Fulminant valvulitis from acute rheumatic fever: successful use of extracorporeal support.

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.

Validation of the CAS neonatal NIRS system by monitoring vv-ECMO patients: preliminary results.

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.

Hair loss after extracorporeal membrane oxygenation.

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 > or =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.

Primary use of the venovenous approach for extracorporeal membrane oxygenation in pediatric acute respiratory failure.

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.

Extracorporeal cardiopulmonary resuscitation for pediatric cardiac patients.

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.