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The impact of mechanical ventilation time before initiation of extracorporeal life support on survival in pediatric respiratory failure: A review of the extracorporeal life support registry*

Domico, Michele B. MD; Ridout, Deborah A. MSc; Bronicki, Ronald MD; Anas, Nick G. MD; Cleary, John Patrick MD; Cappon, James MD; Goldman, Allan P. MRCPCH; Brown, Katherine L. MPH, MRCPCH

Pediatric Critical Care Medicine: January 2012 - Volume 13 - Issue 1 - p 16–21
doi: 10.1097/PCC.0b013e3182192c66
Feature Articles

Objective: To evaluate the relationship between duration of mechanical ventilation before the initiation of extracorporeal life support and the survival rate in children with respiratory failure. Extracorporeal life support has been used as a rescue therapy for >30 yrs in children with severe respiratory failure. Previous studies suggest patients who received >7–10 days of mechanical ventilation were not acceptable extracorporeal life support candidates as a result of irreversible lung damage.

Design: A retrospective review encompassing the past 10 yrs of the International Extracorporeal Life Support Organization Registry (January 1, 1999, to December 31, 2008).

Setting: Extracorporeal Life Support Organization Registry database.

Patients: A total of 1325 children (≥ 30 days and ≤ 18 yrs) met inclusion criteria.

Interventions: None.

Measurements and Main Results: The following pre-extracorporeal life support variables were identified as independently and significantly related to the chance of survival: 1) >14 days of ventilation vs. 0–7 days was adverse (odds ratio, 0.32; p < .001); 2) the presence of a cardiac arrest was adverse (odds ratio, 0.56; p = .001); 3) pH per 0.1-unit increase was protective (odds ratio, 1.15; p < .001); 4) oxygenation index, per 10-unit increase was adverse (odds ratio, 0.95; p = .002); and 5) any diagnosis other than sepsis was related to a more favorable outcome. Patients requiring >7–10 or >10–14 days of pre-extracorporeal life support ventilation did not have a statistically significant decrease in survival as compared with patients who received 0–7 days.

Conclusions: There was a clear relationship between the number of mechanical ventilation days before the initiation of extracorporeal life support and survival. However; there was no statistically significant decrease in survival until >14 days of pre-extracorporeal life support ventilation was reached regardless of underlying diagnosis. We found no evidence to suggest that prolonged mechanical ventilation should be considered as a contraindication to extracorporeal life support in children with respiratory failure before 14 days.

From the Department of Pediatrics, Division of Critical Care (MBD, RB, NGA, JC) and Neonatology (JPC), Children's Hospital of Orange County, Orange, CA; the Centre for Paediatric Epidemiology and Biostatistics (DAR), UCL Institute of Child Health, London, UK; and the Cardiac Intensive Care Unit (APG, KLB), Great Ormond Street Hospital for Children NHS Trust, London, UK.

* See also p. 94.

Financial support provided by a grant from the Extracorporeal Life Support Organization.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: MDomico@CHOC.org

Index of referenced International Classification of Diseases, 9th Revision (ICD-9) codes:1) Primary or secondary diagnosis of immune deficiency, cancer or transplantation (ICD-9 codes 042–044, 112.4, 112.5, 112.85, 112.89, 116, 117.3, 117.9, 130.4, 136–136.3, 155, 158.0, 163.9, 170.6, 171.4, 189, 191.9, 194.0, 195.1, 200.22, 201.50, 202.1, 202.10, 202.8, 204, 204.0, 204.00, 204.01, 204.1, 205, 205.0, 205.00, 205.01, 205.1, 205.2, 208.0, 238.7, 279.11, 279.12, 279.2, 279.3, 284.8, 284.9, 288.0, 996.8, 996.81, 996.82, 996.83, 996.84, 996.85, V42.6, V42.7, V42.81); 2) cardiac disease (ICD-9 codes 390–397, 402.91, 410–416.99, 417.1, 420.9–429.9, 441–441.2, 444–444.1, 747.8, 759.31, 759.32, 785.51, 996.01, 996.79, V15.1, V45.81); 3) metabolic disorder (ICD-9 codes 220.8, 270.6, 272.4, 275.4, 277.1, 277.6, 330, 359.8); 4) burn (ICD-9 codes e890–899, 942.3–949); 5) diaphragmatic hernia (ICD-9 codes 519.4, 552.3–555.9); 6) primary diagnosis of airway anomaly (ICD-9 codes 162.0, 519.19, 748.2, 748.3); and 7) sepsis or septic shock (ICD-9 codes 36.2, 38–38.9, 771.8, 785.52, 995.91, 995.92).

©2012The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies