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Defining benefit threshold for extracorporeal membrane oxygenation in children with sepsis—a binational multicenter cohort study

Authors
  • Schlapbach, Luregn J.1, 2, 3
  • Chiletti, Roberto4, 5
  • Straney, Lahn1, 6
  • Festa, Marino7, 8
  • Alexander, Daniel9
  • Butt, Warwick5
  • MacLaren, Graeme5, 10
  • Ganeshalingam, Anusha
  • Sherring, Claire
  • Erickson, Simon
  • Barr, Samantha
  • Schibler, Andreas
  • Long, Debbie
  • Schlapbach, Luregn
  • Alexander, Jan
  • George, Shane
  • Williams, Gary
  • Smith, Vicky
  • Butt, Warwick
  • Delzoppo, Carmel
  • And 8 more
  • 1 The University of Queensland, Brisbane, Australia , Brisbane (Australia)
  • 2 Queensland Children’s Hospital, South Brisbane, QLD, 4101, Australia , South Brisbane (Australia)
  • 3 University of Bern, Bern, Switzerland , Bern (Switzerland)
  • 4 University of Melbourne, Melbourne, Australia , Melbourne (Australia)
  • 5 The Royal Children’s Hospital, Melbourne, Australia , Melbourne (Australia)
  • 6 Monash University, Melbourne, Australia , Melbourne (Australia)
  • 7 Children’s Hospital Westmead, Sydney, Australia , Sydney (Australia)
  • 8 Kids Critical Care Research Group, Kids Research, Sydney Children’s Hospitals Network, Sydney, Australia , Sydney (Australia)
  • 9 Perth Children’s Hospital, Perth, Australia , Perth (Australia)
  • 10 National University Health System, Singapore, Singapore , Singapore (Singapore)
Type
Published Article
Journal
Critical Care
Publisher
BioMed Central
Publication Date
Dec 30, 2019
Volume
23
Issue
1
Identifiers
DOI: 10.1186/s13054-019-2685-1
Source
Springer Nature
Keywords
License
Green

Abstract

BackgroundThe surviving sepsis campaign recommends consideration for extracorporeal membrane oxygenation (ECMO) in refractory septic shock. We aimed to define the benefit threshold of ECMO in pediatric septic shock.MethodsRetrospective binational multicenter cohort study of all ICUs contributing to the Australian and New Zealand Paediatric Intensive Care Registry. We included patients < 16 years admitted to ICU with sepsis and septic shock between 2002 and 2016. Sepsis-specific risk-adjusted models to establish ECMO benefit thresholds with mortality as the primary outcome were performed. Models were based on clinical variables available early after admission to ICU. Multivariate analyses were performed to identify predictors of survival in children treated with ECMO.ResultsFive thousand sixty-two children with sepsis and septic shock met eligibility criteria, of which 80 (1.6%) were treated with veno-arterial ECMO. A model based on 12 clinical variables predicted mortality with an AUROC of 0.879 (95% CI 0.864–0.895). The benefit threshold was calculated as 47.1% predicted risk of mortality. The observed mortality for children treated with ECMO below the threshold was 41.8% (23 deaths), compared to a predicted mortality of 30.0% as per the baseline model (16.5 deaths; standardized mortality rate 1.40, 95% CI 0.89–2.09). Among patients above the benefit threshold, the observed mortality was 52.0% (13 deaths) compared to 68.2% as per the baseline model (16.5 deaths; standardized mortality rate 0.61, 95% CI 0.39–0.92). Multivariable analyses identified lower lactate, the absence of cardiac arrest prior to ECMO, and the central cannulation (OR 0.31, 95% CI 0.10–0.98, p = 0.046) as significant predictors of survival for those treated with VA-ECMO.ConclusionsThis binational study demonstrates that a rapidly available sepsis mortality prediction model can define thresholds for survival benefit in children with septic shock considered for ECMO. Survival on ECMO was associated with central cannulation. Our findings suggest that a fully powered RCT on ECMO in sepsis is unlikely to be feasible.

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