Extracorporeal Membrane Oxygenation Outcomes in Children With Preexisting Neurologic Disorders or Neurofunctional Disability*

Abstract

Patient selection for pediatric extracorporeal membrane oxygenation (ECMO) support has broadened over the years to include children with preexisting neurologic morbidities. We aimed to determine the prevalence and nature of pre-ECMO neurologic disorders or disability and investigate the association between pre-ECMO neurologic disorders or disability and mortality and unfavorable neurologic outcome. DESIGN:Multicenter retrospective observational cohort study. SETTING:Eight hospitals reporting to the Pediatric ECMO Outcomes Registry between October 2011 and June 2019. PATIENTS:Children younger than 18 years supported with venoarterial or venovenous ECMO. INTERVENTIONS:The primary exposure was presence of pre-ECMO neurologic disorders or moderate-to-severe disability, defined as Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) 3-5. The primary outcome was unfavorable outcome at hospital discharge, defined as in-hospital mortality or survival with moderate-to-severe disability (discharge PCPC 3-5 with deterioration from baseline). MEASUREMENTS AND MAIN RESULTS:Of 598 children included in the final cohort, 68 of 598 (11%) had a pre-ECMO neurologic disorder, 70 of 595 (12%) had a baseline PCPC 3-5, and 189 of 592 (32%) had a baseline POPC 3-5. The primary outcome of in-hospital mortality (n = 267) or survival with PCPC 3-5 with deterioration from baseline (n = 39) was observed in 306 of 598 (51%). Overall, one or more pre-ECMO neurologic disorders or disability were present in 226 of 598 children (38%) but, after adjustment for age, sex, diagnostic category, pre-ECMO cardiac arrest, and ECMO mode, were not independently associated with increased odds of unfavorable outcome (unadjusted odds ratio [OR], 1.34; 95% CI, 1.07-1.69; multivariable adjusted OR, 1.30; 95% CI, 0.92-1.82). CONCLUSIONS:In this exploratory study using a multicenter pediatric ECMO registry, more than one third of children requiring ECMO support had pre-ECMO neurologic disorders or disability. However, pre-existing morbidities were not independently associated with mortality or unfavorable neurologic outcomes at hospital discharge after adjustment for diagnostic category and other covariates.

Preselected Choices

“…In this context, a recent report in Pediatric Critical Care Medicine highlights the use of ECMO in children with preexisting neurologic disorders or neurofunctional disabilities (4). In this analysis, almost one-quarter of almost 600 patients had a pre-ECMO neurological condition ( Table 1 ).…”

“…Third, a point of detail: why does the number of patients with developmental delay not match the number of syndromic patients reported in the article? (4)…”

Editor’s Choice Articles for November

“…My next Editor's Choice article comes from the eight U.S. hospitals reporting to the Pediatric ECMO Outcomes Registry (PEDECOR) over a period of almost 8 years. The authors aimed to determine the prevalence and nature of pre-ECMO neurologic disorders or disability, and to investigate any association between such disorders with subsequent unfavorable outcomes (2). The accompanying editorial comes from experienced PCCM authors at centers in Boston, Sydney, and Toronto (5).…”

Discretion Over Discrimination: Toward Good Decisions for Extracorporeal Membrane Oxygenation Use in Patients With Neurological Comorbidities*

“…In this context, the article by Dante et al (7) in this issue of Pediatric Critical Care Medicine provides valuable data around outcomes in patients with preexisting neurologic “disorders” or “neurofunctional disability” supported on ECMO. “Disability” criteria were adjudicated by baseline Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC).…”

“…However, ECMO should be framed as a bridge toward a goal (15). Therefore, when we translate data, such as that offered by Dante et al (7), into discussions with families that weigh benefits and burdens, we must be transparent about what ECMO can or cannot achieve. ECMO cannot address an underlying neurologic illness trajectory or improve quality of life.…”