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Hyperoxia and Hypocapnia During Pediatric Extracorporeal Membrane Oxygenation: Associations With Complications, Mortality, and Functional Status Among Survivors*

Cashen, Katherine DO1; Reeder, Ron PhD2; Dalton, Heidi J. MD3; Berg, Robert A. MD4; Shanley, Thomas P. MD5; Newth, Christopher J. L. MD6; Pollack, Murray M. MD7; Wessel, David MD7; Carcillo, Joseph MD8; Harrison, Rick MD9; Dean, J. Michael MD2; Tamburro, Robert MD10; Meert, Kathleen L. MD1; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN)

Pediatric Critical Care Medicine: March 2018 - Volume 19 - Issue 3 - p 245-253
doi: 10.1097/PCC.0000000000001439
Extracorporeal Support
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Objectives: To determine the frequency of hyperoxia and hypocapnia during pediatric extracorporeal membrane oxygenation and their relationships to complications, mortality, and functional status among survivors.

Design: Secondary analysis of data collected prospectively by the Collaborative Pediatric Critical Care Research Network.

Setting: Eight Collaborative Pediatric Critical Care Research Network–affiliated hospitals.

Patients: Age less than 19 years and treated with extracorporeal membrane oxygenation.

Interventions: Hyperoxia was defined as highest Pao2 greater than 200 Torr (27 kPa) and hypocapnia as lowest Paco2 less than 30 Torr (3.9 kPa) during the first 48 hours of extracorporeal membrane oxygenation. Functional status at hospital discharge was evaluated among survivors using the Functional Status Scale.

Measurements and Main Results: Of 484 patients, 420 (86.7%) had venoarterial extracorporeal membrane oxygenation and 64 (13.2%) venovenous; 69 (14.2%) had extracorporeal membrane oxygenation initiated during cardiopulmonary resuscitation. Hyperoxia occurred in 331 (68.4%) and hypocapnia in 98 (20.2%). Hyperoxic patients had higher mortality than patients without hyperoxia (167 [50.5%] vs 48 [31.4%]; p < 0.001), but no difference in functional status among survivors. Hypocapnic patients were more likely to have a neurologic event (49 [50.0%] vs 143 (37.0%]; p = 0.021) or hepatic dysfunction (49 [50.0%] vs 121 [31.3%]; p < 0.001) than patients without hypocapnia, but no difference in mortality or functional status among survivors. On multivariable analysis, factors independently associated with increased mortality included highest Pao2 and highest blood lactate concentration in the first 48 hours of extracorporeal membrane oxygenation, congenital diaphragmatic hernia, and being a preterm neonate. Factors independently associated with lower mortality included meconium aspiration syndrome.

Conclusions: Hyperoxia is common during pediatric extracorporeal membrane oxygenation and associated with mortality. Hypocapnia appears to occur less often and although associated with complications, an association with mortality was not observed.

1Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan/Wayne State University, Detroit, MI.

2Department of Pediatrics, University of Utah, Salt Lake City, UT.

3Department of Pediatrics, Inova Fairfax Hospital, Falls Church, VA.

4Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, PA.

5Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL.

6Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA.

7Department of Pediatrics, Children’s National Medical Center, Washington, DC.

8Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA.

9Department of Pediatrics, Mattel Children’s Hospital UCLA, Los Angeles, CA.

10Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD.

*See also p. 270.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Supported, in part, by the following cooperative agreements from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services: U10HD050096, U10HD049981, U10HD049983, U10HD050012, U10HD063108, U10HD063106, U10HD063114, and U01HD049934.

All authors received support for article research from the National Institutes of Health (NIH). Drs. Reeder’s, Berg’s, Shanley’s, Newth’s, Pollack’s, and Carcillo’s institutions received funding from the National Institute of Child Health and Human Development. Drs. Dalton’s, Wessel’s, Harrison’s, Dean’s, and Meert’s institutions received funding from the NIH. Dr. Dalton received funding from Maquet and Innovative extracorporeal membrane oxygenation (ECMO) Concepts, and she disclosed off-label product use of ECMO. Dr. Shanley received funding from Springer Publishing, International Pediatric Research Foundation (travel support for biannual meeting), and Raynes McCarty Law Firm. Dr. Newth received funding from Philips Research North America and Covidien. Dr. Tamburro received funding from Springer Publishing; he disclosed government work; and he disclosed receiving grant support from the U.S. Food and Drug Administration Office of Orphan Product Development to study the use of exogenous surfactant in acute lung injury among pediatric hematopoietic cell patients; Ony, Inc. provided the medication free of charge for that trial.

For information regarding this article, E-mail: kmeert@med.wayne.edu

Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies