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OBJECTIVES: To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference. DATA SOURCES: Systematic review was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial meetings of international, interprofessional experts in the management ECMO for critically ill children. STUDY SELECTION: The management of ECMO anticoagulation for critically ill children. DATA EXTRACTION: Within each of eight subgroup, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. DATA SYNTHESIS: A systematic review was conducted using MEDLINE, Embase, and Cochrane Library databases, from January 1988 to May 2021. Each panel developed evidence-based and, when evidence was insufficient, expert-based statements for the clinical management of anticoagulation for children supported with ECMO. These statements were reviewed and ratified by 48 PEACE experts. Consensus was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 23 recommendations, 52 expert consensus statements, and 16 good practice statements covering the management of ECMO anticoagulation in three broad categories: general care and monitoring; perioperative care; and nonprocedural bleeding or thrombosis. Gaps in knowledge and research priorities were identified, along with three research focused good practice statements. CONCLUSIONS: The 91 statements focused on clinical care will form the basis for standardization and future clinical trials.
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Anticoagulantes , Enfermedad Crítica , Oxigenación por Membrana Extracorpórea , Oxigenación por Membrana Extracorpórea/métodos , Humanos , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Niño , Enfermedad Crítica/terapia , Recién Nacido , Lactante , PreescolarRESUMEN
OBJECTIVES: To derive systematic-review informed, modified Delphi consensus regarding anticoagulation monitoring assays and target levels in pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE. DATA SOURCES: A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION: Anticoagulation monitoring of pediatric patients on ECMO. DATA EXTRACTION: Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS: Risk of bias was assessed using the Quality in Prognosis Studies tool or the revised Cochrane risk of bias for randomized trials, as appropriate and the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for clinical recommendations focused on anticoagulation monitoring and targets, using a web-based modified Delphi process to build consensus (defined as > 80% agreement). One weak recommendation, two consensus statements, and three good practice statements were developed and, in all, agreement greater than 80% was reached. We also derived some resources for anticoagulation monitoring for ECMO clinician use at the bedside. CONCLUSIONS: There is insufficient evidence to formulate optimal anticoagulation monitoring during pediatric ECMO, but we propose one recommendation, two consensus and three good practice statements. Overall, the available pediatric evidence is poor and significant gaps exist in the literature.
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Anticoagulantes , Técnica Delphi , Oxigenación por Membrana Extracorpórea , Oxigenación por Membrana Extracorpórea/métodos , Humanos , Anticoagulantes/administración & dosificación , Niño , Monitoreo de Drogas/métodos , ConsensoRESUMEN
OBJECTIVES: To identify and prioritize research questions for anticoagulation and hemostasis management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus. DATA SOURCES: Systematic review was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial consensus conferences of international, interprofessional experts in the management of ECMO for critically ill neonates and children. STUDY SELECTION: The management of ECMO anticoagulation for critically ill neonates and children. DATA EXTRACTION: Within each of the eight subgroups, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. DATA SYNTHESIS: Following the systematic review of MEDLINE, EMBASE, and Cochrane Library databases from January 1988 to May 2021, and the consensus process for clinical recommendations and consensus statements, PEACE panel experts constructed research priorities using the Child Health and Nutrition Research Initiative methodology. Twenty research topics were prioritized, falling within five domains (definitions and outcomes, therapeutics, anticoagulant monitoring, protocolized management, and impact of the ECMO circuit and its components on hemostasis). CONCLUSIONS: We present the research priorities identified by the PEACE expert panel after a systematic review of existing evidence informing clinical care of neonates and children managed with ECMO. More research is required within the five identified domains to ultimately inform and improve the care of this vulnerable population.
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Anticoagulantes , Oxigenación por Membrana Extracorpórea , Oxigenación por Membrana Extracorpórea/métodos , Humanos , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Niño , Recién Nacido , Enfermedad Crítica/terapia , Investigación Biomédica/métodos , Lactante , PreescolarRESUMEN
Pediatric extracorporeal membrane oxygenation is an increasingly utilized, life-saving technology with high mortality and morbidity. A complex technology employed urgently or emergently for some of the sickest children in the hospital by a large multidisciplinary team, ECMO is an ideal area for using quality improvement strategies to reduce the variability in care and improve patient outcomes. We review critical concepts from quality improvement and apply them to patient selection and management, staffing, credentialing and continuing education, and the variability of management among providers and institutions.
