Elsevier

Resuscitation

Volume 96, November 2015, Pages 208-213
Resuscitation

Clinical paper
Survival and neurocognitive outcomes in pediatric extracorporeal-cardiopulmonary resuscitation☆

https://doi.org/10.1016/j.resuscitation.2015.07.034Get rights and content

Abstract

Objective

Extracorporeal Cardiopulmonary Resuscitation (E-CPR) is the initiation of extracorporeal life support during active chest compressions. There are no studies describing detailed neurocognitive outcomes of this population. We aim to describe the survival and neurocognitive outcomes of children who received E-CPR.

Methods

Prospective cohort study. Children who received E-CPR at the Stollery Children's Hospital between 2000 and 2010 were included. Neurocognitive follow-up, including Wechsler Preschool and Primary Scales of Intelligence, was completed at the age of 4.5 years, and at a minimum of 6 months after the E-CPR admission.

Results

Fifty-five patients received E-CPR between 2000 and 2010. Children with cardiac disease had a 49% survival to hospital discharge and 43% survival at age 5-years, with no survivors (n = 4) in those with non-cardiac disease. Pediatric E-CPR survivors had a mean (SD) Full Scale Intelligence quotient (FSIQ) score of 76.5 (15.9); with 4 children (24%) having intellectual disability (defined as FSIQ over 2 standard deviations below the population mean; i.e., <70). Multiple Cox regression analysis found that mechanical ventilation prior to E-CPR, open chest CPR, longer duration of CPR, low pH and more red blood cells given on the first day of ECMO, and longer time for lactate to normalize on ECMO were associated with higher mortality at age 5-years.

Conclusion

Pediatric patients with cardiac disease who required E-CPR had 43% survival at age 5 years. Of concern, the intelligence quotient in E-CPR survivors was significantly lower than the population mean, with 24% having intellectual disability.

Introduction

Since Bartlett and others started using ECMO (Extracorporeal Membrane Oxygenation) to support children with congenital heart disease (CHD) in the 1970s, ECMO has evolved from an extraordinary, last resort, life-saving intervention to a standard of care in many pediatric centers with thousands of patients supported to date.1, 2, 3 Indications for ECMO now include not only cardiovascular and/or respiratory failure but also sustained cardiac arrest (CA). Extracorporeal Cardiopulmonary Resuscitation (E-CPR) is the initiation of ECMO support while active chest compressions are taking place. E-CPR was first described in 1992 and since then its use has increased significantly.4, 5 Survival to hospital discharge in E-CPR patients has ranged between 33 and 79% with better outcomes in those children with CHD.6, 7, 8, 9 The 2010 American Heart Association Guidelines for pediatric cardiopulmonary resuscitation have recommended the use of E-CPR for select cases of refractory CA.10 However, some concern has been raised about the long-term outcome of these children and their need for ongoing health care.11, 12 To date, few studies have reported the long-term neurocognitive outcomes of children who received E-CPR, and none of them provided detail information.13, 14 Hence, we aim to describe eleven years of experience in the use of E-CPR at the Stollery Children's Hospital and the long-term neurocognitive outcomes of those who survived E-CPR. We also aim to identify potentially modifiable predictors around the time of E-CPR that are associated with short and long term outcomes.

Section snippets

Methods

This study is part of an inter-provincial follow-up project conducted in western Canada (the Complex Pediatric Therapies Follow-up Program, CPTFP). Patients were identified at the time of E-CPR and followed prospectively. This study included all children who received E-CPR at the Stollery Children's Hospital between January 2000 and December 2010. E-CPR was defined as ECMO cannulation during active chest compressions. We excluded patients who had a CA outside the hospital or at a different

Description of the cohort

Two hundred and twenty four patients received ECMO between 2000 and 2010, of which 55 (25%) were cannulated during ongoing chest compressions (E-CPR). E-CPR patients received E-CPR at a median (IQR) age of 7.2 (1.7–25.7) months, and weighed a median (IQR) of 6.0 (4.0–11.0) kg. Fifty-one children (93%) had a diagnosis of acquired and/or congenital heart disease, and 4 (7%) had non-cardiac diagnosis. (For a complete list of diagnoses see Appendix III) The majority of the patients, 36 (65%),

Discussion

In this long-term follow-up study of children who received E-CPR at the Stollery Children's Hospital we found that, over an 11 year period, the survival to hospital discharge was 49% for cardiac patients and there were no survivors for the 4 children without heart disease. At 5 years of age 43% of those children with cardiac disease were still alive. Detailed neurocognitive evaluations at 5 years showed that most E-CPR survivors had mean FSIQ, PIQ, VIQ, VMI and GAC scores within 2 SD of the

Conclusion

Pediatric patients with cardiac disease who required E-CPR had a 49% survival to hospital discharge and 43% survival at age 5-years. Markers of tissue perfusion, type and duration of CPR, and mechanical ventilation at the time of CA were potentially modifiable variables associated with survival to age 5-years. This is the first study reporting detailed neurocognitive outcomes of E-CPR survivors and found that global intelligence, vocabulary and adaptation skills were significantly lower than

Funding source

Financial support provided for The Registry and Follow-up of Complex Pediatric Therapies Project by Alberta Health and Wellness with ongoing support from The Stollery Children's Hospital, Edmonton, Alberta, Canada.

Financial disclosure

Dr Garcia Guerra and Dr Lequier have conducted ECMO courses with the support of Maquet. The authors have no financial relationships relevant to this article to disclose.

Conflict of interest statement

The authors have no conflict of interest to disclose.

Acknowledgements

We are deeply indebted to the children and parents attending follow-up for their consistent willingness to travel long distances and participate in our program. To all the members of the Western Canadian Complex Pediatric Therapies Follow-up Group: Reg S Sauve, MD, MSc, Diane M Moddemann, MD, Med, Patricia M Blakley, MD, Anne R Synnes, MDCM, MSc, Joyce R Harder, MD, Reeni Soni, MD, Jaya P Bodani, MD, Ashok P Kakadekar, MD, John D Dyck, MD, Derek G Human, MD.

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    ☆

    A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.07.034.

    1

    Gonzalo Garcia Guerra for the co-authors.

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