Multisite Veno-Venous Cannulation for Neonates and Nonambulatory Children.

OBJECTIVES: Neonates with respiratory failure are ideally supported with veno-venous rather than veno-arterial extracorporeal membrane oxygenation due to the reduced rate of neurologic complications. However, the proportion of neonates supported with veno-venous extracorporeal membrane oxygenation is declining. We report multisite veno-venous extracorporeal membrane oxygenation, accessing the neck, returning to the inferior vena cava via the common femoral vein in neonates and children less than 10 kg. DESIGN: Retrospective case series with 1 year minimum follow-up. PATIENTS: Patients less than 10 kg supported with veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein. SETTING: A 30-bed pediatric intensive care delivering extracorporeal membrane oxygenation to approximately 20 children annually. INTERVENTIONS: Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was delivered using two single lumen cannulae. MEASUREMENTS AND MAIN RESULTS: January 2015 to August 2019, 11 patients underwent veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein with median weight of 3.6 kg (interquartile range 2.8-6.1 kg), and median corrected gestational age of 13 days (interquartile range, 2-175 d). The smallest patient weighed 2.1 kg. Seven patients had comorbidities. Extracorporeal membrane oxygenation was technically successful in all patients with median flows of 126 mL/kg/min (interquartile range, 120-138 mL/kg/min) and median arterial oxygenation saturation of 94% (interquartile range, 91-98%) at 24 hours. Nine survived to home discharge, and two were palliated. Common femoral vein occlusion was observed in all patients on ultrasound post decannulation. There was no clinical or functional deficit in the cannulated limb at follow-up, a minimum of 1 year post extracorporeal membrane oxygenation. CONCLUSIONS: Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was performed safely in patients under 10 kg with the smallest patient weighing 2.1 kg. Although occlusion of the common femoral vein was observed in patients post decannulation, subsequent follow-up demonstrated no clinical implications. We challenge current practice that veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein cannot be performed in nonambulatory patients and suggest that this strategy is preferred over veno-arterial extracorporeal membrane oxygenation in infants requiring extracorporeal membrane oxygenation for respiratory failure.

Thrombophilia in Pediatric Patients with Multisystem Inflammatory Syndrome in Children Secondary to Coronavirus Disease 2019 Supported on Extracorporeal Membrane Oxygenation.

Coronavirus disease 2019 (COVID-19) in adults has been associated with thrombosis. Multisystem inflammatory syndrome in children (MIS-C) with COVID-19 case series have reported high fibrinogen levels, but it is not known whether this causes thrombophilia. We report two patients needing extracorporeal membrane oxygenation (ECMO) who both suffered thrombotic complications. We retrospectively reviewed patients with MIS-C needing ECMO support admitted to a single Paediatric and Cardiac Intensive Care Unit within a regional center for MIS-C in South East England. Two children required ECMO for cardiovascular support. Both developed thrombotic events despite receiving heparin infusions at dosing higher than the interquartile range for our ECMO population. Case 1 developed a right anterior and middle cerebral artery infarct, which led to his death. Case 2 had a right atrial thrombus, which resolved without complication. When compared with patients undergoing ECMO in the same institution in pre-MIS-C era, fibrinogen levels were consistently higher before and during ECMO therapy. MIS-C patients presenting with hyperfibrinogenemia are likely to have a propensity toward thrombotic complications; this must be considered when optimizing the anticoagulation strategy on ECMO.

The relationship between workload and medical staffing levels in a paediatric cardiac intensive care unit.

OBJECTIVE: To evaluate the matching between workload in a paediatric cardiac intensive care unit (ICU) and the corresponding medical staffing levels over a 24-h period. DESIGN: A review of workload measured by: (a) admissions, (b) severity of illness in admissions using case-mix descriptors and mortality as a proxy, (c) cardiac arrests (CA) and (d) extracorporeal membrane oxygenation (ECMO) cannulations. An evaluation of matching between workload and medical staff schedules. SETTING: A tertiary paediatric cardiac ICU. PATIENTS: 2,799 admissions over a 49-month period. RESULTS: New admissions peaked in the evening, and the ratio of doctors' hours to admissions was lowest between 1359 and 2000 h. Although only 515 (17.3%) cases were admitted between 2000 and 0759 h, these were more likely to be emergencies, to have higher Paediatric Index of Mortality 2 (PIM2) scores and to die (p < 0.001). There was an increased adjusted risk of death in admissions between 2000 and 0159 h (p = 0.021). There was no difference in the occurrence of either CA (p = 0.41) or ECMO (p = 0.95) between day and night. The ratio of doctors' hours to CAs and ECMOs was lowest from 2000 to 0800 h. The conventional medical staffing roster generated the greatest concentration of staff in the morning, reducing to the lowest level between 0200 and 0759 h. CONCLUSIONS: Workload was most intense for the in-house team at night, in terms of sicker admissions, ECMOs and cardiac arrests. Conventional roster patterns may not offer ideal matching between staffing and workload. Data analysis of variable and urgent workload may be used to inform medical rosters.