Association of Extracorporeal Membrane Oxygenation Support Adequacy and Residual Lesions With Outcomes in Neonates Supported After Cardiac Surgery*

Howard, Taylor S.; Kalish, Brian T.; Wigmore, Daniel; Nathan, Meena; Kulik, Thomas J.; Kaza, Aditya K.; Williams, Kathryn; Thiagarajan, Ravi R.

doi:10.1097/pcc.0000000000000943

Cited by 52 publications

(63 citation statements)

References 28 publications

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“…First, the finding that 40% of early-ECMO patients had residual anatomic lesions that were corrected by intervention using catheterization or surgery highlights the importance of patient assessment with early TEE and/or cardiac catheterization if patients are not progressing as expected. The safety and importance of TEE and cardiac catheterization to identify and manage residual lesions, particularly in patients on ECMO, has been noted by others [22–28]. Kato et al found that patients who received catheterization within 48 h after ECMO cannulation had fewer respiratory complications and better 30-day survival than those who had later catheterization [27].…”

Section: Discussionmentioning

confidence: 99%

“…Agarwal et al found that earlier detection of residual lesions during the first 3 days of ECMO (compared with later detection) was associated with a higher rate of decannulation and survival to hospital discharge [23]. Howard et al found that the time to diagnosis or correction of residual lesions was significantly shorter in neonatal cardiac ECMO survivors (1 vs 2 days, p = 0.02) [28]. Second, the variables we found as independently predictive of early ECMO may not be easily modifiable.…”

Section: Discussionmentioning

confidence: 99%

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Predictors and outcomes of early post-operative veno-arterial extracorporeal membrane oxygenation following infant cardiac surgery

et al. 2018

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BackgroundWe aimed to determine predictors of, and outcomes after, veno-arterial extracorporeal membrane oxygenation instituted within 48 h after cardiac surgery (early ECMO) in young infants.MethodsPatients ≤ 6 weeks old having cardiac surgery from 2003 to 2012 were enrolled prospectively. Patients cannulated pre-operatively, intra-operatively, or ≥ 48 h post-operatively were excluded. Variables at p ≤ 0.1 on univariate regression were entered into multiple logistic regression to predict early ECMO. Early-ECMO cases were matched 1:2 for six demographic variables, and death by age 2 years old (determined using conditional logistic regression; presented as odds ratio (OR), 95% confidence interval (CI)) and General Adaptive Composite scores at age 2 years (determined using Wilcoxon rank sum) were compared; p ≤ 0.05 was considered statistically significant.ResultsOf 565 eligible patients over the 10-year period, 20 had early ECMO instituted at a mean (standard deviation) of 12.4 (11.4) h post-operatively, 10 of whom had extracorporeal cardiopulmonary resuscitation. Of early-ECMO patients, 8 (40%) were found to have residual anatomic defects requiring intervention with catheterization (n = 1) and/or surgery (n = 7). On multiple regression, the post-operative day 1 highest vasoactive-inotrope score (OR 1.02; 95%CI 1.06,1.08; p < 0.001), highest lactate (OR 1.2; 95%CI 1.06,1.35; p = 0.003), and lowest base deficit (OR 0.82; 95%CI 0.71,0.94; p = 0.004), CPB time (OR 1.01; 95%CI 1.00,1.02; p = 0.002), and single-ventricle anatomy (OR 5.35; 95%CI 1.66,17.31; p = 0.005) were associated with early ECMO. Outcomes at 2 years old compared between early-ECMO and matched patients were mortality 11/20 (55%) vs 11/40 (28%) (OR 3.22, 95%CI 0.98,10.63; p = 0.054) and General Adaptive Composite median 65 [interquartile range (IQR) 58, 81.5] in 9 survivors vs 93 [IQR 86.5, 102.5] in 29 survivors (p = 0.02).ConclusionsThe identified risk factors for, and outcomes after, having early ECMO may aid decision making in the acute period and confirm that neurodevelopmental follow-up for these children is necessary. The hypothesis that earlier institution of ECMO may improve long-term outcomes requires further study.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Predictors and outcomes of early post-operative veno-arterial extracorporeal membrane oxygenation following infant cardiac surgery

et al. 2018

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“…Elevated lactate levels are often a marker of inadequate tissue oxygenation and inability to clear lactate while receiving ECMO may indicate ongoing oxygen debt. Among neonatal and pediatric patients undergoing cardiac ECMO, prior studies have shown elevated lactate more than 24–72 hours post-cannulation is associated with increased mortality (18, 19) and that the time required for lactate to normalize (<2 mmol/L) on ECMO is associated with worse cognitive outcome in survivors (20). A recent study in adults receiving VV ECMO for acute respiratory distress syndrome found increased mortality among those who failed to clear lactate within the first 72 hours of ECMO (21).…”

Section: Discussionmentioning

confidence: 99%

Functional Status of Neonatal and Pediatric Patients After Extracorporeal Membrane Oxygenation*

