Evaluation of Hemodynamic Performance of a Combined ECLS and CRRT Circuit in Seven Positions With a Simulated Neonatal Patient

As it is common for patients treated with extracorporeal life support (ECLS) to subsequently require continuous renal replacement therapy (CRRT), and neonatal patients encounter limitations due to lack of access points, inclusion of CRRT in the ECLS circuit could provide advanced treatment for this population. The objective of this study was to evaluate an alternative neonatal ECLS circuit containing either a Maquet RotaFlow centrifugal pump or Maquet HL20 roller pump with one of seven configurations of CRRT using the Prismaflex 2000 System. All ECLS circuit setups included a Quadrox‐iD Pediatric diffusion membrane oxygenator, a Better Bladder, an 8‐Fr arterial cannula, a 10‐Fr venous cannula, and 6 feet of ¼‐inch diameter arterial and venous tubing. The circuit was primed with lactated Ringer's solution and packed human red blood cells resulting in a total priming volume of 700 mL for both the circuit and the 3‐kg pseudopatient. Hemodynamic data were recorded for ECLS flow rates of 200, 400, and 600 mL/min and a CRRT flow rate of 50 mL/min. When a centrifugal pump is used, the hemodynamic performance of any combined ECLS and CRRT circuit was not significantly different than that of the circuit without CRRT, thus any configuration could potentially be used. However, introduction of CRRT to a circuit containing a roller pump does affect performance properties for some CRRT positions. The circuits with CRRT positions B and G demonstrated decreased total hemodynamic energy (THE) levels at the post‐arterial cannula site, while positions D and E demonstrated increased post‐arterial cannula THE levels compared to the circuit without CRRT. CRRT positions A, C, and F did not have significant changes with respect to pre‐arterial cannula flow and THE levels, compared to the circuit without CRRT. Considering hemodynamic performance, for neonatal combined extracorporeal membrane oxygenation (ECMO) and CRRT circuits with both blood pumps, we recommend the use of CRRT position A due to its hemodynamic similarities to the ECMO circuit without CRRT.     

Clinical outcomes of neonatal and pediatric extracorporeal life support: A seventeen‐year,single institution experience

The objective of this study was to describe a single‐center experience with neonatal and pediatric extracorporeal life support (ECLS) and compare patient‐related outcomes with those of the Extracorporeal Life Support Organization (ELSO) Registry. A retrospective review of subject characteristics, outcomes, and complications of patients who received the ECLS at Penn State Health Children’s Hospital (PSHCH) from 2000 to 2016 was performed. Fisher’s exact test was used to compare the PSHCH outcomes and complications to the ELSO Registry report. Data from 118 patients were included. Survival to discontinuation of the ECLS was 70.3% and 65.2% to discharge/transfer. Following circuitry equipment changes, the survival to discharge/transfer improved for both neonatal (<29 days) and pediatric (29 days to <18 years) patients. The most common complications associated with ECLS were clinical seizures, intracranial hemorrhage, and culture‐proven infection. ECLS for pulmonary support appeared to be associated with a higher risk of circuit thrombus and cannula problems. When compared to the ELSO Registry, low volume ECLS centers, like our institution, can have outcomes that are no different or statistically better as noted with neonatal and pediatric cardiac patients. Pediatric patients requiring pulmonary support appeared to experience more mechanical complications during ECLS suggesting the need for ongoing technological improvement.     

Evolution of Technology,Establishment of Program,and Clinical Outcomes in Pediatric Extracorporeal Membrane Oxygenation: The “SickKids” Experience

Technological development has had a tremendous impact on the management of patients who require extracorporeal membrane oxygenation (ECMO). Team development and education are a vital component of a successful extracorporeal life support (ECLS) Program to reduce complications and subsequently improve clinical outcomes. We sought to review the evolution in technology, importance of team development and training, and report our experience at The Hospital for Sick Children, Toronto. There were a total of 576 ECMO runs in 534 patients (42 repeat ECMO runs) between January 1988 and June 2012. The use of ECMO for cardiac disease has increased in the last decade due to an expanded indication for ECMO in patients with single‐ventricle physiology. Cardiac ECMO still remains a challenge in terms of survival (177/392, 45%). Although development of an ECLS program and team education facilitated extracorporeal cardiopulmonary resuscitation, clinical outcomes were not satisfactory (survival, 33%). The most common complications were hemorrhagic (13.8%), followed by renal (10.6%) and pulmonary dysfunction (6.9%). Advances in technology made management during ECMO safer, and the mechanical complications related to the ECMO system were 6.1%, including circuit changes due to thrombus formation, cannula repositioning, or optimization of size.     

Comparison of Two Types of Neonatal Extracorporeal Life Support Systems With Pulsatile and Nonpulsatile Flow

We compared the effects of two neonatal extracorporeal life support (ECLS) systems on circuit pressures and surplus hemodynamic energy levels in a simulated ECLS model. The clinical set‐up included the Jostra HL‐20 heart–lung machine, either the Medtronic ECMO (0800) or the MEDOS 800LT systems with company‐provided circuit components, a 10 Fr arterial cannula, and a pseudo‐patient. We tested the system in nonpulsatile and pulsatile flow modes at two flow rates using a 40/60 glycerin/water blood analog, for a total of 48 trials, with n = 6 for each set‐up. The pressure drops over the Medtronic ECLS were significantly higher than those over the MEDOS system regardless of the flow rate or perfusion mode (144.8 ± 0.2 mm Hg vs. 35.7 ± 0.2 mm Hg, respectively, at 500 mL/min in nonpulsatile mode, P < 0.001). The preoxygenator mean arterial pressures were significantly increased and the precannula hemodynamic energy values were decreased with the Medtronic ECLS circuit. These results suggest that the MEDOS ECLS circuit better transmits hemodynamic energy to the patient, keeps mean circuit pressures lower, and has lower pressure drops than the Medtronic Circuit.     

Extracorporeal Life Support After Cardiac Surgery in Children: Outcomes From a Single Institution

Extracorporeal life support (ECLS) is used after congenital heart surgery for several indications, including failure to separate from cardiopulmonary bypass, postoperative low cardiac output syndrome, and extracorporeal cardiopulmonary resuscitation. Here, we assessed the outcomes of ECLS in children after cardiac surgery at our institution. Medical records of all children who required postoperative ECLS at our institution were reviewed. Between 2003 and 2011, 36 (1.4%) of 2541 pediatric cardiac surgical cases required postoperative ECLS. Median age of patients was 64 days (range: 0 days–4.1 years). ECLS was in the form of either extracorporeal membrane oxygenation (ECMO; n = 24) or ventricular assist system (VAS; n = 12). Mean duration of ECLS was 4.9 ± 4.2 days. Overall, 21 patients (58%) were weaned off ECLS, and 17 patients (47%) were successfully discharged from the hospital. Patients with biventricular heart (BVH) had higher survival‐to‐hospital discharge rates compared with those with univentricular heart (UVH) (P = 0.019). Regarding ECLS type, UVH patients who received VAS showed higher rates of device discontinuation than UVH patients who received ECMO (P = 0.012). However, rates of hospital discharge were not significantly different between UVH patients who received VAS or ECMO. Surgical interventions, such as banding of Blalock–Taussig shunt to reduce pulmonary blood flow or placing bidirectional cavopulmonary shunt to minimize ventricular volume overload, were effective for weaning off ECLS in patients with UVH. ECLS is beneficial to children with low cardiac output after cardiac surgery. Rates of survival‐to‐hospital discharge were higher in BVH patients than UVH patients. Additional interventions to reduce ventricular volume load may be effective for discontinuing ECLS in patients with UVH.     

Extracorporeal membrane oxygenation cannulation trends for pediatric respiratory failure and central nervous system injury

BackgroundGuidelines regarding arterial cannula site and cannula site-specific risks of central nervous system (CNS) injury for pediatric patients requiring extracorporeal membrane oxygenation (ECMO) support are lacking. We reviewed cannulation trends for pediatric respiratory failure and evaluated CNS complication rates by cannulation site and mode of support.MethodsThe Extracorporeal Life Support Organization (ELSO) registry was queried for all pediatric respiratory failure patients <18 years treated from 1993-2007. The primary outcome was radiographic evidence of CNS injury.ResultsVenoarterial (VA) support was used in 62% of 2617 ECMO runs. The carotid artery was used in 93% of VA patients. Femoral artery use increased in patients >5 years of age and >20 kg. Venovenous (VV) ECMO was used in >50% of children >10 years. No significant difference was identified in CNS injury between carotid and femoral cannulation in any age group but the femoral group was small (4.4%). VA support was independently associated with increased odds of CNS injury compared to VV cannulation (OR, 1.6).ConclusionVA ECMO is the most common mode of support in pediatric respiratory failure patients. Although no significant difference in CNS injury was noted between carotid and femoral artery cannulation, the odds of injury were significantly higher than VV support.     

In Vitro Evaluation of ECG‐Synchronized Pulsatile Flow Using the i‐cor Diagonal Pump in Neonatal and Pediatric ECLS Systems

The objective was to assess the i‐cor electrocardiogram‐synchronized diagonal pump in terms of hemodynamic energy properties for off‐label use in neonatal and pediatric extracorporeal life support (ECLS) circuits. The neonatal circuit consisted of an i‐cor pump and console, a Medos Hilite 800 LT oxygenator, an 8Fr arterial cannula, a 10Fr venous cannula, 91 cm of 0.6‐cm ID arterial tubing, and 91 cm of 0.6‐cm ID venous tubing. The pediatric circuit was identical except it included a 12Fr arterial cannula, a 14Fr venous cannula, and a Medos Hilite 2400 LT oxygenator. Neonatal trials were conducted at 36°C with hematocrit 40% using varying flow rates (200–600 mL/min, 200 mL increments) and postarterial cannula pressures (40–100 mm Hg, 20 mm Hg increments) under nonpulsatile mode and pulsatile mode with various pulsatile amplitudes (1000–4000 rpm, 1000 rpm increments). Pediatric trials were conducted at different flow rates (800–1600 mL/min, 400 mL/min increments). Mean pressure and energy equivalent pressure increased with increasing postarterial cannula pressure, flow rate, and pulsatile amplitude. Physiologic‐like pulsatility was achieved between pulsatile amplitudes of 2000–3000 rpm. Pressure drops were greatest across the arterial cannula. Pulsatile flow generated significantly higher total hemodynamic energy (THE) levels than nonpulsatile flow. THE levels at postarterial cannula site increased with increasing postarterial cannula pressure, pulsatile amplitude, and flow rate. No surplus hemodynamic energy (SHE) was generated under nonpulsatile mode. Under pulsatile mode, preoxygenator SHE increased with increasing postarterial cannula pressure and pulsatile amplitude, but decreased with increasing flow rate. The i‐cor system can provide nonpulsatile and pulsatile flow for neonatal and pediatric ECLS. Pulsatile amplitudes of 2000–3000 rpm are recommended for use in neonatal and pediatric patients.     

Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A (H1N1) 2009 infection in Canada

Background

From March to July 2009, influenza A (H1N1) 2009 (H1N1-2009) virus emerged as a major cause of respiratory failure that required mechanical ventilation. A small proportion of patients who had this condition developed severe respiratory failure that was unresponsive to conventional therapeutic interventions. In this report, we describe characteristics, treatment, and outcomes of critically ill patients in Canada who had H1N1-2009 infection and were treated with extracorporeal lung support (ECLS).

Methods

We report the findings of a case series of six patients supported with ECLS who were included in a cohort study of critically ill patients with confirmed H1N1-2009 infection. The patients were treated in Canadian adult and pediatric intensive care units (ICUs) from April 16, 2009 to August 12, 2009. We describe the nested sample treated with ECLS and compare it with the larger sample.

Results

During the study period, 168 patients in Canada were admitted to ICUs for severe respiratory failure due to confirmed H1N1-2009 infection. Due to profound hypoxemia unresponsive to conventional therapeutic interventions, six (3.6%) of these patients were treated with ECLS in four ICUs. Four patients were treated with veno-venous pump-driven extracorporeal membrane oxygenation (vv-ECMO), and two patients were treated with pumpless lung assist (NovaLung iLA). The mean duration of support was 15 days. Four of the six patients survived (66.6%), one of the surviving patients was supported with iLA and the other three surviving patients were supported with ECMO. The two deaths were due to multiorgan failure, which occurred while the patients were on ECLS.

Interpretation

Extracorporeal lung support may be an effective treatment for patients who have H1N1-2009 infection and refractory hypoxemia. Survival of these patients treated with ECLS is similar to that reported for patients who have acute respiratory distress syndrome of other etiologies and are treated with ECMO.     

