Background: Thrombosis within extracorporeal membrane oxygenation (ECMO) circuits is a common complication that dominates clinical management of patients receiving mechanical circulatory support. Prior studies have identified that over 80% of circuit thrombosis can be attributed to tubing-connector junctions. Methods: A novel connector was designed that reduces local regions of flow stagnation at the tubing-connector junction to eliminate a primary source of ECMO circuit thrombi. To compare clotting between the novel connectors and the traditional connectors, both in vitro loops and an in vivo caprine model of long-term (48 h) ECMO were used to generate tubing-connector junction clots. Results: In vitro, the traditional connectors uniformly (9/9) formed large thrombi, while novel connectors formed a small thrombus in only one of nine ( p < 0.0001). In the long-term goat ECMO circuits, the traditional connectors exhibited more thrombi ( p < 0.04), and these thrombi were more likely to protrude into the lumen of the tubing ( p < 0.001). Conclusion: Both in vitro and in vivo validation experiments successfully recreated circuit thrombosis and demonstrate that the adoption of novel connectors can reduce the burden of circuit thrombosis.

Introduction: Children's Healthcare of Atlanta's new ECMO Specialists are RNs and RRTs and required to learn multiple pumps, modes of ECMO and patient populations. Our orientation process was based on ELSO Training Guidelines requiring 16-32 hours. At 36 hours, we met the guideline, but often additional hours were added haphazardly. We completely de-constructed our educational and bedside orientation process and revised to meet the educational needs of our team. Discussion: A multi-disciplinary team requires a unique perspective when delivery education. After breaking down our old course, we initiated pre course requirements; revised the training course so that didactic is paired with reinforcing simulations; and added skills sessions specific to the Specialist. We revised our bedside orientation process to include six, 12-hour shifts. The new checklist starts with the basic, including a scavenger hunt and then adds new skills and knowledge each shift. Finally, we added an ECMO Mega Simulation Day approximately two months after bedside orientation is complete. This 8-hour day encompasses all of the high and low fidelity simulations on both platforms from the ECMO Training Course. This sim reinforces new skills and increases confidence for the new Specialist. Results: Post Mega Sim the Specialists reported a 29% increase in confidence in emergency management, 27% increase in general management, and 22% increase in confidence in anticoagulation management. In addition, overall test scores improved from 70% Pre Simulation to 95% Post Simulation. Conclusion: Revision of educational process can result in increased confidence and test scores.

Extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support of critically ill patients is used frequently in the pediatric population. ECMO is burdened by complications, including thrombosis and hemorrhage. Here we demonstrate the focused location of clots, their histologic composition, and the relationship of in situ thrombus to local hemodynamics in ECMO circuits. Pediatric ECMO circuits from Children's Healthcare of Atlanta, Emory University (Atlanta, GA) were obtained after removal from extracorporeal support over a 2.5 year period (n = 50). All clots and material deposited within the circuit were recorded. Location of clot was compared with local hemodynamics. Most clots were adherent to the junctions made by the tubing and connectors, as opposed to being randomly disturbed throughout the circuit tubing (p << 0.05). Loose, nonadherent clots were also found at the entry side of oxygenators. The clots colocated directly with zones of low shear rate. Histology revealed a fibrinous composition, consistent with coagulation potentiated by low shear. Centrifugal pump circuits (n = 16) had more clots than roller pump (n = 34) circuits (p << 0.05). In addition, all centrifugal pumps had clots that formed at the top of the pump shaft. The ECMO circuits from our single-center study demonstrate the concentrated location of fibrin clots at low shear zones created by tubing-connector junctions. Type of pump also influences the frequency of clot formation. Since the mechanism of the majority of ECMO circuit thrombosis is low shear and fibrin driven, optimization of hemodynamics and anticoagulation regimen may reduce clot formation and bleeding.

