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Impact of Timing of ECMO Initiation on Outcomes After Pediatric Heart Surgery: A Multi-Institutional Analysis
Punkaj Gupta1,2, Michael J Robertson3, Mallikarjuna Rettiganti4
1Division of Pediatric Critical Care, University of Arkansas for Medical Sciences, Little Rock, AR, USA. pgupta2@uams.edu.
Insights
Timing of extracorporeal membrane oxygenation (ECMO) after pediatric heart surgery does not impact mortality. However, delayed ECMO initiation is linked to longer recovery times, though the clinical significance is minimal.
Area of Science:
- Pediatric Cardiac Surgery
- Extracorporeal Membrane Oxygenation (ECMO)
- Critical Care Medicine
Background:
- Limited understanding exists regarding the impact of extracorporeal membrane oxygenation (ECMO) timing on outcomes in pediatric heart surgery patients.
- Previous studies have not definitively established the relationship between the delay in ECMO initiation and patient prognosis.
Purpose of the Study:
- To investigate the association between the timing of extracorporeal membrane oxygenation (ECMO) initiation and patient outcomes following pediatric heart surgery.
- To determine if increasing time from cardiac surgery to ECMO initiation correlates with adverse outcomes such as mortality or prolonged recovery.
Main Methods:
- Analysis of data from 2908 pediatric patients (≤18 years) who received ECMO post-cardiac surgery between 2004-2013 across 42 hospitals.
- Utilized multivariable logistic regression to assess the relationship between time to ECMO initiation and outcomes including in-hospital mortality, composite poor outcome, and prolonged ICU/hospital stay.
Main Results:
- Increasing time from cardiac surgery to ECMO initiation was not associated with increased in-hospital mortality or composite poor outcome.
- A statistically significant association was found between delayed ECMO initiation and prolonged ECMO duration, mechanical ventilation, ICU stay, and hospital stay.
- The observed increase in prolonged recovery metrics per day of delay was small (1-3%), suggesting limited clinical significance.
Conclusions:
- The timing of extracorporeal membrane oxygenation (ECMO) initiation after pediatric heart surgery does not appear to influence patient mortality.
- Results suggest that ECMO is initiated appropriately based on clinical necessity across diverse patient age groups and surgical complexities.
- Clinical decisions regarding ECMO timing should prioritize patient condition over arbitrary timeframes to optimize outcomes.
Abstract:
Little is known about the relationship of timing of extracorporeal membrane oxygenation (ECMO) initiation on patient outcomes after pediatric heart surgery. We hypothesized that increasing timing of ECMO initiation after heart surgery will be associated with worsening study outcomes. Patients aged ≤18 years receiving ECMO after pediatric cardiac surgery at a Pediatric Health Information System-participating hospital (2004-2013) were included. Outcomes evaluated included in-hospital mortality, composite poor outcome, prolonged length of ECMO, prolonged length of mechanical ventilation, prolonged length of ICU stay, and prolonged length of hospital stay. Multivariable logistic regression models were fitted to study the probability of study outcomes as a function of timing from cardiac surgery to ECMO initiation. A total of 2908 patients from 42 hospitals qualified for inclusion. The median timing of ECMO initiation after cardiac surgery was 0 days (IQR 0-1 day; range 0-294 days). After adjusting for patient and center characteristics, increasing duration of time from surgery to ECMO initiation was not associated with higher mortality or worsening composite poor outcome. However, increasing duration of time from surgery to ECMO initiation was associated with prolonged length of ECMO, prolonged length of ventilation, prolonged length of ICU stay, and prolonged length of hospital stay. Although this relationship was statistically significant, the odds for prolonged length of ECMO, prolonged length of ventilation, prolonged length of ICU stay, and prolonged length of hospital stay increased by only 1-3 % for every 1-day increase in ECMO that may be clinically insignificant. We did not demonstrate any relationship between timing of ECMO initiation and mortality among the patients of varying age groups, and patients undergoing cardiac surgery of varying complexity. We concluded that increasing duration of time from surgery to ECMO initiation is not associated with worsening mortality. Our results suggest that ECMO is initiated at the appropriate time when dictated by clinical situation among patients of all age groups, and among patients undergoing heart operations of varying complexity.
