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Prolonged extracorporeal support for nonneonatal respiratory failure
Insights
Extracorporeal membrane oxygenation (ECMO) can save children with isolated lung failure. However, its use in older children and adults with multiple organ failures remains uncertain and controversial.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiopulmonary Support
- Respiratory Failure Management
Background:
- Extracorporeal membrane oxygenation (ECMO) is established for neonates with pulmonary failure.
- Its application in older children and adults with respiratory failure is less understood and debated.
- This study investigates the efficacy and outcomes of venoarterial ECMO in a pediatric and adolescent population.
Purpose of the Study:
- To evaluate the effectiveness of venoarterial ECMO in children and adolescents experiencing severe respiratory failure.
- To identify factors influencing survival and long-term outcomes in this patient group.
- To assess the safety and complications associated with ECMO in non-neonatal patients.
Main Methods:
- A retrospective analysis of 24 patients (4 months to 16 years) who underwent venoarterial ECMO for respiratory failure over 4 years.
- Data collected included diagnoses, pre-ECMO blood gas values, ECMO duration, cannulation methods, and associated therapies.
- Outcomes assessed included survival rates, long-term sequelae, and complications such as hemorrhage.
Main Results:
- Nine patients (41%) survived ECMO, with eight achieving long-term survival.
- Survivors primarily had isolated pulmonary failure; those with combined cardiac and/or renal failure did not survive.
- Hemorrhage requiring re-exploration was a significant complication, particularly with sternotomy cannulation.
Conclusions:
- Venoarterial ECMO can be a life-saving intervention for pediatric patients with isolated pulmonary failure.
- Its utility in patients with multiorgan failure (pulmonary, cardiac, renal) is uncertain and associated with poor outcomes.
- Further research is needed to optimize ECMO protocols and patient selection for non-neonatal populations.
Abstract:
Extracorporeal membrane oxygenation (ECMO) is effective for newborns with pulmonary failure unresponsive to conventional therapy. However, ECMO for the older child and adult has been controversial and not widely utilized. Over 4 years, 24 patients (aged 4 months to 16 years; 11 boys, 13 girls) underwent venoarterial ECMO (duration, 7 to 19 days) for respiratory failure. The diagnoses were: viral pneumonia (7), hydrocarbon aspiration (6), sepsis with adult respiratory distress syndrome (ARDS) (2), bacterial pneumonitis (2), tracheal stenosis (1), bilateral pulmonary contusion (1), diaphragmatic hernia with ARDS (1), ketoacidosis with ARDS (1), pulmonary artery injection of hydrocarbon (1), drowning (1), and epiglottis with barotrauma (1). Pre-ECMO blood gas ranges (and means) were PO2 18 to 65 (46), and PCO2 47 to 112 (65). Nineteen patients received dopamine, dobutamine, or other inotrope for associated cardiac and/or renal failure. Cannulation for ECMO was through neck or groin vessels in 17, and sternotomy in 7. ECMO flow rates were 150 to 250 mL/kg/min, to maintain PO2 greater than 100 and PCO2 less than 40. Nine patients (41%) survived ECMO, with eight long-term survivors, (4 hydrocarbon aspiration or injection, 1 pulmonary contusion, 1 viral pneumonia, 1 ARDS, 1 barotrauma), three of whom have mild neurological deficit. All patients with sternotomy, and 8 of 15 with neck and/or groin cannulation, required 1 to 5 explorations for hemorrhage while on ECMO. All survivors had primarily pulmonary failure; patients with combinations of pulmonary, cardiac, and renal failure did not survive. ECMO can be life-saving in the child with isolated pulmonary failure, but its efficacy in patients with multiorgan failure is uncertain.