The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO.

Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.

Foundations of a life support equipment exchange platform.

Background: The Extracorporeal Life Support Organization Supplies Platform (https://Supplies.ELSO.org) was created out of Extracorporeal Membrane Oxygenation (ECMO) disposable product shortage prior to and during the Coronavirus Disease 2019 (COVID-19) pandemic. This novel Platform supports Centers in obtaining disposables from other Centers when alternative avenues are exhausted. Methods: Driven by the opportunity for increased patient care by using the product availability of the 962 ELSO centers worldwide was the motivation to form an efficient online supply sharing Platform. The pandemic created by COVID-19 became a catalyst to further recognize the magnitude of the supply disruption on a global scale, impacting allocations and guidelines for institutions, practice, and patient care. Conclusions: Records kept on the Platform website are helpful to the industry by providing insights into where difficulties exist in the supply chain for needed equipment. Yet, the common thread is awareness, of how critical situations can stretch resources and challenge our resolve for the best patient care. ELSO is proud to support member centers in these situations, by providing a means of attaining needed ECMO life support products to cover supply shortages.

Basics of extra corporeal membrane oxygenation: a pediatric intensivist's perspective.

Extra Corporeal membrane oxygenation (ECMO) is one of the most advanced forms of life support therapy in the Intensive Care Unit. It relies on the principle where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) within which blood becomes enriched with oxygen and has carbon dioxide removed. The blood is then returned to the patient via a central vein or an artery. The goal of ECMO is to provide a physiologic milieu for recovery in refractory cardiac/respiratory failure. The technology is not a definitive treatment for a disease, but provides valuable time for the body to recover. In that way it can be compared to a bridge, where patients are initiated on ECMO as a bridge to recovery, bridge to decision making, bridge to transplant or bridge to diagnosis. The use of this modality in children is not backed by a lot of randomized controlled trials, but the use has increased dramatically in our country in last 10 years. This article is not intended to provide an in-depth overview of ECMO, but outlines the basic principles that a pediatric intensive care physician should know in order to manage a kid on ECMO support.

A novel approach to delivery of extracorporeal support using a modified continuous flow ventricular assist device in a mid-volume congenital heart program.

Extracorporeal life support (ECLS) is an essential component of a modern congenital cardiac surgery program. The circuit components and bedside management team may, however, vary among institutions. Here, we evaluate our initial experience with a modified ventricular assist device-based ECLS circuit primarily managed by the bedside nurse. We hypothesize that our outcomes are comparable to Extracorporeal Life Support Organization (ELSO) registry data. All patients who received ECLS from January 1, 2016 to December 31, 2019 at a single institution were included. Primary outcomes were survival to ECLS decannulation and discharge or transfer. Secondary outcomes included complications from ECLS. Data were compared to available ELSO registry data. Thirty-seven patients underwent 44 ECLS runs during the study period. Forty percent of patients had single ventricle physiology. Nearly 46% of patients received ECLS as part of extracorporeal cardiopulmonary resuscitation (eCPR). Survival to ECLS decannulation (68.2%) and survival to discharge or transfer (61.4%) did not differ from overall ELSO outcomes (69.7%, P = .870 and 50.7%, P = .136), as well as survival to discharge or transfer in a comparable cohort of ELSO centers (53.1%, P = .081). Patients with complications had a lower rate of survival to discharge or transfer but this did not reach statistical significance (47.7% vs. 75.0%, P = .455). Neurologic (50.0%), hemorrhagic (45.5%), and renal complications (31.8%) were most common in this cohort. A modified ventricular assist device-based ECLS circuit with primary management by the bedside nurse can provide comparable support in a neonatal and pediatric cardiac surgery population. Cost analyses and further delineation of the complication profile are necessary for a complete characterization of this system.

The use of extracorporeal membrane oxygenation in human immunodeficiency virus-positive patients: a review of a multicenter database.

AIM: We chose to evaluate the survival of extracorporeal membrane oxygenation among patients with human immunodeficiency virus in a multicenter registry. METHODS: Retrospective case review of the Extracorporeal Life Support Organization Registry respiratory failure of all patients with human immunodeficiency virus supported with extracorporeal membrane oxygenation. RESULTS: A total of 126 patients were included. Survival to discharge was 36%. Eight infants were supported with extracorporeal membrane oxygenation and three (37.5%) survived to discharge. Respiratory extracorporeal membrane oxygenation was the primary indication (78%) with a 39% survival, while cardiac and extracorporeal cardiopulmonary resuscitation indications accounted for 16% and 6% of patients with survivals of 30% and 12.5%, respectively. These differences did not reach significance. There were no significant differences between survivors and non-survivors in demographic data, but non-survivors had significantly more non-human immunodeficiency virus pre-extracorporeal membrane oxygenation infections than survivors. There were no differences in other pre-extracorporeal membrane oxygenation supportive therapies, mechanical ventilator settings, or arterial blood gas results between survivors and non-survivors. The median duration of mechanical ventilation prior to cannulation was 52 (interquartile range: 13-140) hours, while the median duration of the extracorporeal membrane oxygenation exposure was 237 (interquartile range: 125-622) hours. Ventilator settings were significantly lower after 24 hours compared to pre-extracorporeal membrane oxygenation settings. Complications during extracorporeal membrane oxygenation exposure including receipt of renal replacement therapy, inotropic infusions, and cardiopulmonary resuscitation were more common among non-survivors compared to survivors. Central nervous system complications were rare. CONCLUSION: Survival among patients with human immunodeficiency virus infection who receive extracorporeal membrane oxygenation was less than 40%. Infections before extracorporeal membrane oxygenation cannulation occurred more often in non-survivors. The receipt of renal replacement therapy, inotropic infusions, or cardiopulmonary resuscitation during extracorporeal membrane oxygenation was associated with worse outcome.

The ELSO Maastricht Treaty for ECLS Nomenclature: abbreviations for cannulation configuration in extracorporeal life support - a position paper of the Extracorporeal Life Support Organization.

BACKGROUND: The Extracorporeal Life Support Organization (ELSO) Maastricht Treaty for Nomenclature in Extracorporeal Life Support (ECLS) established consensus nomenclature and abbreviations for ECLS to ensure accurate, concise communication. METHODS: We build on this consensus nomenclature by layering a framework of precise and efficient abbreviations for cannula configuration that describe flow direction, number of cannulae used, any additional ECLS-related catheters, and cannulation sites. This work is a consensus of international representatives of the ELSO, including those from the North American, Latin American, European, South and West Asian, and Asian-Pacific chapters of ELSO. RESULTS: The classification increases in descriptive capability by introducing a third (cannula tip position) and fourth (cannula dimension) level to those provided in the previous consensus on ECLS cannulation configuration nomenclature. This expansion offers the simplest level needed to convey cannulation information yet allows for more details when required. CONCLUSIONS: A complete nomenclature for ECLS cannulation configurations accommodating future revisions was developed to facilitate ability to compare practices and results, to promote efficient communication, and to improve quality of registry data.

Clinical outcomes of neonatal and pediatric extracorporeal life support: A seventeen-year, single institution experience.

The objective of this study was to describe a single-center experience with neonatal and pediatric extracorporeal life support (ECLS) and compare patient-related outcomes with those of the Extracorporeal Life Support Organization (ELSO) Registry. A retrospective review of subject characteristics, outcomes, and complications of patients who received the ECLS at Penn State Health Children's Hospital (PSHCH) from 2000 to 2016 was performed. Fisher's exact test was used to compare the PSHCH outcomes and complications to the ELSO Registry report. Data from 118 patients were included. Survival to discontinuation of the ECLS was 70.3% and 65.2% to discharge/transfer. Following circuitry equipment changes, the survival to discharge/transfer improved for both neonatal (<29 days) and pediatric (29 days to <18 years) patients. The most common complications associated with ECLS were clinical seizures, intracranial hemorrhage, and culture-proven infection. ECLS for pulmonary support appeared to be associated with a higher risk of circuit thrombus and cannula problems. When compared to the ELSO Registry, low volume ECLS centers, like our institution, can have outcomes that are no different or statistically better as noted with neonatal and pediatric cardiac patients. Pediatric patients requiring pulmonary support appeared to experience more mechanical complications during ECLS suggesting the need for ongoing technological improvement.

