This referral center's prospective inception-cohort study from 1989 to 2000 (Era 1) and 2000 to 2022 (Era 2) included 232 consecutive children having neonatal respiratory extracorporeal membrane oxygenation (ECMO). Kindergarten-age outcomes determined in 137/139 (95.8%) survivors were Wechsler Preschool and Primary Scales of Intelligence, Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI), and sensorimotor disability, with optimal outcome defined as scores greater than or equal to 80 and without disability. In Era 2, there were fewer patients/year, fewer neonates with meconium aspiration syndrome, and more with sepsis, lethal disease, or "other" diagnoses. Era 2 also had higher rates of venoarterial cannulation, cannulation after the first week of life, and extracorporeal cardiopulmonary resuscitation. In survivors, there was a shift in Full-Scale Intelligence Quotient (FSIQ), Verbal IQ, Performance IQ, and VMI to the left of population norms, with scores less than 70 in 16-40% (expected in 2.27% of the normative population), disability in 53%, and optimal outcome in 38%. Era was not independently associated with mortality, optimal outcome, or FSIQ outcomes. Congenital Diaphragmatic Hernia (CDH) was independently associated with lower optimal outcome and FSIQ. Sensorineural hearing loss (bilateral, predominantly high-frequency, often progressive, and of delayed onset) was eliminated from Era 2, despite a concerning incidence of 40% in Era 1. Survival and neurocognitive outcomes after neonatal respiratory ECMO have not changed over 34 years.

This referral center prospective inception cohort study included 84 consecutive children having extracorporeal membrane oxygenation (ECMO) for noncardiac illness indications at the age of less than 6 years from 2000 to 2017. Long-term outcomes were survival, neurocognitive (Wechsler Preschool and Primary Scales of Intelligence) and functional (General Adaptive Composite) scores, and disability, with optimal outcome defined as scores greater than or equal to 80 and without disability. Age at cannulation was 551 (standard deviation [SD] = 571) days, 40 (47.6%) were male, 12 (14.3%) had known chromosomal abnormality, and 15 (17.9%) had nonchromosomal congenital abnormality. Survival was 45 (53.6%) to hospital discharge, and 41 (48.8%) to age 6 years. In 40/41 (97.6%) survivors with follow-up, at mean age of 56.1 (SD = 5.1) months, neurocognitive and functional scores were shifted to the left, with 30-42.5% having a score greater than 2 SD below population norms. Optimal outcome occurred in 11/40 (27.5%) survivors, and 11/84 (13.1%) overall. On multiple regression full-scale intelligence quotient was associated with longer time in pediatric intensive care unit (PICU) pre-ECMO (OR per hour -0.02, 95% confidence interval [CI] = -0.03 to -0.01; p = 0.005), known chromosomal abnormality (odds ratio [OR] = -18.99, 95% CI = -29.04 to -8.04; p = 0.001), and seizure pre-ECMO (OR = -17.00, 95% CI = -30.00 to -4.00; p = 0.012). Predictors of mortality included peak lactate on ECMO and nonchromosomal congenital abnormality. Findings may help with ECMO decision-making and counseling.

Background:Congenital malformations of the trachea are rare but often life-threatening. Limited data have been published on the outcomes of tracheal reconstruction for congenital tracheal stenosis. We sought to describe the outcomes of patients undergoing tracheal reconstruction over 10 years at our centre.Methods:All paediatric patients who underwent long-segment tracheal or bronchial reconstruction from January 1, 2012, to August 31, 2022, were included. The primary outcome was mortality, and secondary outcomes included reoperation and postoperative morbidity. Patients were followed up to 10 years.Results:Thirty-three patients with ages ranging from 1 day to 12 years (mean 8.5 months) at the time of tracheoplasty or bronchoplasty were included, with 5 patients undergoing off-pump tracheal reconstruction. The most common preoperative comorbidities included patent ductus arteriosus (30.3%), atrial septal defect (27.3%), and prematurity (24.2%). There were no deaths postoperatively within the follow-up period. All patients experienced successful reconstruction with no patients requiring reoperation of the trachea. A total of 14 patients (42.4%) required postoperative balloon dilation, 3 (9.1%) required bronchial repair after tracheal repair, and 2 (6.1%) required bronchoscopic tracheal debridement.Conclusions:This single-centre retrospective study provides a large cohort of congenital tracheal reconstruction patients with a survival rate of 100%, experiencing no mortality during follow-up. The majority of patients had preoperative comorbidities and concomitant congenital cardiac defects. Although tracheal reconstruction continues to be complex with significant postoperative morbidity and mortality, the results of our single-centre study demonstrate the continual advancement of this field and the evolving improvement of postoperative outcomes for these patients.

This retrospective cohort study aimed to compare blood component transfusion before and after the implementation of a restrictive transfusion strategy (RTS) in pediatric cardiac Extracorporeal Life Support (ECLS) patients. The study included children admitted to the pediatric cardiac intensive care unit (PCICU) at the Stollery Children's Hospital who received ECLS between 2012 and 2020. Children on ECLS between 2012 and 2016 were treated with standard transfusion strategy (STS), while those on ECLS between 2016 and 2020 were treated with RTS. During the study, 203 children received ECLS. Daily median (interquartile range [IQR]) packed red blood cell (PRBC) transfusion volume was significantly lower in the RTS group; 26.0 (14.4-41.5) vs. 41.5 (26.6-64.4) ml/kg/day, p value <0.001. The implementation of a RTS led to a median reduction of PRBC transfusion of 14.5 (95% CI: 6.70-21.0) ml/kg/day. Similarly, the RTS group received less platelets: median (IQR) 8.4 (4.50-15.0) vs. 17.5 (9.40-29.0) ml/kg/day, p value <0.001. The implementation of a RTS resulted in a median reduction of platelet transfusion of 9.2 (95% CI: 5.45-13.1) ml/kg/day. The RTS resulted in less median (IQR) fluid accumulation in the first 48 hours: 56.7 (2.30-121.0) vs. 140.4 (33.8-346.2) ml/kg, p value = 0.001. There were no significant differences in mechanical ventilation days, PCICU/hospital days, or survival. The use of RTS resulted in lower blood transfusion volumes, with similar clinical outcomes.

OBJECTIVE:To evaluate whether there was any impact on the number of pediatric extracorporeal membrane oxygenation runs and survival rates in the years subsequent to the 2009 pandemic.METHODS:We studied two different periods of extracorporeal membrane oxygenation support for respiratory failure in children by analyzing datasets from the Extracorporeal Life Support Organization. Autoregressive integrated moving average models were constructed to estimate the effect of the pandemic. The year 2009 was the year of intervention (the H1N1 epidemic) in an interrupted time series model. Data collected from 2001 - 2010 were considered preintervention, and data collected from 2010 - 2017 were considered postintervention.RESULTS:There was an increase in survival rates in the period 2010 - 2017 compared to 2001 - 2010 (p < 0.0001), with a significant improvement in survival when extracorporeal membrane oxygenation was performed for acute respiratory failure due to viral pneumonia. The autoregressive integrated moving average model shows an increase of 23 extracorporeal membrane oxygenation runs per year, prior to the point of the level effect (2009). In terms of survival, the preslope shows that there was no significant increase in survival rates before 2009 (p = 0.41), but the level effect was nearly significant after two years (p = 0.05), with a 6% increase in survival. In four years, there was an 8% (p = 0.03) increase in survival, and six years after 2009, there was up to a 10% (p = 0.026) increase in survival.CONCLUSION:In the years following 2009, there was a significant, global incremental increase in the extracorporeal membrane oxygenation survival rates for all runs, mainly due to improvements in the technology and treatment protocols for acute respiratory failure related to viral pneumonia and other respiratory conditions.

This retrospective cohort study describes all children transported on extracorporeal life support (ECLS) by the Stollery Children's Hospital Pediatric Transport team (SCH-PTT) between 2004 and 2018. We compared outcomes and complications between primary (SCH-PTT performed ECLS cannulation) vs. secondary (cannulation performed by referring facility) transports, as well as secondary transports from referring centers with and without an established ECLS cannulation program. SCH-PTT performed 68 ECLS transports during the study period. Median (IQR) transport distance was 298 (298-1,068) kilometers. Mean (SD) times from referral call to ECLS-initiation were: primary transports 7.8 (2.9) vs. 2.5(3.5) hours for secondary transports, p value < 0.001. Complications were common (n = 65, 95%) but solved without leading to adverse outcomes. There were no significant differences in the number of complications between primary and secondary transports. There was no significant difference in survival to ECLS decannulation between primary 9 (90%) and secondary transports 43 (74%), p value = 0.275. ECLS survival was higher for children cannulated by the SCH-PTT or a center with an ECLS cannulation program: 42 (82%) vs. 10 (59%), p value = 0.048. Critically ill children on ECLS can be safely transported by a specialized pediatric ECLS transport team. Secondary transports from a center with an ECLS cannulation program are also safe and have similar results as primary transports.

Pediatric Cardiac Intensive Care, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada Pediatric Intensive Care Unit, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada *See also p. 827. Dr. Ryerson received funding from Instrumentation Laboratory and disclosed off-label product use of bivalirudin. Dr. Lequier has disclosed that he does not have any potential conflicts of interest.

Supplemental Digital Content is available in the text. Objectives: Objective of this study was to determine if bivalirudin resulted in less circuit interventions than unfractionated heparin. A secondary objective was to examine associations between bivalirudin dose and partial thromboplastin time, international normalized ratio, and activated clotting time. Design: Prospective observational. Setting: Medical-surgical and cardiac PICUs. Patients: Neonatal and pediatric extracorporeal membrane oxygenation patients who received bivalirudin anticoagulation. Interventions: None. Measurements and Main Results: Twenty extracorporeal membrane oxygenation runs in 18 patients used bivalirudin; 90% were venoarterial. Median (interquartile range) age was 4.5 months (1.6–35 mo). Thirteen patients (72%) had an underlying cardiac diagnosis. Of the 20 runs using bivalirudin, 16 (80%) were initially started on unfractionated heparin and transitioned to bivalirudin due to ongoing circuit thrombosis despite therapeutic anti-Xa levels (n = 13), ongoing circuit thrombosis with unfractionated heparin greater than or equal to 40 U/kg/hr (n = 2), or absence of increase in ACT after bolus of 100 U/kg of unfractionated heparin and escalation of unfractionated heparin infusion (n = 1). Initial bivalirudin dose ranged from 0.2 to 0.5 mg/kg/hr; no bolus doses were used. Median (range) bivalirudin dose was 0.9 mg/kg/hr (0.15–1.6 mg/kg/hr). Median (interquartile range) time on extracorporeal membrane oxygenation was 226.5 hours (150.5–393.0 hr) including 84 hours (47–335 hr) on bivalirudin. Nonparametric results are as follows: the rate of circuit intervention was significantly lower in patients on bivalirudin than on unfractionated heparin (median [interquartile range]: 0 [0–1] and 1 [1–2], respectively; Wilcoxon p = 0.0126). Bivalirudin dose was correlated to PTT (rs = 0.4760; p < 0.0001), INR (rs = 0.6833; p < 0.0001), and ACT (rs = 0.6161; p < 0.0001). Four patients had a significant bleeding complication on bivalirudin. Survival to hospital discharge was 56%. Conclusions: Bivalirudin appears to be a viable option for systemic anticoagulation in pediatric extracorporeal membrane oxygenation patients who have failed unfractionated heparin, but questions remain namely its optimal monitoring strategy. This pilot study supports the need for larger prospective studies of bivalirudin in pediatric extracorporeal membrane oxygenation, particularly focusing on meaningful monitoring variables.

