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Extracorporeal Membrane Oxygenation for Pediatric Patients With Coronavirus Disease 2019-Related Illness
Robert M MacGregor1, Ryan M Antiel1, Tasnim Najaf2
1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO.
Insights
Pediatric extracorporeal membrane oxygenation (ECMO) centers have established guidelines for COVID-19 patients, with most treating pediatric cases similarly to other viral illnesses. Further research is needed on resource allocation and extracorporeal cardiopulmonary resuscitation (ECPR) use.
Area of Science:
- Pediatric critical care medicine
- Infectious diseases
- Medical ethics
Background:
- Coronavirus disease 2019 (COVID-19) presented unique challenges for pediatric intensive care.
- Extracorporeal membrane oxygenation (ECMO) is a vital life support measure for critically ill patients.
- Guidelines for ECMO use in pediatric COVID-19 patients were rapidly evolving in early 2020.
Purpose of the Study:
- To survey U.S. children's hospitals regarding their ECMO guidelines for COVID-19 pediatric patients.
- To ascertain ECMO leaders' opinions on ethical dilemmas related to pediatric COVID-19 care.
- To understand current practices and inform future recommendations for ECMO in pediatric COVID-19.
Main Methods:
- A confidential, self-administered questionnaire was distributed to 127 U.S. pediatric ECMO centers.
- The survey collected data on existing hospital ECMO guidelines for COVID-19.
- Respondents provided opinions on ethical issues: pediatric prioritization, do-not-resuscitate (DNR) orders, and extracorporeal cardiopulmonary resuscitation (ECPR).
Main Results:
- 47 (37%) of centers had enacted specific ECMO guidelines for COVID-19.
- Most centers (94%) applied similar ECMO indications as for other viral illnesses (e.g., RSV, influenza).
- 98% of leaders opposed DNR orders for pediatric COVID-19 patients; 60% opposed ECPR for COVID-19.
Conclusions:
- The majority of pediatric ECMO centers developed guidelines for COVID-19.
- There is consensus against DNR orders for pediatric COVID-19 patients.
- Further guidance is required for equitable ECMO resource allocation and ECPR appropriateness in pediatric COVID-19.
Objective:
To describe current hospital guidelines and the opinions of extracorporeal membrane oxygenation leaders at U.S. children's hospitals concerning the use of extracorporeal membrane oxygenation for coronavirus disease 2019-positive pediatric patients.
Design:
Confidential, self-administered questionnaire.
Setting:
One hundred twenty-seven U.S. pediatric extracorporeal membrane oxygenation centers.
Subjects:
Extracorporeal membrane oxygenation center program directors and coordinators.
Interventions:
None.
Measurements And Main Results:
In March 2020, a survey was sent to 127 pediatric extracorporeal membrane oxygenation centers asking them to report their current hospital extracorporeal membrane oxygenation guidelines for coronavirus disease 2019-positive patients. Respondents were also asked their opinion on three ethical dilemmas including: prioritization of children over adults for extracorporeal membrane oxygenation use, institution of do-not-resuscitate orders, and the use of extracorporeal cardiopulmonary resuscitation for coronavirus disease 2019-positive patients. Forty-seven extracorporeal membrane oxygenation centers had enacted guidelines including 46 (100%) that offer venovenous-extracorporeal membrane oxygenation and 42 (89%) that offer venoarterial-extracorporeal membrane oxygenation for coronavirus disease 2019-positive pediatric patients. Forty-four centers (94%) stated that the indications for extracorporeal membrane oxygenation candidacy in coronavirus disease 2019 disease were similar to those used in other viral illnesses, such as respiratory syncytial virus or influenza. Most program directors (98%) did not endorse that children hospitalized with coronavirus disease 2019 should be made do-not-resuscitate and had variable opinions on whether children should be given higher priority over adults when rationing extracorporeal membrane oxygenation. Over half of program directors (60%) did not support the use of extracorporeal cardiopulmonary resuscitation for coronavirus disease 2019.
Conclusions:
The majority of pediatric extracorporeal membrane oxygenation centers have proactively established guidelines for the use of extracorporeal membrane oxygenation for coronavirus disease 2019-related illnesses. Further work is needed to help guide the fair allocation of extracorporeal membrane oxygenation resources and to determine the appropriateness of extracorporeal cardiopulmonary resuscitation.
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