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Oxigenación por Membrana Extracorpórea , Niño , Humanos , Mejoramiento de la CalidadRESUMEN
Congenital tuberculosis is a rare infectious disease with less than 500 cases documented worldwide. Mortality is significant, ranging from 34 to 53%, and death without treatment is inevitable. Patients exhibit nonspecific symptoms such as fever, cough, respiratory distress, feeding intolerance, and irritability which can make appropriate diagnosis challenging in Peng et al. (2011) Pediatr Pulmonol 46(12), 1215-1224. Tuberculosis prevalence is particularly high in developing countries where access to resources can be limited in World Health Organization (2019) Global tuberculosis report 2019, Geneva. We present a 2.4-kg premature male infant with acute respiratory distress syndrome secondary to congenital tuberculosis caused by Mycobacterium bovis and tuberculosis-immune reconstitution inflammatory syndrome who was successfully supported with veno-arterial extracorporeal membrane oxygenation.
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Oxigenación por Membrana Extracorpórea , Enfermedades del Recién Nacido , Síndrome de Dificultad Respiratoria , Lactante , Recién Nacido , Humanos , Masculino , Oxigenación por Membrana Extracorpórea/efectos adversos , Síndrome de Dificultad Respiratoria/terapia , Recien Nacido PrematuroRESUMEN
OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has introduced countless challenges to the medical field. Although pediatric patients have been reported to have lower rates of COVID-19 mortality, the presence of pre-existing conditions can heighten the severity of their clinical presentation. This report discusses the potential influence COVID-19 might have on diabetic ketoacidosis. METHODS: Our patient, a 6-year-old girl with known type 1 diabetes, presented with acute onset of abnormal breathing and altered mental status. The day prior, she had 1 episode of emesis, diarrhea, and abdominal pain but no fever. She presented to an outside hospital and was reported to have agonal breathing with a Glasgow Coma Scale score of 8 (eyes open to pain, no verbal response to stimuli, and localized pain). She was promptly intubated, and the initial laboratory tests revealed severe diabetic ketoacidosis (DKA). A family member had COVID-19, and she also tested positive for COVID-19. RESULTS: Our patient's rapid progression and severity of illness require a discussion of how COVID-19 might affect diabetes and indicate opportunities for improving clinical practice in children with pre-existing diabetes. We discussed how COVID-19 might change the underlying pathophysiology of DKA and cause metabolic complications. Possible mechanisms include binding to angiotensin-converting enzyme 2 receptors and enabling a proinflammatory "cytokine storm." Additionally, ketoacidosis and altered mental status have been present in patients with COVID-19 without diabetes, which might potentiate the symptoms in developing DKA. CONCLUSION: Prompt recognition of DKA is warranted, as caregivers may attribute the symptoms to COVID-19 rather than to DKA, resulting in an increased severity of illness on presentation with acute symptom onset, as described in this report.
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Intro: Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure continues to demonstrate improving outcomes, largely due to advances in technology along with refined management strategies despite mounting patient acuity and complexity. Successful use of ECMO requires thoughtful initiation and candidacy strategies, along with reducing the risk of ventilator induced lung injury and the progression to multiorgan failure.Areas Covered: This review describes current ECMO management strategies for neonatal and pediatric patients with acute refractory respiratory failure and summarizes relevant published literature. ECMO initiation and candidacy, along with ventilator and sedation management, are highlighted. Additionally, rapidly expanding areas of interest such as anticoagulation strategies, transfusion thresholds, rehabilitation on ECMO, and drug pharmacokinetics are described.Expert Opinion: Over the last few decades, published studies supporting ECMO use for acute refractory respiratory failure, along with institutional experience, have resulted in increased utilization although more randomized-controlled trials are needed. Future research should focus on filling the knowledge gaps that remain regarding anticoagulation, transfusion thresholds, ventilator strategies, sedation, and approaches to rehabilitation to subsequently implement into clinical practice. Additionally, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations.
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Oxigenación por Membrana Extracorpórea , Síndrome de Dificultad Respiratoria , Insuficiencia Respiratoria , Niño , Enfermedad Crítica , Humanos , Recién Nacido , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/terapia , Ventiladores MecánicosRESUMEN
OBJECTIVES: To compare current practices within the United States of anticoagulation management and blood transfusion in neonatal and pediatric extracorporeal membrane oxygenation patients with a 2013 international report. DESIGN: Cross-sectional survey distributed between August and December 2019. SETTING: Extracorporeal Life Support Organization-registered neonatal and pediatric extracorporeal membrane oxygenation centers in the United States. PARTICIPANTS: Extracorporeal membrane oxygenation medical directors. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-three medical directors at 108 centers responded. After removing four duplicate responses, 79 surveys were analyzed. Seventy-nine percent (n = 62) report a written extracorporeal membrane oxygenation protocol for both anticoagulation and blood product management. Ninety-four percent (n = 74) report unfractionated heparin as their primary anticoagulant; the remaining use the direct thrombin inhibitor, bivalirudin. Ninety percent (n = 71) report measuring antifactor Xa levels. Most centers report using a combination of assays to monitor heparin therapy, either antifactor Xa and activated partial thromboplastin time (54%) or more commonly antifactor Xa and activated clotting time (68%). Forty-one percent use viscoelastic tests to aid management. Goal monitoring levels and interventions generated by out of range values are variable. Fifty-one percent will replace antithrombin. Platelet transfusion thresholds vary by age and center with ranges from 50,000 to 100,000 cells/µL. Eighty-two percent of respondents are willing to participate in a randomized controlled trial comparing anticoagulation strategies for patients receiving extracorporeal membrane oxygenation. CONCLUSIONS: Compared with the 2013 pediatric population, extracorporeal membrane oxygenation center anticoagulation and blood transfusion approaches continue to vary widely. Most report continued use of heparin as their primary anticoagulant and follow a combination of monitoring assays with the majority using the antifactor Xa assay in their practices, a significant shift from prior results. Antithrombin activity levels and viscoelastic tests are followed by a growing number of centers. Platelet transfusion thresholds continue to vary widely. Future research is needed to establish optimal anticoagulation and blood transfusion management.
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Oxigenación por Membrana Extracorpórea , Ejecutivos Médicos , Anticoagulantes , Transfusión Sanguínea , Niño , Estudios Transversales , Heparina , Humanos , Recién Nacido , Estudios Retrospectivos , Encuestas y Cuestionarios , Estados UnidosRESUMEN
BACKGROUND: Factor consumption is common during ECMO complicating the balance of pro and anticoagulation factors. This study sought to determine whether transfusion of coagulation factors using fresh frozen plasma (FFP) increased ECMO circuit life and decreased blood product transfusion. Secondly, it analyzed the association between FFP transfusion and hemorrhagic and thrombotic complications. STUDY DESIGN AND METHODS: Thirty-one pediatric ECMO patients between October 2013 and January 2016 at a quaternary care institution were included. Patients were randomized to FFP every 48 hours or usual care. The primary outcome was ECMO circuit change. Secondary outcomes included blood product transfusion, survival to decannulation, hemorrhagic and thrombotic complications, and ECMO costs. RESULTS: Median (interquartile range [IQR]) number of circuit changes was 0 (0, 1). No difference was seen in percent days without a circuit change between intervention and control group, P = .53. Intervention group patients received median platelets of 15.5 mL/kg/d IQR (3.7, 26.8) vs 24.8 mL/kg/d (12.2, 30.8) for the control group (P = .16), and median packed red blood cells (pRBC) of 7.7 mL/kg/d (3.3, 16.3) vs 5.9 mL/kg/d (3.4, 18.7) for the control group, P = .60. FFP transfusions were similar with 10.2 mL/kg/d (5.0, 13.9) in the intervention group vs 8.8 (2.5, 17.7) for the control group, P = .98. CONCLUSION: In this pilot randomized study, scheduled FFP did not increase circuit life. There was no difference in blood product transfusion of platelets, pRBCs, and FFP between groups. Further studies are needed to examine the association of scheduled FFP with blood product transfusion.
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Transfusión Sanguínea/métodos , Oxigenación por Membrana Extracorpórea , Plasma , Adolescente , Transfusión Sanguínea/mortalidad , Niño , Preescolar , Femenino , Hemorragia/complicaciones , Humanos , Lactante , Recién Nacido , Masculino , Proyectos Piloto , Estudios Retrospectivos , Trombosis/complicacionesRESUMEN
OBJECTIVE: Thrombotic events are potential complications in patients receiving extracorporeal membrane oxygenation (ECMO) necessitating the use of systemic anticoagulation with heparin. Heparin works by potentiating the effects of antithrombin (AT), which may be deficient in critically ill patients and can be replaced. The clinical benefits and risks of AT replacement in children on ECMO remain incompletely understood. METHODS: This single-center, retrospective study reviewed 28 neonatal and pediatric patients supported on ECMO at a tertiary care hospital between April 1, 2013, and October 31, 2014, who received at least 1 dose of AT during their ECMO course. The primary outcome of the study was the change in anti-factor Xa levels after pooled human AT supplementation. Secondary outcomes included the percentage of anti-factor Xa levels within the therapeutic range surrounding AT administration; survival to decannulation; 30 days after cannulation and discharge; time to first circuit change; and incidence of bleeding and thrombotic events. RESULTS: A total of 78 doses of AT were administered during the study period. The mean increase in anti-factor Xa level following AT administration in patients without a ≥10% concurrent change in heparin was 0.075 ± 0.13 international units/mL. A greater percentage of anti-factor Xa levels were therapeutic for the 48 hours following AT administration (64.2% vs 38.6%). Survival and adverse events were similar to Extracorporeal Life Support Organization averages, with the exception of a higher incidence of intracranial hemorrhage. CONCLUSIONS: Patients experienced a small but significant increase in anti-factor Xa level and a greater percentage of therapeutic anti-factor Xa levels following AT supplementation.
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Anticoagulation is essential during extracorporeal membrane oxygenation (ECMO) to prevent catastrophic circuit clotting. Several assays exist to monitor unfractionated heparin (UFH), the most commonly used anticoagulant during ECMO, but no single test or combination of tests has consistently been proven to be superior. This retrospective observational study examines the correlation among antifactor Xa level, activated partial thromboplastin time (aPTT), and UFH dose and the association between antifactor Xa level and aPTT with survival and hemorrhagic and thrombotic complications. Sixty-nine consecutive neonatal and pediatric ECMO patients from September 2012 to December 2014 at a single institution were included. Spearman rank correlation was used to compare antifactor Xa level, aPTT, and UFH dose. Significant but poor correlation exists between antifactor Xa level and UFH dose ρ = 0.1 (p < 0.0001) and aPTT and UFH dose ρ = 0.26 (p < 0.0001). Antifactor Xa level and aPTT were weakly correlated to each other ρ = 0.38 (p < 0.0001). In an univariate analysis, there was no difference between survival and antifactor Xa level, aPTT, or UFH dose. Multiple anticoagulation tests may be superior to a single test during ECMO.
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Anticoagulantes/administración & dosificación , Oxigenación por Membrana Extracorpórea/efectos adversos , Inhibidores del Factor Xa/sangre , Heparina/administración & dosificación , Tiempo de Tromboplastina Parcial , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Estudios RetrospectivosRESUMEN
BACKGROUND: Infection with influenza virus causes substantial morbidity and mortality globally, although antiviral treatments are available. Previous studies have suggested that anti-influenza immune plasma could be beneficial as treatment, but they were not designed as randomised, blinded, placebo-controlled trials. Therefore, we aimed to prospectively evaluate the clinical efficacy of high-titre immune plasma compared with standard low-titre plasma to improve outcomes in patients with severe influenza A infection. METHODS: We did this randomised, double-blind, phase 3 trial at 41 US medical centres to assess the efficacy of high-titre anti-influenza plasma (haemagglutination inhibition antibody titre ≥1:80) compared with low-titre plasma (≤1:10). Children and adults with PCR-confirmed influenza A infection, a National Early Warning score of 3 or greater, and onset of illness within 6 days before randomisation were eligible. Patients were randomly assigned (2:1) using an interactive web response system to receive either two units (or paediatric equivalent) of high-titre plasma (high-titre group) or low-titre plasma (low-titre group), and were followed up for 28 days from randomisation. High-titre and low-titre plasma had the same appearance. Randomisation was stratified by severity (in intensive care unit, not in intensive care but requiring supplemental oxygen, or not in intensive care and not requiring supplemental oxygen) and age (<18 years and ≥18 years). All participants, site staff, and the study team were masked to treatment allocation until after the final database lock. The primary endpoint was clinical status assessed by a six-point ordinal scale on day 7 (death, in intensive care, hospitalised but requiring supplemental oxygen, hospitalised not requiring supplemental oxygen, discharged but unable to resume normal activities, and discharged with full resumption of normal activities) analysed in a proportional odds model (an odds ratio [OR] >1 indicates improvement in clinical status across all categories for the high-titre vs the low-titre group). The primary analysis was done in the intention-to-treat population, excluding two participants who did not receive plasma. This trial is registered with ClinicalTrials.gov, NCT02572817. FINDINGS: Participants were recruited between Jan 26, 2016, and April 19, 2018. Of 200 participants enrolled (177 adults and 23 children), 140 met the criteria for randomisation and were assigned to the high-titre group (n=92) or to the control low-titre group (n=48). One participant from each group did not receive plasma. At baseline, 60 (43%) of 138 participants were in intensive care and 55 (71%) of 78 participants who were not in intensive care required oxygen. 93% of planned plasma infusions were completed. The study was terminated in July, 2018, when independent efficacy analysis showed low conditional power to detect an effect of high-titre plasma even if full accrual (150 participants) was achieved. The proportional OR for improved clinical status on day 7 was 1·22 (95% CI 0·65-2·29, p=0·54). 47 (34%) of 138 participants experienced 88 serious adverse events: 32 (35%) with 60 events in the high-titre group and 15 (32%) with 28 events in the low-titre group. The most common serious adverse events were acute respiratory distress syndrome (ARDS; four [4%] vs two [4%]), allergic transfusion reactions (two [2%] vs two [4%]), and respiratory distress (three [3%] vs none). 65 (47%) participants experienced 183 adverse events: 42 (46%) with 126 events in the high-titre group and 23 (49%) with 57 events in the low-titre group. The most common adverse events were anaemia (four [3%] vs two [4%]) and ARDS (four [3%] vs three [5%]). Ten patients died during the study (six [7%] in the high-titre group vs four [9%] in the low-titre group, p=0·73). The most common cause of death was worsening of acute respiratory distress syndrome (two [2%] vs two [4%] patients). INTERPRETATION: High-titre anti-influenza plasma conferred no significant benefit over non-immune plasma. Although our study did not have the precision to rule out a small, clinically relevant effect, the benefit is insufficient to justify the use of immune plasma for treating patients with severe influenza A. FUNDING: National Institute of Allergy and Infectious Diseases of the National Institutes of Health (Bethesda, MD, USA).
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Anticuerpos Antivirales/uso terapéutico , Inmunización Pasiva/métodos , Virus de la Influenza A , Gripe Humana/terapia , Plasma/inmunología , Adolescente , Adulto , Anciano , Niño , Método Doble Ciego , Femenino , Humanos , Gripe Humana/sangre , Gripe Humana/virología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Adulto JovenRESUMEN
Mud runs are an increasingly popular recreational fitness activity across the United States, combining a running race through an obstacle course with submersion in mud. Recent reports estimate 4 million people have participated in these types of events over the last 5 years. We describe an atypical case of myocarditis and multiorgan failure from disseminated histoplasmosis in a previously healthy pediatric patient, likely acquired during participation in a mud run. Although cases of histoplasmosis-associated endocarditis and pericarditis have been reported in the literature, cases of histoplasmosis myocarditis are rare.
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Histoplasmosis/diagnóstico , Miocarditis/diagnóstico , Miocarditis/microbiología , Carrera , Microbiología del Suelo , Adolescente , Enfermedades Endémicas , Femenino , Histoplasmosis/complicaciones , Histoplasmosis/inmunología , Humanos , Inmunocompetencia , Insuficiencia Multiorgánica/microbiología , Miocarditis/complicaciones , Miocarditis/inmunología , North CarolinaRESUMEN
BACKGROUND: Red blood cell (RBC) transfusion is common in intensive care unit (ICU) patients and is associated with complications that appear related to the duration of blood storage. We hypothesize that hemolysis of stored RBCs results in increases in the availability of non-heme-bound iron, which inhibits macrophage activation. STUDY DESIGN AND METHODS: RBCs were sampled at multiple time points to evaluate hemolysis and iron release. Activation of THP-1 monocytic cells was assessed in the presence of plasma from aged RBCs. Age of transfused blood in our pediatric intensive care unit (PICU) from 2001 to 2006 was analyzed to assess relevance to our patient population. RESULTS: Hemolysis increased significantly during storage time as demonstrated by increases in free heme and hemoglobin. While there was a trend toward elevated levels of non-heme-bound iron, this was not significant (p = 0.07). THP-1 cell activation was inhibited by exposures to both plasma and a ferric compound; the effect of plasma on macrophage activation was not reversed by the iron chelator desferroxamine. Thirty-one percent of our PICU patients received blood older than 2 weeks. CONCLUSION: Hemolysis products increased significantly over time in our stored RBCs. Ferric compounds and plasma from stored blood inhibit THP-1 cell activation. Plasma inhibition does not appear to be due primarily to increased iron. Further studies are needed to define the inhibitory effect of stored blood plasma on macrophage function. Complications related to blood storage are relevant to our PICU patients.
