Extracorporeal Cardiopulmonary Resuscitation in the Pediatric Cardiac Population: In Search of a Standard of Care

Objectives: Although clinical and pharmacologic guidelines exist for the practice of cardiopulmonary resuscitation in children (Pediatric Advanced Life Support), the practice of extracorporeal cardiopulmonary resuscitation in pediatric cardiac patients remains without universally accepted standards. We aim to explore variation in extracorporeal cardiopulmonary resuscitation procedures by surveying clinicians who care for this high-risk patient population. Design: A 28-item cross-sectional survey was distributed via a web-based platform to clinicians focusing on cardiopulmonary resuscitation practices and extracorporeal membrane oxygenation team dynamics immediately prior to extracorporeal membrane oxygenation cannulation. Settings: Pediatric hospitals providing extracorporeal mechanical support services to patients with congenital and/or acquired heart disease. Subjects: Critical care/cardiology specialist physicians, cardiothoracic surgeons, advanced practice nurse practitioners, respiratory therapists, and extracorporeal membrane oxygenation specialists. Interventions: None. Measurements and Main Results: Survey web links were distributed over a 2-month period with critical care and/or cardiology physicians comprising the majority of respondents (75%). Nearly all respondents practice at academic/teaching institutions (97%), 89% were from U.S./Canadian institutions and 56% reported less than 10 years of clinical experience. During extracorporeal cardiopulmonary resuscitation, a majority of respondents reported adherence to guideline recommendations for epinephrine bolus dosing (64%). Conversely, 19% reported using only one to three epinephrine bolus doses regardless of extracorporeal cardiopulmonary resuscitation duration. Inotropic support is held after extracorporeal membrane oxygenation cannulation “most of the time” by 58% of respondents and 94% report using afterload reducing/antihypertensive agents “some” to “most of the time” after achieving full extracorporeal membrane oxygenation support. Interruptions in chest compressions are common during active cannulation according to 77% of respondents. Conclusions: The results of this survey identify wide variability in resuscitative practices during extracorporeal cardiopulmonary resuscitation in the pediatric cardiac population. The deviations from established Pediatric Advanced Life Support CPR guidelines support a call for further inquiry into the pharmacologic and logistical care surrounding extracorporeal cardiopulmonary resuscitation. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/2gIrZ5Y). Supported, in part, by the departmental funds from Texas Children’s Hospital. Dr. Lasa received support for article research from departmental funds. Drs. Topjian and Bembea received support for article research from the National Institute of Health (NIH). Dr. Topjian’s institution received funding from the NIH, and she received funding from expert testimony. Dr. Bembea’s institution received funding from NIH/National Institute of Neurological Disorders and Stroke K23NS076674, and she disclosed off-label product use where extracorporeal membrane oxygenation is not Food and Drug Administration-approved for use longer than 6 hours. Dr. Thiagarajan’s institution received funding from Bristol, Myers, Squibb, and Pfizer. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jjlasa@texaschildrens.org ©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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