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Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation

Barrett, Cindy S. MD; Bratton, Susan L. MD, MPH; Salvin, Joshua W. MD, MPH; Laussen, Peter C. MD; Rycus, Peter T. MPH; Thiagarajan, Ravi R. MBBS, MPH

Pediatric Critical Care Medicine: July 2009 - Volume 10 - Issue 4 - p 445-451
doi: 10.1097/PCC.0b013e318198bd85
Continuing Medical Education Article

Objectives: Extracorporeal membrane oxygenation (ECMO) to aid failed cardiopulmonary resuscitation (CPR) in children is associated with a high incidence of neurologic injury. We sought to identify risk factors for acute neurologic injury in children undergoing ECMO to aid CPR (E-CPR).

Design: Retrospective cohort study using data reported to the Extracorporeal Life Support Organization registry.

Setting: Multi-institutional data.

Patients: Patients <18 years of age undergoing E-CPR during 1992–2005.

Interventions: None.

Measurements and Results: We defined acute neurologic injury as the occurrence of brain death, brain infarction, or intracranial hemorrhage identified by ultrasound or computerized tomography imaging. Of 682 E-CPR patients, 147 (22%) patients had acute neurologic injury. Brain death occurred in 74 (11%), cerebral infarction in 45 (7%), and intracranial hemorrhage in 45 (7%). The in-hospital mortality rate in patients with acute neurologic injury was 89%. In a multivariable logistic regression model, pre-ECMO factors including cardiac disease (odds ratio [OR] 0.46 [95% confidence interval {CI} 0.28–0.76]) and pre-ECMO blood pH ≥6.865 (≥6.865–7.120; OR 0.49 [95% CI 0.25–0.94]; pH >7.120; OR 0.47 [95% CI 0.26–0.85]) compared with pH <6.865 were associated with decreased odds of neurologic injury. During ECMO, neurologic injury was associated with ECMO complications including pulmonary hemorrhage (OR 1.93, 95% CI 1.1–3.4), dialysis use (OR 2.36, 95% CI 1.4–4.0), and CPR during ECMO support (OR 2.08, 95% CI 1.6–3.8).

Conclusions: Neurologic injury is a frequent complication in children undergoing E-CPR. Children with cardiac disease, less severe metabolic acidosis before ECMO, and an uncomplicated ECMO course have decreased odds of sustaining neurologic injury. Providing effective CPR and inclusion of brain protective therapies on ECMO should be considered in the future to improve neurologic outcomes for patients undergoing E-CPR.

Assistant in Cardiology (CSB, JWS), Children's Hospital Boston, Boston, MA; Instructor in Pediatrics (CSB, JWS), Harvard Medical School, Boston, MA; Professor of Pediatrics (SLB), Division of Critical Care Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, UT; Chief (PL), Division of Cardiovascular Critical Care, Department of Cardiology, Department of Anesthesia, Pain, and Perioperative Medicine, Boston, MA; D.D. Hansen Chair in Pediatric Anesthesia (PL), Children's Hospital Boston, Boston, MA; Professor of Anesthesia (PL), Harvard Medical School, Boston, MA; ELSO Registry Manager (PTR), Extracorporeal Life Support Organization (ELSO), University of Michigan, Ann Arbor, MI; and Associate in Cardiology (RRT), Children's Hospital Boston, Boston, MA; Assistant Professor of Pediatrics (CSB, JWS), Harvard Medical School, Boston, MA.

*See alsp p. 525.

The authors have not disclosed any potential conflicts of interest.

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©2009The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies