Showing papers by "Ravi R. Thiagarajan published in 2013"
TL;DR: Summary data from the annual international Extracorporeal Life Support Organization (ELSO) Registry Reports through July 2012 are presented, showing use of ECLS for cardiac support represents a large area of consistent growth.
Abstract: In this article, summary data from the annual international Extracorporeal Life Support Organization (ELSO) Registry Reports through July 2012 are presented. Nearly 51,000 patients have received extracorporeal life support (ECLS). Of the patients, 50% (>25,000) were neonatal respiratory failure, with a 75% overall survival to discharge or transfer. Congenital diaphragmatic hernia remains a major use of ECLS in this population with 51% survival. Extracorporeal life support use for pediatric respiratory failure has nearly doubled since 2000, with approximately 350 patients treated per year in the past 3 years examined (56% survival). Previously stable at about 100 cases a year for a decade, adult respiratory failure ECLS cases increased dramatically in 2009 with the H1N1 influenza pandemic and publication of the Conventional ventilation or ECMO for Severe Adult Respiratory failure (CESAR) trial results and have remained at approximately 400 cases a year through 2011 (55% survival). Use of ECLS for cardiac support represents a large area of consistent growth. Approximately 13,000 patients have been treated with survival to discharge rates of 40%, 49%, and 39% for neonates, pediatric, and adults, respectively.
568 citations
TL;DR: Patient factors, pre-ECMO severity of illness, and use of veno-arterial ECMO are associated with increased neurologic complications, and patient selection, early ECMO deployment, and refining ECMO management strategies for vulnerable populations could be targeted as areas for improvement in neonatal ECMO.
Abstract: Neurologic complications in neonates supported with extracorporeal membrane oxygenation (ECMO) are common and diminish their quality of life and survival. An understanding of factors associated with neurologic complications in neonatal ECMO is lacking. The goals of this study were to describe the epidemiology and factors associated with neurologic complications in neonatal ECMO. Retrospective cohort study of neonates (age ≤30 days) supported with ECMO using data reported to the Extracorporeal Life Support Organization during 2005–2010. Of 7,190 neonates supported with ECMO, 1,412 (20 %) had neurologic complications. Birth weight <3 kg [odds ratio (OR): 1.3; 95 % confidence intervals (CI): 1.1–1.5], gestational age (<34 weeks; OR 1.5, 95 % CI 1.1–2.0 and 34–36 weeks: OR 1.4, 95 % CI 1.1–1.7), need for cardiopulmonary resuscitation prior to ECMO (OR 1.7, 95 % CI 1.5–2.0), pre-ECMO blood pH ≤ 7.11 (OR 1.7, 95 % CI 1.4–2.1), pre-ECMO bicarbonate use (OR 1.3, 95 % CI 1.2–1.5), prior ECMO exposure (OR 2.4, 95 % CI 1.6–2.6), and use of veno-arterial ECMO (OR 1.7, 95 % CI 1.4–2.0) increased neurologic complications. Mortality was higher in patients with neurologic complications compared to those without (62 % vs. 36 %; p < 0.001). Neurologic complications are common in neonatal ECMO and are associated with increased mortality. Patient factors, pre-ECMO severity of illness, and use of veno-arterial ECMO are associated with increased neurologic complications. Patient selection, early ECMO deployment, and refining ECMO management strategies for vulnerable populations could be targeted as areas for improvement in neonatal ECMO.
145 citations
TL;DR: In a propensity score-matched cohort of pediatric ECMO patients, children supported with centrifugal pumps had increased odds of ECMO-related complications and survival to hospital discharge did not differ by pump type.
Abstract: Centrifugal blood pumps are being increasingly utilized in children supported with extracorporeal membrane oxygenation (ECMO). Our aim was to determine if survival and ECMO-related morbidities in children supported with venoarterial (VA) ECMO differed by blood pump type.Children aged less than 18 years who underwent VA ECMO support from 2007 to 2009 and reported to the Extracorporeal Life Support Organization registry were propensity score matched (Greedy 1:1 matching) using pre-ECMO characteristics.A total of 2,656 (centrifugal = 2,231, roller = 425) patients were identified and 548 patients (274 per pump type) were included in the propensity score-matched cohort. Children supported with centrifugal pumps had increased odds of hemolysis (odds ratio [OR], 4.03 95% confidence interval [CI], 2.37-6.87), hyperbilirubinemia (OR, 5.48; 95% CI, 2.62-11.49), need for inotropic support during ECMO (OR, 1.54; 95% CI, 1.09-2.17), metabolic alkalosis (blood pH > 7.6) during ECMO (OR, 3.13; 95% CI, 1.49-6.54), and acute renal failure (OR, 1.61; 95% CI, 1.10-2.39). Survival to hospital discharge did not differ by pump type.In a propensity score-matched cohort of pediatric ECMO patients, children supported with centrifugal pumps had increased odds of ECMO-related complications. There was no difference in survival between groups.
77 citations
TL;DR: Although moderate to severe CHS-AKI is independently associated with prolonged recovery after heart surgery, mild disease does not appear to be.
72 citations
TL;DR: Cardiothoracic surgery trainees found a contextualized ECMO cannulation during cardiopulmonary resuscitation cannulation curriculum to be highly useful and demonstrated sustained improvement in time to cannulation, CECS, and GRS.
Abstract: Introduction American Heart Association guidelines recommend timely extracorporeal membrane oxygenation (ECMO) cannulation during cardiopulmonary resuscitation for pediatric cardiac arrest refractory to conventional resuscitation. Traditional cannulation training relies on the apprenticeship model. We hypothesized that a simulation-based ECMO cannulation curriculum featuring a novel integrated skills trainer would improve ECMO cannulation during cardiopulmonary resuscitation performance by cardiothoracic surgery trainees. Methods An embedded surgical neck cannulation trainer, designed in collaboration with expert surgeons, formed the focus for a simulation-based cannulation curriculum. The course included a didactic presentation and 2 neck cannulations during cardiopulmonary resuscitation with video-assisted expert feedback with a further cannulation at 3 months. Primary outcome was time to cannulation on the trainer. Secondary outcomes were performance on a validated Global Rating Scale (GRS) of surgical technique and a novel Composite ECMO Cannulation Score (CECS). Results Ten cardiothoracic surgery trainees participated. The trainer was rated as authentic, and sessions was rated as highly useful. Median time to cannulation decreased between cannulation 1 and 2 (15 minutes 24 seconds vs. 12 minutes 15 seconds, P = 0.002). Improvement was sustained at 3 months (13 minutes 36 seconds, P = 0.157 vs. attempt 2). Likewise, GRS increased significantly at attempt 2 versus 1 (77% vs. 62%, P = 0.003) as did CECS (88% vs. 52%, P = 0.002). No deterioration in GRS or CECS was measured at 3 months. Conclusions Cardiothoracic surgery trainees found a contextualized ECMO cannulation during cardiopulmonary resuscitation cannulation curriculum to be highly useful and demonstrated sustained improvement in time to cannulation, CECS, and GRS. Further work will focus on determining the clinical impact of this training and defining the optimal interval and number of training sessions.
65 citations
TL;DR: A clear understanding of survival to discharge and long-term functional and neurologic outcomes are essential to guide the use of extracorporeal membrane oxygenation now and in the future.
Abstract: Extracorporeal membrane oxygenation is a commonly used form of mechanical circulatory support in children with congenital or acquired heart disease and cardiac failure refractory to conventional medical therapies. In children with heart disease who suffer cardiac arrest, extracorporeal membrane oxygenation has been successfully used to provide cardiopulmonary support when conventional resuscitation has failed to establish return of spontaneous circulation. Survival to hospital discharge for children with heart disease support is approximately 40% but varies widely based on age, indication for support, and underlying cardiac disease. Although extracorporeal membrane oxygenation is lifesaving in many instances, it is associated with many complications and is expensive. Thus, a clear understanding of survival to discharge and long-term functional and neurologic outcomes are essential to guide the use of extracorporeal membrane oxygenation now and in the future. This review, part of the Pediatric Cardiac Intensive Care Society/Extracorporeal Life Support Organization Joint Statement on Mechanical Circulatory Support, summarizes current knowledge on short- and long-term outcomes for extracorporeal membrane oxygenation used to support children with cardiac disease.
50 citations
TL;DR: Assessment of associated factors, outcomes, and variability in the use of PDC in patients who have undergone cardiac surgery found the possible benefit of earlier intervention for peritoneal access in this high-risk cohort is needed.
25 citations
19 citations
TL;DR: Transcatheter treatment can relieve superior vena cava obstruction and facilitate symptomatic improvement in neonates treated with extracorporeal membrane oxygenation, and is associated with an increased risk of chylothorax.
Abstract: BACKGROUND Obstruction of the superior vena cava is one of the potential complications of neonatal extracorporeal membrane oxygenation. Chylothorax is a known complication of surgery involving the thoracic cavity in children, and of extracorporeal membrane oxygenation. The aim of this study was to evaluate the association between chylothorax and superior vena cava obstruction after neonatal extracorporeal membrane oxygenation. METHODS AND RESULTS Twenty-two patients diagnosed with superior vena cava obstruction at ≤ 6 months of age (median 1.8 months) after neonatal extracorporeal membrane oxygenation were compared with a randomly selected cohort of 44 neonatal extracorporeal membrane oxygenation patients without superior vena cava obstruction. Among patients with superior vena cava obstruction, 18 underwent extracorporeal membrane oxygenation for respiratory disease and four for cardiac insufficiency. Chylothorax was more prevalent among patients with superior vena cava obstruction than controls (odds ratio 9.4 [2.2-40], p = .01) and was associated with extension of obstruction into the left innominate vein. Patients with superior vena cava obstruction were supported by extracorporeal membrane oxygenation for a longer duration than controls. Nineteen patients with superior vena cava obstruction (86%) underwent transcatheter balloon angioplasty and/or stent implantation (median 7 days after diagnosis), which decreased the superior vena cava pressure and superior vena cava-to-right atrium pressure gradient and increased the superior vena cava diameter (all p < 0.001). There were no serious procedural adverse events. Six study patients died within 30 days of the diagnosis of superior vena cava obstruction (including three of nine with chylothorax), which did not differ from controls. During a median follow-up of 2.7 yrs, two additional patients died and nine underwent 14 superior vena cava reinterventions. CONCLUSIONS Among neonates treated with extracorporeal membrane oxygenation, superior vena cava obstruction is associated with an increased risk of chylothorax. In neonates with chylothorax after extracorporeal membrane oxygenation, evaluation for superior vena cava obstruction may be warranted. Although mortality is high in this population, transcatheter treatment can relieve superior vena cava obstruction and facilitate symptomatic improvement.
12 citations
TL;DR: Prospective trials are needed to assess appropriate indications and timing of postoperative peritoneal dialysis catheter placement, with consideration of more aggressive treatment for intraabdominal hypertension.
10 citations
Journal Article•
TL;DR: The authors suggest that age-specific differences in outcomes after out-of-hospital cardiac arrests should be considered, as well as the importance of training in cardiopulmonary resuscitation and automated external defibrillation in schools, as a science advisory from the American Heart Association.
Abstract: 224 www.pccmjournal.org February 2013 • Volume 14 • Number 2 in-hospital ventricular fibrillation in children. N Engl J Med 2006; 354:2328–2339 5. Atkins DL, Everson-Stewart S, Sears GK, et al; Resuscitation Outcomes Consortium Investigators: Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation 2009; 119:1484–1491 6. Donoghue AJ, Nadkarni V, Berg RA, et al; CanAm Pediatric Cardiac Arrest Investigators: Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med 2005; 46:512–522 7. Herlitz J, Svensson L, Engdahl J, et al: Characteristics of cardiac arrest and resuscitation by age group: an analysis from the Swedish Cardiac Arrest Registry. Am J Emerg Med 2007; 25:1025–1031 8. Akahane M, Tanabe S, Ogawa T, et al: Characteristics and Outcomes of Pediatric Out-of-Hospital Cardiac Arrest by Scholastic Age Category. Pediatr Crit Care Med 2013; 14:130–136 9. Kitamura T, Iwami T, Kawamura T, et al; implementation working group for All-Japan Utstein Registry of the Fire and Disaster Management Agency: Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet 2010; 375:1347–1354 10. Nitta M, Iwami T, Kitamura T, et al; Utstein Osaka Project: Age-specific differences in outcomes after out-of-hospital cardiac arrests. Pediatrics 2011; 128:e812–e820 11. Cave DM, Aufderheide TP, Beeson J, et al; American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular Diseases in the Young; Council on Cardiovascular Nursing; Council on Clinical Cardiology, and Advocacy Coordinating Committee: Importance and implementation of training in cardiopulmonary resuscitation and automated external defibrillation in schools: a science advisory from the American Heart Association. Circulation 2011; 123:691–706
01 Jan 2013
TL;DR: Right Ventricle–to–Pulmonary Artery Conduit Outcomes After Bidirectional Glenn Operation: Blalock-Taussig Shunt Versushttp://ats.ctsnetjournals.org/cgi/content/full/83/5/1768 located on the World Wide Web at: the online version of this article, along with updated information and services, is.
Abstract: DOI:€10.1016/j.athoracsur.2006.11.076 Ann Thorac Surg 2007;83:1768-1773 Pedro J. del Nido, John E. Mayer and Ravi R. Thiagarajan Lillian Lai, Peter C. Laussen, Clifford L. Cua, David L. Wessel, John M. Costello,Right Ventricle–to–Pulmonary Artery Conduit Outcomes After Bidirectional Glenn Operation: Blalock-Taussig Shunt Versushttp://ats.ctsnetjournals.org/cgi/content/full/83/5/1768 located on the World Wide Web at: The online version of this article, along with updated information and services, is