Venovenous extracorporeal membrane oxygenation in neonates with respiratory failure

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) has been successful in support of neonates with respiratory failure but requires right common carotid artery ligation. While no short-term neurologic complications have resulted from neonatal carotid ligation, late complications may occur. For both VA ECMO and venovenous (VV) ECMO, blood is drained from the right atrium via a right internal jugular cannula, oxygenated by a membrane lung, and returned to the patient. VV ECMO spares the carotid by perfusing the oxygenated blood into a vein. VV ECMO gave total respiratory support to three neonates with respiratory failure and each infant survived. In comparison with three similar VA ECMO patients, the VV patients required higher ECMO circuit flow rates and had lower systemic arterial Po2s. Length of time on ECMO, length of hospital stay, and neurologic outcome were similar in the VV and VA patients. Differences among the patients were related to their primary disease rather than to the mode of ECMO support. The VV patients had cannulation of the femoral vein for perfusion of oxygenated blood. Late complications may occur from femoral vein ligation as well as from carotid ligation so long-term follow-up is needed to assess these two ECMO techniques.     

Venovenous extracorporeal membrane oxygenation in neonatal systemic artery-to-pulmonary artery shunt operations using a double lumen catheter

The right atrium of the neonate may be too small for direct insertion of 2 venous catheters during intraoperative life support. We inserted a double lumen catheter into the right atrium, and venovenous (V-V) extracorporeal membrane oxygenation (ECMO) was instituted. The patient's arterial oxygen saturation was maintained at 70% to 90%, and hemodynamic stability was obtained during V-V ECMO. V-V ECMO using a double lumen catheter can be easily established in a small neonate, and is an effective support technique for untolerable hypoxemia during systemic-to-pulmonary artery shunt operations.     

Comparison of Hemolysis Between CentriMag and RotaFlow Rotary Blood Pumps During Extracorporeal Membrane Oxygenation

The purpose of this investigation was to compare the hemolysis levels for patients on extracorporeal membrane oxygenation (ECMO) incorporating two different rotary blood pumps (CentriMag [CMAG] and RotaFlow [RF]) in identical circuits otherwise. The difference between the two pumps is the cost. One is 20–30 times less expensive than the other. A retrospective analysis of all patients placed on ECMO from June 2008 through May 2012 was done to evaluate hemolysis. Daily plasma hemoglobin (pHb), lactate dehydrogenase (LDH), and lactate levels were collected on all patients. Values were compared between those patients who received a CMAG and those who received an RF. Patients had to be on ECMO for more than 2 days to be included in the study. Linear mixed effects models were fit to the data to assess differences over time for each continuous outcome. Forty patients were placed on ECMO incorporating CMAG, whereas 40 patients received an RF. There were no significant statistical differences between CMAG and RF groups when comparing days on support (8.7 ± 5.0; 8.4 ± 5.7), age (44.8 ± 18.3; 46.1 ± 16.0), body surface area (2.03 ± 0.36; 1.96 ± 0.31), gender (male: 58%, female: 42%; male: 55%, female: 45%), etiology, type of support (veno‐arterial [VA)]: 78%, veno‐venous [VV)]: 22%; VA: 82%, VV: 18%) and pre‐ECMO LDH levels (4004.0 ± 3583.2; 3603.7 ± 3354.1). There were also no significant differences between the CMAG and RF groups when comparing the mean values for daily pHb levels (5.7 ± 3.6; 5.7 ± 4.2), lactate levels (2.8 ± 1.9; 3.0 ± 2.1), and LDH levels (2656.3 ± 1606.8; 2688.6 ± 1726.1) or daily lactate, LDH, and pHb levels for the first 10 days of support. From our investigation, there is no difference between the CMAG and the RF blood pumps in regard to the creation of hemolysis during ECMO. The difference in cost of the devices does not correlate with the performance and outcomes.     

Effect of pulmonary support using extracorporeal membrane oxygenation for adult liver transplant recipients with respiratory failure

BackgroundAdult liver transplantation (OLT) recipients occasionally show serious acute cardiopulmonary dysfunction, requiring intensive care. We assessed the role of extracorporeal membrane oxygenation (ECMO) support in adult recipients facing acute pulmonary failure and refractory to conventional mechanical ventilation and concurrent nitric oxide gas inhalation.MethodsFrom January 2008 to March 2011, 18 adult OLT recipients at our institution required ECMO support: 12 due to pneumonia and 6 to adult respiratory distress syndrome. Their mean age was 55.7 ± 6.9 years and mean Model for End-stage Liver Disease score, 24.8 ± 8.5. Twelve patients had undergone living donor and six deceased donor OLT.ResultsA venovenous access mode and concurrent continuous venovenous hemodiafiltration were used in all patients. There were no procedure-related complications. Eight patients (44.4%) were successfully weaned from ECMO upon the first attempt after a mean support of 11.9 ± 6.1 days, but the other 10 died due to overwhelming infection. Univariate analysis revealed no significant pre-ECMO risk factor for treatment failure but C-reactive protein concentration at the time of ECMO differed significantly among patients who did versus did not survive after ECMO.ConclusionsECMO as rescue therapy may be a final therapeutic option for OLT recipients with refractory pulmonary dysfunction who would otherwise die due to hypoxemia from severe pneumonia or adult respiratory distress syndrome.     

A complication of ECMO cannula placement resulting in hemodynamic and oxygenation alterations: A case report

Veno-veno extracorporeal membrane oxygenation (VV ECMO) is used as a bridge to recovery in acute respiratory distress syndrome (ARDS) patients who have reversible lung failure. We present a complication of ECMO cannula placement/position resulting in hemodynamic and oxygenation alterations. These demonstrate principles related to the interaction of the VV ECMO circuit and patient cardio-pulmonary physiology. Consideration and comprehension of pulmonary shunt fraction, ECMO cannula recirculation ratio and ECMO blood flow to cardiac output (CO) ratio are central to continuous assessment and diagnosis of cardio-pulmonary changes encountered during management of VV ECMO.     

Distal Limb Perfusion: Achilles' Heel in Peripheral Venoarterial Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is a temporary mechanical circulatory assist method that offers circulatory as well as respiratory support efficiently via peripheral access; however, it is liable to complications. Limb ischemia is one of the notorious complications of ECMO but can be avoided utilizing a proper distal limb perfusion method. A retrospective study of patients undergoing peripheral venoarterial (VA) ECMO for various reasons between June 2010 and December 2012 was performed. All patients were evaluated by our multidisciplinary team for suitability as candidates for ECMO. A peripheral VA‐ECMO circuit was implanted via groin: inflow cannula in the femoral vein, an outflow cannula and distal‐perfusion cannula, or an introducer sheath in the femoral artery. During the study period, 83 patients underwent various types of ECMO; 45 received peripheral VA‐ECMO. Distal limb perfusion was achieved with an introducer sheath (6–8 Fr) in 13 cases and with a distal‐perfusion cannula (10–12 Fr) in 32 cases. Nine (20%) patients developed signs of ischemia; five (11.2%) were treated conservatively, while four (8.8%) required surgical intervention. One patient required a below‐knee amputation. The incidences of limb ischemia and limb ischemia requiring surgical intervention were significantly higher for the introducer sheath compared with the cannula (30.6 vs. 15.6% and 15.4 vs. 6.25%, respectively). Moreover, the patients supported on ECMO with a distal‐perfusion cannula spent a significantly longer time on ECMO compared with the ones in whom an introducer sheath was used (11.9 ± 9.1 vs. 7.7 ± 4.3 days). The mean cannula size was significantly greater than the mean introducer sheath size (11.1 ± 1.3 vs. 7.0 ± 1.1 Fr). Use of a distal‐perfusion cannula is a most reliable method of limb perfusion in peripheral VA‐ECMO. The cannula can ensure adequate and smooth perfusion of the limb owing to its large caliber, its less turbulent flow, the ability it provides to monitor the flow, and the option to attach a side port.     

In Vivo Hemodynamic Performance Evaluation of Novel Electrocardiogram‐Synchronized Pulsatile and Nonpulsatile Extracorporeal Life Support Systems in an Adult Swine Model

The primary objective of this study was to evaluate a novel electrocardiogram (ECG)‐synchronized pulsatile extracorporeal life support (ECLS) system for adult partial mechanical circulatory support for adequate quality of pulsatility and enhanced hemodynamic energy generation in an in vivo animal model. The secondary aim was to assess end‐organ protection during nonpulsatile versus synchronized pulsatile flow mode. Ten adult swine were randomly divided into a nonpulsatile group (NP, n = 5) and pulsatile group (P, n = 5), and placed on ECLS for 24 h using an i‐cor system consisting of an i‐cor diagonal pump, an iLA membrane ventilator, an 18 Fr femoral arterial cannula and a 23/25 Fr femoral venous cannula. Trials were conducted at a flow rate of 2.5 L/min using nonpulsatile or pulsatile mode (with assist ratio 1:1). Real‐time pressure and flow data were recorded using a custom‐based data acquisition system. To the best of our knowledge, the oxygenator and circuit pressure drops were the lowest for any available system in both groups. The ECG‐synchronized i‐cor ECLS system was able to trigger pulsatile flow in the porcine model. After 24‐h ECLS, energy equivalent pressure, surplus hemodynamic energy, and total hemodynamic energy at preoxygenator and prearterial cannula sites were significantly higher in the P group than those in the NP group (P < 0.05). Urine output was higher in P versus NP (3379 ± 443 mL vs. NP, 2598 ± 1012 mL), and the P group seemed to require less inotropic support, but both did not reach statistical significances (P > 0.05). The novel i‐cor system performed well in the nonpulsatile and ECG‐synchronized pulsatile mode in an adult animal ECLS model. The iLA membrane oxygenator had an extremely lower transmembrane pressure gradient and excellent gas exchange capability. Our findings suggest that ECG‐triggered pulsatile ECLS provides superior end‐organ protection with improved renal function and systemic vascular tone.     

Hemodynamic Evaluation of Avalon Elite Bi‐Caval Dual Lumen Cannulas and Femoral Arterial Cannulas

Translational research is a useful tool to provide scientific evidence for cannula selection during extracorporeal life support (ECLS). The objective of this study was to evaluate four Avalon Elite bi‐caval dual lumen cannulas and nine femoral arterial cannulas in terms of flow range, circuit pressure, pressure drop, and hemodynamic energy transmission in a simulated adult ECLS model. A veno‐venous ECLS circuit was used to evaluate four Avalon Elite bi‐caval dual lumen cannulas (20, 23, 27, and 31 Fr), and a veno‐arterial ECLS circuit was used to evaluate nine femoral arterial cannulas (15, 17, 19, 21, and 23 Fr). The two circuits included a Rotaflow centrifugal pump, a Quadrox‐D adult oxygenator, and 3/8 in ID tubing for arterial and venous lines. The circuits were primed with lactated Ringer’s solution and packed human red blood cells (hematocrit 40%). Trials were conducted at rotational speeds from 1000 to 5000 RPM (250 rpm increments) for each Avalon cannula, and at different flow rates (0.5–7 L/min) for each femoral arterial cannula. Real‐time pressure and flow data were recorded for analysis. Small caliber cannulas created higher circuit pressures, higher pressure drops and higher M‐numbers compared with large ones. The inflow side of Avalon dual lumen cannula had a significantly higher pressure drop than the outflow side (inflow vs. outflow: 20 Fr‐100.2 vs. 49.2 mm Hg at 1.1 L/min, 23 Fr‐93.7 vs. 41.4 mm Hg at 1.6 L/min, 27 Fr‐102.3 vs. 42.8 mm Hg at 2.6 L/min, 31 Fr‐98.1 vs. 44.7 mm Hg at 3.8 L/min). There was more hemodynamic energy lost in the veno‐arterial ECLS circuit using small cannulas compared to larger ones (17 Fr vs. 19 Fr vs. 21 Fr at 4 L/min—Medtronic: 71.0 vs. 64.8 vs. 60.9%; Maquet: 71.4 vs. 65.6 vs. 62.0%). Medtronic femoral arterial cannulas had lower pressure drops (Medtronic vs. Maquet at 4 L/min: 17 Fr‐121.7 vs. 125.0 mm Hg, 19 Fr‐71.2 vs. 73.7 mm Hg, 21 Fr‐42.9 vs. 47.4 mm Hg) and hemodynamic energy losses (Medtronic vs. Maquet at 4 L/min: 17 Fr‐43.6 vs. 44.4%, 19 Fr‐31.0 vs. 31.4%, 21 Fr‐20.8 vs. 22.4%) at high flow rates when compared with the Maquet cannulae. The results for this study provided valuable hemodynamic characteristics of all evaluated adult cannulas with human blood in order to guide ECLS cannula selection in clinical practice. Use of larger cannulas are suggested for VV‐ and VA‐ECLS.     