[Maxillary sinusitis as a diagnostical adverse finding of the dental cone-beam computed tomography study]. / Sinusitis maxillaris mint a fogászati cone-beam komputertomográfiás vizsgálat melléklelete.

INTRODUCTION: Cone-beam computed tomography is a frequently used diagnostical method in the head and neck region. The thickening of the maxillary sinus mucosa is often observed in these images. AIM: Determining the prevalence of teeth and roots that can be identified as cause of maxillary odontogenic sinusitis, and recording the average observed mucosa thickening on these images. METHOD: The scans that give the base of the study have been performed by the Department of Dentistry of Medical University of Pécs between 2015-2016. The size of the voxels had been varied between 0.25 and 0.4 mm and the size of the image had been set up to 15×12 cm. The acquisition time had been set up to 27 seconds. RESULTS: 170 cases of the 260 revised records fulfilled the initial criterion conditions. The average mucosa thickness was 8.8 mm. During the present study, the upper first molars palatal and the second molars mesiobuccal roots were mainly associated with maxillary odontogenic sinusitis. CONCLUSION: Whether in the case of chronic maxillary sinusitis that is not or only temporarily responsive to conventional therapy, may it be justifiable to provide dental consultation and cone-beam computed tomography to exclude the dental origin of sinusitis. Orv Hetil. 2017; 158(44): 1747-1753.

The importance of the development of extracorporeal life support simulation centres for improving skills and knowledge during the COVID-19 pandemic.

Introduction: Despite increasing implementation of sophisticated and logistically challenging techniques to support patients in life-threatening conditions in the last years, there were no devoted education centres, especially in coronavirus pandemic. Aim: To assess the value of gaining evidence-based knowledge and improving the skills of physicians by means of simulation techniques in the safe use of extracorporeal technologies to support patients in the life-threatening conditions. Material and methods: In 2019, the National Education Centre for Artificial Life Support and Patient Safety and the frame program of the course of "Artificial Life Support with ECMO". was created. In years 2019-2023, we managed to organise 34 such courses for 405 physicians, which were additionally endorsed by ELSO (Extracorporeal Life Support Organisation). The physicians' cognitive, behavioural, and technical skills were evaluated before and after the courses. Results: The participants' gender was well balanced (54% men and 46% women). Most of them (mainly at the age between 31-40 years) presented more than 5 years of clinical experience, predominantly in anaesthesiology and intensive care (63%). Of note, 54% of them had no experience with ECMO application. In all detailed aspects of cognitive, behavioural, and technical assessment and knowledge scores, significant improvement was observed after the course. Conclusions: The development of a simulation-based education centre was found to be an invaluable achievement that enabled not only successful standardised training and testing of novel or previously accepted procedures, but also the upgrading of technical skills, even in the challenging COVID-19 pandemic period.

Evaluating the impact of ELSO guideline adherence on favorable neurological outcomes among patients requiring extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest.

