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. 2024 Jan 1;25(1):e41-e46.
doi: 10.1097/PCC.0000000000003325. Epub 2023 Jul 18.

Venovenous Extracorporeal Membrane Oxygenation Initiation for Pediatric Acute Respiratory Distress Syndrome With Cardiovascular Instability is Associated With an Immediate and Sustained Decrease in Vasoactive-Inotropic Scores

Daniel Chilcote  1 , Anant Sriram  1 , Julia Slovis  1 , Ryan W Morgan  1 , Douglas E Schaubel  2 , James Connelly  3 , Robert A Berg  1 , Garrett Keim  1 , Nadir Yehya  1 , Todd Kilbaugh  1   3 , Adam S Himebauch  1   3
Affiliations

Venovenous Extracorporeal Membrane Oxygenation Initiation for Pediatric Acute Respiratory Distress Syndrome With Cardiovascular Instability is Associated With an Immediate and Sustained Decrease in Vasoactive-Inotropic Scores

Daniel Chilcote et al. Pediatr Crit Care Med. .

Abstract

Objective: To determine the association of venovenous extracorporeal membrane oxygenation (VV-ECMO) initiation with changes in vasoactive-inotropic scores (VISs) in children with pediatric acute respiratory distress syndrome (PARDS) and cardiovascular instability.

Design: Retrospective cohort study.

Setting: Single academic pediatric ECMO center.

Patients: Children (1 mo to 18 yr) treated with VV-ECMO (2009-2019) for PARDS with need for vasopressor or inotropic support at ECMO initiation.

Measurements and main results: Arterial blood gas values, VIS, mean airway pressure (mPaw), and oxygen saturation (Sp o2 ) values were recorded hourly relative to the start of ECMO flow for 24 hours pre-VV-ECMO and post-VV-ECMO cannulation. A sharp kink discontinuity regression analysis clustered by patient tested the difference in VISs and regression line slopes immediately surrounding cannulation. Thirty-two patients met inclusion criteria: median age 6.6 years (interquartile range [IQR] 1.5-11.7), 22% immunocompromised, and 75% had pneumonia or sepsis as the cause of PARDS. Pre-ECMO characteristics included: median oxygenation index 45 (IQR 35-58), mPaw 32 cm H 2o (IQR 30-34), 97% on inhaled nitric oxide, and 81% on an advanced mode of ventilation. Median VIS immediately before VV-ECMO cannulation was 13 (IQR 8-25) with an overall increasing VIS trajectory over the hours before cannulation. VISs decreased and the slope of the regression line reversed immediately surrounding the time of cannulation (robust p < 0.0001). There were pre-ECMO to post-ECMO cannulation decreases in mPaw (32 vs 20 cm H 2o , p < 0.001) and arterial P co2 (64.1 vs 50.1 mm Hg, p = 0.007) and increases in arterial pH (7.26 vs 7.38, p = 0.001), arterial base excess (2.5 vs 5.2, p = 0.013), and SpO 2 (91% vs 95%, p = 0.013).

Conclusions: Initiation of VV-ECMO was associated with an immediate and sustained reduction in VIS in PARDS patients with cardiovascular instability. This VIS reduction was associated with decreased mPaw and reduced respiratory and/or metabolic acidosis as well as improved oxygenation.

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Conflict of interest statement

Dr. Keim received an institutional grant. Grant funding was paid to the affiliated institutions in support of the ongoing work of Drs. Morgan (National Institutes of Health [NIH] National Heart, Lung, and Blood Institute [NHLBI] K23-HL148541), Berg (NIH 5R01HL147616-03, NIH 1RL1HD107777-01), Yehya (NIH NHLBI 5R01HL148054-03), Schaubel (NIH NIDDK R01-DK070869), and Himebauch (NIH NHLBI K23-HL153759). Dr. Himebauch’s institution received funding from the NHLBI. Drs. Himebauch, Sriram, and Morgan received support for article research from the NIH. Dr. Sriram’s institution received funding from the NHBLI (K23-HL153759). Dr. Morgan’s institution received funding from the NHBLI (K23HL148541). Dr. Yehya’s institution received funding from Pfizer. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1:
Figure 1:
Regression discontinuity plot of vasoactive-inotrope score (VIS) versus time (hours). Time 0 indicates time of VV-ECMO cannulation. Shaded area represents the 95% confidence interval.
See this image and copyright information in PMC

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