Rescue extracorporeal membrane oxygenation in children with refractory cardiac arrest

We describe our experience with extracorporeal cardiopulmonary resuscitation (CPR) using extracorporeal membrane oxygenation (ECMO) in children with refractory cardiac arrest, and determine predictors for mortality. ECMO support was instituted on 42 children, median age 0.7 years (1 day-17.8 years), median weight 7.05 (range 2.7-80) kg who suffered refractory cardiac arrest (1992-2008). Patients were postcardiotomy (n=27), or had uncorrected congenital heart diseases (n=3), cardiomyopathy (n=3), myocarditis (n=2), respiratory failure (n=3), or had trauma (n=4). Cannulation site was the chest in all except for three neonates who were cannulated through the neck vessels and two children who had femoral cannulation. ECMO was successfully discontinued in 17 patients. Primary cause of mortality was neurological injury. Pre-ECMO CPR duration for survivors against those who died was a mean of 35±1.3 min vs. a mean of 46±4.2 min. Age, weight, sex, anatomic diagnosis, etiology (surgical vs. medical) were not significant predictors of poor outcome. Prolonged CPR and high-dose inotropes are significant predictors of mortality. Rescue ECMO support in children with refractory cardiac arrest can achieve acceptable survival and neurological outcomes.     

Pathophysiology of cardiac extracorporeal membrane oxygenation

The treatment of cardiogenic shock using inotropic agents and vascular volume expansion places an added burden on the heart. The resultant increase in cardiac work may cause myocardial ischemia and lead to cardiac arrest. Extracorporeal membrane oxygenation (ECMO) may be used to treat cardiogenic shock. It supports systemic circulation, assures diastolic perfusion of the myocardium, and reduces cardiac workload. The rise in blood pressure associated with restoring systemic circulation afterloads the heart and can cause left atrial hypertension and pulmonary edema. ECMO does not automatically reduce cardiac work, especially in the presence of residual shunts. Left atrial drainage or decompression may be essential in certain patients both to avert pulmonary edema and to reduce cardiac work.     

Beneficial outcome after prostaglandin-induced post-partum cardiac arrest using levosimendan and extracorporeal membrane oxygenation

BACKGROUND: Administration of high doses of prostaglandins is a frequently performed and effective method for the treatment of atonic uterine haemorrhage in order to increase uterine muscle tone. Rarely, however, these drugs may cause life-threatening complications including bronchospasm, acute pulmonary oedema and myocardial infarction caused by coronary spasms. METHODS: We discuss the management of a patient suffering post-partum atonic uterine bleeding, catecholamine-resistant cardiac arrest and fulminant pulmonary failure due to deleterious side-effects of treatment with prostaglandins. RESULTS: During therapy resistant cardiopulmonary resuscitation, the addition of levosimendan to standard medications resulted in a prompt stabilization of haemodynamics. Subsequent treatment of pulmonary failure was successfully managed with ECMO. CONCLUSION: Although levosimendan is not approved for pharmacological treatment of cardiopulmonary arrest, the beneficial effects in this patient suggest an important role of calcium sensitization and vasodilation during prostaglandin-induced cardiac arrest.     

The development and use of extracorporeal membrane oxygenation in neonates

Extracorporeal membrane oxygenation (ECMO) is the utilization of a modified heart-lung machine to provide temporary support for patients with severe respiratory or cardiac failure. In contrast to patients managed with traditional cardiopulmonary bypass, patients on ECMO undergo cannulation of relatively accessible blood vessels, are maintained at normal body temperature, and only require partial anticoagulation with heparin. Although first developed for use in adults, ECMO has been most successful in the treatment of newborn infants with life-threatening pulmonary failure. Since 1974, over 17,000 infants have received ECMO with a 78% survival rate. There is a 15%-20% incidence of neurodevelopmental disabilities among ECMO survivors.     

Termination of extracorporeal membrane oxygenation for cardiac support

The determination of when to stop extracorporeal membrane oxygenation (ECMO) rests upon demonstration of the return of adequate cardiac function to support vital organs and permit subsequent recovery. In general, patients with myocardial stun will recover function within several days. Factors that limit recovery include elevated end diastolic pressures leading to marginal myocardial perfusion, ongoing organ damage, massive anasarca, or progressive deterioration in lung function. Following a trial of slow weaning of ECMO support to condition the heart to take over the entire system flow requirements, decannulation can be accomplished in a standard fashion. When weaning is not successful and additional time does not lead to adequate recovery of cardiac function, physicians and nurses must be prepare to realistically advise families regarding such options as cardiac transplantation or withdrawal of support. It is critically important to provide an open and nonjudgmental environment for families to make these difficult decisions. The greatest difficulties involve ethical and emotional decisions that need to be made in a timely fashion to prevent undo burden on the patient when further ECMO support is futile.     

