Extracorporeal Membrane Oxygenation Support Among Children with Adenovirus Infection

Abstract

Overwhelming adenovirus infection requiring extracorporeal membrane oxygenation (ECMO) support carries a high mortality in pediatric patients. The objective of this study was to retrospectively review data from the Extracorporeal Life Support Organization (ELSO) registry for pediatric patients with adenovirus infection and define for this patient cohort: 1) clinical characteristics, 2) survival to hospital discharge, and 3) factors associated with mortality before hospital discharge. In this retrospective registry study, pediatric patients with adenovirus infection requiring ECMO support identified in an international ECMO registry from 1998 to 2009 were compared for clinical characteristics (demographics, pre-ECMO variables, and complications on ECMO) between survivors and nonsurvivors to hospital discharge. Descriptive statistics and univariate and multivariate logistic analysis were used to compare clinical characteristics among survivors and nonsurvivors. For children requiring ECMO support for adenovirus, the survival at hospital discharge is 38% (62/163). Among neonates (<31 days of age), the survival at hospital discharge was only 11% (6/54). Among patient factors, neonatal age (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.62-10.87), a decrease of 0.1 unit in pre-ECMO pH (OR, 1.77; 95% CI, 1.3-2.42), the presence of sepsis (OR, 4.55; 95% CI, 1.47-14.15), and increased peak inspiratory pressures (OR, 1.04; 95% CI, 1.01-1.08) were all independently associated with in-hospital mortality. ECMO complications independently associated with in-hospital mortality were presence of pneumothorax (OR, 3.57; 95% CI, 1.19-10.7), pH less than 7.2 (OR, 5.94; 95% CI, 1.04-34.1), and central nervous system hemorrhage (OR, 25.36; 95% CI, 1.47-436.7). In this retrospective cohort study of pediatric patients with adenovirus infection supported on ECMO, survival to hospital discharge was 38% but was much lower in neonates. Neonatal presentation, degree of acidosis, sepsis, and increased PIP are factors present before decisions are made regarding a trial of ECMO, whereas pneumothorax and brain hemorrhage were ECMO-related complications independently associated with mortality.

Severe Adenovirus Pneumonia Requiring Extracorporeal Membrane Oxygenation Support in Immunocompetent Children

“…Previous data analysis showed that for children requiring ECMO support for adenovirus infection, the survival rate was only 25% (39), the lowest among the viral types (11,13,31,40), while another review of the Extracorporeal Life Support Organization Registry published in 2014 showed the survival rate at hospital discharge was 38% (41). It was demonstrated that early institution of ECMO in a ventilated patient was associated with improved survival, and late cannulation beyond 6 days was related to an increase in mortality (42,43).…”

Severe ARDS caused by adenovirus: early initiation of ECMO plus continuous renal replacement therapy

“…Low et al (2013) reported three patients with confirmed HAdV-7 ARDS who were treated with VV ECMO; the reported survival rates were poor. Prodhan et al (2014) also reported that only 62 (38.0%) of 163 children with adenovirus pneumonia supported using ECMO survived. However, both of our patients survived throughout the period of ECMO support.…”

“…Extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy for patients with severe ARDS caused by HAdV, but the outcome was not satisfactory (Gu et al 2012; Sun et al 2014; Prodhan et al 2014). However, the greatest benefit of ECMO is protecting the lungs from high-pressure mechanical ventilation and oxygen toxicity, minimizing on-going lung injury.…”

Management of severe viral infections in the pediatric intensive care unit

“…Ancillary measures such as ensuring adequate nutrition, aggressively treating bacterial co-infections, and allowing for viral clearance will optimize the chances at a good outcome. The role of extracorporeal membrane oxygenation support in these children has been associated with poor results [40]. All children with adenoviral pneumonia will require close follow-up upon hospital discharge, given ongoing supportive therapy requirements and the high risk of developing long-term respiratory disease.…”