Central nervous system complications during pediatric extracorporeal life support: incidence and risk factors.
ABSTRACT Identify the incidence and risk factors for development of acute, severe central nervous system (CNS) complications of pediatric extracorporeal life support (ECLS).
Retrospective review of Extracorporeal Life Support Organization (ELSO) registry database.
Pediatric intensive care units of 115 tertiary centers internationally.
Pediatric patients, 1 month to 18 yrs of age, who had ECLS between the years 1981-2002.
Data concerning 4,942 patients who underwent one run of ECLS were analyzed. Six hundred thirty-six patients (12.9%) developed acute, severe CNS complications. Patients who required ECLS during extracorporeal cardiopulmonary resuscitation (n = 161; 3.3%) were more likely to develop CNS complications (n = 42; 26.1%) than patients who did not have extracorporeal cardiopulmonary resuscitation (p < .001; odds ratio [OR], 2.48; 95% confidence interval [CI], 1.73-3.57). Stepwise logistic regression analysis of therapies patients received before initiation of ECLS showed that the use of a left ventricular assist device (p = .001; OR, 3.45; 95% CI, 1.64-7.22), bicarbonate (p < .001; OR, 1.61; 95% CI, 1.26-2.05), and vasopressor/inotropic medications (p = .035; OR, 1.22; 95% CI, 1.01-1.48) were significant independent predictors of development of CNS complications. Among patients who had pulmonary failure as an indication for ECLS, the CNS complication rate was significantly higher for those treated with venoarterial ECLS than those who had venovenous ECLS (13.5% vs. 5.7%; p < .001; OR, 0.43; 95% CI, 0.34-0.67). Multiple logistic regression analysis of the complications other than CNS complications associated with the use of ECLS showed that pH <7.20, creatinine concentration >3.0 mg/dL, use of inotropes, presence of myocardial stun, and requirement of cardiopulmonary resuscitation during ECLS independently predicted development of CNS complications.
Patients who have metabolic acidosis, a bicarbonate or inotrope/vasopressor requirement, cardiopulmonary resuscitation, or a left ventricular assist device before initiation of ECLS are at greater risk for development of CNS complications. After initiation of ECLS, patients who develop renal failure or metabolic acidosis or undergo venoarterial ECLS should be closely monitored for development of CNS complications.
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ABSTRACT: Extracorporeal membrane oxygenation is a commonly used form of mechanical circulatory support in children with congenital or acquired heart disease and cardiac failure refractory to conventional medical therapies. In children with heart disease who suffer cardiac arrest, extracorporeal membrane oxygenation has been successfully used to provide cardiopulmonary support when conventional resuscitation has failed to establish return of spontaneous circulation. Survival to hospital discharge for children with heart disease support is approximately 40% but varies widely based on age, indication for support, and underlying cardiac disease. Although extracorporeal membrane oxygenation is lifesaving in many instances, it is associated with many complications and is expensive. Thus, a clear understanding of survival to discharge and long-term functional and neurologic outcomes are essential to guide the use of extracorporeal membrane oxygenation now and in the future. This review, part of the Pediatric Cardiac Intensive Care Society/Extracorporeal Life Support Organization Joint Statement on Mechanical Circulatory Support, summarizes current knowledge on short- and long-term outcomes for extracorporeal membrane oxygenation used to support children with cardiac disease.Pediatric Critical Care Medicine 06/2013; 14(5):S73-S83. DOI:10.1097/PCC.0b013e318292e3fc · 2.33 Impact Factor
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ABSTRACT: Background Cardiac disease is a leading cause of stroke in children, yet limited data support the current stroke prevention and treatment recommendations. A multi-disciplinary panel of clinicians was convened in February 2014 by the International Pediatric Stroke Study group to identify knowledge gaps and prioritize clinical research efforts for children with cardiac disease and stroke. Results Significant knowledge gaps exist including a lack of data on stroke incidence, predictors, primary and secondary stroke prevention, hyperacute treatment and outcome in children with cardiac disease. Commonly used diagnostic techniques including brain CT and ultrasound have low rates of stroke detection and diagnosis is frequently delayed. The challenges of research studies in this population include epidemiological barriers to research such as small patient numbers, heterogeneity of cardiac disease, and co-existence of multiple risk factors. Based on stroke burden and study feasibility, studies involving mechanical circulatory support, single ventricle patients, early stroke detection strategies, and understanding secondary stroke risk factors and prevention are the highest research priorities over the next 5 to 10 years. The development of large-scale multi-center and multi-specialty collaborative research is a critical next step. The designation of centers of expertise will assist in clinical care and research. Conclusions There is an urgent need for additional research to improve the quality of evidence in guideline recommendations for cardiogenic stroke in children. While significant barriers to clinical research exist, multi-center and multi-specialty collaboration is an important step towards advancing clinical care and research for children with cardiac disease and stroke.Pediatric Neurology 01/2014; 52(1). DOI:10.1016/j.pediatrneurol.2014.09.016 · 1.50 Impact Factor
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ABSTRACT: Up to 40% of infants with persistent pulmonary hypertension (PPHN) remains refractory to conventional therapies, and extracorporeal membrane oxygenation (ECMO) is offered as an effective support for this group. However, ECMO is a highly invasive and risky procedure with devastating complications such as intracranial hemorrhage (ICH). In this study, we aimed to determine the risk factors for ICH in infants with PPHN. A case-control study of patients admitted to the pediatric intensive care unit (PICU) with PPHN requiring ECMO support was conducted. The study was carried out at a 25-bed PICU in large urban tertiary care children's hospital. A total number of 32 subjects were studied. Patients with and without ICH during ECMO were evaluated for activated clotting time (ACT), heparin dosing, platelet count, coagulation profile such as activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), fibrinogen level, vital signs including heart rate and mean arterial pressure (MAP), transfusion history, gestational age, and severity of pre-ECMO illness as possible risk factors. Low fibrinogen level (115 ± 13 mg/dl) and low platelet counts (37.4 ± 18.3 Thousand/μl) were associated with higher incidence of ICH (p = 0.009 and p = 0.005, respectively). Elevated MAP (69 ± 4.34 mmHg) was also noticed in ICH patients (p = 0.006). Results demonstrated that low fibrinogen level and low platelet count were associated with ICH in PPHN patients on ECMO. While on ECMO support, maintaining fibrinogen and platelet counts within normal ranges seems crucial to prevent ICH in PPHN patients. This is the first report identifying low fibrinogen level among the risk factors for ICH in infants with PPHN on ECMO support.12/2015; 3(1):6. DOI:10.1186/s40560-015-0071-x