Central nervous system complications during pediatric extracorporeal life support: Incidence and risk factors

Department of Pediatrics, University of Washington, Seattle, USA.
Critical Care Medicine (Impact Factor: 6.31). 12/2005; 33(12):2817-24. DOI: 10.1097/01.CCM.0000189940.70617.C3
Source: PubMed


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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    • "ECMO duration did not differ significantly between survivors to hospital discharge and nonsurvivors. This finding is consistent with other reports [2, 5, 13, 17]. At our institution, although the timing of ECMO decannulation procedures varied widely and an intracranial hemorrhage is generally a contraindication to ECMO continuation, this finding may indicate that providing adequate pre-ECMO oxygen delivery affects overall survival to hospital discharge more than the ECMO course, itself, and any ECMO complications. "
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    ABSTRACT: Extracorporeal cardiopulmonary resuscitation (ECPR) allows clinicians to potentially rescue pediatric patients unresponsive to traditional cardiopulmonary resuscitation (CPR). Clinical and laboratory variables predictive of survival to hospital discharge are beginning to emerge. In this retrospective, historical cohort case series, clinical, and laboratory data from 31 pediatric patients (<21 years of age) receiving ECPR from March 2000 to April 2006 at our university-affiliated, tertiary-care children's hospital were statistically analyzed in an attempt to identify variables predictive of survival to hospital discharge. Seven patients survived to hospital discharge (23%), and 24 patients died. Survival was independent of gender, age, and CPR duration. ECPR survival was, however, associated with a lower pre-ECPR phosphorus concentration (P = 0.002) and a lower pre-ECPR creatinine concentration (P = 0.05). A classification tree analysis, using, in part, a pre-ECPR phosphorus concentration threshold and a CPR ABG base excess concentration threshold, yielded a 96% nominal accuracy of predicting survival to hospital discharge or death. A large, multicenter, prospective cohort study aimed at validating these predictive variables is needed to guide appropriate ECPR patient selection. This study reveals the potential survival benefit of ECPR for pediatric patients, regardless of CPR duration prior to ECPR cannulation.
    Preview · Article · Feb 2010 · Pediatric Cardiology
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    • "A 2005 review of the ELSO database reported a 26%incidence of acute severe central nervous system complications in children who received ECPR [13]. This incidence was significantly higher than in children managed with ECMO for cardiac or respiratory failure without cardiac arrest, but not different from those who suffered a cardiac arrest before ECMO but had spontaneous circulation at the time of cannulation. "
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    ABSTRACT: The purpose of this article is to discuss the indications for extracorporeal cardiopulmonary resuscitation (ECPR), physiologic and mechanical issues that arise in patients managed with ECPR, and optimal patient selection for ECPR. ECPR can provide very good outcomes for some children who, in all likelihood, would otherwise have died. Having the capability to routinely offer ECPR represents an enormous institutional commitment of people and resources. For ECPR to be successful, it must be rapidly deployed, patients must be selected with care, and consistently excellent conventional CPR must take place while awaiting ECPR.
    Preview · Article · Sep 2008 · Pediatric Clinics of North America

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