Single-Center Experience Using the Cardiohelp System for Neonatal and Pediatric Extracorporeal Membrane Oxygenation.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) systems have continued to evolve and improve with the development of smaller and portable systems. The Cardiohelp (Maquet Getinge Cardiopulmonary AG, Rastatt, Germany) portable life support device is a compact ECMO system used widely in adults and for ECMO transport. Reports of its use in neonatal and pediatric centers remain limited. In this single-center retrospective review, we describe our institutional experience with the Cardiohelp. DESIGN: Single-center retrospective review. SETTING: Neonatal ICUs and PICUs in a tertiary-care children's hospital. PATIENTS: Seventeen pediatric patients on ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Median (interquartile range, IQR) of patient age was 0.5 years (0-7 yr). Eleven of 17 patients were on veno-arterial ECMO, five on veno-venous ECMO, and one on veno-venoarterial ECMO. All veno-venous and veno-venoarterial runs ( n = 6) were accomplished with bicaval, dual-lumen cannulae. Median duration on Cardiohelp was 113 hours (IQR 50-140 hr). Median anti-Xa level for patients was 0.43 IU/mL (IQR 0.35-0.47 IU/mL), with median heparin dose of 23.6 U/kg/hr (IQR 17.6-28.1 U/kg/hr). Median plasma-free hemoglobin was 41.4 mg/dL (IQR 30-60 mg/dL). Circuit change was required in three cases. Fourteen patients survived ECMO, with 13 patients surviving to discharge. CONCLUSIONS: We have used the Cardiohelp system to support 17 neonatal and pediatric ECMO patients, without complications. Further studies are warranted to compare complications, outcomes, and overall cost with other institutions and other existing ECMO systems.

Awake Neonatal Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is used in patients with acute respiratory failure that is not responsive to conventional management. The practice of awake ECMO has become an area of interest but with limited data and experience. Most reported experience comes from adult and pediatric populations. Traditional management of these patients still includes mechanical ventilator support and often requires the use of sedatives for provision of safe care. We present a series of eight neonates who were electively extubated while on ECMO, with expanded discussion of two representative cases. We discuss the rationale for extubation and outcomes. The greatest benefit of this management was seen in patients with significant air leak, and in no reported case did we experience any adverse effects or complications as a direct result of extubation while on ECMO. In conclusion, in our experience, awake neonatal ECMO appears safe and effective and may offer significant advantages over traditional management in certain clinical scenarios. Prospective comparison trials are warranted to further investigate the clinical benefits and risks of awake neonatal ECMO.

Status asthmaticus requiring extracorporeal membrane oxygenation associated with rhinovirus infection.

Objective: Evolving research links human rhinovirus (HRV) with status asthmaticus (SA) as well as severe respiratory illness in patients with atopy and asthma. This case series reviews five episodes of HRV-associated SA that required extracorporeal membrane oxygenation (ECMO). Methods: Charts of four patients, five total episodes of ECMO, with SA secondary to HRV were reviewed in this IRB-approved case series. Outcomes included demographic information, past medical history, clinical parameters and spirometry. Results: Patients (three male, one female), mean age 9 years (range 7-12 years) at the time of admission, were African American, on Medicaid, carried a diagnosis of persistent asthma, and had documented non-adherence to prescribed, daily controller medications. One patient had passive smoke exposure. All patients had a mean IgE of 734 (range 12-2497) with seasonal allergic rhinitis was diagnosed in three patients. Cases occurred in spring (3/5) and fall (2/5). Venous/venous ECMO (4/5) or venous/arterial ECMO (1/5) was continued for a mean duration of 4.2 days (range 3-7 days). Spirometry after hospitalization had a mean FEV1 of 1.59 L (81% predicted, range 69%-91%), and an FEF25%-75% 1.13 L (47.5% predicted, range 41%-65%) at an average of 16.7 weeks post ECMO. Conclusions: This case series highlights the association between persistent, poorly controlled asthma and severe SA with HRV infection resulting in ECMO. Despite life-threatening illness, these patients did not demonstrate significant large-airway obstruction following infection. However, patients showed persistently abnormal small airway function, which could be a risk factor or early evidence of vulnerability to infection.

Extracorporeal Membrane Oxygenation in a Pediatric Patient with Hepatopulmonary Syndrome and Interrupted Inferior Vena Cava After Living Related Liver Donation.

Extracorporeal membrane oxygenation (ECMO) is used for cardiopulmonary dysfunction. Hepatopulmonary syndrome (HPS) occurs in the setting of liver failure and may cause hypoxemia. Previous reports have described the use of ECMO for HPS after liver transplant. Our patient is a 19-month-old female with biliary atresia, an interrupted inferior vena cava, and HPS on 8 liters per minute of high-flow oxygen. Following liver transplantation, her postoperative course was complicated by severe hypoxemia requiring ECMO. Due to her interrupted inferior vena cava, our standard bi-caval cannula could not be used. Hence, a 16-French double lumen venovenous right internal jugular to right atrial cannula was used to provide extracorporeal life support. She was decannulated after 17 days, remained intubated for 2 days, and weaned to room air over the next 3 weeks. This is the third pediatric liver transplant patient supported with ECMO identified in the literature, and the youngest and smallest of those reported. This approach to cannulation is unique because of the use of a double lumen venovenous cannula for HPS in a child, selected due to complex anatomy. Posttransplant ECMO may provide pediatric patients with HPS and posttransplant hypoxemia a period of support for their pulmonary remodeling and recovery from HPS.

Extracorporeal membrane oxygenation support in individuals with thoracic insufficiency.

INTRODUCTION: Respiratory failure is the leading cause of mortality in individuals with congenital spine and rib deformities. We present a case report of a child with Jeune syndrome surviving respiratory failure using extracorporeal membrane oxygenation (ECMO). We also summarize thoracic insufficiency syndrome cases reported in the Extracorporeal Life Support Organization (ELSO) registry. CASE REPORT: A two-year-old male with a chest circumference less than a third percentile for age was admitted with influenza pneumonia developing a peak oxygenation index of 103.5. The child survived to baseline pulmonary function after nine days of venous-arterial ECMO support. DISCUSSION: The ELSO registry contained 27 individuals with a surrogate diagnosis of thoracic insufficiency (0.05%). There was no significant difference in survival to discharge for thoracic insufficiency patients (52%) compared to a previously healthy population supported with ECMO. CONCLUSION: ECMO is safe and may be effective in supporting individuals with thoracic insufficiency.

Pediatric Extracorporeal Cardiopulmonary Resuscitation Patient With Traumatic Subarachnoid Hemorrhage and Takotsubo Syndrome.

Takotsubo syndrome is rare in pediatric patients but must be considered in patients with subarachnoid hemorrhage with pulmonary edema and cardiomyopathy. A systematic, collaborative approach is needed to facilitate emergent transfer of patients where extracorporeal cardiopulmonary resuscitation (e-CPR) is used as a lifesaving measure. Extracorporeal membrane oxygenation (ECMO) use in transport requires preplanning, role delineation, resources, and research efforts to be successful. We present an unusual transport case of successful e-CPR/ECMO treatment of Takotsubo syndrome in a 12-year-old boy with an isolated traumatic intracranial injury, cardiomyopathy with pulmonary edema, and multiple cardiac arrests.