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Objective: To evaluate the relationship between duration of mechanical ventilation before the initiation of extracorporeal life support and the survival rate in children with respiratory failure. Extracorporeal life support has been used as a rescue therapy for >30 yrs in children with severe respiratory failure. Previous studies suggest patients who received >7-10 days of mechanical ventilation were not acceptable extracorporeal life support candidates as a result of irreversible lung damage., Design: A retrospective review encompassing the past 10 yrs of the International Extracorporeal Life Support Organization Registry (January 1, 1999, to December 31, 2008)., Setting: Extracorporeal Life Support Organization Registry database., Patients: A total of 1325 children (≥ 30 days and ≤ 18 yrs) met inclusion criteria., Interventions: None., Measurements and Main Results: The following pre-extracorporeal life support variables were identified as independently and significantly related to the chance of survival: 1) >14 days of ventilation vs. 0-7 days was adverse (odds ratio, 0.32; p < .001); 2) the presence of a cardiac arrest was adverse (odds ratio, 0.56; p = .001); 3) pH per 0.1-unit increase was protective (odds ratio, 1.15; p < .001); 4) oxygenation index, per 10-unit increase was adverse (odds ratio, 0.95; p = .002); and 5) any diagnosis other than sepsis was related to a more favorable outcome. Patients requiring >7-10 or >10-14 days of pre-extracorporeal life support ventilation did not have a statistically significant decrease in survival as compared with patients who received 0-7 days., Conclusions: There was a clear relationship between the number of mechanical ventilation days before the initiation of extracorporeal life support and survival. However; there was no statistically significant decrease in survival until >14 days of pre-extracorporeal life support ventilation was reached regardless of underlying diagnosis. We found no evidence to suggest that prolonged mechanical ventilation should be considered as a contraindication to extracorporeal life support in children with respiratory failure before 14 days.

Objective: To describe the use of a multidisciplinary approach to sepsis surveillance and evaluate impact on outcome., Design: Prospective clinical study or clinical audit cycle., Setting: Tertiary pediatric extracorporeal membrane oxygenation (ECMO) center., Patients: Patients were 215 children supported with ECMO January 1999 to December 2004., Interventions: A multidisciplinary team met monthly to evaluate cases of bloodstream infection and mediastinitis, review trends, and update unit policies. Changes in practice were made at the end of 2001 in order to address a perceived high rate of sepsis: a) reeducation; b) introduction of electively preprimed ECMO circuits; and c) preference for neck rather than chest cannulation in cardiac patients. Prophylactic antibiotics were used from preprocedure for 24 hrs only throughout the study., Measurements and Main Results: Over the entire study period, 39 children had 47 septic episodes, with a rate of 24.9 per 1000 ECMO days. Multiple logistic regression analyses indicated that infection was associated with duration of ECMO support (odds ratio 1.24; 95% confidence interval 1.15, 1.35 per day) and case type: Closed vs. open chest was protective in cardiac patients (odds ratio 0.08; 95% confidence interval 0.01, 0.50). Infection increased the odds of death by 2.01 (95% confidence interval 1.00, 4.05), but this effect was less important than case type and ECMO days. After policy changes were implemented, there was a reduction in sepsis from 29.3 to 20.1 episodes per 1000 ECMO days. There was reduced sepsis in respiratory patients: neonates from 28.0 to 6.6 and pediatric patients from 42.4 to 16.9 episodes per 1000 ECMO days. Despite policy changes, sepsis remained a problem in cardiac patients with open sternum: 65.1 per 1000 ECMO days., Conclusions: ECMO support is a high-risk setup for nosocomial infection, in particular for cardiac patients with open sternum for whom antibiotic prophylaxis is justified. Multidisciplinary surveillance offers an excellent approach for quality improvement in this challenging field.

Objective: A systemic insult is associated with subsequent hyporesponsiveness to endotoxin (as measured by ex vivo tumor necrosis factor [TNF]-alpha production) and an increased risk of late nosocomial infection in some patients. When combined with low monocyte surface major histocompatibility complex class II expression, this state of altered host defense is now commonly referred to as immunoparalysis. This study was undertaken to delineate the relationship between observed levels of the anti-inflammatory cytokine interleukin-10, common genetic polymorphisms that influence these levels, and the occurrence and severity of endotoxin hyporesponsiveness in children following elective cardiac surgery requiring cardiopulmonary bypass., Design: A prospective observational clinical study., Setting: A tertiary pediatric cardiac center., Patients: Thirty-six infants and children <2 yrs of age undergoing elective cardiac surgery requiring cardiopulmonary bypass., Interventions: None., Measurements and Main Results: We investigated the production of TNF-alpha, interleukin-6, interleukin-8, interleukin-1 receptor antagonist, and interleukin-10 in whole blood in response to lipopolysaccharide (Neisseria meningitides 10 ng/mL) in samples drawn before, during, and up to 48 hrs after surgery. Patients were genotyped for the -1082, -819, and -592 interleukin-10 promoter polymorphisms. Whole blood cytokine response to lipopolysaccharide was reduced postoperatively to 100 pg/mL) over the first 48 hrs were more likely to have an uncomplicated short stay (odds ratio 4.7, 95% confidence interval 1-22)., Conclusions: Immediately following cardiac surgery, many children become relatively refractory to lipopolysaccharide stimulation. This immunoparalysis appears to be related in part to high circulating levels of interleukin-10 and places these patients at increased risk of postoperative complications. Interleukin-10 genotype may be a risk factor for immunoparalysis.

We describe a 2 year-old girl with end-stage dilated cardiomyopathy in whom extracorporeal membrane oxygenation (ECMO) was used for mechanical cardiac assistance. After 4 weeks, ECMO-related complications necessitated change to a Berlin Heart Left Ventricular Assist Device (LVAD), and she received a successful cardiac transplant after a total of 106 days on mechanical cardiac support.

Objectives: Severe bleeding is a recognized complication during mechanical cardiopulmonary support with extracorporeal membrane oxygenation. We present the use of recombinant activated factor VII (rFVIIa) for severe, refractory bleeding during extracorporeal membrane oxygenation support after open-heart surgery for congenital heart disease., Design: Retrospective review of all patients receiving rFVIIa on extracorporeal membrane oxygenation., Setting: A pediatric extracorporeal membrane oxygenation center located within the cardiac intensive care unit of a tertiary care children's hospital., Patients: Four patients treated with rFVIIa for refractory bleeding on extracorporeal membrane oxygenation., Interventions: The patients received rFVIIa for severe, refractory blood loss despite applying clotting products and aprotinin infusion and excluding surgical reasons., Measurements and Main Results: rFVIIa was given 4-7 hrs after commencing extracorporeal membrane oxygenation; a second identical dose was administered 4 hrs later. Bleeding decreased significantly in all patients within 30 mins after the first dose of rFVIIa; no side effects were observed., Conclusions: rFVIIa is effective to achieve control of refractory hemorrhage in patients on extracorporeal membrane oxygenation. Now a randomized controlled trial to evaluate risks and benefits of rFVIIa on patients undergoing extracorporeal membrane oxygenation is required.

Objective: To assess the durability of wet-preprimed extracorporeal membrane oxygenation (ECMO) circuits for potential use in resuscitation after a 2-wk period of storage., Design: Experimental laboratory study., Setting: Tertiary care pediatric cardiac intensive care unit., Subjects: None., Interventions and Measurements: 14 ECMO circuits (polyvinyl chloride and super-Tygon tubing with hollow-fiber oxygenator, Medos Hilite 800LT) were primed with crystalloid under sterile conditions and stored for 0 (control, n = 4), 7 (n = 5) and 14 (n = 5) days and maintained at 8 degrees C on pump at 10 rpm and gas flow at 0.2 L/min. Daily samples were inspected for plasticizers by means of high-performance liquid chromatography and for microorganisms by culture and polymerase chain reaction techniques. After storage, the oxygenators were primed with red blood cells (hemoglobin, 12 g/dL) and tested in vitro with a deoxygenator according to Association for Advancement of Medical Instrumentation standards. Oxygen and CO(2) transfer rates were calculated by standard formulae at maximum blood flow (800 mL/min) and maximum sweep gas flow (1.6 L/min)., Main Results: Oxygen transfer was linearly related to venous oxygen saturation, increasing by 11 mL/min for each 10% decrease in venous oxygen saturation. Estimated oxygen transfer at venous oxygen saturation of 60% was 45.8 mL/min (95% confidence interval [CI], 43.5-48.1) for controls, 51.0 mL/min (95% CI, 48.9-53.2) for 7-day oxygenators, and 49.0 mL/min (95% CI, 47.8-50.1) for 14-day oxygenators. CO(2) transfer declined to 29.2 mL/min at 14 days of storage, a mean fall of 11.5 mL/min (95% CI, 4.2-18.7) in comparison with 7-day storage. All circuits were free from microbes/microbial DNA. Plasticizer levels fell below the lower limit of detection (0.003 microg/mL) at 7 and 14 days., Conclusions: A wet-preprimed ECMO circuit with hollow-fiber membrane oxygenator can be stored for up to 2 wks with adequately preserved function if prepared appropriately. These data may improve safe access to rapid-response ECMO support.

Objective: Description of a novel method of left ventricular decompression by a percutaneous technique under transthoracic echocardiographic guidance., Design: Case report., Setting: Supraregional cardiac referral center., Patient: PATIENT with end-stage cardiomyopathy., Interventions: Percutaneous insertion of a modified Mullins transseptal sheath under transthoracic echocardiographic guidance., Measurements and Main Results: Successful decompression of the left ventricle and subsequent orthotopic heart transplantation., Conclusions: In patients at high risk of bleeding, a percutaneous technique may be useful for left ventricular decompression.