Purpose: Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary mechanical life support for critically ill patients. ECMO is burdened by both thrombotic and hemorrhagic complications. Recently there has been a clinical shift from roller pumps to centrifugal pumps. In this study, we report on bulk thrombus formation within pumps recovered from clinical use. We then replicate this thrombus formation in vitro.Methods: Clinical pediatric ECMO circuits driven with the Sorin Revolution were collected from 16 patients. The location and extent of thrombus formation in the pumps were recorded. Pump heads were also tested in a laboratory circulatory loop. The location, extent, and appearance of the thrombi were recorded. Thrombi were examined histologically using Carstairs' stain.Results: Gross thrombus was observed in all pump heads at the stainless steel bearing at the inlet. In 19% of the pumps larger thrombi grew into the head over the cone and along the vanes. The thrombi were adherent and cohesive upon extraction. The thrombus formation was strikingly similar between the clinical pump heads and in vitro pump heads. Histology of both clinical and experimental samples exhibited a platelet-rich thrombus.Conclusions: Our studies have revealed platelet-rich thrombus in clinical and in vitro circuits. The location and composition of the thrombi suggest that the exposed metal shaft was initially covered by contact activated coagulation followed by large-scale growth by rapid platelet accumulation from high shear rates at the inlet. The in vitro system may be used to further identify the mechanisms for pump thrombus and test new designs.

Background. Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to improve survival after in-hospital pediatric cardiac arrest. We describe our experience with ECPR for refractory cardiac arrest in pediatric cardiac patients.Methods. We performed a retrospective analysis of the use of venoarterial extracorporeal membrane oxygenation (ECMO) for in-hospital cardiac arrest from 2002 to 2011. The primary endpoint was survival to discharge, and the secondary endpoint was long-term functional neurologic status.Results. Of 160 total uses of cardiac ECMO in 159 patients, 90 (56%) were ECPR (mean age 2.05 years; range, 0 days to 16.5 years). Sixty-four patients (71%) were postoperative, of which 36 were single ventricle and 28 were biventricular. Nine patients (10%) had cardiomyopathy-myocarditis, and 17 patients (19%) were nonpostoperative (5 single ventricle; 12 biventricular). Fifty-nine patients (66%) had open chest cannulation, and 31 (34%) had peripheral cannulation. Fifty patients (56%) survived to discharge. Duration of ECMO was 4.3 +/- 4.0 days (median 3) for survivors and 6.3 +/- 5.4 days (median 5) for nonsurvivors (p < 0.05). On follow-up, almost half of survivors without genetic syndromes had normal neurologic status.Conclusions. Extracorporeal cardiopulmonary resuscitation is an appropriate application of ECMO in pediatric cardiac patients. We report overall survival of 56%. Cardiomyopathy patients have favorable outcomes (89% survival). Biventricular patients have better outcomes then single ventricle patients (p < 0.01). Extracorporeal cardiopulmonary resuscitation also seems to be a good strategy for nonpostoperative patients (71% survival). Nearly half of postoperative patients (46%) resuscitated with ECPR survived to hospital discharge.

Objective: To describe an unusual case of fulminant rheumatic fever presenting acutely as severe respiratory failure managed with extracorporeal membrane oxygenation and ultimately valve replacement while on extracorporeal membrane oxygenation. Design: Case report. Setting: Large quaternary care pediatric intensive care unit. Patient: A 6-yr-old female with profound respiratory failure found to be due to mitral valve dysfunction stemming from acute fulminant rheumatic fever. Interventions and Main Results: The patient was originally maintained on venovenous extracorporeal membrane oxygenation but required conversion to venoarterial extracorporeal membrane oxygenation due to the progression of her mitral valve disease. Her condition did not improve with atrial septostomy, and she required valve replacement while anticoagulated. She was decannulated in the operating room and extubated 2 days later, and she survived to discharge. The institutional review board subsequently granted a waiver of consent for a report of this case. Conclusions: Manifestations of rheumatic fever can develop acutely even in the setting of an industrialized country. Valvulitis with severe, isolated mitral valve dysfunction may masquerade initially as respiratory failure. Multiple invasive procedures can be performed successfully while patients are fully anticoagulated and on extracorporeal membrane oxygenation support.

