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Extracorporeal membrane oxygenation for refractory septic shock in children: one institution's experience
Graeme Maclaren1, Warwick Butt, Derek Best
1Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia.
Insights
Venoarterial extracorporeal membrane oxygenation (ECMO) can safely support children with refractory septic shock. This study shows ECMO is a viable option, even in cases of cardiac arrest, with good survival rates and no long-term disability in survivors.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular support
- Extracorporeal life support
Background:
- Septic shock in children can lead to circulatory collapse.
- Refractory septic shock requires advanced hemodynamic support.
- Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a potential treatment option.
Purpose of the Study:
- To evaluate the institutional experience with VA-ECMO in pediatric septic shock.
- To assess the safety and efficacy of VA-ECMO for hemodynamic support in critically ill children.
- To determine survival rates and functional outcomes in this patient population.
Main Methods:
- Retrospective case series of 45 children with refractory septic shock.
- Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was utilized for hemodynamic support.
- Data collected included pre-cannulation status, ECMO parameters, complications, and survival to discharge.
Main Results:
- Forty-five children received VA-ECMO for septic shock; 18 (40%) had cardiac arrest prior to cannulation.
- Median ECMO duration was 84 hours. Mechanical circuit complications occurred in 38%, bleeding in 24%.
- Survival to hospital discharge was 47%. Central atrioaortic cannulation was associated with improved survival (73% vs 44%, p=.05). No survivors had severe disability.
Conclusions:
- VA-ECMO is a safe and effective resuscitation tool for children with septic shock and circulatory collapse.
- Sepsis and multiorgan failure should not preclude ECMO consideration.
- Findings support existing guidelines for ECMO use in pediatric septic shock.
Objective:
To report our institutional experience of venoarterial extracorporeal membrane oxygenation (ECMO) in children with septic shock and circulatory collapse.
Design:
Retrospective case series.
Setting:
Intensive care unit of a tertiary pediatric referral center.
Patients:
Forty-five children with refractory septic shock who received venoarterial ECMO for hemodynamic support.
Interventions:
Venoarterial ECMO.
Measurements And Main Results:
We measured mean arterial pressure and inotropes before cannulation, ventilator settings, oxygenation, site and cause of infection, time on ECMO, complications of ECMO relating to the circuit or anticoagulation, survival to hospital discharge, and functional outcome assessment. Between July 1988 and October 2006, 441 children at our institution received extracorporeal life support for a variety of indications. Forty-five (10%) with septic shock received venoarterial ECMO specifically for hemodynamic support. Eighteen (40%) of these had suffered cardiac arrest and were receiving chest compressions immediately before cannulation. The median time spent on ECMO was 84 hrs (range, 32-135). There were mechanical problems with the ECMO circuit requiring intervention in 17 (38%) patients, such as oxygenator or pump head failure, clots in the circuit, or cannulae malposition. This caused no long-term harm in any but one of the patients, who died during a circuit change. Eleven patients (24%) had clinically apparent episodes of bleeding that required surgical intervention or blood transfusion. Twenty-one (47%) patients survived to hospital discharge. Atrioaortic cannulation through a sternotomy incision was associated with an improvement in survival to hospital discharge (73% of those with central cannulation survived vs. 44% without, p = .05). No survivors had severe disability at long-term follow-up.
Conclusions:
Extracorporeal membrane oxygenation can be safely used to resuscitate and support children with sepsis and refractory shock. Sepsis and multiorgan failure should not be considered a contraindication to ECMO. This study adds support to existing guidelines.
