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Extracorporeal Membrane Oxygenation in Pediatric Pulmonary Hypertension
Emily Morell1, Satish K Rajagopal1, Peter Oishi1,2
1Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA.
Insights
Children with pulmonary hypertension needing extracorporeal membrane oxygenation (ECMO) have higher mortality rates. Key risk factors for death include young age, pre-ECMO acidosis, and complications like pulmonary hemorrhage and neurologic issues.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiopulmonary Support
- Pediatric Cardiology
Background:
- Pulmonary hypertension (PH) in children presents significant management challenges.
- Extracorporeal membrane oxygenation (ECMO) is a vital but high-risk intervention for critically ill pediatric patients.
- Understanding outcomes for PH patients on ECMO is crucial for improving care.
Purpose of the Study:
- To elucidate the epidemiology of pediatric pulmonary hypertension.
- To detail critical care interventions for PH patients undergoing ECMO.
- To analyze mortality rates and identify risk factors in this population.
Main Methods:
- Retrospective analysis of prospectively collected multicenter data from the Extracorporeal Life Support Organization (ELSO) registry.
- Inclusion criteria: Pediatric patients (28 days to 18 years) diagnosed with pulmonary hypertension.
- Analysis of 634 ECMO runs (605 patients) between 2007 and 2018.
Main Results:
- Pediatric PH patients on ECMO had a higher mortality rate (51.3%) compared to those without PH (44.8%).
- Significant mortality predictors included younger age, pre-ECMO cardiac arrest, severe acidosis, and ECMO complications (e.g., pulmonary hemorrhage, neurologic issues, renal replacement therapy).
- Pneumonia as a co-diagnosis was associated with lower mortality (OR 0.5). Prediction models showed increasing accuracy with more variables (AUC 0.62–0.75).
Conclusions:
- Pediatric patients with pulmonary hypertension requiring ECMO face significantly increased mortality risk.
- Identifying high-risk PH patients on ECMO through factors like age, pre-existing acidosis, and specific complications can guide clinical decisions.
- Improved prognostic awareness for PH patients on ECMO may enhance clinical management and outcomes.
Objective:
To describe the epidemiology, critical care interventions, and mortality of children with pulmonary hypertension receiving extracorporeal membrane oxygenation.
Design:
Retrospective analysis of prospectively collected multicenter data.
Setting:
Data entered into the Extracorporeal Life Support Organization database between January 2007 and November 2018.
Patients:
Pediatric patients between 28 days and 18 years old with a diagnosis of pulmonary hypertension.
Measurements And Main Results:
Six hundred thirty-four extracorporeal membrane oxygenation runs were identified (605 patients). Extracorporeal membrane oxygenation support type was pulmonary (43.1%), cardiac (40.2%), and extracorporeal cardiopulmonary resuscitation (16.7%). The majority of cannulations were venoarterial (80.4%), and 30% had a pre-extracorporeal membrane oxygenation cardiac arrest. Mortality in patients with pulmonary hypertension was 51.3% compared with 44.8% (p = 0.001) in those without pulmonary hypertension. In univariate analyses, significant predictors of mortality included age less than 6 months and greater than 5 years; pre-extracorporeal membrane oxygenation cardiac arrest; pre-extracorporeal membrane oxygenation blood gas with pH less than 7.12, PaCO2 greater than 75, PaO2 less than 35, and arterial oxygen saturation less than 60%; extracorporeal membrane oxygenation duration greater than 280 hours; extracorporeal cardiopulmonary resuscitation; and extracorporeal membrane oxygenation complications including cardiopulmonary resuscitation, inotropic support, myocardial stun, tamponade, pulmonary hemorrhage, intracranial hemorrhage, seizures, other hemorrhage, disseminated intravascular coagulation, renal replacement therapy, mechanical/circuit problem, and metabolic acidosis. A co-diagnosis of pneumonia was associated with significantly lower odds of mortality (odds ratio, 0.5; 95% CI, 0.3-0.8). Prediction models were developed using three sets of variables: 1) pre-extracorporeal membrane oxygenation (age, absence of pneumonia, and pH < 7.12; area under the curve, 0.62); 2) extracorporeal membrane oxygenation related (extracorporeal cardiopulmonary resuscitation, any neurologic complication, pulmonary hemorrhage, renal replacement therapy, and metabolic acidosis; area under the curve, 0.72); and 3) all variables combined (area under the curve, 0.75) (p < 0.001).
Conclusions:
Children with pulmonary hypertension who require extracorporeal membrane oxygenation support have a significantly greater odds of mortality compared with those without pulmonary hypertension. Risk factors for mortality include age, absence of pneumonia, pre-extracorporeal membrane oxygenation acidosis, extracorporeal cardiopulmonary resuscitation, pulmonary hemorrhage, neurologic complications, renal replacement therapy, and acidosis while on extracorporeal membrane oxygenation. Identification of those pulmonary hypertension patients requiring extracorporeal membrane oxygenation who are at even higher risk for mortality may inform clinical decision-making and improve prognostic awareness.
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