Adam Himebauch, MD
Assistant Professor of Anesthesiology and Critical Care Medicine
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Anant Sriram, BS
N/A
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Julia Slovis, MD
MD
Childrens Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Ryan Morgan, MD, MTR
Assistant Professor of Anesthesia, Critical Care, & Pediatrics
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
James Connelly, BS, RRT-NPS, FELSO
ECMO Program Manager
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Robert Berg, MD, MCCM (he/him/his)
Division Chief, Pediatric Critical Care Medicine
Children's Hospital of Philadelphia
Merion Station, Pennsylvania, United States
Disclosure information not submitted.
Garrett Keim, MD (he/him/his)
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Disclosure information not submitted.
Nadir Yehya, MD, MSCE
Children's Hospital of Philadelphia
Cherry Hill, NJ
Disclosure information not submitted.
Todd Kilbaugh, MD
Associate Professor of Anesthesia, Critical Care, & Pediatrics
Childrens Hospital of Philadelphia, United States
Disclosure information not submitted.
Title: VVDL-ECMO is associated with decreased inotropic requirements in pediatric ARDS
INTRODUCTION/HYPOTHESIS: The hemodynamic effects of VVDL-ECMO when used for pediatric ARDS are ill-defined. Our hypothesis was that the initiation of VVDL-ECMO in hemodynamically unstable ARDS patients would be associated with decreased inotropic requirements.
Methods: Retrospective single-center cohort study (2013-2019, age 1 month to 18 years) of pediatric patients cannulated to VVDL-ECMO for ARDS with need for vasopressor or inotropic support at the time of cannulation. Vasopressor (VS) and inotropic (IS) scores were calculated and clinical data collected immediately prior and 2, 4, 6, 12, 18, and 24 hours post-cannulation. The primary outcome was change in IS at 2 hours. Wilcoxon sign-rank test compared pre- and post-ECMO variables. Bivariate linear regression tested associations between the change in IS and VS and changes in ventilator and metabolic parameters.
Results: 19 patients met inclusion criteria: median age 6 years (IQR 1.5-14); 4 (21%) were immunocompromised; and 15 (79%) had pneumonia or sepsis as the cause of ARDS. Pre-ECMO characteristics included: median oxygenation index 40 (IQR 25-58); mean airway pressure (mPaw) 30 cm H2O (24-34); 15 (83%) were on inhaled nitric oxide; and 14 (74%) were on an advanced mode of ventilation. All patients had VVDL catheters placed in the right internal jugular vein, no patients converted to VA-ECMO, and 15 (74%) survived. Median ECMO duration was 214 hours (IQR 144-316). Following initiation of ECMO, IS decreased by 60% in the first 2 hours (median 10 [IQR 3-20] vs 4 [3-15], p=0.03) and continued to decrease over 24 hours while VS were unchanged in the first 2 hours (median 0 [IQR 0-12] vs 0 [IQR 0-5], p=0.72) and remained low over 24 hours. The median ECMO circuit flow at 2 hours was 70 mL/kg (IQR 58-80 mL/kg). The change in IS at 2 hours was associated with the change in mPaw when controlling individually for change in pH (p=0.002), change in paCO2 (p=0.009), and change in base excess (p=0.011), respectively. These associations were not observed for VS.
Conclusions: In pediatric patients with ARDS and vasoactive requirement, initiation of VVDL-ECMO was associated with decreased IS within 2 hours that was maintained over 24 hours. This data suggests that VVDL-ECMO may be considered as the primary ECMO modality in hemodynamically unstable pediatric ARDS patients.