Surgical aspects of pediatric cardiac extracorporeal membrane oxygenation

Because children with severe myocardial dysfunction have limited therapeutic options, mechanical support of a failing heart is a matter of great interest. In the setting of cardiogenic shock or severe low cardiac output and hypoperfusion, extracorporeal membrane oxygenation (ECMO) can produce decisive improvements. The criteria for successful treatment include appropriate patient selection, improved surgical techniques and experience, higher recognition and anticipation of complications, and minimized delay in initiation of ECMO. Because the need for mechanical circulatory support may arise pre-, intra-, and postoperatively, every pediatric cardiac surgeon must be familiar with the principles and the surgical aspects of ECMO.     

Use of roller pump in venovenous extracorporeal membrane oxygenation as an emergency rescue procedure

A 41 years old male patient, having acute respiratory distress syndrome (ARDS) due to viral pneumonia, was put on venovenous (VV) extracorporeal membrane oxygenation (ECMO). After 3 h of initiation, the ECMO pump malfunctioned. The patient was initially managed on a hand crank for 5 h. However, as another machine would be available after 12–24 h, we decided to use a roller pump with a conventional cardiopulmonary bypass (CPB) circuit. We successfully manage this crisis with this technique without any complications. This technique can be lifesaving in catastrophic situations such as ECMO console or pump failures when there are neither backup machines nor service engineers available.     

Vascular access in the neonate following extracorporeal membrane oxygenation

An infant maintained on extracorporeal membrane oxygenation (ECMO) has unlimited vascular access. When the infant is returned to conventional ventilator therapy, the need for vascular access persists for days to weeks. Providing alternative central venous access may be problematic, particularly while the infant is still heparinized during the first 12 hours after decannulation. In this study, secondary central venous catheters (CVC) were placed, at the time of decannulation, into the internal jugular vein from which the venous bypass cannula is removed. Fifty-four of 90 infants supported with ECMO had secondary CVCs placed (60%) and vascular access maintained for 2 to 122 days (mean, 17.5 days). Four catheters were removed for culture-proved line sepsis (7.4%). Neck wounds were reexplored for bleeding, while on bypass, in 2 of 4 patients in the sepsis group. There were no deaths related to catheter sepsis. Catheter-related septic infants had been on bypass for 50 to 88 hours (mean, 72.7 hours) as compared with 11 to 312 hours (mean, 104 hours) for the entire ECMO group, P = NS. This experience (942 catheter-days) suggests that secondary CVC placement into the vein used for bypass is safe with infectious complications comparable to catheters placed through primary wounds. Infants requiring neck explorations for bleeding while on bypass are not candidates for secondary CVC placement.     

Cost-utility analysis of salvage cardiac extracorporeal membrane oxygenation in children

BACKGROUND: Indications for extracorporeal membrane oxygenation therapy have expanded to include cardiopulmonary arrest and support after congenital heart surgery. Data from a national registry have reported that cardiac patients have the poorest survival of all extracorporeal membrane oxygenation recipients. Concerns have been raised about the appropriateness of such an aggressive strategy, especially in light of the high costs and potential for long-term neurologic disability. We reviewed our experience with salvage cardiac extracorporeal membrane oxygenation to determine the cost-utility, which accounts for both costs and quality of life. METHODS: Medical records of patients with congenital heart disease receiving salvage cardiac extracorporeal membrane oxygenation between January 2000 and May 2004 were reviewed. Charges for all medical care after the institution of extracorporeal membrane oxygenation were determined and converted to costs by published standards. The quality-of-life status of survivors was determined with the Health Utilities Index Mark II. RESULTS: Salvage cardiac extracorporeal membrane oxygenation was instituted in 32 patients (18 for cardiopulmonary arrest and 14 for cardiac failure after heart surgery) at a median age of 2.0 months (range, 4 days to 5.1 years). Congenital heart disease was present in 27 (84%). The mean duration of extracorporeal membrane oxygenation support was 5.1 +/- 4.1 days. Survival to hospital discharge was 50%, including 1 patient bridged to heart transplantation. Survival to 1 year was 47%. The mean score of the Health Utilities Index for the survivors was 0.75 +/- 0.19 (range, 0.41-1.0). The median cost for hospital stay after the institution of extracorporeal membrane oxygenation was USD 156,324 per patient. The calculated cost-utility for salvage extracorporeal membrane oxygenation in this population was USD 24,386 per quality-adjusted life-year saved, which would be considered within the range of accepted cost-efficacy (< USD 50,000 per quality-adjusted life-year saved). CONCLUSIONS: Salvage cardiac extracorporeal membrane oxygenation results in reasonable survival and is justified on a cost-utility basis.     

