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Focal Cerebral Injury in Pediatric Extracorporeal Life Support: Timing in Relation to Cannulation or Other Circuit
Mauro Caffarelli1,2, Yi Li3, Edilberto Amorim2
1Department of Pediatrics, University of California, San Francisco, San Francisco, CA.
Insights
Extracorporeal life support (ECLS) can cause focal cerebral injury (FCI) in children and young adults, often within 48 hours of circuit events. Increased neurological monitoring during ECLS is crucial for early detection and management of these brain injuries.
Area of Science:
- Pediatric Critical Care Medicine
- Neurocritical Care
- Extracorporeal Membrane Oxygenation (ECMO) Research
Background:
- Extracorporeal life support (ECLS) is a vital intervention for critically ill children and young adults with cardiorespiratory failure.
- Neurological complications, including focal cerebral injury (FCI), are significant concerns in patients undergoing ECLS.
- Understanding the timing of FCI relative to ECLS circuit events is crucial for improving patient outcomes.
Purpose of the Study:
- To investigate the temporal relationship between ECLS circuit interruptions and the onset of focal cerebral injury (FCI) in pediatric and young adult patients.
- To identify the time course of FCI development in relation to ECLS cannulation, decannulation, and circuit interruptions.
- To inform clinical practice regarding neurological monitoring during ECLS.
Main Methods:
- Retrospective analysis of neuroimaging data from pediatric patients (<21 years) undergoing ECLS between January 1, 2015, and December 31, 2023.
- Definition of FCI based on radiographic criteria (ischemia/hemorrhage >1 cm³ or subdural hemorrhage with midline shift).
- Correlation of FCI timing with ECLS circuit events (cannulation, decannulation, interruptions) using institutional registry data and chart review.
Main Results:
- Twenty out of 101 ECLS runs (94 patients) showed evidence of FCI, including ischemic stroke, intraparenchymal hemorrhage, and subdural hemorrhage.
- The majority of FCIs (18 out of 20) were identified within 48 hours of an ECLS circuit event.
- Electroencephalography (EEG) monitoring revealed new-onset subclinical abnormalities as the initial sign of FCI in 8 out of 13 cases.
- FCI was associated with significantly lower survival to decannulation (p = 0.007).
Conclusions:
- Focal cerebral injury related to ECLS frequently occurs within 48 hours of circuit events in pediatric and young adult populations.
- These findings underscore the importance of heightened neurological surveillance during ECLS.
- Proactive monitoring and timely intervention for neurological complications can potentially improve outcomes for ECLS patients.
Objectives:
To review the timing of extracorporeal life support (ECLS)-related focal cerebral injury (FCI) in relation to circuit interruptions in children and young adults.
Design:
Retrospective study from January 1, 2015, to December 31, 2023.
Setting:
Single-center academic children's hospital.
Patients:
Children and young adults younger than 21 years old who had neuroimaging during or after ECLS. Multiple ECLS runs in individual patients were analyzed as distinct runs.
Interventions:
None.
Measurements And Main Results:
FCI was radiographically defined as lateralized ischemia or hemorrhagic parenchymal brain injury greater than 1 cm 3 or as subdural hemorrhage causing midline shift. Timing of clinical FCI documentation was abstracted from chart review and based on times of new-onset focal neurologic examination findings, focal electroencephalography findings, or incidental discovery on imaging. In instances of FCI, electroencephalography reports and inpatient progress notes were reviewed to identify electroencephalography-related timing of FCI. Institutional ECLS registry data were used to identify times of circuit events (i.e., cannulation, decannulation, and circuit interruptions). The probable time course of FCI after circuit events was evaluated in the ECLS runs with an imaging diagnosis of FCI, and summarized using cumulative distribution with 95% CI. In 101 ECLS runs in 94 patients with brain imaging, 20 had FCI: ischemic stroke in 12, intraparenchymal hemorrhage in six, and subdural hemorrhage with midline shift in two. Eighteen FCIs were documented within 48 hours of a circuit event. Among 13 FCIs with electroencephalography recording at the time of FCIs, eight had new-onset subclinical electroencephalography abnormality as the initial documented sign of FCI. The presence of FCI vs. not was associated with lower survival to decannulation ( p = 0.007).
Conclusions:
In this single-center retrospective series, 2015-2023, the majority of ECLS-related FCIs were evident within 48 hours of ECLS cannulation, decannulation, or circuit interruption. These events warrant increased surveillance for neurologic complications.
