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Ravi R. Thiagarajan - One of the best experts on this subject based on the ideXlab platform.
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Extracorporeal Membrane Oxygenation in Pediatric Pulmonary Hypertension.
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Car, 2020Co-Authors: Emily Morell, Satish K. Rajagopal, Peter Oishi, Ravi R. Thiagarajan, Jeffrey R. Fineman, Martina A. SteurerAbstract:OBJECTIVE To describe the epidemiology, critical care interventions, and mortality of children with pulmonary hypertension receiving Extracorporeal Membrane Oxygenation. DESIGN Retrospective analysis of prospectively collected multicenter data. SETTING Data entered into the Extracorporeal Life Support Organization database between January 2007 and November 2018. PATIENTS Pediatric patients between 28 days and 18 years old with a diagnosis of pulmonary hypertension. MEASUREMENTS AND MAIN RESULTS Six hundred thirty-four Extracorporeal Membrane Oxygenation runs were identified (605 patients). Extracorporeal Membrane Oxygenation support type was pulmonary (43.1%), cardiac (40.2%), and Extracorporeal cardiopulmonary resuscitation (16.7%). The majority of cannulations were venoarterial (80.4%), and 30% had a pre-Extracorporeal Membrane Oxygenation cardiac arrest. Mortality in patients with pulmonary hypertension was 51.3% compared with 44.8% (p = 0.001) in those without pulmonary hypertension. In univariate analyses, significant predictors of mortality included age less than 6 months and greater than 5 years; pre-Extracorporeal Membrane Oxygenation cardiac arrest; pre-Extracorporeal Membrane Oxygenation blood gas with pH less than 7.12, PaCO2 greater than 75, PaO2 less than 35, and arterial oxygen saturation less than 60%; Extracorporeal Membrane Oxygenation duration greater than 280 hours; Extracorporeal cardiopulmonary resuscitation; and Extracorporeal Membrane Oxygenation complications including cardiopulmonary resuscitation, inotropic support, myocardial stun, tamponade, pulmonary hemorrhage, intracranial hemorrhage, seizures, other hemorrhage, disseminated intravascular coagulation, renal replacement therapy, mechanical/circuit problem, and metabolic acidosis. A co-diagnosis of pneumonia was associated with significantly lower odds of mortality (odds ratio, 0.5; 95% CI, 0.3-0.8). Prediction models were developed using three sets of variables: 1) pre-Extracorporeal Membrane Oxygenation (age, absence of pneumonia, and pH < 7.12; area under the curve, 0.62); 2) Extracorporeal Membrane Oxygenation related (Extracorporeal cardiopulmonary resuscitation, any neurologic complication, pulmonary hemorrhage, renal replacement therapy, and metabolic acidosis; area under the curve, 0.72); and 3) all variables combined (area under the curve, 0.75) (p < 0.001). CONCLUSIONS Children with pulmonary hypertension who require Extracorporeal Membrane Oxygenation support have a significantly greater odds of mortality compared with those without pulmonary hypertension. Risk factors for mortality include age, absence of pneumonia, pre-Extracorporeal Membrane Oxygenation acidosis, Extracorporeal cardiopulmonary resuscitation, pulmonary hemorrhage, neurologic complications, renal replacement therapy, and acidosis while on Extracorporeal Membrane Oxygenation. Identification of those pulmonary hypertension patients requiring Extracorporeal Membrane Oxygenation who are at even higher risk for mortality may inform clinical decision-making and improve prognostic awareness.
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Outcomes of Pediatric Patients Treated With Extracorporeal Membrane Oxygenation for Intractable Supraventricular Arrhythmias.
