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Imaging of cerebral complications of extracorporeal membrane oxygenation in infants with congenital heart disease - ultrasound with multimodality correlation.

ABSTRACT: Cranial ultrasound on neonatal intensive care units is generally performed by intensive care physicians, but radiologists often provide this crucial bedside test to children on specialist paediatric cardiac intensive care units. On a paediatric cardiac intensive care unit, complex congenital cardiac conditions are commonly encountered in both pre- and postoperative scenarios, often with the use of extracorporeal membrane oxygenation (ECMO), which both increases the risks of a number of neurologic complications and results in significant changes in vascular physiology. The aim of this pictorial essay is to discuss cranial ultrasound technique, demonstrate the changes in Doppler flow profiles resulting from veno-arterial extracorporeal membrane oxygenation and congenital cardiac conditions, and illustrate commonly encountered intracranial complications of extracorporeal membrane oxygenation support in congenital cardiac care.

SUBMITTER: Svrckova P

PROVIDER: S-EPMC7286855 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Imaging of cerebral complications of extracorporeal membrane oxygenation in infants with congenital heart disease - ultrasound with multimodality correlation.

Svrckova Patricia P Meshaka Riwa R Holtrup Melanie M Aramburo Angela A Mankad Kshitij K Kazmi Farhat F Owens Catherine M CM Gala-Peralta Sandra S Semple Thomas T

Pediatric radiology 20200215 7

Cranial ultrasound on neonatal intensive care units is generally performed by intensive care physicians, but radiologists often provide this crucial bedside test to children on specialist paediatric cardiac intensive care units. On a paediatric cardiac intensive care unit, complex congenital cardiac conditions are commonly encountered in both pre- and postoperative scenarios, often with the use of extracorporeal membrane oxygenation (ECMO), which both increases the risks of a number of neurologi ...[more]

PMID: 32062720

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Project description:Extracorporeal membrane oxygenation is a potentially life-saving intervention in refractory cardiopulmonary failure, but it requires anticoagulation to prevent circuit thromboses, which exposes the patient to hemorrhagic complications. Heparin has traditionally been the anticoagulant of choice, but the direct thrombin inhibitor bivalirudin is routinely used in cases of heparin-induced thrombocytopenia and has been suggested as a superior choice. We sought to examine the timing of hemorrhagic and thrombotic complications after extracorporeal membrane oxygenation cannulation and to compare the rates of such complications between patients anticoagulated with heparin versus bivalirudin.DesignRetrospective cohort study.SettingJohns Hopkins Hospital patients between January 2016 and July 2019.PatientsAdult (> 18 yr) extracorporeal membrane oxygenation patients.InterventionsPatients were anticoagulated either with heparin or bivalirudin.Measurements and main resultsWe compared rates of hemorrhagic and thrombotic complications by time on heparin versus bivalirudin and characterized the average time to each complication. Of 144 extracorporeal membrane oxygenation patients (mean age 55.3 yr; 58% male), 41% were on central venoarterial extracorporeal membrane oxygenation, 40% on peripheral venoarterial extracorporeal membrane oxygenation, and 19% on venovenous extracorporeal membrane oxygenation. Thirteen patients (9%) received bivalirudin during their extracorporeal membrane oxygenation run, due to concern for (n = 8) or diagnosis of (n = 4) heparin-induced thrombocytopenia or for heparin resistance (n = 1). The rate of hemorrhagic or thrombotic complications did not differ between heparin (0.13/d) and bivalirudin (0.06/d; p = 0.633), but patients on bivalirudin received significantly fewer blood transfusions (1.0 U of RBCs/d vs 2.9/d on heparin; p < 0.001).ConclusionsOur results confirm the safety and efficacy of bivalirudin as an alternative anticoagulant in extracorporeal membrane oxygenation and suggest a potential benefit in less blood product transfusion, although prospective studies are needed to evaluate the true effect of bivalirudin versus the disease processes that prompted its use in our study population.

Project description:BackgroundExtracorporeal membrane oxygenation (ECMO) is associated with neurologic morbidity and mortality. We investigated whether cerebral regional oxygen saturation (rSO2) is associated with neurologic outcomes and survival in children on ECMO.MethodsThis was a retrospective observational study of children aged 1 day to 20 years who underwent ECMO with routine cerebral rSO2 monitoring in the pediatric intensive care unit at a single academic center between February 2008 and September 2014. We collected all serial rSO2 values recorded in the electronic medical record during the ECMO course. Favorable outcome was defined as survival with Pediatric Cerebral Performance Category (PCPC) ≤ 2 at hospital discharge or no decline from baseline PCPC.ResultsWe reviewed data from 153 patients who underwent 156 ECMO runs. The median age was 12.5 days (interquartile range [IQR], 2 days-15 months). Ninety-nine (64%) patients survived to hospital discharge, and 82/99 (83%) survivors had favorable neurologic outcome by discharge PCPC. Neuroimaging studies were obtained in 135 (87%) patients, 59 (44%) of which showed abnormal findings. Ninety-two (59%) patients had any rSO2 ≤ 50%, 60 (38%) had any rSO2 decline > 20% from baseline, and 26 (17%) had any rSO2 decline > 20% from the reading 1 h prior. Any rSO2 ≤ 50% and any rSO2 decline > 20% from baseline were each associated with unfavorable outcome at hospital discharge (multivariable-adjusted odds ratio [OR], 2.82 [95% CI 1.10-7.25] and 4.52 [95% CI 1.76-11.58], respectively). rSO2 decline > 20% from the reading 1 h prior was not significantly associated with the outcomes.ConclusionAmong children in one institution who underwent routine clinical rSO2 monitoring during ECMO, rSO2 decline was associated with unfavorable short-term neurologic outcome and death after adjusting for potential confounders. The effectiveness of initiating early preventative measures in these high-risk patients needs further study.

Dataset Information

Imaging of cerebral complications of extracorporeal membrane oxygenation in infants with congenital heart disease - ultrasound with multimodality correlation.

Publications

Imaging of cerebral complications of extracorporeal membrane oxygenation in infants with congenital heart disease - ultrasound with multimodality correlation.

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