Childhood Obesity and Extracorporeal Membrane Oxygenation: Special Considerations for Successful Outcomes

Abstract

The effects of obesity on venoarterial extracorporeal membrane oxygenation (VA-ECMO) outcomes in pediatric population are unknown. We performed retrospective analysis of 41 children (age 2–18 years) undergoing VA-ECMO. The percentage difference between actual body weight and lean body weight, referred to as Δmass, was calculated. Ratios of Δmass to ECMO flow were calculated at 4 and 24 hours. In patients with Δmass:flow ≥ 0.1 at 4 hours, higher 24-hour lactates (20.0 vs. 14.5 mg/dL; p = 0.002) and inotrope scores (17.3 vs. 11.2; p = 0.015) were observed. However, elevated Δmass:flow was not associated with mortality, and in-hospital mortality rates between groups were similar (53 vs. 45%; p = 0.647). In obese pediatric patients requiring VA-ECMO, increased flow is necessary to avoid complications of hypoperfusion and related complications.

Keywords

VA-ECMO - obesity - children

• References

• 1 Paden ML, Conrad SA, Rycus PT, Thiagarajan RR ; ELSO Registry. Extracorporeal Life Support Organization Registry Report 2012. ASAIO J 2013; 59 (3) 202-210
• 2 Ehren H, Frenckner B, Palmér K. In-vitro evaluation of neonatal ECMO cannulae with regard to flow characteristics. Perfusion 1990; 5 (1) 45-51
• 3 Gander JW, Fisher JC, Reichstein AR , et al. Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem. J Pediatr Surg 2010; 45 (11) 2136-2140
• 4 Foley PJ, Morris RJ, Woo EY , et al. Limb ischemia during femoral cannulation for cardiopulmonary support. J Vasc Surg 2010; 52 (4) 850-853
• 5 Bisdas T, Beutel G, Warnecke G , et al. Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. Ann Thorac Surg 2011; 92 (2) 626-631
• 6 Read R, St Cyr J, Tornabene S, Whitman G. Improved cannulation method for extracorporeal membrane oxygenation. Ann Thorac Surg 1990; 50 (4) 670-671
• 7 Madershahian N, Nagib R, Wippermann J, Strauch J, Wahlers T. A simple technique of distal limb perfusion during prolonged femoro-femoral cannulation. J Card Surg 2006; 21 (2) 168-169
• 8 Spurlock DJ, Toomasian JM, Romano MA, Cooley E, Bartlett RH, Haft JW. A simple technique to prevent limb ischemia during veno-arterial ECMO using the femoral artery: the posterior tibial approach. Perfusion 2012; 27 (2) 141-145
• 9 Haley MJ, Fisher JC, Ruiz-Elizalde AR, Stolar CJH, Morrissey NJ, Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child. J Pediatr Surg 2009; 44 (2) 437-440
• 10 Saeed D, Stosik H, Islamovic M , et al. Femoro-femoral versus atrio-aortic extracorporeal membrane oxygenation: selecting the ideal cannulation technique. Artif Organs 2014; 38 (7) 549-555
• 11 Kanji HD, Schulze CJ, Oreopoulos A, Lehr EJ, Wang W, MacArthur RM. Peripheral versus central cannulation for extracorporeal membrane oxygenation: a comparison of limb ischemia and transfusion requirements. Thorac Cardiovasc Surg 2010; 58 (8) 459-462
• 12 Kurkluoglu M, Hynes CF, Alfares FA , et al. Choice of peripheral venoarterial extracorporeal membrane oxygenation cannulation site in patients above 15 kilograms. J Card Surg 2015; 30 (5) 461-465
• 13 Vander Salm TJ. Prevention of lower extremity ischemia during cardiopulmonary bypass via femoral cannulation. Ann Thorac Surg 1997; 63 (1) 251-252
• 14 Jackson KW, Timpa J, McIlwain RB , et al. Side-arm grafts for femoral extracorporeal membrane oxygenation cannulation. Ann Thorac Surg 2012; 94 (5) e111-e112
• 15 Cunningham SA, Kramer MR, Narayan KM. Incidence of childhood obesity in the United States. N Engl J Med 2014; 370 (5) 403-411
• 16 Al-Soufi S, Buscher H, Nguyen ND, Rycus P, Nair P. Lack of association between body weight and mortality in patients on veno-venous extracorporeal membrane oxygenation. Intensive Care Med 2013; 39 (11) 1995-2002
• 17 Hutagalung R, Marques J, Kobylka K , et al. The obesity paradox in surgical intensive care unit patients. Intensive Care Med 2011; 37 (11) 1793-1799
• 18 Hogue Jr CW, Stearns JD, Colantuoni E , et al. The impact of obesity on outcomes after critical illness: a meta-analysis. Intensive Care Med 2009; 35 (7) 1152-1170
• 19 Christiaens V, Lijnen HR. Angiogenesis and development of adipose tissue. Mol Cell Endocrinol 2010; 318 (1–2): 2-9
• 20 Hausman GJ, Richardson RL. Adipose tissue angiogenesis. J Anim Sci 2004; 82 (3) 925-934
• 21 Peters AM, Snelling HL, Glass DM, Bird NJ. Estimation of lean body mass in children. Br J Anaesth 2011; 106 (5) 719-723
• 22 Gaies MG, Gurney JG, Yen AH , et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med 2010; 11 (2) 234-238
• 23 Maclaren G, Butt W, Best D, Donath S, Taylor A. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution's experience. Pediatr Crit Care Med 2007; 8 (5) 447-451
• 24 MacLaren G, Butt W, Best D, Donath S. Central extracorporeal membrane oxygenation for refractory pediatric septic shock. Pediatr Crit Care Med 2011; 12 (2) 133-136
• 25 Stöhr F, Emmert MY, Lachat ML , et al. Extracorporeal membrane oxygenation for acute respiratory distress syndrome: is the configuration mode an important predictor for the outcome?. Interact Cardiovasc Thorac Surg 2011; 12 (5) 676-680
• 26 Ius F, Sommer W, Tudorache I , et al. Veno-veno-arterial extracorporeal membrane oxygenation for respiratory failure with severe haemodynamic impairment: technique and early outcomes. Interact Cardiovasc Thorac Surg 2015; 20 (6) 761-767
• 27 Morris MC, Ittenbach RF, Godinez RI , et al. Risk factors for mortality in 137 pediatric cardiac intensive care unit patients managed with extracorporeal membrane oxygenation. Crit Care Med 2004; 32 (4) 1061-1069
• 28 Mehta NM, Turner D, Walsh B , et al. Factors associated with survival in pediatric extracorporeal membrane oxygenation—a single-center experience. J Pediatr Surg 2010; 45 (10) 1995-2003