Central extracorporeal membrane oxygenation for refractory pediatric septic shock

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. DESIGN: Retrospective case series. SETTING: Intensive care unit of a tertiary referral pediatric hospital. PATIENTS: Twenty-three children with refractory septic shock who received central ECMO primarily as circulatory support. INTERVENTIONS: Central ECMO. MEASUREMENTS AND MAIN 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.