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Car, 2020Co-Authors: Stephanie Ghaleb, Ravi R. Thiagarajan, David S. Cooper, Richard J. CzosekAbstract:OBJECTIVES Extracorporeal Membrane Oxygenation is used to support refractory cardiorespiratory failure. Outcomes and complications when Extracorporeal Membrane Oxygenation is used to support cardiorespiratory failure secondary to arrhythmia in pediatric patients remain poorly defined. Our purpose is to describe pediatric patients requiring Extracorporeal Membrane Oxygenation support for supraventricular arrhythmias in the context of normal cardiac anatomy and congenital heart disease and identify patient/peri-Extracorporeal Membrane Oxygenation variables associated with Extracorporeal Membrane Oxygenation-related complications and survival. DESIGN Retrospective multicenter review from 1993 to 2016. SETTING Extracorporeal Life Support Organization registry. SUBJECTS Patients younger than 21 years old requiring Extracorporeal Membrane Oxygenation support for supraventricular arrhythmias. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 342 patients were identified (weight, 3.8 kg [3.2-7.5 kg]; age at Extracorporeal Membrane Oxygenation initiation, 24 d [6-222]; 61% male). Sixty-five percentage survived to hospital discharge. Complications were frequent (85%) and most commonly cardiac related (31%). In multivariable modeling, mortality was associated with congenital heart disease, time from intubation to Extracorporeal Membrane Oxygenation initiation, use of bicarbonate prior to Extracorporeal Membrane Oxygenation, Extracorporeal Membrane Oxygenation duration, and the presence of a complication. The presence of any complication was associated with a three-fold increase in the odds of death. In subgroup analysis of isolated supraventricular arrhythmias patients, similar patient and Extracorporeal Membrane Oxygenation characteristics were associated with outcome. A lower pre-Extracorporeal Membrane Oxygenation pH and PCO2 and site of venous cannulation were associated with complications (p < 0.02). CONCLUSIONS Extracorporeal Membrane Oxygenation use for medically refractory supraventricular arrhythmias was associated with a 65% survival to hospital discharge. However, there was a high rate of complications, the presence of which was associated with decreased survival. Complications appeared to be related to pre-Extracorporeal Membrane Oxygenation clinical status and whether earlier Extracorporeal Membrane Oxygenation cannulation prior to patient deterioration would improve outcomes needs additional evaluation.
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Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs.
Pediatric Critical Care Medicine, 2017Co-Authors: Susan L. Bratton, Titus Chan, Cindy Barrett, Jacob Wilkes, Laura M. Ibsen, Ravi R. ThiagarajanAbstract:OBJECTIVES: Only a small fraction of pediatric cardiac surgical patients are supported with Extracorporeal Membrane Oxygenation following cardiac surgery, but Extracorporeal Membrane Oxygenation use is more common among those undergoing higher complexity surgery. We evaluated Extracorporeal Membrane Oxygenation metrics indexed to annual cardiac surgical volume to better understand Extracorporeal Membrane Oxygenation use among U.S. cardiac surgical programs. DESIGN: Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used Extracorporeal Membrane Oxygenation. PATIENTS: All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Both Extracorporeal Membrane Oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal Membrane Oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received Extracorporeal Membrane Oxygenation. Median case mix adjusted rate of Extracorporeal Membrane Oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal Membrane Oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without Extracorporeal Membrane Oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with Extracorporeal Membrane Oxygenation. The median reduction in case mix adjusted surgical mortality from Extracorporeal Membrane Oxygenation surgical survival was 30.1%. The median Extracorporeal Membrane Oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median Extracorporeal Membrane Oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% Extracorporeal Membrane Oxygenation use). Extracorporeal Membrane Oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. CONCLUSIONS: Risk adjusted Extracorporeal Membrane Oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of Extracorporeal Membrane Oxygenation utilization, efficacy, and impact on cardiac surgery mortality.
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Association of Hospital Structure and Complications With Mortality After Pediatric Extracorporeal Membrane Oxygenation.
