Objectives: Standards for neuromonitoring during extracorporeal membrane oxygenation support do not currently exist, and there is wide variability in practice. We present our institutional experience at an academic children’s hospital since establishment of a continuous electroencephalography monitoring protocol for extracorporeal membrane oxygenation patients. Design: Retrospective, single-center study. Setting: Neonatal ICU and PICU in an urban, quaternary care center. Patients: All neonatal and pediatric patients requiring extracorporeal membrane oxygenation. Interventions: None. Measurements and Main Results: During the study period, 70 patients were cannulated for extracorporeal membrane oxygenation and had continuous electroencephalography monitoring for greater than 24 hours. Electroencephalographic seizures were observed in 16 of 70 patients (23%), including five patients (7%) who were in status epilepticus. Among patients with continuous electroencephalography seizures, nine (56%) had subclinical nonconvulsive status epilepticus and eight (50%) had seizures in the initial 24 hours of extracorporeal membrane oxygenation support. Survival to hospital discharge was significantly greater for extracorporeal membrane oxygenation patients without seizures (74% vs 44%; p = 0.02). Conclusions: Seizures occur in a significant proportion of pediatric and neonatal extracorporeal membrane oxygenation patients, frequently in the initial 24 hours after extracorporeal membrane oxygenation cannulation. Because seizures are associated with significantly decreased survival, neuromonitoring early in the extracorporeal membrane oxygenation course is important and useful. Further studies are needed to correlate electroencephalography findings with neurologic outcome.
Hemolysis is a common complication of pediatric extracorporeal membrane oxygenation. We found that patients with hemolysis (plasma-free hemoglobin > 30 mg/dL) had a 10-fold increase in in-hospital mortality. In our study cohort, hemolysis was associated with continuous ultrafiltration use, but not continuous renal replacement therapy. Additionally, our results suggest that the degree of coagulopathy (international normalized ratio > 3.5) at the time of cannulation influences hemolysis. Additional prospective studies are necessary to define further strategies to prevent hemolysis and improve outcomes in pediatric extracorporeal membrane oxygenation patients.
Surgeons are no strangers to mass casualty incidents. Although the coronavirus disease 2019 (COVID-19) epidemic may not involve many trips to the operating room, the lessons learned in organizational management of prior natural disasters, mass shootings, and transportation incidents are valuable. At our institution, more than a quarter of patients who initially present with COVID-19 have been intubated, requiring multiple, time-consuming bedside procedures for hemodynamic monitoring and central venous access. As the hospital architecture has changed to suit the demands of the coronavirus pandemic, its workforce has also needed to evolve.In response, the surgical residency has created a special team, the surgical workforce activation team (SWAT), to help offload procedural work from the other emergency medicine, critical care, and medicine departments. The mission of the SWAT is to build and deploy a specialized team of clinicians with the skill set to efficiently perform bedside procedures in an effort to support our colleagues, reduce health care personnel exposure, preserve personal protective equipment, and provide quality care to patients during the COVID-19 pandemic. We have performed common, time-consuming procedures, including setting up central catheters, arterial catheters, and dialysis catheters, thereby alleviating the workflow of intensive care unit (ICU) teams.
Lower-extremity ischemia is a significant complication in children on femoral venoarterial extracorporeal membrane oxygenation (VA ECMO). Our institution currently routinely uses distal perfusion catheters (DPCs) in all femoral arterial cannulations in attempts to reduce ischemia. We performed a single-center, retrospective review of pediatric patients supported with femoral VA ECMO from January 2005 to November 2015. The outcomes of patients with prophylactic DPC placement at cannulation (prophylactic DPC) were compared to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complication requiring invasive intervention (fasciotomy or amputation) was the primary outcome. Twenty-nine patients underwent a total of 31 femoral arterial cannulations, 17 with prophylactic DPC and 14 with reactive DPC. Ischemic complications requiring invasive intervention developed in 2 of 17 (12%) prophylactic DPC patients versus 4 of 14 (29%) reactive DPC. In the reactive DPC group, 7 of 14 (50%) had ischemic changes postcannulation, six underwent DPC placement, and three out of six of these patients still required invasive intervention. One of the seven patients had ischemic changes, did not undergo DPC, and required amputation. While a greater percentage of patients in the prophylactic group was cannulated during extracorporeal cardiopulmonary resuscitation (ECPR), statistical significance was not otherwise demonstrated. We demonstrate feasibility of superficial femoral artery (SFA) access in pediatric patients. We note fewer ischemic complications with prophylactic DPC placement, and observe that salvaging a limb with a reactive DPC was only successful 50% of the time. Although there was no statistical difference in the primary outcome between the two groups, limitations and confounding factors include small sample size and a greater percentage of patients in the prophylactic DPC group cannulated with ECPR in progress.
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