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Venovenous Extracorporeal Membrane Oxygenation Initiation for Pediatric Acute Respiratory Distress Syndrome With

Daniel Chilcote¹, Anant Sriram¹, Julia Slovis¹

¹Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA.

Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

|July 18, 2023

Insights

Initiating venovenous extracorporeal membrane oxygenation (VV-ECMO) significantly reduced vasoactive-inotropic scores (VISs) in pediatric acute respiratory distress syndrome (PARDS) patients with cardiovascular instability, improving their overall condition.

Area of Science:

Pediatric Critical Care Medicine
Cardiovascular Physiology
Respiratory Medicine

Background:

Pediatric acute respiratory distress syndrome (PARDS) often involves cardiovascular instability requiring significant vasoactive-inotropic support.
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a life-saving intervention for severe respiratory failure.

Purpose of the Study:

To investigate the association between initiating VV-ECMO and changes in vasoactive-inotropic scores (VISs) in pediatric patients with PARDS and cardiovascular instability.

Main Methods:

Retrospective cohort study of 32 children (1 month to 18 years) treated with VV-ECMO for PARDS between 2009-2019.
Vasoactive-inotropic scores (VISs), mean airway pressure (mPaw), and blood gas values were analyzed hourly for 24 hours before and after VV-ECMO cannulation.
Regression discontinuity analysis was used to assess immediate changes around cannulation.

Main Results:

VV-ECMO initiation was associated with a significant and immediate decrease in VIS (robust p < 0.0001).
Mean airway pressure (mPaw) decreased, while arterial pH, base excess, and oxygen saturation (SpO2) improved post-cannulation.
Patients experienced reduced respiratory and/or metabolic acidosis following VV-ECMO initiation.

Conclusions:

Initiation of VV-ECMO leads to an immediate and sustained reduction in the need for vasoactive-inotropic support in pediatric patients with PARDS and cardiovascular instability.
This reduction in VIS is linked to improved respiratory mechanics, oxygenation, and acid-base balance.

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Abstract

Objective:

To determine the association of venovenous extracorporeal membrane oxygenation (VV-ECMO) initiation with changes in vasoactive-inotropic scores (VISs) in children with pediatric acute respiratory distress syndrome (PARDS) and cardiovascular instability.

Design:

Retrospective cohort study.

Setting:

Single academic pediatric ECMO center.

Patients:

Children (1 mo to 18 yr) treated with VV-ECMO (2009-2019) for PARDS with need for vasopressor or inotropic support at ECMO initiation.

Measurements And Main Results:

Arterial blood gas values, VIS, mean airway pressure (mPaw), and oxygen saturation (Sp o2 ) values were recorded hourly relative to the start of ECMO flow for 24 hours pre-VV-ECMO and post-VV-ECMO cannulation. A sharp kink discontinuity regression analysis clustered by patient tested the difference in VISs and regression line slopes immediately surrounding cannulation. Thirty-two patients met inclusion criteria: median age 6.6 years (interquartile range [IQR] 1.5-11.7), 22% immunocompromised, and 75% had pneumonia or sepsis as the cause of PARDS. Pre-ECMO characteristics included: median oxygenation index 45 (IQR 35-58), mPaw 32 cm H 2o (IQR 30-34), 97% on inhaled nitric oxide, and 81% on an advanced mode of ventilation. Median VIS immediately before VV-ECMO cannulation was 13 (IQR 8-25) with an overall increasing VIS trajectory over the hours before cannulation. VISs decreased and the slope of the regression line reversed immediately surrounding the time of cannulation (robust p < 0.0001). There were pre-ECMO to post-ECMO cannulation decreases in mPaw (32 vs 20 cm H 2o , p < 0.001) and arterial P co2 (64.1 vs 50.1 mm Hg, p = 0.007) and increases in arterial pH (7.26 vs 7.38, p = 0.001), arterial base excess (2.5 vs 5.2, p = 0.013), and SpO 2 (91% vs 95%, p = 0.013).

Conclusions:

Initiation of VV-ECMO was associated with an immediate and sustained reduction in VIS in PARDS patients with cardiovascular instability. This VIS reduction was associated with decreased mPaw and reduced respiratory and/or metabolic acidosis as well as improved oxygenation.

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