Pediatric and Neonatal Extracorporeal Membrane Oxygenation

Abstract

Objective Extracorporeal membrane oxygenation, an accepted rescue therapy for refractory cardiopulmonary failure, requires a complex multidisciplinary approach and advanced technology. Little is known about the relationship between a center’s case volume and patient mortality. The purpose of this study was to analyze the relationship between hospital extracorporeal membrane oxygenation annual volume and in-hospital mortality and assess if a minimum hospital volume could be recommended. Design Retrospective cohort study Setting A retrospective cohort admitted to children’s hospitals in the Pediatric Health Information System database from 2004-2011 supported with extracorporeal membrane oxygenation was identified. Indications were assigned based on patient age (neonatal vs. pediatric), diagnosis, and procedure codes. Average hospital annual volume was defined as 0-19, 20-49, or ≥50 cases per year. Maximum likelihood estimates were used to assess minimum annual case volume. Patients A total of 7322 pediatric patients aged 0-18 years of age were supported with extracorporeal membrane oxygenation and had an indication assigned. Interventions None Measurements and Main Results Average hospital extracorporeal membrane oxygenation volume ranged from 1-58 cases per year. Overall mortality was 43% but differed significantly by indication. After adjustment for case-mix, complexity of cardiac surgery, and year of treatment, patients treated at medium (OR 0.86, 95% CI 0.75-0.98) and high (OR 0.75, 95% CI 0.63-0.89) volume centers had significantly lower odds of death compared to those treated at low volume centers. The minimum annual case load most significantly associated with lower mortality was 22 (95% CI 22-28). Conclusion Pediatric centers with low extracorporeal membrane oxygenation average annual case volume had significantly higher mortality and a minimum volume of 22 cases per year was associated with improved mortality. We suggest this threshold be evaluated by additional study.

Association of Hospital-Level Volume of Extracorporeal Membrane Oxygenation Cases and Mortality. Analysis of the Extracorporeal Life Support Organization Registry

“…These findings are similar to, and expand on, results described in previous studies of ECMO for children in the United States (15,16). When considering more recent data during a period of rapid expansion and Definition of abbreviations: ECMO = extracorporeal membrane oxygenation; ECPR = ECMO during cardiopulmonary resuscitation; n = number of patients; N = number of centers; pH = arterial blood pH; PF ratio = the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen; pre-ECMO hours of mechanical ventilation = the number hours of mechanical ventilation a patient received prior to ECMO cannulation.…”

“…The following variables were chosen: calendar year in which ECMO was delivered (15,23); patient age (23)(24)(25); primary diagnosis (23)(24)(25)(26)(27); ECMO support type (16,27); presence of pre-ECMO acute renal failure (23,26,27); presence of comorbid conditions (23,28); pre-ECMO cardiac arrest (25,29); and pre-ECMO measures including duration of mechanical ventilation (23,25,30), arterial blood pH (23,27,31), Pa CO 2 (25), and the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PF ratio) (1,23). In neonatal patients, case-mix was also adjusted for gestational age (24) and birth weight (24).…”

Inter-hospital transports on extracorporeal membrane oxygenation in different health-care systems

“…The higher the number, the better the outcome. For the pediatric and neonatal populations (15,16), the cut-off is to perform at least 20 to 30 annual ECMOs runs to do significantly better than the low-volume centers (defined as five or fewer runs per year). Further, the lower limit for a positive learning curve and maintenance of competence require at least 20 treatments per annum.…”

Addressing the challenges of ECMO simulation

“…(11,12) In addition, there is relatively strong evidence showing that hospitals with higher numbers of ECMO cases tend to achieve better patient outcomes. (13,14) This can be partly explained by the fact that the clinicians in hospitals managing higher numbers of ECMO patients gain more ECMO exposure and experience, which in turn helps fine-tune and retain their skill-set.…”