title: Central extracorporeal membrane oxygenation for refractory pediatric septic shock.
abstract: OBJECTIVE
  To demonstrate positive outcome, to achieve higher flow rates, and to reverse shock more quickly by implementing central extracorporeal membrane oxygenation (ECMO) in children with refractory septic shock. Children hospitalized with sepsis have significant mortality rates. The development of shock is the most important risk factor for death. For children with septic shock refractory to all other forms of therapy, ECMO has been recommended but estimated survival is <50% and the best method of applying the technology is unknown. In recent years, our institutional practice has been to cannulate children with refractory septic shock directly through the chest (central, atrioaortic ECMO) to achieve higher blood flow rates.
  
  
  METHODS
  Retrospective case series.
  
  
  METHODS
  Intensive care unit of a tertiary referral pediatric hospital.
  
  
  METHODS
  Twenty-three children with refractory septic shock who received central ECMO primarily as circulatory support.
  
  
  METHODS
  Central ECMO.
  
  
  RESULTS
  The primary outcome measure was survival to hospital discharge. Pre-ECMO circulatory and ventilatory parameters, infecting organism, duration and complications of ECMO and length of hospital stay were also collected. Twenty-three patients (median: age, 6 yrs; weight, 20 kg) over a 9-yr period were included. All patients had microbiological evidence of infection, and meningococcemia was the most common diagnosis. Twenty-two (96%) patients had failure of at least three organ systems, and all patients received at least two inotropes with a mean inotrope score of 82.2 (sd, 115.6). Eight (35%) patients suffered cardiac arrest and required external cardiac massage before ECMO. Eighteen (78%) patients survived to be decannulated off ECMO, and 17 (74%) children survived to hospital discharge. Higher pre-ECMO arterial lactate levels were associated with increased mortality (11.7 mmol/L in nonsurvivors vs. 6.0 mmol/L in survivors, p = .007).
  
  
  CONCLUSIONS
  Central ECMO seems to be associated with better survival than conventional ECMO and should be considered by clinicians as a viable strategy in children with refractory septic shock.
authors.affiliation: Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia. gmaclaren@iinet.net.au
authors.forename: Graeme
authors.initials: G
authors.lastname: MacLaren
authors.forename: Warwick
authors.initials: W
authors.lastname: Butt
authors.forename: Derek
authors.initials: D
authors.lastname: Best
authors.forename: Susan
authors.initials: S
authors.lastname: Donath
mesh_terms: D002648:Child; D002675:Child, Preschool; D019992:Databases as Topic; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012772:Shock, Septic / Q000628:therapy*; D016019:Survival Analysis; D016896:Treatment Outcome; D014739:Victoria