Extracorporeal membrane oxygenation after stem cell transplant: Clinical decision-making in the absence of evidence

Abstract

The boundaries among standard therapy, innovative therapy, and research can be quite fluid. This case illustrates the ethical imperative to consider therapies that may be appropriate for a critically ill child even without evidence predictive of success, to have entry criteria and treatment protocols for such therapies, and to collect data from such experiences to advance the standard of care.

Extracorporeal membrane oxygenation for support of children after hematopoietic stem cell transplantation: the Extracorporeal Life Support Organization experience

“…Furthermore, some HSCT cases receiving ECMO may not have been captured because diagnostic codes used for study inclusion were not listed on the patients who had HSCT within the registry. In fact, the 2 noted case reports [30,31] were published by centers that submit patient data to the ELSO registry but were not found in the current review of the database.…”

“…To date, 2 case reports have documented successful runs of a child with SCID [30] and another with stage III neuroblastoma [31]. However, as Wolfson et al [31] cite, lack of data exists to guide clinicians in making decisions as to whether to provide this option to such ill children. We reviewed the ELSO registry experience of patients who had HSCT placed on ECMO to determine the outcomes and suggest recommendations for clinicians considering ECMO in the pediatric patient who had HSCT.…”

“…Two case reports have described the use of extracorporeal membrane oxygenation (ECMO) in support of children requiring mechanical ventilation for complications of bone marrow transplantation for severe combined immunodeficiency (SCID) [30] and neuroblastoma [31]. We sought to review a broader database of children to determine the experience with children receiving ECMO support after HSCT.…”

Extracorporeal Membrane Oxygenation for Acute Pediatric Respiratory Failure

“…More recent data suggests that an earlier transition from conventional ventilation to HFOV may improve survival, but mortality remains high [68]. With regard to the use of ECMO in this patient population, there are sparse case reports documenting the successful use of ECMO to support HSCT patients through posttransplant complications, including diffuse alveolar hemorrhage, [69] idiopathic pulmonary syndrome, [70] and sepsis secondary to neutropenic enterocolitis [71]. However, in an ELSO registry review of 19 children undergoing ECLS following HSCT, 79% died during the ECMO course: seven developed multiorgan failure, three had refractory hemor-rhage, and five had support was withdrawn for others reasons [72].…”

Uncertainties on the Frontier: Rescue Therapy in Pandemic Influenza

“…We must be careful to remember that our own experience in individual cases does not provide generalizable evidence. Wolfson et al, 11 in a report of ECMO used as rescue therapy for an adolescent post-stem cell transplant, summarizes this dilemma:…”