Matthew L Friedman1, Ryan P Barbaro2,3, Melania M Bembea4, Brian C Bridges5, Ranjit S Chima6,7, Todd J Kilbaugh8, Poornima Pandiyan9, Renee M Potera10, Elizabeth A Rosner11, Hitesh S Sandhu12, James E Slaven13, Keiko M Tarquinio14, Ira M Cheifetz15. 1. Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, Indiana. friedmml@iu.edu. 2. Department of Pediatrics, University of Michigan, Ann Arbor, Michigan. 3. Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan. 4. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland. 5. Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee. 6. Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio. 7. Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. 8. Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. 9. Department of Pediatrics, University of Kansas School of Medicine-Wichita, Wichita, Kansas. 10. Department of Pediatrics UT Southwestern Medical Center, Dallas, Texas. 11. Division of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, Grand Rapids, Michigan. 12. Division of Pediatric Critical Care, University of Tennessee Health Sciences Center, Memphis, Tennessee. 13. Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana. 14. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia. 15. Division of Pediatric Critical Care, Duke Children's Hospital and Health Center, Durham, North Carolina.
Abstract
BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator-induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes. METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant. RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1-3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator FIO2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in FIO2 , 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator FIO2 (≥ 0.5) compared to low ventilator FIO2 (> 0.5) (46% vs 22%, P = .001). CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2 , even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO.
BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator-induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes. METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant. RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1-3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator FIO2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in FIO2 , 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator FIO2 (≥ 0.5) compared to low ventilator FIO2 (> 0.5) (46% vs 22%, P = .001). CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2 , even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO.
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Authors: Brian C Bridges; Todd J Kilbaugh; Ryan P Barbaro; Melania M Bembea; Ranjit S Chima; Renee M Potera; Elizabeth A Rosner; Hitesh S Sandhu; James E Slaven; Keiko M Tarquinio; Ira M Cheifetz; Courtney M Rowan; Matthew L Friedman Journal: ASAIO J Date: 2021-08-01 Impact factor: 3.826
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