Development and Validation of a Score to Predict Mortality in Children Undergoing Extracorporeal Membrane Oxygenation for Respiratory Failure: Pediatric Pulmonary Rescue With Extracorporeal Membrane Oxygenation Prediction Score*

Abstract

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.

What is new in pediatric ECMO? 2016, a year in review

“…ECMO is not a solution to all problems, and we need to try and find ways to better predict outcomes and limit complications of therapy. In 2016 a few very important steps have been made with the development of risk estimation scores . Further research can focus on external validation of these scores and identifying other modifiable risk factors that could help improve prognostication.…”

“…In 2016 three pediatric risk estimate scores were published for respiratory ECMO patients and a fourth was published in January 2017 . Previously no risk estimate scores were available for children on ECMO.…”

“…The fourth score that was developed, also used the ELSO registry data from > 4000 children with respiratory ECMO but then validated their score using over 2000 patients from the PHIS dataset . The authors included 14 variables to develop the P‐PREP score (http://www.picuscientist.org/pprep/).…”

Extracorporeal membrane oxygenation with prone position ventilation successfully rescues infantile pertussis: a case report and literature review

“…Patients infected Bordetella pertussis were characterized by cough-associated apnea, cyanosis, PHT and encephalopathy [ 6 ]. When these infants with severe respiratory failure is poorly responsive to conventional and alternative therapies, ECMO can be considered as a promising rescue therapy [ 7 ], even if pertussis itself implies worse outcome among the indications for ECMO initiation for pediatric respiratory failure [ 8 ]. Based on ELSO Registry data, younger age, lower PaO 2 /FiO 2 ratio, vasoactive use, PHT, and a rapidly progressive course were associated with increased mortality [ 3 ].…”

Mechanical Ventilation in Children on Venovenous ECMO

“…Data collection was completed via a HIPAA-compliant online data entry web site (REDCap, Vanderbilt University, Nashville, Tennessee). Pre-ECMO data collected included demographics, Pediatric Pulmonary Rescue With Extracorporeal Membrane Oxygenation Prediction variables, 22 and Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS) variables. 23 Ventilator mode and settings, blood gas values, and ECMO settings were recorded for the first 7 d on ECMO, using values recorded closest to 8 AM.…”