Objectives To evaluate morbidity, mortality, and associated risk factors in late preterm term infants (34-0/7 to 36-6/7 weeks) requiring extra-corporeal membrane oxygenation (ECMO).Study design We reviewed 21 218 neonatal ECMO runs in Extra-corporeal Life Support Organization registry data from 1986-2006. Infants were divided in 3 groups: late preterm (34-0/7 to 36-6/7 weeks), early-term (37-0/7 to 38-6/7 weeks), and full-term (39-0/7 to 42-6/7 weeks).Results There were 14 528 neonatal ECMO runs that met inclusion criteria. Late preterm infants experienced the highest mortality rate on ECMO (late preterm, 26.2%; early-term, 18%; full-term, 11.2%; P < .001) and had longer ECMO runs; they also had higher rates of serious complications. Gestational age was a highly significant predictor for mortality. Late preterm infants with a primary diagnosis of sepsis and persistent pulmonary hypertension had 3-fold higher risk of mortality on ECMO than infants with meconium aspiration.Conclusion Late preterm infants treated with ECMO have higher morbidity and mortality rates than term infants. This underscores the need for special consideration of this vulnerable population in the diagnosis and treatment of hypoxic respiratory failure. (J Pediatr 2011; 159: 192-8).

Children receiving extracorporeal membrane oxygenation (ECMO) for respiratory failure can have significant fluid overload and renal insufficiency. Addition of inline continuous venovenous hemofiltration (CVVH) could provide additional benefits in fluid management compared to use of standard medical therapies with ECMO.

Paden, Matthew L. MD; Wagoner, Scott F. RRT; Heard, Micheal L. RN; Jones, Teresa L. RN; Cardona, Monika F. RN; Fortenberry, James D. MD Author Information

Background. Resuscitation extracorporeal membrane oxygenation (R-ECMO) was introduced at our institution in July 2002. We reviewed the use of venoarterial (VA)-ECMO for cardiac diagnoses at our institution.Methods. Retrospective analysis of patients on VA-ECMO for cardiac failure was performed. Survival was defined as discharge from hospital.Results. Twenty-seven patients were supported with VA-ECMO (median age, 27 days; range, 1 to 640 days; median weight, 3.8 kg; range, 1.8 to 11.3 kg). Diagnoses were cardiomyopathy-myocarditis (CMM) in 8 (30%), systemic-to-pulmonary artery shunt-dependent single ventricle (SV) in 12 (44%), postcardiotomy for biventricular repair (BiV) in 6 (22%), and arrhythmia in 1 (4%). Sixteen of 27 patients survived (59%). Seven of 8 CMM patients survived (88%); 6 (75%) bridged to cardiac recovery, 1 to transplant (13%), and 1 death (13%). Seven of 12 SV patients survived (58%). The SV ECMO indications: post-Norwood ventricular dysfunction (n = 3, 2 deaths), postoperative cardiac failure (n = 6, 2 deaths), respiratory failure (n = 1, 1 death), and acute shunt occlusion (n = 2, 0 deaths). One of 6 BiV patients survived (17%). The BiV ECMO indications: failure to wean from CPB (n = 3, 3 deaths), postoperative cardiac failure (n = 2, 2 deaths), and pulmonary hypertension (n = 1, 0 deaths). Fifteen patients (56%) underwent cardiopulmonary resuscitation during ECMO cannulation. Eleven of 15 R-ECMO patients (73%) survived versus 5 of 12 non-R-ECMO patients (42%, p = 0.13). Median duration of R-ECMO: 66 hours (range, 18 to 179) versus 145 hours (range, 43 to 986, p = 0.01) for non-R-ECMO.Conclusions. Resuscitation extracorporeal membrane oxygenation is an appropriate application in pediatric patients with cardiac disease. Single ventricle patients experiencing cardiopulmonary collapse and CMM patients have favorable outcomes. Failure to wean from CPB and postoperative ventricular failure are higher risk indications.