Cashen

Reeder

Dalton

et al. 2017

Pediatric Critical Care Medicine

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Objective To describe functional status at hospital discharge for neonatal and pediatric patients treated with extracorporeal membrane oxygenation (ECMO), and identify factors associated with functional status and mortality. Design Secondary analysis of observational data collected by the Collaborative Pediatric Critical Care Research Network (CPCCRN) between December 2012 and September 2014. Setting Eight hospitals affiliated with the CPCCRN. Patients Patients were <19 years of age and treated with ECMO. Interventions Functional status was evaluated among survivors using the Functional Status Scale (FSS). Total FSS scores range from 6–30 and are categorized as 6–7 (good), 8–9 (mildly abnormal), 10–15 (moderately abnormal), 16–21 (severely abnormal) and >21 (very severely abnormal). Measurements and Main Results Of 514 patients, 267 (52%) were neonates (≤30 days old). Indication for ECMO was respiratory for 237 (46%), cardiac for 207 (40%) and extracorporeal cardiopulmonary resuscitation (eCPR) for 70 (14%). Among 282 survivors, 89 (32%) had good, 112 (40%) mildly abnormal, 67 (24%) moderately abnormal, and 14 (5%) severely or very severely abnormal function at hospital discharge. Among neonates, development of renal failure and longer hospitalization were independently associated with worse FSS. Chronic conditions, prematurity, venoarterial ECMO, increased red cell transfusion in the first 24 hours of ECMO, and longer ECMO duration were independently associated with mortality. Among pediatric patients, chronic neurologic conditions, tracheostomy or home ventilator, eCPR, hepatic dysfunction and longer intensive care unit stay were independently associated with worse FSS. Chronic cardiac conditions, hepatic dysfunction, and neurologic or thrombotic complications were independently associated with mortality. Achieving blood lactate concentration ≤2 mmol/L during ECMO was independently associated with survival in both neonatal and pediatric patients. Conclusions In this study, about half of ECMO patients survived with good, mildly abnormal or moderately abnormal function at hospital discharge. Patient and ECMO related factors are associated with functional status and mortality.

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“…Pediatric cardiac surgical programs routinely use extracorporeal membrane oxygenation (ECMO) to rescue surgical patients with cardiopulmonary failure, and predictors of ECMO support in these patients have been well documented . However, predictors of ECMO support in adults after CHD surgery have not been previously reported.…”

Section: Introductionmentioning

confidence: 99%

“…3,6 Pediatric cardiac surgical programs routinely use extracorporeal membrane oxygenation (ECMO) to rescue surgical patients with cardiopulmonary failure, and predictors of ECMO support in these patients have been well documented. [7][8][9][10][11] However, predictors of ECMO support in adults after CHD surgery have not been previously reported. Because adult patients are likely to be active participants in their medical decision making, identifying patients who are at increased risk of requiring ECMO support is important for presurgical discussion and planning.…”

Section: Introductionmentioning

confidence: 99%

Predictors of extracorporeal membrane oxygenation support after surgery for adult congenital heart disease in children's hospitals

Dolgner

Krieger

Wilkes

et al. 2019

Congenital Heart Disease

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Objective Adult congenital heart disease (ACHD) patients who undergo cardiac surgery are at risk for poor outcomes, including extracorporeal membrane oxygenation support (ECMO) and death. Prior studies have demonstrated risk factors for mortality, but have not fully examined risk factors for ECMO or death without ECMO (DWE). We sought to identify risk factors for ECMO and DWE in adults undergoing congenital heart surgery in tertiary care children's hospitals. Design All adults (≥18 years) undergoing congenital heart surgery in the Pediatric Health Information System (PHIS) database between 2003 and 2014 were included. Patients were classified into three groups: ECMO‐free survival, requiring ECMO, and DWE. Univariate analyses were performed, and multinomial logistic regression models were constructed examining ECMO and DWE as independent outcomes. Setting Tertiary care children's hospitals. Results A total of 4665 adult patients underwent ACHD surgery in 39 children's hospitals with 51 (1.1%) patients requiring ECMO and 64 (1.4%) patients experiencing DWE. Of the 51 ECMO patients, 34 (67%) died. Increasing patient age, surgical complexity, diagnosis of single ventricle heart disease, preoperative hospitalization, and the presence of noncardiac complex chronic conditions (CCC) were risk factors for both outcomes. Additionally, low and medium hospital ACHD surgical volume was associated with an increased risk of DWE in comparison with ECMO. Conclusions There are overlapping but separate risk factors for ECMO support and DWE among adults undergoing congenital heart surgery in pediatric hospitals.

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Association of Extracorporeal Membrane Oxygenation Support Adequacy and Residual Lesions With Outcomes in Neonates Supported After Cardiac Surgery*

Abstract: Our data suggest that clearance of lactate is an important therapeutic target for patients cannulated to extracorporeal membrane oxygenation. In addition, timely identification of residual lesions and expedient interventions on those lesions may improve survival.

Cited by 52 publications

References 28 publications

Predictors and outcomes of early post-operative veno-arterial extracorporeal membrane oxygenation following infant cardiac surgery

Predictors and outcomes of early post-operative veno-arterial extracorporeal membrane oxygenation following infant cardiac surgery

Functional Status of Neonatal and Pediatric Patients After Extracorporeal Membrane Oxygenation*

Predictors of extracorporeal membrane oxygenation support after surgery for adult congenital heart disease in children's hospitals

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