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Multiple Pediatric Extracorporeal Membrane Oxygenation Runs and Futility. What Are the Limits?
Justus G Reitz1, Areen Almarkhan1, Rittal Mehta1
1From the Department of Cardiovascular Surgery, Children's National Hospital, Washington, District of Columbia.
Insights
Pediatric extracorporeal membrane oxygenation (ECMO) redeployments have poor outcomes. Neurologic findings, longer ECMO duration, and renal replacement therapy predict mortality in children needing multiple ECMO runs.
Area of Science:
- Pediatric critical care medicine
- Cardiopulmonary support technologies
Background:
- Pediatric extracorporeal membrane oxygenation (ECMO) is a life-saving therapy.
- Redeployments, or multiple ECMO runs, are increasingly discussed but have high mortality.
- Predictors of mortality in this vulnerable population require further investigation.
Purpose of the Study:
- To identify predictors of mortality in pediatric patients requiring multiple ECMO runs.
- To analyze the impact of clinical factors on late mortality after multiple ECMO support.
Main Methods:
- Retrospective analysis of clinical data from a single pediatric center (2010-2023).
- Inclusion criteria: pediatric patients with multiple ECMO runs.
- Statistical analysis to determine predictors of late mortality.
Main Results:
- 70 patients (13%) required multiple ECMO runs; 80% died before discharge.
- Late mortality was 89% at a median of 1.6 years.
- Predictors of mortality included: longer first ECMO duration, total ECMO duration, neurologic findings, renal replacement therapy, and lactate levels.
- All patients with neurologic findings before the second ECMO run died.
Conclusions:
- Outcomes for pediatric patients undergoing multiple ECMO runs are poor.
- Neurologic findings are a critical factor, especially before initiating a second ECMO run.
- Clinical assessment of neurologic status is vital when considering further ECMO support in pediatric patients.
Abstract:
Despite high mortality rates, pediatric extracorporeal membrane oxygenation (ECMO) redeployments are frequently discussed in everyday clinical care. We aim to investigate predictors of mortality in those patients. Clinical data from a single pediatric center were retrospectively analyzed. Patients with multiple ECMO runs between 2010 and 2023 were included. A total of 70 (13%) patients required multiple ECMO runs. Of those, 56 (80%) died before discharge; late mortality was 89% at a median of 1.6 (1.0-3.9) years. A total of 47 (67%) patients had neurologic findings. Only one (1%) survivor had a normal neurodevelopmental follow-up. Duration of the first ECMO run (odds ratio [OR]: 2.63, 1.08-7.96), total duration on ECMO (OR: 4.72, 1.29-23.54), neurologic findings at any time (OR: 7.94, 1.46-43.24), need for renal replacement therapy (OR: 4.79, 1.06-25.58), and lactate values correlated with late mortality. All 19 (27%) patients with neurologic findings before the second run died. The frequency of multiple-run ECMOs increased within the study period. Outcomes in pediatric patients with multiple ECMO runs are disheartening. Given all patients in our cohort with neurological findings before the second ECMO run died, neurological findings should be taken into consideration when determining the utility of further ECMO support.
