Disruption of Cerebral Autoregulation Prior to Extracorporeal Membrane Oxygenation Cannulation Contributes to Neurologic Injury in Pediatric Patients

Aim: Neurologic complications are a significant cause of morbidity and mortality for children supported with extracorporeal membrane oxygenation (ECMO). Disruption of cerebral autoregulation (CAR) is associated with neurologic injury for children who require ECMO. The aim of this project was to identify the period of ECMO support which carries the greatest risk of neurologic injury. Materials and Methods: This retrospective cohort study was conducted in children supported on venovenous or venoarterial ECMO between 2020 and 2023 at a single quaternary center. CAR was measured by assessing the wavelet transform coherence of mean arterial blood pressure and cerebral oximetry. Disruption of CAR was assessed by the time-period of ECMO support and then compared between patients in order to determine the association between impaired CAR and neurologic injury determined by neuroimaging. Results: A total of 31 neonates and children who received ECMO support were included. Eleven children developed severe neurologic injury (35%). Peak disruption of CAR during the pre-cannulation period correlated with severe neurologic injury (R²=0.14, p=0.04). Peak disruptions of CAR in the peri-cannulation (R²=0.004, p=0.7) and post-cannulation periods (R²=0.04, p=0.28) were not significant. There were no significant differences in laboratory values or anticoagulation between the groups. There were no differences in CAR disruption between the neonates and the children [18.4 (8.6-35) p=0.09] or for extracorporeal cardiopulmonary resuscitation with respect to the other indications for ECMO [17.5 (6.5-35), p=0.5]. Conclusion: Impaired CAR in the 24 hours preceding ECMO support may represent the most critical window for neuroprotection in pediatric ECMO.