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Lactate and gastrointestinal complications during enteral nutrition in pediatric ECMO patients: a retrospective
Bruna Pinheiro Machado1, Yadigar Ziylan2, Alexia Detheux3
1Department of Paediatrics, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles, Brussels, Belgium. bpm.23@hotmail.com.
Insights
Early enteral nutrition in pediatric extracorporeal membrane oxygenation (ECMO) patients requires caution. High lactate levels at ECMO initiation are linked to severe complications like necrotizing enterocolitis (NEC) and death.
Area of Science:
- Pediatric critical care medicine
- Gastroenterology
- Cardiovascular surgery
Background:
- Early enteral nutrition (EN) in pediatric extracorporeal membrane oxygenation (ECMO) patients is challenging due to metabolic instability, feeding intolerance, and risk of intestinal ischemia.
- Hyperlactatemia indicates low tissue perfusion and may be associated with adverse outcomes.
Purpose of the Study:
- To identify risk factors for gastrointestinal intolerance (GI) and necrotizing enterocolitis (NEC) in pediatric patients on veno-arterial (VA) or veno-venous (VV) ECMO.
- To evaluate the association between lactate levels and complications in pediatric ECMO patients.
Main Methods:
- Retrospective cohort study of 127 pediatric ECMO patients (VA or VV) at a single center.
- Analysis of gastrointestinal symptoms, NEC incidence, and lactate levels at ECMO initiation and during the study.
- Comparison of outcomes between VV-ECMO and VA-ECMO groups.
Main Results:
- Diarrhea on Day 2 was more frequent in VV-ECMO patients (13.7%) than VA-ECMO patients (0%).
- Necrotizing enterocolitis (NEC) occurred in 5.1% of VV-ECMO and 10.2% of VA-ECMO patients.
- Patients with GI complications on Day 2 had lower lactate, PRISM, and PIM scores at ECMO initiation. Higher lactate levels at cannulation were associated with NEC and death.
Conclusions:
- Early EN in pediatric ECMO patients should be approached cautiously due to potential GI complications and a notable incidence of NEC.
- High lactate levels at ECMO cannulation appear to be a significant risk factor for severe complications, including NEC and mortality.
Abstract:
Early enteral nutrition in patients undergoing extracorporeal membrane oxygenation (ECMO) is particularly challenging due to metabolic instability, feeding intolerance, and the risk of intestinal ischemia. This study aimed to identify risk factors for gastrointestinal intolerance (GI) and necrotizing enterocolitis (NEC) in pediatric patients supported with veno-arterial (VA) or veno-venous (VV) ECMO. This monocentric and retrospective cohort study involved 127 pediatric patients who underwent ECMO in the pediatric intensive care unit of the Queen Fabiola Children's University Hospital, Belgium, between January 2011 and December 2023. Diarrhea on Day 2 (D2) occurred in 13.7% of the VV-ECMO patients (10/73) but not in any of the VA-ECMO patients (p = 0.013). The frequencies of other gastrointestinal symptoms, such as vomiting, abdominal distension, and gastrointestinal hemorrhage, did not significantly differ between the groups during the study period. NEC occurred in 5.1% of VV-ECMO patients (4/78) and 10.2% of VA-ECMO patients (5/49) (p = 0.230). Enteral nutrition was initiated within 48 h of ECMO cannulation in 110/127 patients (86.6%). Patients who presented with gastrointestinal complications on D2 had a low lactate value at ECMO initiation (3.61 ± 0.56 mmol/l versus 5.42 ± 0.44 mmol/l (p = 0.013)) and a low PRISM (19 ± 3 versus 25 ± 1 (p = 0.033)) and PIM (12 ± 5 versus 18 ± 2 (p = 0.288)). Patients with NEC presented non significantly higher lactate levels on D0 and D2. Lactatemia was significantly lower for living patients on D0 and D2.
Conclusion:
This study suggests that early EN in pediatric ECMO patients should be approached with caution. Mild digestive complications can occur, and the incidence of NEC can be high. High lactate levels at ECMO cannulation appear to be associated with severe complications such as death and NEC.
What Is Known:
• Hyperlactatemia is a valuable indicator of low tissue perfusion.
What Is New:
• The findings of this study suggest that patients who developed NEC had higher lactate levels at the time of cannulation than at the time of NEC diagnosis. • Lactatemia seems to be a risk factor for severe complications such as NEC and death rather than a risk factor for mild GI complications.
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