Pediatric Critical Care Medicine, 2016Co-Authors: Viviane G. Nasr, David Faraoni, James A. Dinardo, Ravi R. ThiagarajanAbstract:OBJECTIVES: Extracorporeal Membrane Oxygenation is increasingly utilized to provide cardiopulmonary support to critically ill children. Although life-saving in many instances, Extracorporeal Membrane Oxygenation support is associated with considerable morbidity and mortality. This study evaluates the effect of Extracorporeal Membrane Oxygenation complications and Extracorporeal Membrane Oxygenation hospital characteristics on mortality in neonates and children supported with Extracorporeal Membrane Oxygenation. DESIGN: Retrospective analysis of administrative data. SETTING: Data from 31 U.S. states included in 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database. PATIENTS: Children treated with Extracorporeal Membrane Oxygenation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Study subject were identified using International Classification of Diseases, 9th Edition Clinical Modification code 39.65 and classified into six diagnostic categories: 1) cardiac surgery, 2) non-surgical heart disease, 3) congenital diaphragmatic hernia, 4) neonatal respiratory failure, 5) pediatric respiratory failure, and 6) sepsis. Demographics, hospital characteristics, and outcome information were used in a multivariate logistic regression analysis to determine factors associated with mortality. We identified 1,465 children treated with Extracorporeal Membrane Oxygenation. Overall mortality was 40% (591/1,465). Mortality was independently associated with diagnosis (heart disease: odds ratio, 1.7; p = 0.01; congenital diaphragmatic hernia: odds ratio, 5.1; p < 0.001; and sepsis odds ratio: 2.4; p = 0.003 compared with neonatal respiratory failure) time from hospital admission to Extracorporeal Membrane Oxygenation of more than 10 days (odds ratio, 4.5; p < 0.001) and Extracorporeal Membrane Oxygenation complications (renal [odds ratio: 5; p < 0.001] and neurologic [odds ratio, 1.4; p = 0.03] injury). In addition, hospitals with bed size less than 400 had higher mortality (odds ratio, 1.4; p = 0.02). In patients with any Extracorporeal Membrane Oxygenation complication, probability of mortality was lower for Extracorporeal Membrane Oxygenation patients in larger hospitals, 38% (95% CI, 37-39) versus 44% (95% CI, 43-46) with p value of less than 0.001. CONCLUSIONS: Extracorporeal Membrane Oxygenation mortality was significantly associated with patient diagnosis, time to Extracorporeal Membrane Oxygenation initiation, Extracorporeal Membrane Oxygenation complications, and Extracorporeal Membrane Oxygenation hospital bed size. Improved survival in larger hospitals supports centralization of Extracorporeal Membrane Oxygenation services to larger centers.
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Extracorporeal Membrane Oxygenation for the support of adults with acute myocarditis
Critical Care Medicine, 2015Co-Authors: Wesley J Diddle, Satish K. Rajagopal, Peter T. Rycus, Melvin C Almodovar, Ravi R. ThiagarajanAbstract:Objectives: To characterize survival outcomes for adult patients with acute myocarditis supported with Extracorporeal Membrane Oxygenation and identify risk factors for in-hospital mortality. Design: Retrospective review of Extracorporeal Life Support Organization registry database. Setting: Data reported to Extracorporeal Life Support Organization by 230 Extracorporeal Membrane Oxygenation centers. Patients: Patients 16 years old or older supported with Extracorporeal Membrane Oxygenation for myocarditis during 1995 to 2011. Interventions: None. Measurements and Main Results: There were 150 separate runs of Extracorporeal Membrane Oxygenation for 147 patients with a diagnosis of acute myocarditis in the Extracorporeal Life Support Organization database from 1995 through 2011. Survival to hospital discharge was 61%. Nine patients underwent heart transplantation, and transplant-free survival to discharge was 56%. Extracorporeal Membrane Oxygenation was deployed during Extracorporeal cardiopulmonary resuscitation in 31 patients (21% of the cohort). In a multivariate model evaluating pre–Extracorporeal Membrane Oxygenation and Extracorporeal Membrane Oxygenation support factors, pre–Extracorporeal Membrane Oxygenation arrest (adjusted odds ratio, 2.4; 95% CI, 1.1–5.0) and need for higher Extracorporeal Membrane Oxygenation flows at 4 hours post–Extracorporeal Membrane Oxygenation cannulation (odds ratio, 2.8; 95% CI, 1.1–7.3) were associated with increased odds of in-hospital mortality. In a second multivariate model evaluating adverse events while on Extracorporeal Membrane Oxygenation, central nervous system injury (odds ratio, 26.5; 95% CI, 7.3–96.6), renal failure (odds ratio, 3.6; 95% CI, 1.4–9.3), arrhythmia (odds ratio, 5.8; 95% CI, 2.2–15.1), and hyperbilirubinemia (odds ratio, 9.1; 95% CI, 2.6–31.8) were associated with increased odds of in-hospital mortality. Conclusions: Extracorporeal Membrane Oxygenation can be used effectively in adults with myocarditis to support the circulation while awaiting myocardial recovery. Early Extracorporeal Membrane Oxygenation deployment prior to cardiac arrest may be associated with better outcomes.
