title: Evaluating cannulation strategies used during second courses of extracorporeal membrane oxygenation in a large cohort of pediatric patients.
abstract: OBJECTIVE
  After a successful course of extracorporeal membrane oxygenation (ECMO), patients can deteriorate and a second ECMO course may be contemplated. When a second ECMO course becomes necessary in pediatric patients, survival rates comparable to the first ECMO course are possible. The perceived difficulties involved in recannulation after an initial ECMO course can prevent clinicians from reliably offering a second ECMO run to an eligible pediatric patient. We hypothesized that national ECMO registry data could provide cannulation templates for pediatric patients requiring a second ECMO course.
  
  
  METHODS
  We obtained data from the Extracorporeal Life Support Organization registry (1981-2007) on patients 1 to 18 years old who required single-run ECMO (SRE) or multiple-run ECMO (MRE). Primary outcome measures were complications and survival. Cannulation-specific variables were compared using chi(2) methods (Fisher exact, McNemar's). Statistical significance was assumed at P < .05.
  
  
  RESULTS
  A total of 3810 (96.8%) children underwent SRE and 127 (3.2%) required MRE. Survival was similar in both groups (49% vs 44%; P = .28). Cannulation data were available in 2539 SRE (67%) and 88 MRE (69%) cases. Compared with SRE, first ECMO courses in MRE patients consisted of fewer cervical (52.3% vs 71.7%; P < .001) but more femoral (20.5% vs 10.7%; P = .01) and central (27.3% vs 17.6%; P = .02) cannulations. In MRE patients, central cannulation was more frequent in second vs first ECMO courses (43.0% vs 27.3%; P = .03). Multiple-run ECMO survival was unaffected by cannulation strategy. Multiple-run ECMO patients with unchanged cannulation sites between first and second ECMO courses had fewer total complications than those requiring new cannulation sites (3.7 vs 5.1; P = .04).
  
  
  CONCLUSIONS
  Second ECMO courses in pediatric patients can achieve survival comparable to the first course, but more often require central cannulation. Reusing cannulation sites for a second ECMO course is associated with fewer total complications than cannulating at new sites. These data provide guidance when considering cannulation strategies for second ECMO courses in pediatric patients.
authors.affiliation: Division of Pediatric Surgery, Morgan Stanley Children's Hospital of NY Presbyterian, Columbia University Medical Center, New York, 10032, USA.
authors.forename: Jason C
authors.initials: JC
authors.lastname: Fisher
authors.forename: Charles J H
authors.initials: CJ
authors.lastname: Stolar
authors.forename: Robert A
authors.initials: RA
authors.lastname: Cowles
mesh_terms: D000293:Adolescent; D002404:Catheterization / Q000379:methods*; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D007223:Infant; D008297:Male; D012042:Registries; D012131:Respiratory Insufficiency / Q000628:therapy*; D019233:Retreatment; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome