Impact of multiple organ system dysfunction and nosocomial infections on survival of children treated with extracorporeal membrane oxygenation after heart surgery.
OBJECTIVE
To evaluate whether cardiac and noncardiac variables may be used to predict survival in children treated with extracorporeal membrane oxygenation (ECMO) after cardiopulmonary bypass and to determine when to discontinue ECMO support.


METHODS
Retrospective review.


METHODS
Neonatal and pediatric intensive care units of Kosair Children's Hospital.


METHODS
Fifty-nine children treated with ECMO after cardiopulmonary bypass from 1987 through 1996.


METHODS
None.


RESULTS
Medical, nursing, operative, and perfusion records for each patient were reviewed. The primary outcome measure was survival to hospital discharge. Cardiac and noncardiac variables were recorded at serial times. Nineteen of 59 patients (32%) survived. No cardiac variable was a clinically useful predictor of survival or marker for when to discontinue ECMO. Among the noncardiac variables, progressive multiple organ system dysfunction and development of a nosocomial infection were significantly associated with nonsurvival. No patient with a positive blood culture (n = 3) within the first 24 hrs of ECMO survived, and 21 of 24 children with a positive culture from any site during ECMO died (p = .007). Despite their higher mortality, children with positive cultures were supported with ECMO significantly longer than those with negative cultures (275+/-168 vs. 135+/-108 hrs, respectively; p = .0004). For all patients, the longest duration of ECMO that resulted in survival was 256 hrs. For children with a positive culture, the longest duration of support that resulted in survival was 200 hrs.


CONCLUSIONS
Support with ECMO beyond 256 hrs was not associated with survival. Progressive multiple organ system dysfunction and nosocomial infections have a negative impact on survival. Serious consideration should be given to discontinuing ECMO support whenever there is a progressive increase in the number of abnormally functioning organ systems, a nosocomial infection occurs, or native cardiac function has not improved significantly by 250 hrs of ECMO support.
Montgomery
V L
VL
Department of Pediatrics, Kosair Children's Hospital, Louisville, KY 40202-3830, USA.
Strotman
J M
JM
Ross
M P
MP
D001794:Blood Pressure; D002315:Cardiopulmonary Bypass / Q000009:adverse effects* / Q000401:mortality; D002675:Child, Preschool; D003428:Cross Infection / Q000209:etiology* / Q000401:mortality / Q000628:therapy*; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006330:Heart Defects, Congenital / Q000601:surgery*; D006339:Heart Rate; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018447:Medical Futility; D009102:Multiple Organ Failure / Q000209:etiology* / Q000401:mortality / Q000628:therapy*; D018579:Patient Selection; D011182:Postoperative Care / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome