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Evaluating Mortality Risk Adjustment Among Children Receiving Extracorporeal Support for Respiratory Failure

Barbaro, Ryan P.*,†; Boonstra, Philip S.; Kuo, Kevin W.§; Selewski, David T.; Bailly, David K.; Stone, Cheryl L.#; Chow, Chin Ying**; Annich, Gail M.††; Moler, Frank W.*; Paden, Matthew L.#

doi: 10.1097/MAT.0000000000000813

This study evaluates whether three commonly used pediatric intensive care unit (PICU) severity of illness scores, pediatric risk of mortality score (PRISM) III, pediatric index of mortality (PIM) 2, and pediatric logistic organ dysfunction (PELOD), are the appropriate tools to discriminate mortality risk in children receiving extracorporeal membrane oxygenation (ECMO) support for respiratory failure. This study also evaluates the ability of the Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS) to discriminate mortality risk in the same population, and whether Ped-RESCUERS’ discrimination of mortality is improved by additional clinical and laboratory measures of renal, hepatic, neurologic, and hematologic dysfunction. A multi-institutional retrospective cohort study was conducted on children aged 29 days to 17 years with respiratory failure requiring respiratory ECMO support. Discrimination of mortality was evaluated with the area under the receiver operating curve (AUC); model calibration was measured by the Hosmer–Lemeshow goodness of fit test and Brier score. Admission PRISM-III, PIM-2, and PELOD were found to have poor ability to discriminate mortality with an AUC of 0.56 [0.46–0.66], 0.53 [0.43–0.62], and 0.57 [0.47–0.67], respectively. Alternatively, Ped-RESCUERS performed better with an AUC of 0.68 [0.59–0.77]. Higher alanine aminotransferase, ratio of the arterial partial pressure of oxygen the fraction of inspired oxygen, and lactic acidosis were independently associated with mortality and, when added to Ped-RESCUERS, resulted in an AUC of 0.75 [0.66–0.82]. Admission PRISM-III, PIM-2, and PELOD should not be used for pre-ECMO risk adjustment because they do not discriminate death. Extracorporeal membrane oxygenation population-derived scores should be used to risk adjust ECMO populations as opposed to general PICU population-derived scores.

From the *Division of Pediatric Critical Care, University of Michigan, Ann Arbor

Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, Ann Arbor

School of Public Health Department of Biostatistics, University of Michigan, Ann Arbor

§Division of Pediatric Critical Care, Stanford University, Palo Alto, California

Division of Nephrology, University of Michigan, Ann Arbor

Division of Pediatric Critical Care, University of Utah, Salt Lake City

#Division of Pediatric Critical Care, Emory University/Children’s Healthcare of Atlanta, Georgia

**Pediatric Critical Care, Queen Mary Hospital, Hong Kong

††Department of Critical Care Medicine, University of Toronto, Canada.

Submitted for consideration August 2017; accepted for publication in revised form March 2018.

Disclosure: Drs. Barbaro and Annich acknowledge that they are on the Extracorporeal Life Support Organization steering committee. Dr. Barbaro received grant funding from Extracorporeal Life Support Organization. Dr. Bailly received funding from the National Institutes of Health (NIH) Loan Repayment Program; he received support for article research from the NIH; and he received funding from Orca Health. Dr. Moler’s institution received funding from the NIH. Dr. Paden received funding from law firms for expert review; he disclosed off-label product use of extracorporeal membrane oxygenation (all ECMO use is offlabel); and he disclosed he holds multiple patents for a pediatric renal replacement device (not commercially available and not mentioned in this manuscript). The other authors have no conflicts of interest to report.

Dr. Barbaro received an Extracorporeal Life Support Organization grant to support this work. The funding organization had no role in the design and conduct of the study; the management, analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

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Correspondence: Ryan Barbaro, University of Michigan, 1500 East Medical Center Drive, Mott F-6790/Box 5243, Ann Arbor, MI 48109. Email:

Copyright © 2019 by the American Society for Artificial Internal Organs