198 L . Gutiérrez-Soriano et al .: J Extra Corpor Technol 2023 , 55 , 197 – 200
Table 1 . Laboratory tests progression . Pre Sx : Presurgical ; IPP : Immediate postoperative period ; CNN : During cannulation ; ECMO : Once in ECMO .
Lab test |
Pre Sx |
IPP |
CNN |
ECMO |
Day 1 |
Day 2 |
Day 3 |
Day 4 |
Hemoglobin ( g / dL ) |
10.81 |
10 |
12 |
9 |
9.5 |
13 |
11 |
12 |
11.3 |
Hematocrit (%) |
33 |
29 |
33 |
22 |
25 |
42 |
32 |
36 |
31.4 |
pH |
7.46 |
7.53 |
7.17 |
7.19 |
6.7 |
7.13 |
7.37 |
7.4 |
7.3 |
pCO 2 ( mmHg ) |
18.7 |
8.7 |
7.4 |
13 |
58 |
58 |
33 |
33 |
58.5 |
pO 2 ( mmHg ) |
30.9 |
52 |
190 |
241 |
67 |
156 |
185 |
211 |
77.8 |
HCO 3 ( mEq / L ) |
21.8 |
13 |
6.7 |
8.2 |
7.8 |
21 |
19 |
21 |
29.1 |
BE ( mEq / L ) |
�1.2 |
15 |
�22 |
�20 |
�27 |
�6 |
�5.4 |
�3.7 |
1.9 |
SATO 2 (%) |
99.3 |
94 |
99 |
99 |
64 |
98 |
99 |
99 |
99 |
FiO 2 (%) |
50 |
100 |
100 |
100 |
100 |
100 |
100 |
100 |
80 |
Lactate ( mg / dL ) |
1 |
7.26 |
17 |
13.6 |
11 |
2.3 |
1.5 |
1.4 |
1.9 |
with a single dose of 43 s . The Ventricular septal defect was closed with a Gore-Tex patch ( G . Barco S . A , Bogota Colombia ) and primary surgical closure was performed to the atrial septal defect . The total perfusion and aortic clamp time was 76 min and 43 min respectively . The patient was weaned from bypass without complications and was transferred to the intensive care unit with mechanical ventilation and a norepinephrine dose of 0.02 mcg / kg / min , and laboratory results as seen in Table 1 in the immediate postoperative period .
Oxygen desaturation , bradycardia , and asystole were documented in the early perioperative period while the patient was in a respiratory therapy session . Immediately , high-quality CPR ( cardiopulmonary resuscitation ) was initiated and echocardiographic findings showed severe biventricular enlargement with akinesia of the right ventricle and hypokinesia of the left ventricle . Emergent sternotomy and open heart massage were performed achieving arterial blood pressures around 90 / 50 mmHg and 100 / 60 mmHg . Because of edema and heart enlargement , central cannulation for VA ECMO ( venoarterial ECMO ) was done after 1 h of cardiac arrest .
After VA ECMO was initiated , suboptimal flow was reached despite venous cannula manipulation and transfusion of RBC , ( red blood cells ) plasma and albumin administration . Anisocoria with nonreactive pupils was documented . After our inability to flow on ECMO as well as a very high lactate level , the decision was made to stop ECMO and return to CPR ( Table 1 ). After the venous cannula was removed and reinserted , optimal flow with the ECMO was reached and a new arterial blood sample was taken , showing a lactate of 13 . ECMO was resumed after 1 h and 30 min of cardiac arrest and lasted for 2 days . A neurological examination was performed .
The patient ’ s anisocoria resolved within 24 h of V-A ECMO support and lactate levels also decreased to normal ( Table 1 ). An LV Vent was added to the left ventricle because echocardiographic findings showed severe biventricular enlargement and dysfunction . Despite optimal anticoagulation , thrombosis of the vent was documented on the second day of support , requiring vent exchange . Transfontanel ultrasound was performed and shown to be normal , and on the third brain , tomography was also normal . A transthoracic Cardiac Echo showed biventricular function improving with an LVEF ( left ventricular ejection fraction ) of 40 % and two residual ventricular septal defects . Patient underwent decannulation and repair of the residual ventricular septal defect under cardiopulmonary bypass , with 60 min of aortic cross-clamp and 110 min of perfusion .
During the early post-operative ICU stay the patient was treated with milrinone , norepinephrine , and vasopressin infusions . ECMO therapy had a duration of two days , mechanical ventilatory weaning was done on day 24 and extubation was performed without complications . The patient was transferred to a general ward and then discharged home after 40 days . Mild abnormally low muscle tone was observed at discharge , without other neurological deficits , and with proper extremity movement .
Discussion
Pediatric in-hospital cardiac arrest ( IHCA ) has been reported in 1 – 3 % of pediatric intensive care units ( ICU ) admissions and up to 6 % of children admitted to a cardiac ICU [ 1 ]. In the last 25 years , the survival to hospital discharge after pediatric IHCA has improved from 9 % to 13.7 % and up to 35 % [ 2 , 3 ]. The improvement in outcomes was attributed partly to the impact of ECMO as a rescue strategy when prolonged conventional CPR cannot restore spontaneous circulation [ 1 ]. As shown by results from the large GWTG-R IHCA database , which included pediatric patients treated with at least 10 min of in-hospital CPR , showing that patients who received ECPR had higher odds of surviving to discharge than those who received prolonged conventional CPR [ 4 ].
In ECPR ( Extracorporeal Cardiopulmonary Resuscitation ) patients with sudden or unexpected pulselessness caused by the cessation of cardiac mechanical activity receive venoarterial extracorporeal membrane oxygenation ( VA-ECMO ). Extracorporeal life support organization ( ELSO ) and American Heart Association ( AHA ) guidelines now recognize ECPR as a technique that can be considered in select cardiac arrest patients . Refractory cardiac arrest is defined by the lack of return of spontaneous circulation within a period of at least 30 min of high-quality cardiopulmonary resuscitation ( CPR ). Two main factors impact the outcomes in these cases and the survival with ECPR ( Extracorporeal Cardiopulmonary Resuscitation ): The cause of arrest and the quality of resuscitation . Better outcomes have been seen when ECPR is implemented within the first 30 min of arrest [ 4 ]. ECPR in pediatric patients has been recommended in children with heart disease when the