POINTS CLÉS Les patients infectés par le nouveau coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2) peuvent demeurer asymptomatiques ou développer la maladie à coronavirus 2019 (COVID-19), caractérisée par une infection et une inflammation des voies respiratoires inférieures[1

OBJECTIVES:To describe the characteristics of fluid accumulation in critically ill children and evaluate the association between the degree, timing, duration, and rate of fluid accumulation and patient outcomes. DESIGN:Retrospective cohort study. SETTING:PICUs in Alberta, Canada. PATIENTS:All children admitted to PICU in Alberta, Canada, between January 1, 2015, and December 31, 2015. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:A total of 1,017 patients were included. Fluid overload % increased from median (interquartile range) 1.58% (0.23-3.56%; n = 1,017) on day 1 to 16.42% (7.53-27.34%; n = 111) on day 10 among those remaining in PICU. The proportion of patients (95% CI) with peak fluid overload % greater than 10% and greater than 20% was 32.7% (29.8-35.7%) and 9.1% (7.4-11.1%), respectively. Thirty-two children died (3.1%) in PICU. Peak fluid overload % was associated with greater PICU mortality (odds ratio, 1.05; 95% CI, 1.02-1.09; p = 0.001). Greater peak fluid overload % was associated with Major Adverse Kidney Events within 30 days (odds ratio, 1.05; 95% CI, 1.02-1.08; p = 0.001), length of mechanical ventilation (B coefficient, 0.66; 95% CI, 0.54-0.77; p < 0.001), and length of PICU stay (B coefficient, 0.52; 95% CI, 0.46-0.58; p < 0.001). The rate of fluid accumulation was associated with PICU mortality (odds ratio, 1.15; 95% CI, 1.01-1.31; p = 0.04), Major Adverse Kidney Events within 30 days (odds ratio, 1.16; 95% CI, 1.03-1.30; p = 0.02), length of mechanical ventilation (B coefficient, 0.80; 95% CI, 0.24-1.36; p = 0.005), and length of PICU stay (B coefficient, 0.38; 95% CI, 0.11-0.66; p = 0.007). CONCLUSIONS:Fluid accumulation occurs commonly during PICU course and is associated with considerable mortality and morbidity. These findings highlight the need for the development and evaluation of interventional strategies to mitigate the potential harm associated with fluid accumulation.

KEY POINTS Patients infected with the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may be asymptomatic or develop coronavirus disease 2019 (COVID-19), which is characterized by lower respiratory tract infection and inflammation.[1][1] About 14% of people with

Objectives: To quantify and identify factors associated with large RBC exposure in children supported with extracorporeal membrane oxygenation. Design: Retrospective cohort study. Setting: Single tertiary care children's hospital. Patients: One-hundred twenty-two children supported with extracorporeal membrane oxygenation for greater than 12 hours during January 1, 2015, to December 31, 2016. Interventions: None. Measurements and Main Results: Clinical, laboratory, and survival data were obtained from medical records. Only data from patients' first extracorporeal membrane oxygenation run were used. The primary outcome was RBC volume exposure during extracorporeal membrane oxygenation (mL/kg/d). Patients with RBC exposure volume greater than 75th percentile were categorized as high RBC use patients. A bleeding day was identified if mediastinum or cannula sites were explored and/or Factor VIIa administration, gastrointestinal, pulmonary, or intracranial hemorrhages occurred. Median age was 0.3 years (interquartile range, 0-3 yr). Congenital heart disease (n = 56; 46%) was the most common diagnosis. Median RBC volume transfused during extracorporeal membrane oxygenation was 39mL/kg/d (interquartile range, 21-66mL/kg/d). High RBC use patients were more likely be supported by venoarterial extracorporeal membrane oxygenation (100 vs 76%; p = 0.006), have congenital heart disease (68 vs 39%; p = 0.02), and experience bleeding (33 vs 11% d; p < 0.001). High RBC use patients showed a trend toward higher in-hospital mortality (58 vs 37%; p = 0.07). In the multivariable analysis, younger age (-9% per year; 95% CI, -10% to -7%; p < 0.001), more blood draws per day (+8%; 95% CI, 6-11%; p < 0.001), and higher proportion of bleeding days (+22% per 10% increase; 95% CI, 16-29%; p < 0.001) were associated with larger RBC exposure (model R-2 = 0.66). Conclusions: Bleeding during extracorporeal membrane oxygenation, frequent laboratory draws, and younger age were associated with increased RBC exposure during extracorporeal membrane oxygenation. Higher transfusion volume was associated with increased mortality.

