Can the outcome of pediatric extracorporeal membrane oxygenation after cardiac surgery be predicted?
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Published on: May 26, 2023
Ghassan Baslaim1, Jill Bashore, Faiz Al-Malki
1Division of Cardiothoracic Surgery and Cardiac Surgery Intensive Care Unit, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.
Insights
Predicting outcomes in pediatric cardiac surgery patients on extracorporeal membrane oxygenation (ECMO) is crucial. Renal failure, stroke, and disseminated intravascular coagulopathy (DIC) indicate high mortality, guiding ECMO support decisions.
Area of Science:
- Pediatric Cardiac Surgery
- Extracorporeal Membrane Oxygenation
- Critical Care Medicine
Background:
- Extracorporeal membrane oxygenation (ECMO) is a life-support measure for critically ill pediatric patients.
- Predicting outcomes and determining optimal ECMO duration in children post-cardiac surgery remains challenging.
Purpose of the Study:
- To assess clinical and biochemical predictors of outcome in pediatric cardiac surgery patients receiving ECMO.
- To identify criteria for discontinuing ECMO support.
Main Methods:
- Retrospective review of 26 pediatric patients treated with ECMO after cardiac surgery.
- Analysis of clinical variables, biochemical markers, and patient outcomes.
Main Results:
- Forty-six percent of patients survived ECMO and were discharged.
- Development of renal failure, stroke, and disseminated intravascular coagulopathy (DIC) were associated with increased mortality (p=0.022, p=0.021, p=0.002 respectively).
- Single ventricle physiology and truncus arteriosus repair were associated with poorer outcomes.
Conclusions:
- Renal failure, stroke, and DIC during ECMO are strong indicators of poor prognosis.
- Patients with single ventricle physiology or repaired truncus arteriosus may have limited benefit from ECMO.
- Lactate levels, inotrope score, and ECMO duration (over 3 days) can inform decisions on ECMO discontinuation.
Purpose:
The purpose of this study is to assess whether clinical and biochemical variables may be used to predict outcome in children treated with extracorporeal membrane oxygenation (ECMO) after cardiac surgery and to determine when to discontinue ECMO support.
Methods:
We retrospectively reviewed the medical records of 26 children treated with ECMO after cardiac surgery at our institution from October 2000 to May 2004.
Results:
Patients mean age was 16.4 months (range, two weeks to 144 months) and mean weight was 6.3 kg (range, 2.2-26 kg). Of the 26 children requiring ECMO support, 23 underwent biventricular repair, and 3 had single ventricle procedure. None of the single ventricle repair or the truncus arteriosus repair group survived the ECMO support. Twelve patients (46%) survived the ECMO support and were discharged from hospital. Four patients needed ECMO support after 45 min (mean) of cardiopulmonary resuscitation (CPR) time (range = 30-55 min) with 2/4 survived to discharge. All patients who survived to discharge showed no evidence of neurological deficit or disseminated intravascular coagulopathy (DIC) whereas 5 patients died following stroke, and 8 following DIC, respectively (p = 0.021 and 0.002). Renal failure developed in 8 cases (1 survivor and 7 nonsurvivors, p = 0.022). Seventeen patients (65%) required re-exploration of the mediastinum for bleeding. Length of time on ECMO, although it was longer among the nonsurvivors, was not significantly different between the survivor (74.5 hours) and nonsurvivor (118.2 hours) groups (p = 0.41). Inotrope score at ECMO initiation and serum lactate within 72 hours of ECMO were calculated and the difference between the two groups was not significantly related to survival (p = 0.29 and 0.22 respectively).
Conclusion:
Our findings suggest patients who develop renal failure, stroke and DIC during ECMO support have a high mortality. Patients with single ventricle physiology, and repaired truncus arteriosus may benefit less from ECMO support and have an increased risk of death. Elevated levels of lactate during the first 72 hours, high inotrope score at the initiation of ECMO and long ECMO support duration (more than 3 days) are all potential variables that can be used in determining when to discontinue ECMO support.