Matthew Bacchetta - One of the best experts on this subject based on the ideXlab platform.
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Bleeding, Thromboembolism, and Clinical Outcomes in Venovenous Extracorporeal Membrane Oxygenation.
Critical care explorations, 2020Co-Authors: John W Stokes, Whitney D Gannon, Wren H Sherrill, Leslie B Armistead, Matthew Bacchetta, Todd W Rice, Matthew W Semler, Jonathan D CaseyAbstract:Bleeding and thromboembolism are common during venovenous Extracorporeal Membrane Oxygenation. The relative frequency of these complications and their impact on clinical outcomes have not been described, and no randomized trials exist to guide anticoagulation strategies in Extracorporeal Membrane Oxygenation. Our objective was to examine the relative frequencies of bleeding and thromboembolic events and their associations with survival among a cohort of consecutive patients receiving venovenous Extracorporeal Membrane Oxygenation. Retrospective cohort study. A single academic medical center. Adult patients receiving venovenous Extracorporeal Membrane Oxygenation and anticoagulation. Eligibility criteria for this analysis were selected to emulate the population that would be recruited for a randomized trial of anticoagulation strategies during venovenous Extracorporeal Membrane Oxygenation. Patients were excluded if they had active bleeding or thromboembolism prior to Extracorporeal Membrane Oxygenation initiation, a history of trauma or surgery in the 7 days prior to Extracorporeal Membrane Oxygenation initiation, an arterial Extracorporeal Membrane Oxygenation cannula, or if they received greater than 48 hours of Extracorporeal Membrane Oxygenation support at another institution. None. Outcomes included bleeding and thromboembolic events, duration of Extracorporeal Membrane Oxygenation support, hospital length of stay, and in-hospital survival among 55 patients receiving venovenous Extracorporeal Membrane Oxygenation. Bleeding events occurred in 25 patients (45.5%), and thromboembolism occurred in eight patients (14.5%). Bleeding events were associated with longer duration of Extracorporeal Membrane Oxygenation support (p = 0.007) and worse in-hospital survival (p = 0.02). Thromboembolic events did not appear to be associated with clinical outcomes. In this cohort of patients receiving venovenous Extracorporeal Membrane Oxygenation and anticoagulation, bleeding occurred more frequently than thromboembolism and was associated with worse survival. These results highlight the need for randomized trials to evaluate the safety and efficacy of continuous IV anticoagulation among patients receiving venovenous Extracorporeal Membrane Oxygenation. Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.
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the sport model Extracorporeal Membrane Oxygenation using the subclavian artery
The Annals of Thoracic Surgery, 2014Co-Authors: Mauer Biscotti, Matthew BacchettaAbstract:Venoarterial Extracorporeal Membrane Oxygenation is used for patients with refractory cardiopulmonary failure. Arterial cannulation by means of femoral arteries is fraught with potential complications. We present a technique for subclavian artery cannulation to provide a safe and durable means of venoarterial Extracorporeal Membrane Oxygenation support.
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Extracorporeal Membrane Oxygenation as a bridge to lung transplantation and recovery
The Journal of Thoracic and Cardiovascular Surgery, 2012Co-Authors: Jeffrey Javidfar, Daniel Brodie, Alex Iribarne, Julissa Jurado, Matthew Lavelle, Keith Brenner, Selim Arcasoy, Joshua R Sonett, Matthew BacchettaAbstract:Objective Respiratory failure develops in many patients on lung transplant waiting lists before a suitable donor organ becomes available. Extracorporeal Membrane Oxygenation may be used to bridge such patients to recovery or lung transplantation. Methods This is a review of a single-institution's experience with placing patients on Extracorporeal Membrane Oxygenation with the intention of bridging them to lung transplantation. End points included successful bridging, duration of Extracorporeal Membrane Oxygenation support, extubation, weaning from Extracorporeal Membrane Oxygenation, overall survival, and Extracorporeal Membrane Oxygenation–related complications. During an approximate 5-year period, acute respiratory failure developed in 18 patients (median age, 34 years) on the institution's lung transplant waiting list (8 hypoxemic, 9 hypercarbic, and 1 combined) who were placed on Extracorporeal Membrane Oxygenation (13 venovenous and 5 venoarterial). Results All patients achieved appropriate Extracorporeal Membrane Oxygenation blood flow rates (median, 4.05 L/min) and good gas exchange (median, on Extracorporeal Membrane Oxygenation partial pressure of arterial carbon dioxide 43 mm Hg and partial pressure of arterial oxygen 196 mm Hg). Thirteen patients (72%) were successfully bridged: 10 to transplant and 3 returned to baseline function. Eleven patients (61%) survived beyond 3 months, including the 10 (56%) who underwent transplantation and are still alive. The median duration of Extracorporeal Membrane Oxygenation support for patients who underwent transplantation was 6 days (3.5-31 days) versus 13.5 days (11-19 days) for those who did not undergo transplantation ( P = .45). Six patients (33%) were extubated on Extracorporeal Membrane Oxygenation, 4 of whom underwent transplantation. Four patients (22%) who were too unstable for conventional interhospital transfer were transported on Extracorporeal Membrane Oxygenation to Columbia University Medical Center. This subgroup had a 75% bridge to transplant or recovery rate and 100% survival in transplanted patients. Conclusions Extracorporeal Membrane Oxygenation is a safe and effective means of bridging well-selected patients with refractory respiratory failure to lung transplantation or return to their baseline condition.
Felix Oberender - One of the best experts on this subject based on the ideXlab platform.
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venoarterial Extracorporeal Membrane Oxygenation versus conventional therapy in severe pediatric septic shock
Pediatric Critical Care Medicine, 2018Co-Authors: James D. Fortenberry, Felix Oberender, Anusha Ganeshalingham, Michael J Hobson, Robert Jan Houmes, Kevin Morris, Andrew Numa, Susan DonathAbstract:OBJECTIVES: The role of venoarterial Extracorporeal Membrane Oxygenation in the treatment of severe pediatric septic shock continues to be intensely debated. Our objective was to determine whether the use of venoarterial Extracorporeal Membrane Oxygenation in severe septic shock was associated with altered patient mortality, morbidity, and/or length of ICU and hospital stay when compared with conventional therapy. DESIGN: International multicenter, retrospective cohort study using prospectively collected data of children admitted to intensive care with a diagnosis of severe septic shock between the years 2006 and 2014. SETTING: Tertiary PICUs in Australia, New Zealand, Netherlands, United Kingdom, and United States. PATIENTS: Children greater than 30 days old and less than 18 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 2,452 children with a diagnosis of sepsis or septic shock, 164 patients met the inclusion criteria for severe septic shock. With conventional therapy (n = 120), survival to hospital discharge was 40%. With venoarterial Extracorporeal Membrane Oxygenation (n = 44), survival was 50% (p = 0.25; CI, -0.3 to 0.1). In children who suffered an in-hospital cardiac arrest, survival to hospital discharge was 18% with conventional therapy and 42% with venoarterial Extracorporeal Membrane Oxygenation (Δ = 24%; p = 0.02; CI, 2.5-42%). Survival was significantly higher in patients who received high Extracorporeal Membrane Oxygenation flows of greater than 150 mL/kg/min compared with children who received standard Extracorporeal Membrane Oxygenation flows or no Extracorporeal Membrane Oxygenation (82%, 43%, and 48%; p = 0.03; CI, 0.1-0.7 and p < 0.01; CI, 0.2-0.7, respectively). Lengths of ICU and hospital stay were significantly longer for children who had venoarterial Extracorporeal Membrane Oxygenation. CONCLUSIONS: The use of venoarterial Extracorporeal Membrane Oxygenation in severe pediatric sepsis is not by itself associated with improved survival. However, venoarterial Extracorporeal Membrane Oxygenation significantly reduces mortality after cardiac arrest due to septic shock. Venoarterial Extracorporeal Membrane Oxygenation flows greater than 150 mL/kg/min are associated with almost twice the survival rate of conventional therapy or standard-flow Extracorporeal Membrane Oxygenation.
