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Peripheral Veno-Arterial-Extracorporeal Membrane Oxygenation for Refractory Septic Shock in Children: A Multicenter
Brielle Warnock1,2, Gina Maria Lafferty3,4, Abdelaziz Farhat5
1Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
Insights
Peripheral veno-arterial ECMO effectively supports pediatric septic shock patients. Achieving high pump flows and improving vasoactive inotropic scores within hours of cannulation are key to survival.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiovascular Support
- Septic Shock Management
Background:
- Extracorporeal membrane oxygenation (ECMO) is a vital rescue therapy for pediatric refractory septic shock.
- Central cannulation is often preferred, but peripheral veno-arterial (VA) ECMO use is increasing.
- This study evaluates peripheral VA ECMO outcomes in pediatric septic shock.
Purpose of the Study:
- To assess survival rates in pediatric patients with septic shock treated with peripheral VA ECMO.
- To identify mortality risk factors associated with peripheral VA ECMO support.
- To evaluate the efficacy of peripheral VA ECMO in supporting cardiac function and tissue oxygenation.
Main Methods:
- Retrospective review of 40 pediatric patients receiving peripheral VA ECMO for refractory septic shock (2006-2020).
- Comparison of clinical characteristics between survivors and non-survivors.
- Analysis of pump flow rates and vasoactive inotropic scores (VIS).
Main Results:
- Overall survival to discharge was 52.5%, rising to 62.5% excluding oncologic cases.
- Higher initial pump flow rates (≥98 mL/kg/min) were significantly associated with survival (P=.050).
- A rapid decrease in VIS within 24 hours correlated with lower mortality.
Conclusions:
- Peripheral VA ECMO is a safe and effective support strategy for pediatric refractory septic shock.
- Establishing high ECMO pump flows early is crucial for successful outcomes.
- Improvement in vasoactive inotropic scores post-cannulation indicates better prognosis.
Background:
Extracorporeal membrane oxygenation (ECMO) is utilized as a rescue therapy in the management of pediatric patients with refractory septic shock. Multiple studies support the use of a central cannulation strategy in these patients. This study aimed to assess the survival of and identify mortality risk factors in pediatric patients supported with peripheral veno-arterial (VA) ECMO in the setting of septic shock.
Methods:
We retrospectively reviewed and compared clinical characteristics of 40 pediatric patients supported with peripheral VA ECMO for refractory septic shock, at two tertiary care children's hospitals from 2006 to 2020. Our hypothesis was that peripheral VA ECMO is effective in supporting cardiac function and improving tissue oxygenation in most pediatric patients with refractory septic shock.
Results:
The overall rate of survival to discharge was 52.5%, comparable to previously reported survival for pediatric sepsis on ECMO. With the exclusion of patients with an oncologic process, the survival rate rose to 62.5%. There was a statistically significant difference in mean pump flow rates within 2 hours of initiation of ECMO between survivors and non-survivors (98 mL/kg/min vs 76 mL/kg/min, P = .050). There was no significant difference between pre-ECMO vasoactive inotropic score (VIS) in survivors and non-survivors. A faster decrease in VIS in the first 24 hours was associated with lower mortality.
Conclusions:
From this large case series, we conclude that peripheral VA ECMO is a safe and effective modality to support pediatric patients with refractory septic shock, provided there is establishment of high ECMO pump flows in the first few hours after cannulation and improvement in the VIS.