Department of Pediatric Critical Care, Children's Healthcare of Atlanta at Egleston/Emory University, Atlanta, GA (Paden) Department of Pediatric Critical Care, Children's Healthcare of Atlanta at Egleston, Atlanta, GA (Wangoner, Fortenberry)

The CAS neonatal NIRS system determines absolute regional brain tissue oxygen saturation (SnO2) and brain true venous oxygen saturation (SnvO2) non-invasively. Since NIRS-interrogated tissue contains both arterial and venous blood from arterioles, venules, and capillaries, SnO2 is a mixed oxygen saturation parameter, having values between arterial oxygen saturation (SaO2) and cerebral venous oxygen saturation (SvO2). To determine a reference for SnO2, the relative contribution of SvO2 to SaO2 drawn from a brain venous site vs. systemic SaO2 is approximately 70:30 (SvO2:SaO2). If the relationship of the relative average contribution of SvO2 and SaO2 is known and does not change to a large degree, then NIRS true venous oxygen saturation, SnvO2, can be determined non-invasively using SnO2 along with SaO2 from a pulse oximeter.

Background Mortality in severe congenital diaphragmatic hernia (CDH), defined as requirement for extracorporeal membrane oxygenation (ECMO), remains variable. Predictors of mortality and poor long-term neurodevelopmental outcome have not been well described. Objective To describe mortality and poor neurodevelopmental outcome in CDH-ECMO infants and identify associated risk factors pre-ECMO. Methods We retrieved data for CDH-ECMO infants at CHOA (1991-2004). Predictive risk factors included pre-ECMO birth weight (BW), gestational age (GA), pH, PaO2, PaCO2, oxygenation index (OI), mean airway pressure (MAP), prothrombin time (PT), and others. Chi square, Student t-test, and logistic regression were used when appropriate (significance: p Results Of 70 infants with CDH-ECMO, 12 (17.14%) were placed on venoarterial ECMO, 58 (82.85%) on venovenous ECMO (3 converted to arterial). GA was 38.2 ± 1.9 w; BW was 3160 ± 480 g. A total of 47 (67%) infants survived. There was no difference in pre-ECMO MAP (18.3 ± 3.9 CM H2O vs. 18.8 ± 4.7 CM H2O) or OI (54.6 ± 23.4 vs. 66.3 ± 32.9) between survivors and nonsurvivors. Before ECMO, nonsurvivors had a significantly higher PaCO2 (70 ≤ 24.2 vs. 57.9 ± 19.8 torr; p = .034), lower pH (7.17 ± 0.14 vs. 7.24 ± 0.14; p = .038) and higher PT (44.6 ± 6.2 vs. 18.7 ± 4.9; p = .042). A total of 23 (49%) survivors had neurodevelopmental evaluation (Bayley Scales of Infant Development) at 12 months and 18 (38%) at 24 months of age. At 12 months, mean Mental Developmental Index (MDI) was 84.77 ± 17.59 (50 to 107) and the Psychomotor Developmental Index (PDI) was 75.16 ± 21.29 (50 to 108). At 24 months, MDI was 84.23 ± 18.34 (50 to 115) and PDI was 71.58 ± 19.61 (50 to 103). At 12 and 24 months 13% of the infants had an MDI ≤ 70 and 38% had a PDI ≤ 70. A significantly higher OI pre-ECMO was predictive of MDI/PDI > 70 (59.1 ± 11.1 vs. 42.4 ± 15.6; p = .017). Conclusion In this population, 67% of infants CDH-ECMO survive to discharge. Higher PaCO2, lower pH, and higher PT pre-ECMO were significant predictors for mortality. CDH-ECMO survivors are at risk for cognitive delay and more severe neuromotor delay at 12 and 24 months of age. Higher OI pre-ECMO was a significant predictor for worse long-term outcome. Risk/benefit of using ECMO before prolonged hypercarbia, acidemia, coagulopathy, and high OI needs to be evaluated.

