498 - Bridge to Diagnosis: Should We Broaden Pediatric ECMO Indications?

Publication Number: 498.4556

Rafael A. Klein-Cloud, Cohen Children's Medical Center, Brooklyn, NY, United States; Todd Sweberg, Cohen Children's Medical Center, New Hyde Park, NY, United States; Jose M. Prince, Cohen Children's Medical Center, New Hyde Park, NY, United States; Naina Bagrodia, Cohen Children's Medical Center, New Hyde Park, NY, United States

Background: The Extracorporeal Life Support Organization states Extracorporeal Membrane Oxygenation (ECMO) is indicated for respiratory and/or cardiac failure with a “potentially reversible etiology.” Many institutional practices were to withhold ECMO if a reversible etiology was not diagnosed at the time of cannulation due to severe morbidity and resources involved with ECMO. Recently, the number of absolute contraindications for ECMO have been decreasing, and often patients are cannulated as a “bridge to diagnosis.”

Objective: To broaden the indications for pediatric ECMO support

Design/Methods: Retrospective single-center review including pediatric ( < 18 years) cannulated onto peripheral ECMO, analyzing years 2013-2014 (Early) and years 2023-2024 (Late). Patients pending discharge were excluded. Chart review was performed to identify whether the cannulation team knew the diagnosis at the time of cannulation. Chi squared analysis was performed using Microsoft Excel.

Results: 22 patients were cannulated in the Early group (2013-2014), and 40 patients were cannulated in the Late group (2023-2024), with one in the Late group excluded as discharge status is pending. 44/61 patients (72.1%) were cannulated onto venoarterial (VA) ECMO, and in the Early group 12/22 patients (54.5%) were cannulated onto VA ECMO, compared to 32/39 patients (82.1%) in the Late group. Extracorporeal cardiopulmonary resuscitation (ECPR) was performed 1 time in the Early group, and 7 times in the Late group. There was no difference in the rates of survival to discharge or transfer between the Early and Late groups (54.5% and 56.4%, respectively, p = 0.89). Overall, the diagnosis was known at the time of cannulation in 43/61 (70.5%) patients, with 22/22 patients (100%) in the Early group, and 22/39 patients (53.8%) in the Late group. On chi-squared analysis, knowledge of the diagnosis at the time of cannulation was not associated with survival to discharge or transfer (p = 0.58).

Conclusion(s): Compared to 10 years ago, our institution has been cannulating more patients onto ECMO with an unknown diagnosis at the time of cannulation, as a bridge to diagnosis and subsequent appropriate treatment. The data show that despite this trend of cannulating more patients without an established diagnosis, the rate of survival to discharge is unchanged. This is early evidence that diagnosis of a reversible cause should not be an absolute requirement for ECMO cannulation and indications may be broadened. Further study is needed to analyze why recent patients are being cannulated onto VA ECMO and requiring ECPR at higher rates.