entrustable professional activities, which we believe can be broadly applied to any physician training in pediatric cardiac critical care, irrespective of individual training pathway. Next steps include incorporation of these entrustable professional activities into curriculum design and trainee assessment tools.