OBJECTIVES:To describe a single center's experience with the primary use of venovenous cannulation for supporting pediatric acute respiratory failure patients with extracorporeal membrane oxygenation (ECMO).DESIGN:Retrospective chart review of all patients receiving extracorporeal life support at a single institution.SETTING:Pediatric intensive care unit at a tertiary care children's hospital.PATIENTS:Eighty-two patients between the ages of 2 wks and 18 yrs with severe acute respiratory failure.INTERVENTIONS:ECMO for acute respiratory failure.MEASUREMENTS AND MAIN RESULTS:From January 1991 until April 2002, 82 pediatric patients with acute respiratory failure were cannulated for ECMO support. Median duration of ventilation before ECMO was 5 days (range, 1-17 days). Sixty-eight of these patients (82%) initially were placed on venovenous ECMO. Fourteen patients were initiated and remained on venoarterial support, including six in whom venovenous cannulae could not be placed. One patient was converted from venovenous to venoarterial support due to inadequate oxygenation. Venoarterial patients had significantly greater alveolar-arterial oxygen gradients and lower PaO(2)/FIO(2) ratios than venovenous patients (p <.03). Fifty-five of 81 venovenous patients received additional drainage cannulae (46 of 55 with an internal jugular cephalad catheter). Thirty-five percent of venovenous patients and 36% of venoarterial patients required at least one vasopressor infusion at time of cannulation (p = nonsignificant); vasopressor dependence decreased over the course of ECMO in both groups. Median duration on venovenous ECMO for acute hypoxemic respiratory failure was 218 hrs (range, 24-921). Venovenous ECMO survivors remained cannulated for significantly shorter time than nonsurvivors did (median, 212 vs. 350 hrs; p =.04). Sixty-three of 82 ECMO (77%) patients survived to discharge-56 of 68 venovenous ECMO (81%) and nine of 14 venoarterial ECMO (64%).CONCLUSIONS:Venovenous ECMO can effectively provide adequate oxygenation for pediatric patients with severe acute respiratory failure receiving ECMO support. Additional cannulae placed at the initiation of venovenous ECMO could be beneficial in achieving flow rates necessary for adequate oxygenation and lung rest.

Objective To discuss the factors associated with hair loss reported after the completion of extracorporeal membrane oxygenation. Design Prospective survey and retrospective chart review. Setting Tertiary care pediatric and adult extracorporeal membrane oxygenation program in a children’s hospital. Patients All patients aged ≥60 months who underwent extracorporeal membrane oxygenation for respiratory or cardiac failure. Interventions Telephone survey of all patients or patient families who met study entry criteria. Measurements and Main Results Twelve extracorporeal membrane oxygenation patients met entry criteria. Nine were contacted and surveyed. Seven children and one adult reported hair loss. One child had no reported hair loss. One patient had a reported hair loss of <10%, three had 25% hair loss, two had 50% hair loss, and two had >50% hair loss. Initial hair loss occurred between 2 wks and 3 months after extracorporeal membrane oxygenation and lasted from 1 to 6 months. No patient sought medical treatment and all reported regrowth of their hair by 6 months after identifying the initial hair loss. Conclusions Hair loss after critical illness is a well-documented phenomenon. Hair loss after extracorporeal membrane oxygenation has not been previously reported. The etiology of the hair loss is probably multifactorial and resolves spontaneously. Patients and families should be educated about hair loss as a potential side effect of extracorporeal membrane oxygenation during their post-extracorporeal membrane oxygenation and discharge teaching.