Use of Extracorporeal Membrane Oxygenation in Acutely Poisoned Pediatric Patients in United States: A Retrospective Analysis of the Extracorporeal Life Support Registry From 2003 to 2019

Abstract

OBJECTIVES: To describe the use of extracorporeal membrane oxygenation (ECMO) in the management of pediatric poisoning in the United States and to identify predictors of mortality. DESIGN: Retrospective cohort study. SETTING: Data reported to the Extracorporeal Life Support Organization by 76 U.S. ECMO centers from 2003 to 2019. PATIENTS: Pediatric patients (0–18 yr) receiving ECMO for poisoning. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During our study period, 86 cases of acute poisoning were identified and included in the analysis. The median age was 12.0 year and 52.9% were female. The most commonly reported substance exposures were hydrocarbon (n = 17; 19.8%), followed by chemical asphyxiants (n = 14; 16.3%), neuroactive agents (n = 14; 16.3%), opioid/analgesics (n = 13; 15.1%), and cardiovascular agents (n = 12; 14.0%). Single substance exposures were reported in 83.7% of the cases. The intention of the exposure was unknown in 65.1%, self-harm in 20.9% and 10.5% was unintentional exposure. Fifty-six patients (65.1%) survived. Venoarterial ECMO was used more frequently than venovenous ECMO, and its use increased significantly during the study period (p < 0.01). A bimodal distribution of ECMO support was observed among two age groups: less than or equal to 3 years (n = 34) and 13–17 years (n = 41). Hemodynamic and metabolic parameters improved for all patients with ECMO. Persistent systolic hypotension, acidemia/metabolic acidosis, and elevated Pao2) after 24 hours of ECMO support were associated with mortality. Time from PICU admission to ECMO cannulation was not significantly different between survivors (24.0 hr; interquartile range [IQR], 11.0–58.0 hr) and nonsurvivors (30.5 hr; IQR, 10.0–60.2 hr; p = 0.58). ECMO duration and PICU length of stay were significantly longer in survivors than in nonsurvivors (139.5 vs 70.5 hr; p = 0.007 and 25.0 vs 4.0 d; p = 0.002, respectively). CONCLUSIONS: ECMO may improve the hemodynamic and metabolic status of poisoned pediatric patients. Persistent hypotension, acidemia/acidosis, and elevated Pao2 after 24 hours of ECMO were associated with mortality.

Antidepressant Poisoning Trends in Pediatric Intensive Care

“…Interventions frequently performed to treat antidepressant drug toxicity include administering substances to prevent or reduce absorption of the toxic substance through the GI tract, giving an antidote (if available), sodium bicarbonate administration for alkalization, ILE therapy, and extracorporeal supportive treatments 19,20 …”

“…6 Interventions frequently performed to treat antidepressant drug toxicity include administering substances to prevent or reduce absorption of the toxic substance through the GI tract, giving an antidote (if available), sodium bicarbonate administration for alkalization, ILE therapy, and extracorporeal supportive treatments. 19,20 One of the treatments used in OG antidepressant poisoning is intravenous sodium bicarbonate therapy. Plasma alkalization is another commonly used method in antidepressant poisoning, especially in patients with signs of severe cardiovascular and neurological toxicity due to TCAs.…”

Surgical Science and the Evolution of Critical Care Medicine

“…Relatedly, the articulation of ECMO rescue teams to bring therapies to patients too unstable to travel has expanded access to life-saving therapy by both ground and air ambulance modalities (155). ECMO survival rates have increased, with survival for adult pulmonary ECLS 66%, adult cardiac ECLS 59%, and ECPR 41% from the April 2022 ELSO Registry Report; pediatric and neonatal ECLS survival rates are even higher including when used to help manage pediatric poisoning or stem cell transplantation (156)(157)(158). The number of ECMO centers has also increased significantly from 150 in 2008 to over 500 in 2022, paralleling the increase in indications, as well as dwindling contraindications for ECLS approaches including as a bridge to Left Ventricular Assist Device placement for cardiogenic shock management or pulmonary embolism rescue (159)(160)(161).…”

Pediatric Highlights From the Extracorporeal Life Support Organization Registry: 2017–2022

“…Di Nardo et al observed that 86 acutely poisoned pediatric patients were rescued with ECMO in the USA from 2003 to 2019. 28 The use of ECMO in these patients progressively increased over time, reflecting the overall increased use of ECMO for diverse medical indications. Hydrocarbons, chemical asphyxiants, neuroactive agents, opioid/analgesics, and cardiovascular agents were the most frequently reported exposures requiring ECMO.…”