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Beating the Odds: Survival After Extracorporeal Membrane Oxygenation Decannulation Due to Poor Prognosis in
Aurélie Wanders1, Ravi R Thiagarajan2,3, Justyna Swol4,5
1From the Pediatric Intensive Care Unit, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospital, Geneva, Geneva University of Medicine, Geneva, Switzerland.
Insights
Survival after pediatric Extracorporeal Membrane Oxygenation (ECMO) decannulation for poor prognosis is rare but possible. Lower pre-ECMO lactate and pulmonary indications may predict unexpected recovery, underscoring complex ethical decisions.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiopulmonary Support
- Medical Ethics
Background:
- Extracorporeal membrane oxygenation (ECMO) is vital for critically ill children.
- Discontinuation decisions for poor prognosis are ethically challenging.
- Outcomes after decannulation for futility are poorly understood.
Purpose of the Study:
- To investigate survival rates and predictors following pediatric ECMO decannulation for perceived futility.
- To analyze characteristics of survivors versus nonsurvivors in this specific cohort.
Main Methods:
- Retrospective cohort study utilizing the Extracorporeal Life Support Organization (ELSO) registry.
- Analysis of pediatric ECMO cases from 2013-2023, focusing on those decannulated for poor prognosis.
- Comparison of patient demographics, ECMO parameters, complications, and outcomes between survivors and nonsurvivors.
Main Results:
- Only 18 out of 6,662 (0.3%) patients decannulated for poor prognosis survived to discharge.
- Survivors had lower pre-ECMO lactate levels (2.7 vs. 6.2 mmol/L) and more pulmonary indications (44% vs. 27%).
- Survivors experienced fewer complications and longer ECMO duration, with less frequent venoarterial support.
Conclusions:
- Survival after ECMO decannulation for futility is exceptionally rare (1 in 370 cases).
- Lower lactate and pulmonary indications may suggest potential for unexpected recovery.
- Highlights the inherent uncertainty in prognostication and the need for individualized, multidisciplinary decision-making.
Abstract:
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for critically ill children. However, decisions regarding discontinuation due to poor prognosis remain ethically complex. While outcomes after successful weaning are well described, survival following decannulation for perceived futility is poorly understood. We conducted a retrospective cohort study using the Extracorporeal Life Support Organization (ELSO) registry, including pediatric ECMO runs from 2013 to 2023. Among 6,662 cases decannulated for poor prognosis, we identified patients who survived until hospital discharge. Patient characteristics, ECMO parameters, complications, and outcomes were compared between survivors and nonsurvivors. Of 6,662 cases, 18 patients (0.3%) survived to discharge. Baseline characteristics were similar between groups. Survivors more often had pulmonary indications (44% vs. 27%, p = 0.2) and significantly lower pre-ECMO lactate levels (median 2.7 vs. 6.2 mmol/L, p = 0.031). They also experienced fewer on-ECMO complications (median 1 vs. 2, p = 0.11) and longer ECMO duration (8 vs. 4 days, p = 0.07). Venoarterial support was less frequent among survivors (61% vs. 80%). Survival after ECMO decannulation for poor prognosis is rare but possible (1/370 cases). Lower pre-ECMO lactate levels and pulmonary indications may indicate potential for unexpected recovery, highlighting uncertainty in prognostication and the importance of individualized, multidisciplinary decision-making.