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Conservación de la Sangre/efectos adversos , Eritrocitos , Hemo/metabolismo , Hemoglobinas/metabolismo , Hemólisis/fisiología , Hierro/sangre , Activación de Macrófagos/fisiología , Biomarcadores/sangre , Conservación de la Sangre/métodos , Conservación de la Sangre/estadística & datos numéricos , Células Cultivadas , Niño , Envejecimiento Eritrocítico/fisiología , Transfusión de Eritrocitos/efectos adversos , Transfusión de Eritrocitos/estadística & datos numéricos , Eritrocitos/metabolismo , Eritrocitos/patología , Eritrocitos/fisiología , Humanos , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Modelos Lineales , Factores de TiempoRESUMEN
BACKGROUND: Respiratory failure and acute respiratory distress syndrome secondary to H1N1 influenza infection is a source of substantial morbidity and mortality, having caused over 265,000 hospitalizations in the United States in 2009. During the H1N1 pandemic, up to 31% of the H1N1 patients required intensive care unit admission, and many were refractory to maximal conventional therapies. These most critically ill patients may require extracorporeal membrane oxygenation (ECMO) for survival. METHODS: We retrospectively reviewed the medical records of the 7 patients with refractory hypoxemia due to H1N1 influenza who were treated with ECMO in our pediatric intensive care unit. RESULTS: Five of the 7 patients survived to hospital discharge. The cohort's mean age was 21 years, and 4 were female. At admission to the pediatric intensive care unit, 6 had at least one comorbid condition, 6 were mechanically ventilated, and one was in shock. All 7 patients were treated with oral oseltamivir, high-frequency oscillatory ventilation, and inhaled nitric oxide prior to ECMO. Five received intravenous steroids, and 2 were treated with compassionate-use intravenous zanamivir. The mean duration of pre-ECMO ventilation was 8.7 days (range 14 h to 25 d). Mean oxygenation index was 50 (range 26-73) at ECMO cannulation. Six received venovenous ECMO, and one received venoarterial ECMO. The mean duration of ECMO was 432 hours (range 192-890 h). CONCLUSIONS: This series suggests that ECMO is a viable treatment for refractory hypoxemia secondary to H1N1 influenza infection in both pediatric and adult patients.
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Oxigenación por Membrana Extracorpórea , Subtipo H1N1 del Virus de la Influenza A , Gripe Humana/complicaciones , Insuficiencia Respiratoria/terapia , Adolescente , Adulto , Antivirales/uso terapéutico , Niño , Enfermedad Crítica , Femenino , Humanos , Unidades de Cuidado Intensivo Pediátrico , Masculino , Oseltamivir/uso terapéutico , Insuficiencia Respiratoria/mortalidad , Insuficiencia Respiratoria/virología , Estudios Retrospectivos , Adulto Joven , Zanamivir/uso terapéuticoRESUMEN
Transfusion of red blood cells can be a life-saving therapy both for patients with chronic anemias and for those who are critically ill with acute blood loss. However, transfusion has been associated with significant morbidity. Chronic transfusion results in accumulation of excess iron that surpasses the binding capacity of the major iron transport protein, transferrin. The resulting non-transferrin bound iron (NTBI) can catalyze the production of highly reactive oxygen species (ROS) leading to significant and wide spread injury to the liver, heart, and endocrine organs as well as increases in infection. Acute transfusion of red blood cells in critically ill patients likewise has significant effects including increased mortality, prolonged hospital stays, and elevated risk of nosocomial infection. These effects appear to be more profound with increasing age of stored blood. The progressive release of free iron associated with storage time suggests that morbidity following acute transfusion, like that seen in chronic transfusion, may be due in part to elevated levels of NTBI. It is clear that transfusion is necessary in many instances; however, its risks and benefits must be carefully balanced before proceeding to avoid unnecessary iron toxicity.