Pediatric Intensive Care Unit, Stollery Children's Hospital, Edmonton, AB, Canada *See also p. 1126. The authors have disclosed that they do not have any potential conflicts of interest.

ECLS Program, Division of Critical Care, Stollery Children’s Hospital, Edmonton, AB, Canada *See also p. 561. The authors have disclosed that they do not have any potential conflicts of interest.

Objectives: A continuous infusion of unfractionated heparin is the most common anticoagulant used for pediatric patients on extracorporeal life support. The objective of this study was to compare extracorporeal life support complications and outcomes between two large-volume pediatric extracorporeal life support centers that use different anticoagulation strategies. Design: Prospective, observational cohort study. Setting: The University of Michigan used simple anticoagulation monitoring, whereas the University of Alberta used an intensive anticoagulation monitoring strategy. Patients: Pediatric patients on extracorporeal life support. Interventions: None. Measurements and Main Results: The primary outcome measure was major bleeding per extracorporeal life support run defined as bleeding that was retroperitoneal, pulmonary, or involved the CNS; bleeding greater than 20 mL/kg over 24 hours; or bleeding that required surgical intervention. Secondary outcomes measured were patient thrombosis per run, circuit thrombosis per run, and survival to hospital discharge per patient. Eighty-eight patients (95 runs) less than 18 years old were enrolled at the two centers over 2 years. The two centers enrolled different extracorporeal life support populations; University of Alberta enrolled more postcardiac surgical patients (74% vs 47%; p = 0.005). The indication for extracorporeal life support support also varied by center (p = 0.04). The two centers used similar proportions of VA extracorporeal life support (p = 0.3). Median (interquartile range) unfractionated heparin doses were similar between University of Michigan and University of Alberta, 30 (21–34) U/kg/hr and 26 (22–31) U/kg/hr, p value equals to 0.3, respectively. Median (interquartile range) antifactor Xa was lower in the University of Michigan cohort (0.23 [0.19–0.28] vs 0.41 [0.36–0.46] U/mL; p < 0.001). There was no significant difference in major bleeding (15% University of Michigan vs 21% University of Alberta; p = 0.6) or in patient thromboses (18% University of Michigan vs 13% University of Alberta; p = 0.5). There was no significant difference in survival to hospital discharge (University of Michigan 63% vs University of Alberta 73%; p = 0.1). Conclusions: Although this prospective cohort study compared different pediatric extracorporeal life support populations, the results did not identify a significant difference in outcomes between simple and intensive anticoagulation monitoring strategies.

Aim Unintentional drowning is a significant public health concern in the United States and represents a leading cause of death in the pediatric population. Extracorporeal life support (ECLS) may be used to support drowning victims, but outcomes have not been well defined. This study examined survival rates and risk factors for death in this population. Methods Retrospective data from the Extracorporeal Life Support Organization registry was examined to determine outcomes of ECLS and risk factors for death in drowning victims. Results Two hundred forty-seven patients who received ECLS following a drowning event between 1986 and 2015 were identified. Eighty-four (34%) did not experience cardiac arrest prior to ECLS, whereas 86 (35%) experienced a pre-ECLS cardiac arrest but had return of spontaneous circulation prior to ECLS, and 77 (31%) were placed on ECLS during cardiopulmonary resuscitation (ECPR). Overall survival was 51.4%; 71.4% in patients who did not experience a cardiac arrest, 57.0% in patients who required cardiopulmonary resuscitation prior to ECLS, and 23.4% in patients who received ECPR (p < 0.001). Logistic regression analysis identified ECPR, venoarterial mode of ECLS, renal failure, and cardiopulmonary resuscitation during ECLS as risk factors associated with mortality. Conclusions Outcomes in drowning victims supported with ECLS are encouraging; particularly in patients who do not experience cardiac arrest. These data suggest that early initiation of ECLS in drowning patients with respiratory insufficiency may be beneficial to reduce the likelihood of complete cardiopulmonary failure and ECPR. Additionally, ECLS appears to improve survival in patients who experience post-drowning cardiac arrest.

Commentary on: Lasa JJ, Rogers RS, Localio R, et al. Extracorporeal Cardiopulmonary Resuscitation (E-CPR) During pediatric in-hospital cardiopulmonary arrest is associated with improved survival to discharge: a report from the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) registry. Circulation 2016;133:165–76[OpenUrl][1][Abstract/FREE Full Text][2]. Data from national and international paediatric databases indicate that the use of extracorporeal cardiopulmonary resuscitation (E-CPR) is increasing.1 Considering the significant resources and cost involved in the use of E-CPR, its use needs to be critically examined to optimise outcomes. This large, multicentre study compared conventional cardiopulmonary resuscitation (C-CPR) and (E-CPR) in paediatric in-hospital cardiac arrest (IHCA). This is a retrospective multicentre cohort study that used data from the American Heart Association Get with the Guidelines Registry. The study included all children (<18 years of age) who had an IHCA and received CPR for ≥10 min between 1 January 2000 and 31 December, 2011. Patients from hospitals with no E-CPR cases, obstetric and trauma diagnosis, missing E-CPR or survival information and … [1]: {openurl}?query=rft.jtitle%253DCirculation%26rft_id%253Dinfo%253Adoi%252F10.1161%252FCIRCULATIONAHA.115.016082%26rft_id%253Dinfo%253Apmid%252F26635402%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=circulationaha&resid=133/2/165&atom=%2Febmed%2F21%2F6%2F227.atom

Background: The optimal anticoagulation strategy for venovenous extracorporeal membrane oxygenation (VV-ECMO) is not known.Objectives: To evaluate the safety of anticoagulation strategies and monitoring during VV-ECMO for respiratory failure.Data sources: We conducted a systematic review to evaluate the association between anticoagulation strategies during VV-ECMO and prespecified outcomes, including major bleeding episodes, thrombotic events, and in-hospital mortality. We included articles published between 1977 and January 30, 2015. Study quality was assessed using the Newcastle-Ottawa scoring system. A separate meta-analysis was not planned.Data extraction: Data were independently extracted by two authors and collected on a standardized report form.Synthesis: A total of 18 studies (n = 646) were included; 17 studies enrolled patients with acute respiratory distress syndrome. Across all studies, the duration of VV-ECMO support ranged from 4 to 20 days. Patients received an average of 2.3 (+/- 3.9) units of transfused red blood cells per day. The bleeding rate across all studies was 16%, and the rate of thrombosis was 53%. Among seven studies (199 patients) targeting a specified activated partial thromboplastin time (aPTT), there were 37 (19%) major bleeding episodes and 53 (27%) major thromboses. Among five studies (43 patients) with aPTT targets of 60 seconds or greater, there were 24 (56%) bleeding episodes and 3 (7%) clotting events. Three studies (156 patients) with an aPTT target under 60 seconds reported 13 (8%) and 50 (32%) significant bleeding and thrombotic events, respectively. The most commonly reported thrombotic events were circuit-related clotting and deep-vein thrombosis. Mortality during VV-ECMO varied across the studies, ranging from 0 to at least 50% at heterogeneous time points. The totalnumberofdeaths for all studies combined was 186 (29%).Conclusions: The role and optimal therapeutic targets for anticoagulation during VV-ECMO are unclear. Previously published studies are limited by retrospective, observational design, small cohorts, and patient heterogeneity. The clinical significance of reported thrombotic complications is largely unknown. This systematic review underscores the need for randomized controlled trials of anticoagulation strategies for patients undergoing VV-ECMO for respiratory failure.