(1686) Venoarterial ECMO for Pediatric Septic Shock: A Review of the ELSO Registry

Introduction: Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) may be used as salvage therapy for pediatric refractory septic shock. Data are limited to small studies; optimal patient selection, timing, and ECMO management are ill-defined. Our aims were to describe the current landscape of VA ECMO utilization for pediatric refractory septic shock and examine clinical variables associated with survival.

Methods: Retrospective analysis of the multicenter Extracorporeal Life Support Organization Registry database from 2016 to 2023 including children aged 29 days to 18 years old who received VA ECMO for sepsis/septic shock. Patients with >1 ECMO run or extracorporeal cardiopulmonary resuscitation were excluded. Data variables included demographics, ECMO pump flows, cannulation strategy, diagnoses, blood gas and hemodynamic data, and ECMO complications. The primary study outcome was survival to discharge.

Results: There were 338 patients included in the final analysis. Median age was 5.9 years [1.6-11.8] and 52% were male. Overall survival to discharge was 48%. Cardiac arrest prior to ECMO occurred in 33% of patients. Median ECMO duration was 107 hours [48-165]. Cannulation strategies were central (16%), peripheral (83%), or both (1%). Pediatric complex chronic conditions were present in 48% of patients. Pre-ECMO pH was 7.19 [7.07-7.29] and lactate 6.2 [3.8-11.6]. At 24 hours on ECMO, pH was 7.37 [7.31-7.41] and lactate 3.3 [2.0-7.0]. Pump flow was 99 cc/kg/min [76-123] at 24 hours. ECMO complications included mechanical (26%), hemorrhagic (21%), neurologic (33%), renal (52%), cardiovascular (14%), pulmonary (10%), and metabolic (20%). Survival was positively associated with older age (p < 0.001) and female gender (OR 1.641 [1.07-2.52]; p = 0.024), and negatively associated with pre-ECMO cardiac arrest (OR 0.491 [0.307-0.785]; p = 0.003), pH (p < 0.01), and lactate (p < 0.001) both pre-ECMO and at 24 hours on ECMO.

Conclusions: Our large cohort of VA ECMO for pediatric refractory septic shock revealed an overall survival of 48%. We identified key clinical variables associated with survival including age, gender, pre-ECMO arrest, pre-ECMO and on-ECMO lactic acidosis. Further research is needed to refine optimal patient selection and ECMO management.