AIM: Selecting the appropriate candidates for extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) is challenging. Previously, the Extracorporeal Life Support Organization (ELSO) guidelines suggested the example of inclusion criteria. However, it is unclear whether patients who meet the inclusion criteria of the ELSO guidelines have more favorable outcomes. We aimed to evaluate the relationship between the outcomes and select inclusion criteria of the ELSO guidelines. METHODS: We conducted a post-hoc analysis of a multicenter prospective study conducted between 2019 and 2021. Adult patients with OHCA treated with ECPR were included. The primary outcome was a favorable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days. An ELSO criteria score was assigned based on four criteria: (i) age < 70 years; (ii) witness; (iii) bystander CPR; and (iv) low-flow time (<60 min). Subgroup analysis based on initial cardiac rhythm was performed. RESULTS: Among 9,909 patients, 227 with OHCA were included. The proportion of favorable neurological outcomes according to the number of ELSO criteria met were: 0.0% (0/3), 0 points; 0.0% (0/23), 1 point; 3.0% (2/67), 2 points; 7.3% (6/82), 3 points; and 16.3% (7/43), 4 points. A similar tendency was observed in patients with an initial shockable rhythm. However, no such relationship was observed in those with an initial non-shockable rhythm. CONCLUSION: Patients who adhered more closely to specific inclusion criteria of the ELSO guidelines demonstrated a tendency towards a higher rate of favorable neurological outcomes. However, the relationship was heterogeneous according to initial rhythm.

Infection in ECMO patients: Changes in epidemiology, diagnosis and prevention.

Patients with prolonged duration of extracorporeal membrane oxygenation support (ECMO) are a vulnerable population for sepsis, particularly ventilator-associated pneumonia and bloodstream infections. Rates differ between venous-arterial and venous-venous ECMO patients and according to the cannulation technique used. The presence of particular organisms depends on local epidemiology, antibiotic exposure, and the duration of the intervention; patients undergoing ECMO for more than three weeks present a high risk of persistent candidemia. Recognizing predisposing factors, and establishing the best preventive interventions and therapeutic choices are critical to optimizing the management of these complications. Infection control practices, including shortening the period of the indwelling devices, and reducing antibiotic exposure, must be followed meticulously. Innovations in oxygenator membranes require an updated approach. Hand hygiene and avoiding breaking the circuit-oxygenator sterility are cornerstones. ECMO management would benefit from clearer definitions, optimization of infection control strategies, and updated infectious clinical practice guidelines.

Standardized therapies after ECMO program (STEP); a novel approach to pediatric post-ECMO care.

BACKGROUND: The study objective was to characterize compliance with Standardized Therapy after ECMO Program (STEP), an intentional discharge pathway for extracorporeal membrane oxygenation (ECMO) survivors in a US pediatric hospital. METHODS: The program identified pediatric ECMO survivors before discharge, appropriate consultations were reviewed and requested, families were educated on ECMO sequelae, and ECMO summaries were sent to pediatricians. Compliance with institutional post-ECMO guidelines was evaluated before and after STEP implementation. RESULTS: We identified 77 ECMO survivors to hospital discharge (36 [46.8%] before and 41 [53.2%] after STEP implementation). There was a significant increase in complete (38.8% vs. 74.2%, p < 0.001) and time-appropriate neurodevelopmental testing (71.4% vs. 95.6%, p = 0.03). Significant increase in inpatient evaluations by neurology (52.7% vs. 75.6%, p = 0.03) and audiology (66.7% vs. 87.8%, p = 0.02), and in referrals for outpatient audiology (66.6 vs. 95.1%, p = 0.002), physical therapy (P.T.) (63.8% vs. 95.1%, p = 0.001), occupational therapy (O.T.) (63.8% vs. 95.1%, p = 0.001) and speech-language pathology (S.L.P.) (55.5% vs. 95.1%, p < 0.001) were noted. CONCLUSION: Implementing an intentional discharge pathway for pediatric ECMO survivors (STEP) successfully increases inpatient and outpatient compliance with hospital and Extracorporeal life support organization (ELSO) follow-up guidelines. It leads to timely and complete neurodevelopmental evaluation.

Venoarterial extracorporeal membrane oxygenation for cardiac support in human immunodeficiency virus-positive patients: a case report and review of a multicentre registry.

