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Venoarterial Extracorporeal Membrane Oxygenation Versus Conventional Therapy in Severe Pediatric Septic Shock*

Oberender, Felix, MRCPCH, PhD, FCICM1,2; Ganeshalingham, Anusha, MBChB, FCICM3; Fortenberry, James D., MD, MCCM, FAAP4,5; Hobson, Michael J., MD6,7; Houmes, Robert J., MD, PhD8; Morris, Kevin P., MBBS (Hons), MRCP(UK), MD, FRCPCH9; Numa, Andrew, MBBS, FRACP, FCICM10; Hoq, Mohammad M., MSc (Statistics), MPH11; Donath, Susan, MA, MEc, BSc11; Beca, John, MBChB, FRACP, FCICM3; Butt, Warwick, FRACP, FCICM12,13

Pediatric Critical Care Medicine: October 2018 - Volume 19 - Issue 10 - p 965–972
doi: 10.1097/PCC.0000000000001660
Extracorporeal Support

Objectives: The role of venoarterial extracorporeal membrane oxygenation in the treatment of severe pediatric septic shock continues to be intensely debated. Our objective was to determine whether the use of venoarterial extracorporeal membrane oxygenation in severe septic shock was associated with altered patient mortality, morbidity, and/or length of ICU and hospital stay when compared with conventional therapy.

Design: International multicenter, retrospective cohort study using prospectively collected data of children admitted to intensive care with a diagnosis of severe septic shock between the years 2006 and 2014.

Setting: Tertiary PICUs in Australia, New Zealand, Netherlands, United Kingdom, and United States.

Patients: Children greater than 30 days old and less than 18 years old.

Interventions: None.

Measurements and Main Results: Of 2,452 children with a diagnosis of sepsis or septic shock, 164 patients met the inclusion criteria for severe septic shock. With conventional therapy (n = 120), survival to hospital discharge was 40%. With venoarterial extracorporeal membrane oxygenation (n = 44), survival was 50% (p = 0.25; CI, –0.3 to 0.1). In children who suffered an in-hospital cardiac arrest, survival to hospital discharge was 18% with conventional therapy and 42% with venoarterial extracorporeal membrane oxygenation (Δ = 24%; p = 0.02; CI, 2.5–42%). Survival was significantly higher in patients who received high extracorporeal membrane oxygenation flows of greater than 150 mL/kg/min compared with children who received standard extracorporeal membrane oxygenation flows or no extracorporeal membrane oxygenation (82%, 43%, and 48%; p = 0.03; CI, 0.1–0.7 and p < 0.01; CI, 0.2–0.7, respectively). Lengths of ICU and hospital stay were significantly longer for children who had venoarterial extracorporeal membrane oxygenation.

Conclusions: The use of venoarterial extracorporeal membrane oxygenation in severe pediatric sepsis is not by itself associated with improved survival. However, venoarterial extracorporeal membrane oxygenation significantly reduces mortality after cardiac arrest due to septic shock. Venoarterial extracorporeal membrane oxygenation flows greater than 150 mL/kg/min are associated with almost twice the survival rate of conventional therapy or standard-flow extracorporeal membrane oxygenation.

1The Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia.

2Monash University School of Medicine, Melbourne, VIC, Australia.

3Intensive Care Unit, Starship Children’s Hospital Auckland, Auckland, New Zealand.

4Pediatric Intensive Care Unit, Children’s Healthcare of Atlanta at Egleston, Atlanta, GA.

5Emory University School of Medicine, Atlanta, GA.

6Intensive Care Unit, Riley Hospital for Children, Indianapolis, IN.

7Indiana University School of Medicine, Indianapolis, IN.

8Intensive Care Unit, Sophia Children’s Hospital, Rotterdam, The Netherlands.

9Intensive Care Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom.

10Intensive Care Unit, Sydney Children’s Hospital, Sydney, NSW, Australia.

11Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, VIC, Australia.

12Intensive Care Unit, The Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia.

13University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Melbourne, VIC, Australia.

*See also p. 1000.

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).

Dr. Fortenberry received funding from legal firm for provision of expert testimony. Dr. Houmes’ institution received funding from consultancy and training for Xenios GmBH (not related to this study). Dr. Hoq’s institution received funding from Murdoch Childrens Research Institute, Royal Children’s Hospital, and disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Felix Oberender, MRCPCH, PhD, FCICM, The Royal Children’s Hospital Melbourne, Intensive Care Unit, Flemington Road, Parkville, VIC 3052, Australia. E-mail: felix.oberender@monashhealth.org; ofelix@gmx.net

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