No abstract

Disclaimer: This guideline describes the ECMO circuit for all patient populations. These guidelines describe safe practice based on extensive experience and are considered consensus guidelines. These guidelines are not intended to define standard of care and are revised at regular intervals as new information, devices, medications, and techniques become available.

Objective To determine the effect of therapeutic plasma exchange (TPE) on hemodynamics, organ failure, and survival in children with multiple organ dysfunction syndrome (MODS) due to sepsis requiring extracorporeal life support (ECLS). Design A retrospective analysis. Setting A pediatric intensive care unit (PICU) in an academic children’s hospital. Patients 14 consecutive children with sepsis and MODS who received TPE while on ECLS from 2005 to 2013. Interventions Median of 3 cycles of TPE with median of 1.0 times the estimated plasma volume per exchange. Measurements and Main Results Organ Failure Index (OFI) and Vasoactive-Inotropic Score (VIS) were measured before and after TPE use. PICU survival in our cohort was 71.4%. OFI decreased in patients following TPE [pre: 4.1 ± 0.7 vs. post: 2.9 ± 0.9 (mean ±SD); p = 0.0004]. Patients showed improved VIS following TPE [pre: 24.5 (13.0–69.8) vs. post: 5.0 (1.5–7.0), median (25th–75th); p = 0.0002]. Among all patients, the change in OFI was greater for early TPE use than late use [pre: −1.7 ±1.2 vs. post: −0.9 ±0.6; p = 0.14], similar to the change in VIS [pre: −67.5 (28.0–171.2) vs. post: −12.0 (7.2–18.5); p = 0.02]. Among survivors, the change in OFI was greater among early TPE use than late use [early: −2.3 ±1.0 vs. late: −0.8 ± 0.8; p = 0.03], as was the change in VIS [early: −42.0 (16.0–76.3) vs. late: −12.0 (5.3–29.0); p=0.17]. The mean duration of ECLS after TPE according to timing of TPE was not statistically different among all patients or among survivors. Conclusions The use of TPE in children on ECLS with sepsis-induced MODS is associated with organ failure recovery and improved hemodynamic status. Initiating TPE early in the hospital course was associated with greater improvement in organ dysfunction and decreased requirement for vasoactive and/or inotropic agents.

The veno-venoarterial (VVA) mode of extracorporeal membrane oxygenation (ECMO) is defined by having both venous and arterial reinfusion cannulas. It is purposed to improve upper body oxygenation as the venous reinfusion cannula is typically placed in the upper body. We performed a single-center retrospective review to better characterize the patients placed on this mode. Adults (n = 23) were 40.4 ± 14.7 years old and were supported with ECMO for a median of 141 (97, 253) hours, with VVA support 110 (63, 179) hours. Ten (43%) were initially cannulated VVA; reasons for conversion included cardiac failure (46%), North-South syndrome (38%), and worsening hypoxia (15%). Survival was 39% and neurological complications 13%. Pediatrics (n = 8) were 13.0 ± 2.4 years old and were supported with ECMO for a median of 258 (168, 419) hours, with VVA support 131 (98, 161) hours. One (12.5%) was initially cannulated VVA; reasons for conversion were North-South syndrome (42%), cardiac failure (29%), and worsening hypoxia (29%). Survival was 71% and neurological complications 29%. We concluded that there was neither survival advantage nor complication reduction with the VVA mode in this cohort; however, VVA does have value for unique clinical situations when conventional ECMO modes do not meet support needs.