Survival after extracorporeal cardiopulmonary resuscitation in infants and children with heart disease
We investigated survival and predictors of mortality for infants and children with heart disease treated with extracorporeal membrane oxygenation as an aid to cardiopulmonary resuscitation.
Children (<18 years) with heart disease who received extracorporeal cardiopulmonary resuscitation and were reported to the Extracorporeal Life Support Organization database were evaluated. Patients were classified into one of 3 groups based on underlying cardiac physiology: single ventricle, 2 ventricles, and cardiac muscle disease. Patients with eligible procedure codes were assigned a Risk Adjustment for Congenital Heart Surgery-1 classification.
Four hundred ninety-two patients were eligible for analysis, and 279 (57%) were assigned a Risk Adjustment for Congenital Heart Surgery-1 category. Overall survival was 42%. In a multivariable logistic regression analysis, significant pre-extracorporeal predictors for mortality included single-ventricle physiology (odds ratio, 1.6; 95% confidence interval, 1.05-2.4), a history of a stage 1-type procedure (odds ratio, 2.7; 95% confidence interval, 1.2-6.2), and extreme acidosis (arterial blood gas pH < 7.01; odds ratio, 2.2; 95% confidence interval, 1.3-3.7). Right carotid artery cannulation was associated with decreased mortality risk (odds ratio, 0.6; 95% confidence interval, 0.4-0.9). During extracorporeal support, complications, including renal injury, evidence of neurologic injury, and persistent acidosis, were associated with an increased risk of hospital mortality.
Use of extracorporeal membrane oxygenation as an adjunct to cardiopulmonary resuscitation resulted in hospital survival in 42% of infants and children with heart disease. Underlying cardiac physiology and associated cardiac surgical procedures influenced mortality, as did pre-extracorporeal resuscitation status and extracorporeal membrane oxygenation-associated complications.
Available from: Graham D Pavitt
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ABSTRACT: The eukaryotic initiation factor 2B (eIF2B) is a five-subunit guanine nucleotide exchange factor, that functions during translation initiation to catalyze the otherwise slow exchange of GDP for GTP on its substrate eIF2. Assays to measure substrate interaction and guanine nucleotide release ability of eIF2B require the complex to be purified free of interacting proteins. We have also found that a subcomplex of two subunits, gamma and epsilon or the largest one, epsilon alone, promotes this activity. Within eIF2Bepsilon, the catalytic center requires the C-terminal 200 residues only. Here, we describe our protocols for purifying the Saccharomyces cerevisiae eIF2B complexes and the catalytic subunit using FLAG-tagged proteins overexpressed in yeast cells. Using commercially available FLAG-affinity resin and high salt buffer, we are able to purify active eIF2B virtually free of contaminants.
Available from: Adnan Bhutta
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ABSTRACT: To describe our experience using extracorporeal cardiopulmonary resuscitation (ECPR) in resuscitating children with refractory cardiac arrest in the intensive care unit (ICU) and to describe hospital survival and neurologic outcomes after ECPR.
A retrospective chart review of a consecutive case series of patients requiring ECPR from 2001 to 2006 at Arkansas Children's Hospital. Data from medical records was abstracted and reviewed. Primary study outcomes were survival to hospital discharge and neurological outcome at hospital discharge.
During the 6-year study period, ECPR was deployed 34 times in 32 patients. 24 deployments (73%) resulted in survival to hospital discharge. Twenty-eight deployments (82%) were for underlying cardiac disease, 3 for neonatal non-cardiac (NICU) patients and 3 for paediatric non-cardiac (PICU) patients. On multivariate logistic regression analysis, only serum ALT (p-value=0.043; OR, 1.6; 95% confidence interval, 1.014-2.527) was significantly associated with risk of death prior to hospital discharge. Blood lactate at 24h post-ECPR showed a trend towards significance (p-value=0.059; OR, 1.27; 95% confidence interval, 0.991-1.627). The Hosmer-Lemeshow tests (p-value=0.178) suggested a good fit for the model. Neurological evaluation of the survivors revealed that there was no change in PCPC scores from a baseline of 1-2 in 18/24 (75%) survivors.
ECPR can be used successfully to resuscitate children following refractory cardiac arrest in the ICU, and grossly intact neurologic outcomes can be achieved in a majority of cases.
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ABSTRACT: To describe survival outcomes for pediatric patients supported with extracorporeal membrane oxygenation for severe myocarditis and identify risk factors for in-hospital mortality.
Retrospective review of Extracorporeal Life Support Organization registry database.
Data reported to Extracorporeal Life Support Organization from 116 extracorporeal membrane oxygenation centers.
Patients < or = 18 yrs of age supported with extracorporeal membrane oxygenation for myocarditis during 1995 to 2006.
Of 19,348 reported pediatric extracorporeal membrane oxygenation uses from 1995 to 2006, 260 runs were for 255 patients with a diagnosis of myocarditis (1.3%). Survival to hospital discharge was 61%. Seven patients (3%) underwent heart transplantation and six patients survived to discharge. Of 100 patients not surviving to hospital discharge, extracorporeal membrane oxygenation support was withdrawn in 70 (70%) with multiple organ failure as the indication in 58 (83%) patients. In a multivariable model, female gender (adjusted odds ratio, 2.3, 95% confidence interval, 1.3-4.2), arrhythmia on extracorporeal membrane oxygenation (adjusted odds ratio, 2.7, 95% confidence interval, 1.5-5.1), and renal failure requiring dialysis (adjusted odds ratio, 5.1, 95% confidence interval, 2.3-11.4) were associated with increased odds of in-hospital mortality.
Extracorporeal membrane oxygenation is a valuable tool to rescue children with severe cardiorespiratory compromise related to myocarditis. Female gender, arrhythmia on extracorporeal membrane oxygenation, and need for dialysis during extracorporeal membrane oxygenation were associated with increased mortality.
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