The role and optimal therapeutic targets for anticoagulation during VV-ECMO are unclear. Previously published studies are limited by retrospective, observational design, small cohorts, and patient heterogeneity. The clinical significance of reported thrombotic complications is largely unknown. This systematic review underscores the need for randomized controlled trials of anticoagulation strategies for patients undergoing VV-ECMO for respiratory failure.

The extracorporeal membrane oxygenation (ECMO) circuit is made of a number of components that have been customized to provide adequate tissue oxygen delivery in patients with severe cardiac and/or respiratory failure for a prolonged period of time (days to weeks). A standard ECMO circuit consists of a mechanical blood pump, gas exchange device, and a heat exchanger all connected together with circuit tubing. ECMO circuits can vary from simple to complex and may include a variety of blood flow and pressure monitors, continuous oxyhemoglobin saturation monitors, circuit access sites and a bridge connecting the venous access and arterial infusion limbs of the circuit. Significant technical advancements have been made in the equipment available for short and long term ECMO applications. Contemporary ECMO circuits have greater biocompatibility and allow for more prolonged cardiopulmonary support time, while minimizing the procedure-related complications of bleeding, thrombosis and other physiologic derangements that were so common with the early application of ECMO. Modern era ECMO circuitry and components are simpler, safer, more compact and can be used across a wide variety of patient sizes from neonates to adults.

We reviewed reported survival and neurological outcomes, and predictors of these outcomes for pediatric cardiac extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR). We searched PubMed from 2000 to April 2011. Cumulative survival after cardiac ECMO in children was 788/1755 (45%); renal dysfunction, dialysis, neurologic complication, lactate, and ECMO duration consistently predicted this outcome, whereas single ventricle and ECPR did not. Neurological outcomes after cardiac ECMO were based on poorly described telephone questions in two studies for 47 patients with 51% significantly impaired and detailed follow-up testing for 42 patients in three studies with mental delay in 38% and mental score >85 (average or above) in 33%. Cumulative survival after ECPR in children was 371/762 (49%); noncardiac disease, renal dysfunction, neurologic complication, and pH on extracorporeal life support consistently predicted this outcome, whereas duration of CPR did not. Neurological outcomes after ECPR were based predominantly on the pediatric cerebral performance category (PCPC) score by chart review, with 161/181 (79%) having PCPC <2. No study reported detailed follow-up testing for survivors of ECPR. Survival outcomes of most cardiac subgroups were similar, except for concerning mortality in cavopulmonary connection patients. Priority areas for study include identification of potentially modifiable predictors of long-term outcomes.

Cardiac extracorporeal life support had a 41% 2-year survival. Potentially modifiable variables (time for lactate to normalize and highest inotrope score early during extracorporeal life support) explained 69% of mental score variance.

Extracorporeal life support (ECLS) is a modified form of cardiopulmonary bypass used to provide prolonged tissue oxygen delivery in patients with respiratory and/or cardiac failure. The first large-scale success of ECLS was achieved in the management of term newborns with respiratory failure. ECLS has become an accepted therapeutic modality for neonates, children, and adults who have failed conventional therapy and in whom cardiac and/or respiratory insufficiency is potentially reversible. The use of ECLS allows one to reduce other cardiopulmonary supports and apply a gentle ventilation strategy in a population of severely compromised critical care patients. ECLS has now been employed in more than 26,000 neonatal and pediatric patients with an overall survival rate of 68%. ECLS has evolved significantly over 25 years of clinical practice; patient selection for this complex and highly invasive therapy, as well as how ECLS is employed in different patient groups, is constantly changing. Generally, ECLS is used more liberally now than in the past. The number of patients requiring this support, however, is declining yearly, and those patients who receive ECLS compose a more severe subset of an intensive care population. This review provides an overview of the development of ECLS and the equipment and techniques employed. The use of ECLS for neonatal respiratory failure, pediatric respiratory failure, and cardiac support are outlined. Management of the ECLS patient is discussed in detail, and outcome of these patients is reviewed. Finally, current trends and future implications of ECLS in neonatal and pediatric critical care are addressed.

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Unfractionated heparin (UFH) is required in children on extracorporeal life support (ECLS) to maintain circuit patency. When high-dose UFH is inadequate to maintain an anticoagulant effect, the addition of antithrombin concentrate (ATC) is considered. The objective of this study was to review clinical experience giving 1,000 units (U) of ATC to patients on ECLS and UFH anticoagulation. Specifically, antithrombin (AT) levels pre- and post-administration of high-dose ATC, estimation of the efficacy of high-dose ATC administration as measured by the level of anticoagulation, and the incidence of adverse effects were determined. A retrospective chart review of all infants and children on ECLS who received ATC between June 2008 and May 2011 at Stollery Children's Hospital, Edmonton, Canada, was performed. A total of 78 doses of ATC were administered to 36 patients with a median age of 2.9 months (interquartile range, 0.6-12.6) on ECLS. Mean dose of ATC was 241 U/kg (95% confidence interval, 199-283). Mean AT level pre- and post-administration was 0.40 and 0.93 U/ml, respectively. Mean anti-Xa level pre- and post-AT administration was 0.23 and 0.41 U/ml, respectively. There were no associated acute adverse events. The administration of high-dose ATC decreases UFH dose requirements.

Objectives: To describe the characteristics of fluid accumulation in critically ill children and evaluate the association between the degree, timing, duration, and rate of fluid accumulation and patient outcomes. Design: Retrospective cohort study. Setting: PICUs in Alberta, Canada. Patients: All children admitted to PICU in Alberta, Canada, between January 1, 2015, and December 31, 2015. Interventions: None. Measurements and Main Results: A total of 1,017 patients were included. Fluid overload % increased from median (interquartile range) 1.58% (0.23–3.56%; n = 1,017) on day 1 to 16.42% (7.53–27.34%; n = 111) on day 10 among those remaining in PICU. The proportion of patients (95% CI) with peak fluid overload % greater than 10% and greater than 20% was 32.7% (29.8–35.7%) and 9.1% (7.4–11.1%), respectively. Thirty-two children died (3.1%) in PICU. Peak fluid overload % was associated with greater PICU mortality (odds ratio, 1.05; 95% CI, 1.02–1.09; p = 0.001). Greater peak fluid overload % was associated with Major Adverse Kidney Events within 30 days (odds ratio, 1.05; 95% CI, 1.02–1.08; p = 0.001), length of mechanical ventilation (B coefficient, 0.66; 95% CI, 0.54–0.77; p < 0.001), and length of PICU stay (B coefficient, 0.52; 95% CI, 0.46–0.58; p < 0.001). The rate of fluid accumulation was associated with PICU mortality (odds ratio, 1.15; 95% CI, 1.01–1.31; p = 0.04), Major Adverse Kidney Events within 30 days (odds ratio, 1.16; 95% CI, 1.03–1.30; p = 0.02), length of mechanical ventilation (B coefficient, 0.80; 95% CI, 0.24–1.36; p = 0.005), and length of PICU stay (B coefficient, 0.38; 95% CI, 0.11–0.66; p = 0.007). Conclusions: Fluid accumulation occurs commonly during PICU course and is associated with considerable mortality and morbidity. These findings highlight the need for the development and evaluation of interventional strategies to mitigate the potential harm associated with fluid accumulation.