TY - JOUR
T1 - Extracorporeal Membrane Oxygenation Cannulation Timing in the Pediatric Myocarditis Population
T2 - An Exploratory Analysis From the Extracorporeal Life Support Organization Registry
AU - Gutierrez, Maria E.
AU - Anders, Marc
AU - Guffey, Danielle
AU - Denfield, Susan W.
AU - Deshpande, Shriprasad R.
AU - Rajagopal, Satish K.
AU - Thiagarajan, Ravi R.
AU - Alexander, Peta M.A.
AU - Lasa, Javier J.
N1 - Funding Information:
Dr. Thiagarajan received funding from the Extracorporeal Life Support Organization and Society of Critical Care Medicine. Dr. Alexander’s institution received funding from Novartis. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Publisher Copyright:
Copyright © 2022 The Authors.
PY - 2022/12/30
Y1 - 2022/12/30
N2 - OBJECTIVES: Children presenting with acute myocarditis may experience rapid clinical deterioration requiring extracorporeal membrane oxygenation (ECMO); however, our understanding of best practices and timing of ECMO initiation are lacking. We explored the relationships between pre-cannulation factors and survival in this high-acuity patient population. DESIGN: Retrospective review of a large international registry. Primary outcome was survival to hospital discharge, stratified by incident cardiac arrest (CA) prior to ECMO and time to cannulation after intubation. SETTING AND SUBJECTS: The Extracorporeal Life Support Organization registry was queried for patients less than or equal to 18 years old receiving ECMO support for myocarditis between 2007 and 2018. Exclusion criteria included being nonindex runs, non-venoarterial ECMO or missing data points for main variables studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Population characteristics and survival were compared using ttest, Wilcoxon rank-sum test, or Fisher exact test. Multivariable logistic regression was used for significant factors in the unadjusted logistic regression. Among 506 index ECMO runs in pediatric patients with myocarditis, survival for the cohort was 72%, with no difference between early and late eras (2007–2012 vs 2013–2018; p = 0.69). Survivors demonstrated higher pre-ECMO pH levels as well as shorter intubation-to-cannulation (ITC) times (3hr [interquartile range (IQR)], 1–14hr vs 6hr [IQR, 2–20 hr]; p = 0.021). CA occurred within 24 hours prior to ECMO cannulation, including extracorporeal cardiopulmonary resuscitation, in 54% of ECMO runs (n = 273). Accounting for the interaction between pre-ECMO CA occurrence and ITC time, longer ITC time remained associated with lower survival for patients who did not experience a CA prior to ECMO, with adjusted odds ratio of 0.09 (IQR, 0.02–0.40; p = 0.002) for ITC time greater than or equal to 18 hours. CONCLUSIONS: The results of this multicenter analysis of ECMO utilization and outcomes for pediatric myocarditis suggest that patients approaching ECMO cannulation who have not experienced CA may have better survival outcomes if cannulated onto ECMO early after intubation.
AB - OBJECTIVES: Children presenting with acute myocarditis may experience rapid clinical deterioration requiring extracorporeal membrane oxygenation (ECMO); however, our understanding of best practices and timing of ECMO initiation are lacking. We explored the relationships between pre-cannulation factors and survival in this high-acuity patient population. DESIGN: Retrospective review of a large international registry. Primary outcome was survival to hospital discharge, stratified by incident cardiac arrest (CA) prior to ECMO and time to cannulation after intubation. SETTING AND SUBJECTS: The Extracorporeal Life Support Organization registry was queried for patients less than or equal to 18 years old receiving ECMO support for myocarditis between 2007 and 2018. Exclusion criteria included being nonindex runs, non-venoarterial ECMO or missing data points for main variables studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Population characteristics and survival were compared using ttest, Wilcoxon rank-sum test, or Fisher exact test. Multivariable logistic regression was used for significant factors in the unadjusted logistic regression. Among 506 index ECMO runs in pediatric patients with myocarditis, survival for the cohort was 72%, with no difference between early and late eras (2007–2012 vs 2013–2018; p = 0.69). Survivors demonstrated higher pre-ECMO pH levels as well as shorter intubation-to-cannulation (ITC) times (3hr [interquartile range (IQR)], 1–14hr vs 6hr [IQR, 2–20 hr]; p = 0.021). CA occurred within 24 hours prior to ECMO cannulation, including extracorporeal cardiopulmonary resuscitation, in 54% of ECMO runs (n = 273). Accounting for the interaction between pre-ECMO CA occurrence and ITC time, longer ITC time remained associated with lower survival for patients who did not experience a CA prior to ECMO, with adjusted odds ratio of 0.09 (IQR, 0.02–0.40; p = 0.002) for ITC time greater than or equal to 18 hours. CONCLUSIONS: The results of this multicenter analysis of ECMO utilization and outcomes for pediatric myocarditis suggest that patients approaching ECMO cannulation who have not experienced CA may have better survival outcomes if cannulated onto ECMO early after intubation.
KW - acute myocarditis
KW - cardiac arrest
KW - extracorporeal membrane oxygenation
KW - pediatric myocarditis
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U2 - 10.1097/CCE.0000000000000826
DO - 10.1097/CCE.0000000000000826
M3 - Article
C2 - 36619364
AN - SCOPUS:85145943296
SN - 2639-8028
VL - 5
JO - Critical Care Explorations
JF - Critical Care Explorations
IS - 1
M1 - e0826
ER -