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Extracorporeal membrane oxygenation for postoperative cardiac support in children
Insights
Extracorporeal membrane oxygenation (ECMO) can successfully manage severe cardiac failure in children after surgery, leading to good recovery despite common complications. This pediatric cardiac support offers a lifeline for critically ill young patients.
Area of Science:
- Pediatric Cardiology
- Cardiothoracic Surgery
- Critical Care Medicine
- Mechanical Circulatory Support
Background:
- Prolonged circulatory support for cardiac failure is established in adults but underutilized in pediatric populations.
- Pediatric patients with refractory postoperative cardiac failure present unique management challenges.
- Limited data exists on the efficacy and safety of extracorporeal membrane oxygenation (ECMO) in critically ill children post-cardiac surgery.
Purpose of the Study:
- To evaluate the effectiveness and outcomes of using extracorporeal membrane oxygenation (ECMO) for pediatric patients experiencing severe, refractory cardiac failure post-cardiac operation.
- To assess the complications and long-term functional recovery in children treated with ECMO for postoperative cardiac insufficiency.
Main Methods:
- A retrospective analysis of 13 pediatric patients (9 days to 17.6 years) treated with ECMO for refractory cardiac failure between January 1982 and December 1985.
- Patients received ECMO support for durations ranging from 12 hours to 9 days, with varying cannulation sites (groin or chest) and flow rates.
- Data collected included patient demographics, underlying cardiac conditions, ECMO parameters, complications (bleeding, renal insufficiency, mediastinitis), and clinical outcomes.
Main Results:
- Seven out of 13 pediatric patients were successfully weaned from ECMO, with five demonstrating excellent functional recovery and normal cardiac function at long-term follow-up (up to 4.3 years).
- Major complications were frequent, including reexploration for bleeding (7 patients), renal insufficiency (5 patients), and mediastinitis (3 patients).
- Neurologic sequelae contributed to ECMO failure in three patients, and there was one in-hospital and one late death post-ECMO.
Conclusions:
- Extracorporeal membrane oxygenation (ECMO) is a viable and effective treatment for profound cardiac insufficiency in pediatric patients following cardiac operations, offering a chance for significant functional recovery.
- Despite the potential for excellent outcomes, the use of ECMO in this critically ill pediatric population is associated with a high incidence of major complications.
- Careful patient selection and management are crucial for optimizing outcomes and mitigating risks associated with pediatric ECMO therapy.
Abstract:
Prolonged circulatory support for cardiac failure has been increasingly successful in adults but has had very limited use in children. From January 1982 to December 1985, 13 children with postoperative cardiac failure refractory to conventional therapy were treated with extracorporeal membrane oxygenation. Ages ranged from 9 days to 17.6 years (mean = 3.8 years); weights ranged from 2.8 to 50 kg (mean = 13.8 kg). Seven patients had obstructive lesions of the right ventricle, such as pulmonary stenosis and tetralogy; the other patients had tricuspid atresia, truncus arteriosus, complete transposition, total anomalous pulmonary venous connection, pericardial tamponade, and a drug reaction after heart transplantation. One patient (nonsurvivor), who could not be separated from cardiopulmonary bypass, required extracorporeal membrane oxygenation in the operating room. In the remaining 12, the interval between operation and the start of extracorporeal membrane oxygenation ranged from 9 to 50 hours (mean = 22.2 hours). Four patients were cannulated through the groin and nine through the chest. Peak flows ranged from 1.05 to 2.74 L/min/m2 (mean 1.92 L/min/m2). Duration of oxygenator support ranged from 12 hours to 9 days (mean = 3.4 days). Seven patients required reexploration for bleeding. Renal insufficiency developed in five patients, four of whom underwent hemodialysis or ultrafiltration during extracorporeal membrane oxygenation. Two patients had evidence of clots in the oxygenator circuit. Seven patients were weaned from extracorporeal membrane oxygenation. Failure to wean from the oxygenator was related to neurologic sequelae of prolonged hypotension before institution of oxygenation in three patients. Mediastinitis developed in three of the seven patients who were weaned. One of these three died in the hospital 74 days after being weaned from the oxygenator. There has been one late death 6 months after oxygenator support was withdrawn. At most recent examination, five children were well, with normal cardiac function 7 months to 4.3 years postoperatively (mean = 32 months). This series suggests that profound cardiac insufficiency in children after cardiac operations can be successfully managed with extracorporeal membrane oxygenation with excellent functional recovery, although major complications are common in this critically ill group of patients.