J Extra Corpor Technol 2024 , 56 , 94 – 100 Ó The Author ( s ), published by EDP Sciences , 2024 https :// doi . org / 10.1051 / ject / 2024009
Available online at : ject . edpsciences . org
ORIGINAL ARTICLE
Standardized therapies after ECMO program ( STEP ); a novel approach to pediatric post-ECMO care
Rebekah K . H . Shappley ( MD ) 1 , 2 , Christen M . Holder ( MD ) 3 , 4 , Constance E . Poplos ( MS ) 5 , Pilar Anton-Martin ( MD , PhD ) 6 , Thomas Spentzas ( MD , MS ) 1 , 2 , Toni M . Whitaker ( MD ) 7 , Swati Karmarkar ( MBBS ) 8 , Samir H . Shah ( MD , MBA ) 1 , 2 , and Hitesh S . Sandhu ( MBBS ) 1 , 2 ,*
1 Department of Pediatrics , Division of Critical Care , University of Tennessee Health Science Center , Memphis , TN 38103 , USA 2 Le Bonheur Children ’ s Hospital , Memphis , TN 38103 , USA 3 Department of Pediatrics , Division of Neurology , University of Tennessee Health Science Center , Memphis , TN 38103 , USA 4 Neuroscience Institute , Le Bonheur Children ’ s Hospital , Memphis , TN 38103 , USA 5 University of Tennessee Health Science Center , College of Medicine , Memphis , TN 38103 , USA 6 Department of Pediatrics , Children ’ s Hospital of Philadelphia , Philadelphia , PA 19104 , USA 7 Department of Pediatrics , Division of Development Pediatrics , University of Tennessee Health Science Center , Memphis , TN 38103 , USA 8 Baylor College of Medicine , Houston , TX 77030 , USA
Received 5 March 2024 , Accepted 13 May 2024
Abstract – Background : The study objective was to characterize compliance with Standardized Therapy after ECMO Program ( STEP ), an intentional discharge pathway for extracorporeal membrane oxygenation ( ECMO ) survivors in a US pediatric hospital . Methods : The program identified pediatric ECMO survivors before discharge , appropriate consultations were reviewed and requested , families were educated on ECMO sequelae , and ECMO summaries were sent to pediatricians . Compliance with institutional post-ECMO guidelines was evaluated before and after STEP implementation . Results : We identified 77 ECMO survivors to hospital discharge ( 36 [ 46.8 %] before and 41 [ 53.2 %] after STEP implementation ). There was a significant increase in complete ( 38.8 % vs . 74.2 %, p < 0.001 ) and time-appropriate neurodevelopmental testing ( 71.4 % vs . 95.6 %, p = 0.03 ). Significant increase in inpatient evaluations by neurology ( 52.7 % vs . 75.6 %, p = 0.03 ) and audiology ( 66.7 % vs . 87.8 %, p = 0.02 ), and in referrals for outpatient audiology ( 66.6 vs . 95.1 %, p = 0.002 ), physical therapy ( P . T .) ( 63.8 % vs . 95.1 %, p = 0.001 ), occupational therapy ( O . T .) ( 63.8 % vs . 95.1 %, p = 0.001 ) and speech-language pathology ( S . L . P .) ( 55.5 % vs . 95.1 %, p < 0.001 ) were noted . Conclusion : Implementing an intentional discharge pathway for pediatric ECMO survivors ( STEP ) successfully increases inpatient and outpatient compliance with hospital and Extracorporeal life support organization ( ELSO ) follow-up guidelines . It leads to timely and complete neurodevelopmental evaluation .
Key words : Pediatric ECMO , Follow-up care , Post-ECMO follow-up care , Intentional discharge pathway , ELSO , Neuro developmental follow-up .
Introduction
The expanding application of ECMO support has improved hospital discharge numbers and a growing realization that ECMO survivors have medical , developmental , and social needs that require early identification and structured follow-up [ 1 – 3 ]. ECMO has immediate risks ( e . g ., bleeding , thrombosis , cerebral hemorrhage , decreased hippocampus volume ) and long-term deficits [ 4 – 9 ]. While many patients thrive , some may demonstrate sequelae of critical illness , such as post-intensive care syndrome , with or without sequelae of ECMO itself .
* Corresponding author : hsandhu @ uthsc . edu
Children who survive ECMO are at risk for developmental delays and the “ growing into deficits ” phenomenon where effects of early subtle injuries are detected , especially when higher cognitive functions require those injured regions [ 2 , 3 , 10 – 13 ]. Neonates who develop appropriate motor skills may still be at risk for other deficits and need longer-term developmental follow-up . Other post-ECMO challenges include poor exercise tolerance , decreased respiratory function , and renal dysfunction [ 2 ]. Early identification and appropriate therapies can make a difference in long-term neurological outcomes , as shown by a randomized control trial that improved visuospatial memory in neonatal ECMO survivors after therapy [ 14 ].
Extracorporeal Life Support Organization ( ELSO ) first published follow-up guidelines in 1994 and updated them in 1997
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