Seizures in Children with Cardiac Disease on Extracorporeal Membrane Oxygenation
Daniel O Hassumani1, Mu Shan2, Christopher W Mastropietro3
1Section of Pediatric Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
Insights
Pediatric seizures during extracorporeal membrane oxygenation (ECMO) for cardiac issues are common, affecting 18% of patients. Risk factors include cardiac arrest and specific cannulation sites, highlighting the need for continuous EEG monitoring.
Area of Science:
- Pediatric Cardiology
- Neurocritical Care
- Extracorporeal Life Support
Background:
- Children on extracorporeal membrane oxygenation (ECMO) face increased seizure risk.
- Previous studies lacked population homogeneity, necessitating focused research.
- This study addresses seizure incidence and risk factors in pediatric cardiac ECMO patients.
Purpose of the Study:
- To determine the seizure rate in pediatric patients undergoing ECMO for cardiac conditions.
- To identify specific risk factors associated with seizure development in this population.
- To inform clinical practice regarding monitoring and management.
Main Methods:
- Retrospective cohort study of pediatric patients (2014-2018) with cardiac disease on ECMO.
- Continuous electroencephalogram (cEEG) monitoring for at least 48 hours post-ECMO initiation.
- Analysis of clinical data, including pre-ECMO status, cannulation, and outcomes.
Main Results:
- Seizures occurred in 18% of pediatric ECMO patients, often subclinical (65%) and progressing to status epilepticus (40%).
- Risk factors included pre-ECMO cardiac arrest (OR 5.7), extracorporeal cardiopulmonary resuscitation (OR 5.2), cervical cannulation, lower pH, and higher lactate.
- Seizure patients experienced longer ICU stays, worse pediatric cerebral performance scores, and trended towards lower survival rates.
Conclusions:
- Seizures are a frequent complication (18%) in pediatric cardiac ECMO patients.
- Subclinical seizures and status epilepticus are common, underscoring the need for vigilant monitoring.
- Continuous EEG is crucial, particularly for patients with cardiac arrest, extracorporeal cardiopulmonary resuscitation, or severe acidosis.
Background:
Children supported with extracorporeal membrane oxygenation (ECMO) have been shown to be at risk for developing seizures. However, previous studies have consisted of heterogeneous patient populations. We aimed to describe the rate of seizures in pediatric patients receiving ECMO for cardiac indications and to identify risk factors for the occurrence of this complication.
Methods:
This is a retrospective cohort study of consecutive pediatric patients on ECMO for congenital or acquired cardiac disease between 2014 and 2018 at a tertiary care pediatric hospital.
Results:
We reviewed 110 children, of whom 104 (95%) received continuous electroencephalogram for at least 48 h after ECMO initiation. Seizures were observed in 20 (18%) children. Seizures were subclinical only in 13 (65%) patients, and 8 (40%) developed status epilepticus. The median time from ECMO initiation to first seizure was 34 h (25%, 75%: 19, 44). Children with seizures were more likely to have suffered pre-ECMO cardiac arrest (odds ratio 5.7, 95% confidence interval 2.0-16.1, p < 0.001), require extracorporeal cardiopulmonary resuscitation (odds ratio 5.2, 95% confidence interval 1.9-14.7, p < 0.001), and have been cannulated via the cervical vessels (p = 0.029). Children with seizures also had lower pH nadir prior to ECMO (p = 0.015) and had higher peak lactate prior to ECMO (p = 0.002). Patients with seizures had significantly a longer median intensive care unit length of stay, (43 versus 32 days, p = 0.02), had a significantly worse pediatric cerebral performance score (2 versus 1, p = 0.03), and tended to have worse survival to hospital discharge (50% versus 71%, p = 0.069).
Conclusions:
Seizures in pediatric patients on ECMO for cardiac indications are common, occurring in nearly one in five patients. Seizures are frequently subclinical only and often progress to status epilepticus. Continuous electroencephalogram is therefore warranted for this patient population, especially in the setting of cardiac arrest, extracorporeal cardiopulmonary resuscitation, or severe metabolic acidosis.
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