Survival outcomes after rescue extracorporeal cardiopulmonary resuscitation in pediatric patients with refractory cardiac arrest

Abstract

Objectives: We report our experience with extracorporeal cardiopulmonary resuscitation with extracorporeal membrane oxygenation in children having cardiac arrest refractory to conventional cardiopulmonary resuscitation and explore predictors for favorable outcome (survival with grossly intact neurologic status). Methods:We reviewed all patients who required extracorporeal cardiopulmonary resuscitation from 2000 to 2005. Multivariable regression analysis determined factors associated with favorable outcome and time-related survival.Results: Eighty children, median age 150 days (range: 1 day-17.6 years), required venoarterial extracorporeal cardiopulmonary resuscitation. There were several categories of disease among the patients: postcardiotomy (n ϭ 39), unoperated congenital heart disease (n ϭ 17), cardiomyopathy (n ϭ 12), respiratory failure (n ϭ 9), or myocarditis (n ϭ 3). Cannulation sites were neck (n ϭ 45) or chest (n ϭ 36). Median duration of extracorporeal membrane oxygenation was 4 days (range: 1-22). Extracorporeal membrane oxygenation was successfully discontinued in 42 (54%) patients: wean (n ϭ 35), heart transplantation (n ϭ 7). Survival till hospital discharge was 27 (34%) patients. Most common cause of death was ischemic brain injury (n ϭ 17). Twenty-four (30%) patients had a favorable outcome. Median duration of cardiopulmonary resuscitation for patients with favorable versus unfavorable outcome was 46 minutes (range: 14 -95; interquartile range: 29 -55) versus 41 minutes (range: 19 -110; interquartile range: 30 -55), P ϭ .916. According to the logistic regression model, none of the following factors was a significant predictor of favorable outcome: age, weight, sex, etiology (cardiac vs noncardiac), duration of cardiopulmonary resuscitation, cannulation site, timing, or location of extracorporeal membrane oxygenation institution.Conclusions: Acceptable survival and neurologic outcomes (30%) can be achieved with extracorporeal cardiopulmonary resuscitation in children after prolonged cardiac arrest (up to 95 minutes) refractory to conventional resuscitation measures. Heart transplantation is often needed for successful extracorporeal cardiopulmonary resuscitation exit strategy. Lack of predictors of poor outcome support aggressive attempts to initiate extracorporeal cardiopulmonary resuscitation in all patients, followed by subsequent assessment of organ salvage. I n-hospital cardiac arrest is associated with high mortality and subsequent morbidity in surviving children. [1][2][3][4][5][6][7][8][9] Additionally, increased duration of cardiopulmonary resuscitation (CPR) is associated with higher mortality and permanent central nervous system damage. After CPR duration lasting more than 30 minutes, survival with conventional CPR measures ranges between 0% and 5%. 1,2

Saving life and brain with extracorporeal cardiopulmonary resuscitation: A single-center analysis of in-hospital cardiac arrests

“…Our study supports a number of findings from an E-CPR study done in pediatric patients, which demonstrated that patient demographic factors such as age, weight and sex do not effect survival [6], and another paper indicating a correlation with duration of ECMO [16]. Our study also partially agrees with major conclusions from previous studies of adult E-CPR patients, which indicate that a state of acidosis is correlated with poor E-CPR outcomes [20].…”

“…E-CPR provides a method to stabilize hemodynamics and provide end-organ perfusion when traditional CPR is inadequate and the cause of cardiac arrest is reversible. While many studies have assessed the efficacy of E-CPR in pediatric populations [5][6][7], fewer have investigated it in an adult population. The studies of adult populations have assessed the success of E-CPR in adult populations by mortality, and many have not taken end-organ function into account.…”

Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease

“…Additional efforts are targeted at correcting hematologic deficiencies, including maintaining the hemoglobin >10 mg/dL, platelet count >100 000 per 1 mm 3 , fibrinogen >200 mg/dL, and AT III >1 U/mL. 501 In an effort to limit contact activation during ECMO support, internal surface modifications have been made to ECMO materials. Among the most commonly used is covalently bonded heparin (Carmeda, Medtronic Cardiopulmonary, Anaheim, CA).…”

“…This has been applied to all components of the circuit, including the internal tubing surfaces, cannulas, heat exchanger, and oxygenator. Alsoufi and colleagues 501 reported the outcome of 3 adult patients supported with a heparin-bonded ECMO circuit for postcardiotomy failure. All 3 patients were weaned from support, and 2 were long-term survivors.…”

Pediatric Neurocritical Care

“…Survival for pediatric patients has been reported as anywhere from 23 to 73% based on published, single-center experiences [174][175][176][177][178][179][180][181][182]. Two multicenter registry database analyses have also been performed.…”