Susan L. Bratton - One of the best experts on this subject based on the ideXlab platform.
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Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs.
Pediatric Critical Care Medicine, 2017Co-Authors: Susan L. Bratton, Titus Chan, Cindy Barrett, Jacob Wilkes, Laura M. Ibsen, Ravi R. ThiagarajanAbstract:OBJECTIVES: Only a small fraction of pediatric cardiac surgical patients are supported with Extracorporeal Membrane Oxygenation following cardiac surgery, but Extracorporeal Membrane Oxygenation use is more common among those undergoing higher complexity surgery. We evaluated Extracorporeal Membrane Oxygenation metrics indexed to annual cardiac surgical volume to better understand Extracorporeal Membrane Oxygenation use among U.S. cardiac surgical programs. DESIGN: Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used Extracorporeal Membrane Oxygenation. PATIENTS: All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Both Extracorporeal Membrane Oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal Membrane Oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received Extracorporeal Membrane Oxygenation. Median case mix adjusted rate of Extracorporeal Membrane Oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal Membrane Oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without Extracorporeal Membrane Oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with Extracorporeal Membrane Oxygenation. The median reduction in case mix adjusted surgical mortality from Extracorporeal Membrane Oxygenation surgical survival was 30.1%. The median Extracorporeal Membrane Oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median Extracorporeal Membrane Oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% Extracorporeal Membrane Oxygenation use). Extracorporeal Membrane Oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. CONCLUSIONS: Risk adjusted Extracorporeal Membrane Oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of Extracorporeal Membrane Oxygenation utilization, efficacy, and impact on cardiac surgery mortality.
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Prolonged Extracorporeal Membrane Oxygenation for children with respiratory failure.
Pediatric Critical Care Medicine, 2012Co-Authors: Thomas V. Brogan, Ravi R. Thiagarajan, Peter T. Rycus, Luke Zabrocki, Susan L. BrattonAbstract:Objective: Extracorporeal Membrane Oxygenation is used to support children with respiratory failure. When Extracorporeal Membrane Oxygenation duration is prolonged, decisions regarding ongoing support are difficult as a result of limited prognostic data. Design: Retrospective case series. Setting: Multi-institutional data reported to the Extracorporeal Life Support Organization Registry. Patients: Patients aged 1 month to 18 yrs supported with Extracorporeal Membrane Oxygenation for respiratory failure from 1993 to 2007 who received support for ≥21 days. Interventions: None. Measurements and Main Results: Of the 3213 children supported with Extracorporeal Membrane Oxygenation during the study period, 389 (12%) were supported ≥21 days. Median patient age was 9.1 months (interquartile range, 2.5–41.7 months). Median weight was 6.7 kg (interquartile range, 3.5–15.8 kg). Survival for this group was 38%, significantly lower than survival reported for children supported ≤14 days (61%, p < .001). Among children supported with Extracorporeal Membrane Oxygenation for ≥21 days, no differences were found between survivors and nonsurvivors with regard to acute pulmonary diagnosis, pre-Extracorporeal Membrane Oxygenation comorbidities, pre-Extracorporeal Membrane Oxygenation adjunctive therapies, or pre-Extracorporeal Membrane Oxygenation blood gas parameters. Only peak inspiratory pressure was significantly different in survivors. Complications occurring on Extracorporeal Membrane Oxygenation were more common among nonsurvivors. The use of inotropic infusion (odds ratio 1.64; 95% confidence interval 1.07–2.52), acidosis (pH
Wenje Ko - One of the best experts on this subject based on the ideXlab platform.
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Extracorporeal Membrane Oxygenation resuscitation in adult patients with refractory septic shock.
