Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs*

Abstract

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) has been used successfully to support adults with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related cardiac or respiratory failure refractory to conventional therapies. Comprehensive reports of children and adolescents with SARS-CoV-2–related ECMO support for conditions, including multisystem inflammatory syndrome in children (MIS-C) and acute COVID-19, are needed. DESIGN: Case series of patients from the Overcoming COVID-19 public health surveillance registry. SETTING: Sixty-three hospitals in 32 U.S. states reporting to the registry between March 15, 2020, and December 31, 2021. PATIENTS: Patients less than 21 years admitted to the ICU meeting Centers for Disease Control criteria for MIS-C or acute COVID-19. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The final cohort included 2,733 patients with MIS-C ( n = 1,530; 37 [2.4%] requiring ECMO) or acute COVID-19 ( n = 1,203; 71 [5.9%] requiring ECMO). ECMO patients in both groups were older than those without ECMO support (MIS-C median 15.4 vs 9.9 yr; acute COVID-19 median 15.3 vs 13.6 yr). The body mass index percentile was similar in the MIS-C ECMO versus no ECMO groups (89.9 vs 85.8; p = 0.22) but higher in the COVID-19 ECMO versus no ECMO groups (98.3 vs 96.5; p = 0.03). Patients on ECMO with MIS-C versus COVID-19 were supported more often with venoarterial ECMO (92% vs 41%) for primary cardiac indications (87% vs 23%), had ECMO initiated earlier (median 1 vs 5 d from hospitalization), shorter ECMO courses (median 3.9 vs 14 d), shorter hospital length of stay (median 20 vs 52 d), lower in-hospital mortality (27% vs 37%), and less major morbidity at discharge in survivors (new tracheostomy, oxygen or mechanical ventilation need or neurologic deficit; 0% vs 11%, 0% vs 20%, and 8% vs 15%, respectively). Most patients with MIS-C requiring ECMO support (87%) were admitted during the pre-Delta (variant B.1.617.2) period, while most patients with acute COVID-19 requiring ECMO support (70%) were admitted during the Delta variant period. CONCLUSIONS: ECMO support for SARS-CoV-2–related critical illness was uncommon, but type, initiation, and duration of ECMO use in MIS-C and acute COVID-19 were markedly different. Like pre-pandemic pediatric ECMO cohorts, most patients survived to hospital discharge.

Executive Summary: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE (PEACE) Consensus Conference*

“…At the time of the PEACE consensus conference, the use of ECMO support for pediatric patients with COVID-19 was not well known. We did not have access to the 2023 meta-analysis data about 110 pediatric cases in the worldwide literature ( 10 ), nor did we have information about 108 U.S.-based cases managed 2020–2021 ( 11 ). For this reason, we are unable to comment with confidence on whether our consensus statements apply to this patient population.…”

Editor’s Choice Articles for May

“…The entire cohort included 2,733 patients, of whom 108 were supported with ECMO. In addition to important information about the time course of care, the authors also show data that add to PCCM's focus on social determinants of health (2, 3), with analyses according to race, ethnicity, healthcare insurance status, and social vulnerability index (1). All these themes are discussed in the accompanying editorial (4), and it is also worth rereading PCCM's approach to SARS-CoV-2related research (5): we are committed to innovation and new perspectives, and the 2020/2021 US registry satisfies these criteria.…”

“…Bembea MM, Loftis LL, Thiagarajan RR, et al; Overcoming Investigators: Extracorporeal Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs (1).…”

“…The authors have identified 44 studies (18 observational, four case series, and 22 case reports) involving 110 children receiving ECMO in the period up to March 2022. The review is a comprehensive summary of the literature up to PCCM's latest edition (1), and the accompanying editorial provides a unique assessment of what these data mean in the wider context of the literature in adults (7).…”

What’s new in neonatal and pediatric extracorporeal membrane oxygenation in 2022–2023? Insights from the EuroELSO congress 2023

“…In 2022 and 2023 we also got the first pediatric data from United States on the use of ECMO in patients with multisystem inflammatory syndrome associated to COVID-19 (MIS-C) and with severe acute respiratory syndrome coronavirus 2 (COVID-19). Using a hospital-based surveillance registry Bembea et al 24 described the clinical characteristics and outcomes of patients with MIS-C and with severe COVID-19 PARDS supported with ECMO between March 2020 till December 2021. In this public registry, the use of ECMO to manage these patients was uncommon (108 patients from 62 hospitals).…”