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[Analysis of risk factors of central nervous system complications supported on extracorporeal membrane oxygenation]

Y Q Ren¹, Y C Zhang¹, J Y Shi¹

¹Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200062, China.

Zhonghua Er Ke Za Zhi = Chinese Journal of Pediatrics

|October 8, 2022

Insights

Central nervous system (CNS) complications are common in children on extracorporeal membrane oxygenation (ECMO). A low pre-ECMO pH value (<7.325) is a significant risk factor, suggesting strategies to reduce veno-arterial ECMO and surgical cannulation may improve outcomes.

Area of Science:

Pediatric Critical Care Medicine
Neonatal and Pediatric Cardiology
Neurology and Neurosurgery

Background:

Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for critically ill children with cardiorespiratory failure.
Central nervous system (CNS) complications represent a significant concern in pediatric patients undergoing ECMO, impacting short- and long-term outcomes.
Identifying modifiable risk factors is crucial for optimizing ECMO management and improving patient safety.

Purpose of the Study:

To investigate the incidence and risk factors associated with CNS complications in pediatric patients receiving ECMO.
To identify specific clinical and laboratory parameters predictive of CNS complications during ECMO support.
To evaluate the impact of ECMO mode and cannulation strategy on the occurrence of CNS complications.

Main Methods:

Retrospective analysis of clinical data from 82 children treated with ECMO between December 2015 and December 2021.
Patients were categorized into CNS complication and non-CNS complication groups for comparative analysis.
Statistical methods included Chi-square test, t test, rank sum test, Kaplan-Meier survival analysis, and ROC curve analysis.

Main Results:

Eighteen out of 82 children (22%) developed CNS complications, including cerebral hemorrhage and epilepsy.
Veno-arterial ECMO (17/18) and surgical cannulation (16/18) were significantly associated with a higher incidence of CNS complications.
Lower pre-ECMO pH (7.24 vs 7.35, P<0.001) and decreased platelet count 24h post-ECMO initiation (66 vs 107, P=0.041) were linked to CNS complications.
ROC analysis identified a pre-ECMO pH value of 7.325 as an optimal cut-off for predicting CNS complications (AUC=0.738).

Conclusions:

CNS complications are a frequent occurrence in pediatric ECMO patients.
A pre-ECMO pH value below 7.325 is a significant risk factor for developing CNS complications.
Minimizing veno-arterial ECMO configurations and surgical cannulation may reduce the incidence of CNS complications.

Read full analysis

Abstract:

Objective: To investigate the risk factors of central nervous system (CNS) complications in children undergoing extracorporeal membrane oxygenation (ECMO) support. Methods: The clinical data, ECMO parameters, laboratory examination and outcome (follow-up to 90 d after discharge) of 82 children treated with ECMO in the pediatric intensive care unit (PICU) of Shanghai Children's Hospital from December 2015 to December 2021 were analyzed retrospectively in this study. The patients were divided into CNS complication group and non-CNS complication group. The ECMO mode, ECMO catheterization mode, clinical and laboratory indicators pre-ECMO and 24 h after ECMO initiation, in-hospital mortality and 90-day mortality were compared with Chi-square test, t test and nonparametric rank sum test. Kaplan-Meier method was used to draw survival curve, and Log-rank test was used to compare the difference in survival rate. The receiver operating characteristic (ROC) curve was used to evaluate the power of variables to predict CNS complications. Results: A total of 82 children were treated with ECMO, including 49 males and 33 females, aged 34 (8, 80) months. There were 18 cases suffering CNS complications, including cerebral hemorrhage in 8 cases, epilepsy in 6 cases, simple cerebral infarction in 3 cases, and cerebral hemorrhage combined with cerebral infarction in 1 case. Veno-arterial ECMO accounted for a greater proportion in CNS complication group (17/18 vs. 67% (43/64), χ²=4.02, P=0.045). A higher percentage of children with CNS complications underwent surgical cannulation compared to those in non-CNS complication group (16/18 vs. 53% (34/64), χ²=7.55, P=0.006). The laboratory results indicated that lower pre-ECMO pH value (7.24 (7.15, 7.28) vs. 7.35 (7.26, 7.45), Z=-3.65, P<0.001) and platelet count 24 h after ECMO initiation (66 (27, 135) ×10⁹/L vs. 107 (61, 157) ×10⁹/L, Z=-2.04, P=0.041) were associated with CNS complications. In the CNS complication group, 7 children died during hospitalization and 7 died during 90-day after admission, and there was no significant difference compared with those in the non-CNS complication group (7/18 vs. 31% (20/64), 7/18 vs. 34% (22/64), both P>0.05). The ROC curve analysis indicated that the area under the ROC curve for pre-ECMO pH value was 0.738 (95%CI 0.598-0.877), and the optimal cut-off value was 7.325. Conclusions: CNS complications in children undergoing ECMO support are common. Pre-ECMO pH value <7.325 is a risk factor for CNS complications. Reducing the veno-arterial ECMO and surgical cannulation can help reduce the occurrence of CNS complications.

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