BACKGROUND: Human immunodeficiency virus (HIV) is associated with increased risk of heart failure via multiple mechanisms both in patients with and without access to highly active antiretroviral therapy (HAART). Limited information is available on outcomes among this population supported on Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO), a form of temporary mechanical circulatory support. METHODS: We aimed to assess outcomes and complications among patients with HIV supported on VA ECMO reported to a multicentre registry and present a case report of a 32 year old male requiring VA ECMO for cardiogenic shock as a consequence of his untreated HIV and acquired immune deficiency syndrome (AIDS). A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) registry data from 1989 to 2019 was performed in HIV patients supported on VA ECMO. RESULTS: 36 HIV positive patients were reported to the ELSO Database who received VA ECMO during the study period with known outcomes. 15 patients (41%) survived to discharge. No significant differences existed between survivors and non-survivors in demographic variables, duration of VA ECMO support or cardiac parameters. Inotrope and/or vasopressor requirement prior to or during VA ECMO support was associated with increased mortality. Survivors were more likely to develop circuit thrombosis. The patient presented was supported on VA ECMO for 14 days and was discharged from hospital day 85. CONCLUSIONS: A limited number of patients with HIV have been supported with VA ECMO and more data is required to ascertain the indications for ECMO in this population. HIV should not be considered an absolute contraindication to VA ECMO as they may have comparable outcomes to other patient groups requiring VA ECMO support.

Early Blood Pressure Variables Associated With Improved Outcomes in VA-ECLS: The ELSO Registry Analysis.

BACKGROUND: As utilization of veno-arterial extracorporeal life support (VA-ECLS) in treatment of cardiogenic shock (CS) continues to expand, clinical variables that guide clinicians in early recognition of myocardial recovery and therefore, improved survival, after VA-ECLS are critical. There remains a paucity of literature on early postinitiation blood pressure measurements that predict improved outcomes. OBJECTIVES: The objective of this study is to help identify early blood pressure variables associated with improved outcomes in VA-ECLS. METHODS: The authors queried the ELSO (Extracorporeal Life Support Organization) registry for cardiogenic shock patients treated with VA-ECLS or venovenous arterial ECLS between 2009 and 2020. Their inclusion criteria included treatment with VA-ECLS or venovenous arterial ECLS; absence of pre-existing durable right, left, or biventricular assist devices; no pre-ECLS cardiac arrest; and no surgical or percutaneously placed left ventricular venting devices during their ECLS runs. Their primary outcome of interest was the survival to discharge during index hospitalization. RESULTS: A total of 2,400 CS patients met the authors' inclusion criteria and had complete documentation of blood pressures. Actual mortality during index hospitalization in their cohort was 49.5% and survivors were younger and more likely to be Caucasian, intubated for >30 hours pre-ECLS initiation, and had a favorable baseline SAVE (Survival After Veno-arterial ECMO) score (P < 0.05 for all). Multivariable regression analyses adjusting for SAVE score, age, ECLS flow at 4 hours, and race showed that every 10-mm Hg increase in baseline systolic blood pressure (HR: 0.92 [95% CI: 0.89-0.95]; P < 0.001), and baseline pulse pressure (HR: 0.88 [95% CI: 0.84-0.91]; P < 0.001) at 24 hours was associated with a statistically significant reduction in mortality. CONCLUSIONS: Early (within 24 hours) improvements in pulse pressure and systolic blood pressure from baseline are associated with improved survival to discharge among CS patients treated with VA-ECLS.

Implementation and outcomes of an urban mobile adult extracorporeal life support program.

