PALM DESERT, CALIF. – Venoarterial extracorporeal circulation membrane oxygenation appears to be the primary mode of treatment for septic patients, but new research suggests that venovenous ECMO confers a significant survival benefit in select noncardiac pediatric patients with sepsis.
"ECMO is used as a last resort in sepsis, but to date there is really no consensus on the best mode of ECMO to be used" in these patients," Dr. Sean C. Skinner said at the annual meeting of the American Pediatric Surgical Association.
Dr. Sean C. Skinner
To compare venoarterial (VA) with venovenous (VV) ECMO in septic pediatric patients, Dr. Skinner and his associates analyzed Extracorporeal Life Support Organization (ELSO) registry data from 1990 to 2008 in patients younger than age 18 years with a primary, secondary, or discharge diagnosis of sepsis. Patients with congenital heart diagnoses were excluded. The primary outcome was survival.
Patients were grouped by modality (VA vs. VV ECMO) and by three age categories: neonates to 1 month of age, children aged 1 month to 12 years of age, and adolescents older than age 12 years. To assess the patients’ severity of illness, the investigators examined pre-ECMO vasoactive medication and any advanced respiratory support that was provided. Univariate and multivariate analyses were performed.
Of the 4,332 ECMO runs that were analyzed during the study period, 3,256 (75%) were VA and 1,076 (25%) were VV, said Dr. Skinner, a pediatric surgeon at the University of Kentucky, Lexington. Overall survival was 68% and was significantly higher in the VV group, compared with the VA group (79% vs. 64%, respectively). Survival also decreased significantly with age, from 75% of neonates to 40% of children aged 1 month–12 years and 31% of adolescents.
Dr. Skinner reported that there was survival benefit favoring VV in all three age groups. The rate of survival was 83% in neonates who underwent VV vs. 70% in neonates who underwent VA. Survival rates were 64% vs. 37%, respectively, in children 1 month–12 years of age, and were 43% vs. 29%, respectively, in adolescents.
After adjusting for age group, vasoactive medication use, and any advanced respiratory support provided, the investigators found a significant survival benefit to VV ECMO, with an odds ratio for mortality of 2.06 in VA ECMO patients. Advanced age and use of vasoactive medications remain independent mortality risk factors after adjustment (OR, 4.07 for children vs. neonates; OR, 5.84 for adolescents vs. neonates; and OR, 1.28 for those on vasoactive medications vs. those who were not).
Dr. Skinner acknowledged certain limitations of the study: The ELSO registry consists of retrospective data, it was not possible to control for selection bias, and there was limited adjustment for severity of illness.
"We believe that there is a survival benefit in VV vs. VA ECMO in select septic pediatric patients who do not have any underlying congenital heart disease," he concluded. "Patients who have severe cardiac depression may benefit from VA ECMO, but when possible, septic patients can be tried on VV ECMO as a primary modality in a safe manner."
Dr. Skinner said that he had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.