The Journal of Thoracic and Cardiovascular Surgery, 2012Co-Authors: Chun-ta Huang, Piru Tsai, Yi-ju Tsai, Wenje KoAbstract:Objectives Experience with Extracorporeal Membrane Oxygenation for adult patients with refractory septic shock remains limited. We aimed to study the clinical features and outcomes of this patient group in an Extracorporeal Membrane Oxygenation referral center in Taiwan. Methods From January 2005 to December 2010, all adult patients in refractory septic shock and requiring venoarterial Extracorporeal Membrane Oxygenation for circulatory support were included in the present study. The variables analyzed included patient demographics; comorbidities; smoking status; hemodynamic, ventilatory, and laboratory parameters just before Extracorporeal Membrane Oxygenation support; clinical course; Extracorporeal Membrane Oxygenation details; complications; microbiology results; and outcomes. The primary endpoint was survival to hospital discharge. Results A total of 52 patients, 39 men and 13 women, were included during a 6-year period. Their median age and body mass index was 56.8 years and 24.1 kg/m 2 , respectively. Of the 52 patients, 39 (75%) had failure of at least 3 organ systems and 21 (40%) had developed cardiac arrest and received cardiopulmonary resuscitation at Extracorporeal Membrane Oxygenation implantation. Of these 52 patients, 8 (15%) survived to hospital discharge. The nonsurvivors were significantly older than the survivors (59.3 vs 43.8 years; P = .009), and all 20 patients (38%) aged 60 years or older died. Conclusions In our single-center experience with Extracorporeal Membrane Oxygenation for adults with refractory septic shock, the outcomes of these patients remain unsatisfactory. From our findings, we suggest that if Extracorporeal Membrane Oxygenation were to be used in this patient population, age 60 years or older might be a contraindication. Also, central Extracorporeal Membrane Oxygenation could possibly be beneficial according to the favorable pediatric experience in published studies.
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infections occurring during Extracorporeal Membrane Oxygenation use in adult patients
The Journal of Thoracic and Cardiovascular Surgery, 2010Co-Authors: Wenje Ko, Piru Tsai, Yinyin Chang, Yeechun ChenAbstract:Objective The application of Extracorporeal Membrane Oxygenation in adults has been increasing, but infections occurring during Extracorporeal Membrane Oxygenation use are rarely described. Methods We retrospectively analyzed the prospectively collected data on nosocomial infection surveillance of 334 patients aged 16 years or more undergoing their first Extracorporeal Membrane Oxygenation for more than 48 hours at a university hospital from 1996 to 2007 for respiratory (20.4%) and cardiac (79.6%) support. Results During a total of 2559 Extracorporeal Membrane Oxygenation days, 55 episodes of infections occurred in 45 patients (13.5%), including 38 bloodstream (14.85 per 1000 Extracorporeal Membrane Oxygenation days), 6 surgical site, 4 respiratory tract, 3 urinary tract, and 4 other infections. Stenotrophomonas maltophilia (16.7%) and Candida species (14.6%) were the predominant blood isolates. In stepwise logistic regression analysis, longer duration of Extracorporeal Membrane Oxygenation use (odds ratio 1.003; 95% confidence interval, 1.001–1.005; P = . 004), mechanical complications (odds ratio, 4.849; 95% confidence interval, 1.569–14.991; P = . 006), autoimmune disease (odds ratio, 6.997; 95% confidence interval, 1.541–31.766; P = . 012), and venovenous mode (odds ratio, 4.473; 95% confidence interval, 1.001–19.977; P = . 050) were independently associated with a higher risk for infections during Extracorporeal Membrane Oxygenation use. Overall in-hospital mortality was 68.3%, and its independent risk factors included older age (odds ratio, 1.037; 95% confidence interval, 1.021–1.054; P 001), neurologic complications (odds ratio, 51.153; 95% confidence interval, 6.773–386.329; P 001), and vascular complications (odds ratio, 1.922; 95% confidence interval, 1.112–3.320; P 001), but not infections during Extracorporeal Membrane Oxygenation use. Conclusions Bloodstream infection was the most common infection during Extracorporeal Membrane Oxygenation use. Duration of Extracorporeal Membrane Oxygenation, mechanical complications, autoimmune disease, and venovenous mode seemed to be independently associated with infections.