Objective: Although extracorporeal life support (ECLS) has been increasingly adopted as rescue therapy for cardiac and pulmonary failure, it remains limited to specialized centers. The present study reports our institutional experience with mobile ECLS across broad indications, including postcardiotomy syndrome, cardiogenic shock, and COVID-19 acute respiratory failure. Methods: We performed a retrospective review of all patients transported to our institution through our mobile ECLS program from January 1, 2018, to January 15, 2021. Results: Of 110 patients transported to our institution on ECLS, 65.5% required venovenous, 30.9% peripheral venoarterial, and 3.6% central venoarterial support. The most common indications for mobile ECLS were acute respiratory failure (46.4%), COVID-19-associated respiratory failure (19.1%), cardiogenic shock (18.2%) and postcardiotomy syndrome (11.8%). The median pre-ECLS Pao2:Fio2 for venovenous-ECLS was 64 mm Hg (interquartile range [IQR], 53-75 mm Hg) and 95.8 mm Hg (IQR, 55-227 mm Hg) for venoarterial-ECLS, whereas median pH and base deficit were 7.25 (IQR, 7.16-7.33) and 7 mmol/L (IQR, 4-11 mmol/L) for those requiring venoarterial-ECLS. Patients were transported using a ground ambulance from 50 institutions with a median distance of 27.5 miles (IQR, 18.7-48.0 miles). Extracorporeal circulation was established within a median of 45 minutes (IQR, 30-55 minutes) after team arrival. Survival to discharge was 67.3% for those requiring venovenous-ECLS for non-COVID-19 respiratory failure, 52.4% for those with COVID-19%, and 54.1% for those requiring venoarterial-ECLS. Conclusions: Patients can be safely and expeditiously placed on ECLS across broad indications, utilizing ground transportation in an urban setting. Clinical outcomes are promising and comparable to institutional non-transfers and those reported by Extracorporeal Life Support Organization.

Venovenous extracorporeal membrane oxygenation support in patients with COVID-19 respiratory failure: A multicenter study.

Objective: The COVID-19 pandemic presents a high mortality rate amongst patients who develop severe acute respiratory distress syndrome (ARDS). The purpose of this study was to evaluate the outcomes of venovenous extracorporeal membrane oxygenation (VV-ECMO) in COVID-19-related ARDS and identify the patients who benefit the most from this procedure. Methods: Adult patients with COVID-19 and severe ARDS requiring VV-ECMO support at 4 academic institutions between March and October 2020 were included. Data were collected through retrospective chart reviews. Bivariate and multivariable analyses were performed with the primary outcome of in-hospital mortality. Results: Fifty-one consecutive patients underwent VV-ECMO with a mean age of 50.4 years; 64.7% were men. Survival to hospital discharge was 62.8%. Median intensive care unit and hospitalization duration were 27.4 days (interquartile range [IQR], 17-37 days) and 34.5 days (IQR, 23-43 days), respectively. Survivors and nonsurvivors had a median ECMO cannulation time of 11 days (IQR, 8-18) and 17 days (IQR, 12-25 days). The average postdecannulation length of stay was 17.5 days (IQR, 12.4-25 days) for survivors and 0 days for nonsurvivors (IQR, 0-6 days). Only 1 nonsurvivor was able to be decannulated. Clinical characteristics associated with mortality between nonsurviors and survivors included increasing age (P = .0048), hemorrhagic stroke (P = .0014), and postoperative dialysis (P = .0013) were associated with mortality in a bivariate model and retained statistical significance in a multivariable model. Conclusions: This multicenter study confirms the effectiveness of VV-ECMO in selected critically ill patients with COVID-19-related severe ARDS. The survival of these patients is comparable to non-COVID-19-related ARDS.

ECMO in India, SWAAC ELSO: challenges and solutions.

The innovations leading to the development of a new technology such as extracorporeal membrane oxygenation (ECMO) and its progress over the years have been inspiring. Many great personalities were associated with the genesis and re-designing the multiple essential components of ECMO to make it more biocompatible. We discussed the brief history of cardiopulmonary bypass and ECMO. We elucidated the establishment of a commanding center, Extracorporeal Life Support Organization (ELSO) in the USA, ECMO society of India in the sub-continent and the birth of South and West Asia Chapter (SWAC) of ELSO initially, which became South and West Asia, Africa chapter (SWAAC) ELSO later after amalgamation of Africa to this sub-chapter of ELSO.

Mortality trends in neonatal ECMO for pulmonary hypoplasia: A review of the Extracorporeal Life Support Organization database from 1981 to 2016.

BACKGROUND: The purpose of this review is to provide ECMO outcome data for medical personnel who counsel families of patients with pulmonary hypoplasia (PH), often secondary to renal abnormalities. We report diagnoses and outcomes associated with PH in neonates that were treated with ECMO over the past 35 years. METHODS: Retrospective cohort study using the ELSO database for neonates born between 1981 and 2016 with a primary or secondary diagnosis of PH. Five patient groups were created based on ICD-9 codes. Mortality rates were compared and trends over time were investigated. RESULTS: Thirty-three percent of the 1385 patients survived to discharge. Congenital diaphragmatic hernia (CDH) patients had significantly higher mortality than PH patients secondary to renal dysplasia (p < 0.001). Mortality decreased significantly over time for all groups (p < 0.001). The proportion of patients alive at discharge increased over time for CDH patients (p < 0.001), whereas survival decreased for patients with PH secondary to renal dysplasia (p = 0.012). CONCLUSIONS: Neonates with PH that require ECMO have high mortality rates, which have generally decreased over the past 35 years; however, mortality for neonates with PH secondary to renal dysplasia continues to increase. We speculate that the apparent rise in mortality for these patients is because of changes in patient selection subsequent to improvements in non-ECMO ventilatory support. LEVEL OF EVIDENCE: II.

Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) use for severe coronavirus disease 2019 (COVID-19) patients has increased during the course of the pandemic. As uncertainty existed regarding patient's outcomes, early guidelines recommended against establishing new ECMO centers. We aimed to explore the epidemiology and outcomes of ECMO for COVID-19 related cardiopulmonary failure in five countries in the Middle East and India and to evaluate the results of ECMO in 5 new centers. METHODS: This is a retrospective, multicenter international, observational study conducted in 19 ECMO centers in five countries in the Middle East and India from March 1, 2020, to September 30, 2020. We included patients with COVID-19 who received ECMO for refractory hypoxemia and severe respiratory acidosis with or without circulatory failure. Data collection included demographic data, ECMO-related specific data, pre-ECMO patient condition, 24 h post-ECMO initiation data, and outcome. The primary outcome was survival to home discharge. Secondary outcomes included mortality during ECMO, survival to decannulation, and outcomes stratified by center type. RESULTS: Three hundred and seven COVID-19 patients received ECMO support during the study period, of whom 78 (25%) were treated in the new ECMO centers. The median age was 45 years (interquartile range IQR 37-52), and 81% were men. New center patients were younger, were less frequently male, had received higher PEEP, more frequently inotropes and prone positioning before ECMO and were less frequently retrieved from a peripheral center on ECMO. Survival to home discharge was 45%. In patients treated in new and established centers, survival was 55 and 41% (p = 0.03), respectively. Multivariable analysis retained only a SOFA score < 12 at ECMO initiation as associated with survival (odds ratio, OR 1.93 (95% CI 1.05-3.58), p = 0.034), but not treatment in a new center (OR 1.65 (95% CI 0.75-3.67)). CONCLUSIONS: During pandemics, ECMO may provide favorable outcomes in highly selected patients as resources allow. Newly formed ECMO centers with appropriate supervision of regional experts may have satisfactory results.

Practical Considerations for and Outcomes of Interfacility ECMO Transfer of Patients With COVID-19 During a Pandemic: Mayo Clinic Experience.

Interfacility transport of a critically ill patient with acute respiratory distress syndrome (ARDS) may be necessary for a higher level of care or initiation of extracorporeal membrane oxygenation (ECMO). During the COVID-19 pandemic, ECMO has been used for patients with severe ARDS with successful results. Transporting a patient after ECMO cannulation by the receiving facility brings forth logistic challenges, including availability of adequate personal protective equipment for the transport team and hospital capacity management issues. We report our designated ECMO transport team's experience of 5 patients with COVID-19-associated severe ARDS after cannulation at the referring facility. Focusing on transport-associated logistics, creation of checklists, and collaboration with emergency medical services partners is necessary for safe and good outcomes for patients while maintaining team safety.