Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation

Objectives: Extracorporeal membrane oxygenation (ECMO) to aid failed cardiopulmonary resuscitation (CPR) in children is associated with a high incidence of neurologic injury. We sought to identify risk factors for acute neurologic injury in children undergoing ECMO to aid CPR (E-CPR). Design: Retrospective cohort study using data reported to the Extracorporeal Life Support Organization registry. Setting: Multi-institutional data. Patients: Patients < 18 years of age undergoing E-CPR during 1992-2005. Interventions: None. Measurements and Results: We defined acute neurologic injury as the occurrence of brain death, brain infarction, or intracranial hemorrhage identified by ultrasound or computerized tomography imaging. Of 682 E-CPR patients, 147 (22%) patients had acute neurologic injury. Brain death occurred in 74 (11%), cerebral infarction in 45 (7%), and intracranial hemorrhage in 45 (7%). The in-hospital mortality rate in patients with acute neurologic injury was 89%. In a multivariable logistic regression model, pre-ECMO factors including cardiac disease (odds ratio [OR] 0.46 [95% confidence interval (CI) 0.28-0.76]) and pre-ECMO blood pH >= 6.865 (>= 6.865-7.120; OR 0.49 [95% CI 0.25-0.94]; pH > 7.120; OR 0.47 [95% CI 0.26-0.85]) compared with pH < 6.865 were associated with decreased odds of neurologic injury. During ECMO, neurologic injury was associated with ECMO complications including pulmonary hemorrhage (OR 1.93, 95% CI 1.1-3.4), dialysis use (OR 2.36, 95% CI 1.4-4.0), and CPR during ECMO support (OR 2.08, 95% CI 1.6-3.8). Conclusions: Neurologic injury is a frequent complication in children undergoing E-CPR. Children with cardiac disease, less severe metabolic acidosis before ECMO, and an uncomplicated ECMO course have decreased odds of sustaining neurologic injury. Providing effective CPR and inclusion of brain protective therapies on ECMO should be considered in the future to improve neurologic outcomes for patients undergoing E-CPR. (Pediatr Crit Care Med 2009;10:445-451)