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INTRODUCTION: Around 3.2%-8.4% of patients receive venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support after pediatric cardiac surgery. The desired outcome is "bridge-to-recovery" in most cases. There is no universally agreed protocol, and given the associated costs and complications rates, the decisions as of when and when not to institute VA ECMO are largely empirical. METHODS: A retrospective review of the ECMO database at the Scottish Pediatric Cardiac Services (SPCS) was undertaken. Inclusion criterion encompassed all children (<16 years of age) who were supported with VA ECMO following cardiac surgery between January 2011 and October 2016. The timing of ECMO support was divided into three distinct phases: "endofcase" or intheatre ECMO for patients unable to effectively wean from cardiopulmonary bypass (CPB), ECMO for cardiopulmonary resuscitation ("ECPR"), and Intensive Care Unit ECMO for "failing maximal medial therapy" following cardiac surgery. The patients were analyzed to identify survival rates, adverse prognostic indicators, and complication rates. RESULTS: We identified 66 patients who met the inclusion criterion. 30day survival rate was 45% and survival rate to hospital discharge was 44% (the difference represents one patient). On followup (median: 960 days, range: 42-2010 days), all survivors to hospital discharge were alive at review date. "End-of-case" ECMO showed a trend toward better survival of the three subcategories ("end of case," ECPR, and ECMO for "failing maximal medical therapy" survival rates were 47%, 41%, and 37.5%, respectively, P = 0.807). The poorest survival rates were in the younger children (<6 months, P = 0.502), patients who had prolonged CPB (P = 0.314) and aortic crossclamp times (P = 0.146), and longer duration of ECMO (>10 days, P = 0.177). CONCLUSIONS: Allcomers VA ECMO following pediatric cardiac surgery had survival to discharge rate of 44%. Elective "end-of-case" ECMO carries better survival rates and therefore ECMO instituted early maybe advantageous. Prolonged ECMO support has a direct correlation with mortality.
RESUMO
The wet priming of extracorporeal membrane oxygenation systems and storage of these systems for rapid deployment is common practice in many clinical centers. This storage policy is, however, seen by many to be controversial due to the potential adverse effects associated with the migration of the di(2-ethylhexyl) phthalate plasticizer (DEHP) from the polyvinyl chloride (PVC) circuit tubing and issues surrounding the maintenance of sterility. This study was performed to evaluate the effects of both short and long-term storage and priming fluid type on plasticizer migration from four commonly used PVC tubes in extracorporeal membrane oxygenation therapy circuits. The four tubes incorporating three plasticizers, two DEHP, one tri(2-ethylhexyl) trimellitate (TOTM), and one dioctyl adipate (DOA) were exposed to each of the three priming fluids for a period of 28 days. Samples were taken at time intervals of 1, 4, 8, 24, and 48 hours, followed by samples at 7, 14, and 28 days. Each sample was processed using a spectrophotomer and the concentration of plasticizer leaching into each solution at each time-point determined. There was a time dependent increase in plasticizer leached from each tube. The migration was greatly affected by both the priming fluid and tubing type. The migration of DEHP was higher than that of TOTM and DOA over both the short and long-term exposure levels. Plasticizer migration occurs from all of the tubes tested over the long term. The TOTM and DOA tubes performed better than the DEHP counterparts in the short term. Selection of priming fluid has a major bearing on plasticizer migration with significant lipid and protein containing fluids promoting higher migration than simple sodium chloride .9% solution prime. The results suggest that DOA tubing and sodium chloride. 9% solution priming fluid should be selected if wet primed perfusion circuits are to be used over short terms of storage.