Primary extracorporeal membrane oxygenation versus primary ventricular assist device implantation in low cardiac output syndrome following cardiac operation

Mechanical support is often the only therapeutic option in low cardiac output (LCO) following cardiac operation using extracorporeal circulation (ECC). However, the question whether primary ventricular assist device (VAD) or primary extracorporeal membrane oxygenation (ECMO) followed by secondary VAD implantation is superior remains unclear. We analyzed the outcome of 183 patients with LCO following ECC. Primary VAD implantation (VAD) was performed on 20 patients and 163 patients underwent ECMO implantation (ECMO). Out of this group, 13 patients received a secondary VAD (ECMO-VAD). Age was significantly lower in the VAD group, while gender and type of operation were similarly distributed. Thirty-day mortalities were 50, 75, and 46% (VAD, ECMO, and ECMO-VAD, respectively; P < 0.05 ECMO vs. VAD and ECMO-VAD). Survival was best with VAD implantation 1.2 +/- 1.2 days following LCO. In conclusion, the outcome of LCO following ECC remains poor. Early VAD support provides best survival. Primary or secondary VAD implantation has no impact on survival.     

The use of extracorporeal membrane oxygenation in a child with adult respiratory distress syndrome following post-obstruction pulmonary oedema

The use of extracorporeal membrane oxygenation (ECMO) for post-operative complications is not well described. ECMO, a partial venoarterial cardiopulmonary bypass, may permit the reversal of pulmonary insult from barotrauma and oxygen toxicity. This report concerns an 8-year-old girl who developed post-obstruction pulmonary oedema and adult respiratory distress syndrome (ARDS) after a general anaesthetic for an attempted aspiration of a peritonsillar abscess and demonstrates an effective use of this technique. In this patient, the extreme levels of ventilatory support required post-operatively caused haemodynamic instability and severe barotrauma. The institution of ECMO with accompanying decrease in ventilatory support resulted in rapid resolution of haemodynamic instability, hypoxia, and pulmonary pathology.     

Financial implications of using extracorporeal membrane oxygenation following heart transplantation

OBJECTIVESPrimary graft dysfunction after heart transplant is associated with high morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) can be used to wean patients from cardiopulmonary bypass. This study retrospectively reviews a single-centre experience of post-transplant ECMO in regard to outcomes and associated costs. Open in a separate windowMETHODSBetween May 2006 and May 2019, a total of 267 adult heart transplants were performed. We compared donor and recipient variables, ECMO duration and the incidence of renal failure, bleeding, infection and cost analysis between ECMO and non-ECMO groups.RESULTSECMO support was required postoperatively to manage primary graft dysfunction in 72 (27%) patients. The mean duration of ECMO support was 6 ± 3.2 days. Mean ischaemic times were similar between the groups. There was a significantly higher proportion of ventricular assist device explant to transplant in the ECMO group versus non-ECMO (38.2% vs 14.1%; P < 0.0001). ECMO patients had a longer duration of stay in the intensive care unit (P < 0.0001) and total hospital stay (P < 0.0001). Greater mortality was observed in the ECMO group (P < 0.0001). The median cost of providing ECMO was £18 000 [interquartile range (IQR): £12 750–£24 000] per patient with an additional median £35 225 (IQR: £21 487.25–£51 780.75) for ITU stay whilst on ECMO. The total median cost per patient inclusive of hospital stay, ECMO and dialysis costs was £65 737.50 (IQR: £52 566.50–£95 221.75) in the non-ECMO group compared to £145 415.71 (IQR: £102 523.21–£200 618.96) per patient in the ECMO group (P < 0.0001).CONCLUSIONSPatients with primary graft dysfunction following heart transplantation who require ECMO are frequently bridged to a recovery; however, the medium and longer-term survival for these patients is poorer than for patients who do not require ECMO.     

Pediatric cardiac extracorporeal membrane oxygenation in congenital heart disease: the cardiologist's view

Abstract: There is no doubt that extracorporeal membrane oxygenation (ECMO) as a powerful therapeutic modality in critically ill newborn infants and older children with congenital heart disease has implications for the pediatric cardiologist. His responsibilities as consultant in the intensive care unit include screening for unsuspected cyanotic heart disease in neonatal candidates referred for ECMO and appraisal of surgical repair in postcardiotomy patients as well as assessment of postoperative hemodynamics and detection of complications during perfusion. A close cooperation between intensive care specialists and other appropriate specialists (pediatric cardiologists, cardiac surgeons, and anesthesiologists) is required for the process of decision making prior to initiation of postoperative ECMO in the individual patient with congenital heart disease. Long-term survival, morbidity, cerebrovascular complications, and neurodevelopmental sequelae of these near miss children remain a critical issue. Furthermore, there is a strong need for professional psychosocial support of affected parents, both in the hospital and after discharge.