Extracorporeal Membrane Oxygenation for Critically Ill Patients With 2009 Influenza A (H1N1)-Related Acute Respiratory Distress Syndrome: Preliminary Experience From a Single Center

From early May 2009, the novel influenza A (H1N1) pandemic affected mainland China. Of those infected, a small proportion of patients developed acute respiratory distress syndrome (ARDS) so rapidly and severely that conventional ventilation treatment was ineffective. As an alternative treatment, the effect of extracorporeal membrane oxygenation (ECMO) was evaluated. From November 2009 to January 2010, all patients suffering from influenza A (H1N1)‐associated ARDS referred to Beijing Anzhen Hospital for treatment with ECMO were enrolled. We describe the characteristics, treatment, and outcomes of these patients at 1‐ and 3‐month follow‐up. Nine patients (four females; mean age, 31.2 [21–59] years) from four centers were enrolled. All females had a history of recent pregnancy or had recently given birth. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a mean partial pressure of arterial oxygen/fraction of inspired oxygen of 52.9 ± 5.1 (45.0–63.8) mm Hg, positive end‐expiratory pressure of 17.2 ± 4.2 cmH₂O, and a Murray Lung Score of 3.6 (3.25–3.75). All nine patients were treated with veno–venous ECMO via percutaneous access. The mean duration of ECMO support was 436.6 ± 652.1 h (67.0–2160.0). At the end of 1‐year follow‐up, five patients (55.7%) were weaned from ECMO. Five patients (55.7%) survived to hospital discharge. Four patients (44.4%) died while undergoing ECMO. The mean length of intensive care unit and hospital stay was 4–204 days (median, 32) and 4–234 days (median, 38), respectively. There was no significant difference between survivors and nonsurvivors in the screened parameters. Use of ECMO for critically ill patients with 2009 influenza A (H1N1)‐related ARDS is feasible and effective. However, this treatment is technically demanding. For success, careful selection of patients is crucial.     

Extracorporeal life support for posttraumatic acute respiratory distress syndrome at a children's medical center

Background: Primary traumatic injury was considered previously a contraindication for institution of extracorporeal life support because of high risk for persistent or new bleeding. Published experience in adults suggests that extracorporeal membrane oxygenation (ECMO) can successfully support trauma victims with pulmonary failure. The authors reviewed their experience with the use of ECMO in pediatric and adult trauma patients with acute respiratory distress syndrome (ARDS) at a children’s medical center.Methods: ECMO Center records from 1991 through 2001 (76 children, 8 adults) were reviewed to identify all patients with a primary or secondary ICD-9 diagnostic code of posttraumatic ARDS in addition to documented trauma.Results: Five children and 3 adults with traumatic injury and ARDS received ECMO support. Seven patients were injured in motor vehicle collisions; one patient suffered a gunshot wound to the chest. Patient ages ranged from 21 months to 29 years (pediatric median, 4 years; range, 21 months to 18 years). Four patients had pre-ECMO laparotomies, including 3 who required splenectomy. Four patients had liver lacerations, 3 had pulmonary contusions, and 1 had a renal contusion. Median ventilation before ECMO was 6 days (range, 2 to 10). Seven of 8 patients were placed on venovenous (VV) ECMO. Seven patients had significant bleeding on ECMO. Patients were treated with blood product replacement, epsilon-aminocaproic acid (EACA), and aprotinin infusions. Surgical intervention was not required for bleeding. Six patients received hemofiltration. Median time on ECMO was 653 hours (range, 190 to 921 hours). Six of 8 patients overall survived (75%). Four of 5 pediatric patients survived.Conclusions: Children and adults with severe posttraumatic ARDS can be treated successfully on VV extracorporeal support. Hemorrhage occurs frequently but is manageable.     

Extracorporeal life support in pediatric cardiac dysfunction

Background  

Low cardiac output (LCO) after corrective surgery remains a serious complication in pediatric congenital heart diseases (CHD). In the case of refractory LCO, extra corporeal life support (ECLS) extra corporeal membrane oxygenation (ECMO) or ventricle assist devices (VAD) is the final therapeutic option. In the present study we have reviewed the outcomes of pediatric patients after corrective surgery necessitating ECLS and compared outcomes with pediatric patients necessitating ECLS because of dilatated cardiomyopathy (DCM).