Central venoarterial extracorporeal life support in pediatric refractory septic shock: a single center experience

Abstract

Objective: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is recognized as a potential support therapy for pediatric patients with refractory septic shock (RSS). This review aims to report our experience with central VA cannulation in pediatric patients with RSS, and to compare this with peripheral VA ECMO cannulations for this condition at our institution. Design: Retrospective case series. Setting: Pediatric and cardiac intensive care units in an academic pediatric hospital. Patients: All patients 0–18 years old meeting criteria of RSS placed on VA ECMO between January 2011 and December 2018. Interventions: None. Measurements: Demographics, relevant clinical variables, ECMO run details, and outcomes were collected. Results: Between 2011 and 2018, 14 children were placed on VA ECMO for RSS. Nine were cannulated centrally, with the rest placed on peripheral VA ECMO. Overall survival to hospital discharge was 57.1% (8/14), with 66.7% of the central cannulation cohort surviving versus 40% in the peripheral cannulation (p = 0.34). Median ECMO duration was 147.1 hours (IQR: 91.9–178.6 hours), with survivors having a median length of 147.1 (IQR: 138.5–185.7) versus non survivors 114.7 hours (IQR: 63.7–163.5), p = 0.48. Overall median ICU length of stay (LOS) was 19 days (IQR: 10.5–42.2). The median % maximum flow achieved on VA ECMO was higher in the central cannulation group at 179.6% (IQR: 154.4–188.1) versus the peripheral with 133.5% (98.1–149.1), p = 0.01. Functional status scale (FSS) was used to capture morbidity. All survivors had a mean increase in their FSS from baseline. In the centrally cannulated group, 50% (4/8) received mediastinal exploration, but none developed mediastinitis. In terms of blood product utilization, the central cannulation received more platelets compared to the peripherally cannulated group (median 15.6 vs 3.3 mL/kg/day, p = 0.03). Conclusion: A central approach to VA ECMO cannulation is feasible and has potential for good patient outcomes in selected patients.

Short‐Term Mortality Among Pediatric Patients With Heart Diseases Undergoing Veno‐Arterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta‐Analysis

“…The inconsistent data still exist. 52 , 54 , 55 , 56 , 57 , 58 , 59 In a study with 777 children who received VA‐ECMO support for heart diseases, Merrill et al 52 found that patients were older (median age, 0.64 versus 0.10 years) and patient weight was greater (median weight, 7.0 kg versus 4.0 kg) in survivors compared with nonsurvivors. By univariate and multivariate analyses, it similarly indicated that older or overweight children had a better chance of surviving to hospital discharge.…”

“…Similarly, a recent single‐center study on VA‐ECMO support for refractory septic shock in children reported a survival rate of 66.7% in central cannulation patients compared with 40% in patients receiving peripheral cannulation. 59 Early central cannulation providing adequate hemodynamic support before more severe and potentially irreversible organ dysfunction develops may contribute to better outcomes. However, we found central cannulation was associated with higher mortality.…”

Advances in Extracorporeal Support Technologies in Critically Ill Children

“…Central cannulation is commonly used in patients with recent sternotomy as it allows quick access to the right atrial appendage and the ascending aorta. Central cannulation has shown some benefit in pediatric patients in septic shock as this allows larger cannulas to be placed, allowing higher flow rates [ 16 – 18 ]. Although ECMO provides right and left ventricular support in patients with biventricular circulation, it does not provide active decompression of the left ventricle.…”

Role of Extracorporeal Membrane Oxygenation in Adults and Children With Refractory Septic Shock: A Systematic Review and Meta-Analysis

“…An assessment of the funnel plots of all the patients is shown in Figure 3. The 14 studies included in the systemic review and meta-analysis that reported on children with refractory septic shock requiring ECMO are shown in Table 1 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). And the details of the cohort studies are summarized in Table 2.…”