Pediatric Respiratory Failure and Support With Prolonged Extracorporeal Membrane Oxygenation: Multicenter Cohort Using the Extracorporeal Life Support Organization Registry, 1989–2021

Abstract

OBJECTIVES: To characterize outcomes in children supported with 14 days or more of extracorporeal membrane oxygenation (ECMO) for respiratory indications. DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) registry. SETTING: ECMO centers contributing to the ELSO registry from 1989 to 2021. PATIENTS: Children of 1-18 years supported with ECMO for respiratory failure for 14 days or more. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 7334 children supported with ECMO for respiratory failure, and 1863 (25%) needed 14 days or more. Median patient age was 6.8 years, weight 23 kg, and overall survival was 50%. The median (interquartile range [IQR]) duration of ECMO was 22.5 days (IQR, 17.3-32.8 d). Survival was associated with shorter ECMO runs (21 vs. 24 d; p < 0.001), and shorter time from intubation to ECMO initiation (78 vs. 102 hr; p = 0.009). By duration, survival was: 54% for 14-28 days; 40% for 29-56 days; and 43% for less than 8-56 days. By duration of ECMO support, there was a nonlinear association between time and mortality, with an increase in risk of death up to 60 days, and a plateau thereafter (p < 0.001). Multivariable regression showed a greater risk of death with primary diagnoses of neoplasms and hematologic diseases, pre-ECMO renal support, higher oxygenation index, and presence of multiple complications. Also, year of ECMO support was associated with hospital mortality. CONCLUSIONS: In children of 1-18 years with prolonged ECMO runs for respiratory indications, there was an associated decline in survival with increasing duration of ECMO up to 60 days, and thereafter mortality rate plateaued. Accruing multiple complications on ECMO is also associated with increased odds of mortality. We suggest that a new definition of prolonged ECMO be 28 days, based on survival trends in this 1989-2021 ELSO dataset, and future prospective studies should capture more clinical data throughout their ECMO course to better determine patient prognosis.