RESUMEN
OBJECTIVES: In children with cardiac disease, common indications for extracorporeal membrane oxygenation (ECMO) include refractory cardiopulmonary resuscitation (E-CPR), failure to separate from cardiopulmonary bypass (OR-ECMO), and low cardiac output syndrome (LCOS-ECMO). Despite established acceptance, ECMO outcomes are suboptimal with a survival between 38% and 55%. We evaluated factors associated with significantly increased survival in cardiac patients requiring ECMO. METHODS: We conducted a retrospective investigation of consecutive patients undergoing ECMO between 2006 and 2010. Demographic, pre-ECMO, ECMO, and post-ECMO parameters were analyzed. Neurologic outcomes were assessed with the pediatric overall performance category scale at the latest follow-up. RESULTS: There were 3524 admissions, 95 (3%) of which necessitated ECMO; 40 (42%) E-CPR, 31 (33%) OR-ECMO, and 24 (25%) LCOS-ECMO. The overall hospital survival was 73%. The within-groups hospital survival was 75% in E-CPR, 77% OR-ECMO and 62% LCOS-ECMO. In the multivariable logistic regression analysis, chromosomal anomalies (odds ratio [OR], 8; 95% confidence interval [CI], 2-35), single ventricle (OR ,6; 95% CI, 3-33), multiple ECMO runs (OR, 15; 95% CI, 4-42), higher 24-hour ECMO flows (OR, 8; 95% CI, 4-22), decreased lung compliance (OR, 5; 95% CI, 2-16), and need for plasma exchange (OR, 5; 95% CI, 3-18) were all significant factors associated with mortality. From the univariate analysis, a common parameter associated with mortality within all groups was intracranial hemorrhage. At 1.9 years (0.9, 2.9) of follow-up, 66% were still alive, and 89% of survivors had normal function or only mild neurodevelopmental disability. CONCLUSIONS: ECMO was successfully used in children with cardiac disease with 73% and 66% short- and intermediate-term survival, respectively. The majority of the survivors had normal function or only a minimal neurodevelopmental deficit.
Asunto(s)
Oxigenación por Membrana Extracorpórea , Cardiopatías Congénitas/terapia , Factores de Edad , Distribución de Chi-Cuadrado , Desarrollo Infantil , Preescolar , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/mortalidad , Femenino , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/mortalidad , Mortalidad Hospitalaria , Humanos , Lactante , Recién Nacido , Modelos Logísticos , Masculino , Análisis Multivariante , Sistema Nervioso/crecimiento & desarrollo , Enfermedades del Sistema Nervioso/etiología , Enfermedades del Sistema Nervioso/fisiopatología , Oportunidad Relativa , Pennsylvania , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Postoperative tachyarrhythmias remain a common complication after congenital cardiac operations. Dexmedetomidine (DEX), an α-2 adrenoreceptor agonist, can have a therapeutic role in supraventricular tachyarrhythmias for cardioversion to sinus rhythm or heart rate control. Whether routine perioperative use of DEX decreases the incidence of supraventricular and ventricular tachyarrhythmias was studied. METHODS: In this prospective cohort study, 32 pediatric patients undergoing cardiothoracic operations received DEX and were compared with 20 control patients who did not receive DEX. RESULTS: Dexmedetomidine was started after anesthesia induction and continued intraoperatively and postoperatively for 38±4 hours (mean dose, 0.76±0.04 µg/kg/h). Ten control patients and 2 DEX patients sustained 16 episodes of tachyarrhythmias (p=0.001), including a 25% vs 0% (p=0.01) incidence of ventricular tachycardia and 25% vs 6% (p=0.05) of supraventricular arrhythmias in the control and DEX group, respectively. Transient complete heart block occurred in 2 control patients and in 1 DEX patient. Control patients had a higher heart rate (141±5 vs 127±3 beats/min, p=0.03), more sinus tachycardia episodes (40% vs 6%; p=0.008), required more antihypertensive drugs with nitroprusside (20±7 vs 4±1 µg/kg; p=0.004) and nicardipine (13±5 vs 2±1 µg/kg; p=0.02), and required more fentanyl (39±8 vs 19±3 µg/kg; p=0.005). CONCLUSIONS: Perioperative use of dexmedetomidine is associated with a significantly decreased incidence of ventricular and supraventricular tachyarrhythmias, without significant adverse effects.