Advertisement

ECMO Use in the Pediatric Immunocompromised Hematology/Oncology Patient

  • Robert A. NieblerEmail author
  • Leslie E. Lehmann
Chapter

Abstract

The use of extracorporeal membrane oxygenation (ECMO) has expanded dramatically since its introduction in the late 1970s. While hematologic or oncologic comorbidities were considered near absolute contraindications to ECMO only a decade ago, recent successful case reports and database reviews have indicated that ECMO has been and can be used successfully in this patient population. In this chapter we provide an introduction to ECMO with some of the important considerations regarding the circuitry/application. This is followed by a review of the current available literature regarding the use of ECMO in immunocompromised/oncology/hematopoietic stem cell transplant patients. Finally, we propose a process by which a clinician may approach the decision as to whether ECMO should be considered given the complex nature of each individual patient.

Keywords

Extracorporeal membrane oxygenation Pediatric Immunocompromised Hematology Oncology Hematopoietic stem cell transplant Sepsis Acute respiratory distress syndrome 

References

  1. 1.
    Baffes TG, Fridman JL, Bicoff JP, Whitehill JL. Extracorporeal circulation for support of palliative cardiac surgery in infants. Ann Thorac Surg. 1970;10(4):354–63.CrossRefGoogle Scholar
  2. 2.
    Hill JD, O’Brien TG, Murray JJ, Dontigny L, Bramson ML, Osborn JJ, Gerbode F. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med. 1972;286(12):629–34.CrossRefGoogle Scholar
  3. 3.
    Bartlett RH, Andrews AF, Toomasian JM, Haiduc NJ, Gazzaniga AB. Extracorporeal membrane oxygenation for newborn respiratory failure: forty-five cases. Surgery. 1982;92(2):425–33.PubMedGoogle Scholar
  4. 4.
    Extracorporeal Life Support Organization. ECLS registry report-international summary. 2017.Google Scholar
  5. 5.
    Barrett CS, Jaggers JJ, Cook EF, Graham DA, Yarlagadda VV, Teele SA, Almond CS, Bratton SL, Seeger JD, Dalton HJ, Rycus PT, Laussen PC, Thiagarajan RR. Pediatric ECMO outcomes: comparison of centrifugal versus roller blood pumps using propensity score matching. ASAIO J. 2013;59(2):145–51.CrossRefGoogle Scholar
  6. 6.
    O’Brien C, Monteagudo J, Schad C, Cheung E, Middlesworth W. Centrifugal pumps and hemolysis in pediatric extracorporeal membrane oxygenation (ECMO) patients: an analysis of extracorporeal life support organization (ELSO) registry data. J Pediatr Surg. 2017;52(6):975–8.CrossRefGoogle Scholar
  7. 7.
    Stanzel RD, Henderson M. Clinical evaluation of contemporary oxygenators. Perfusion. 2016;31(1):15–25.CrossRefGoogle Scholar
  8. 8.
    Kinsella JP, Gerstmann DR, Rosenberg AA. The effect of extracorporeal membrane oxygenation on coronary perfusion and regional blood flow distribution. Pediatr Res. 1992;31(1):80–4.CrossRefGoogle Scholar
  9. 9.
    Secker-Walker JS, Edmonds JF, Spratt EH, Conn AW. The source of coronary perfusion during partial bypass for extracorporeal membrane oxygenation (ECMO). Ann Thorac Surg. 1976;21(2):138–43.CrossRefGoogle Scholar
  10. 10.
    Gupta P, Robertson MJ, Beam B, Gossett JM, Schmitz ML, Carroll CL, Edwards JD, Fortenberry JD, Butt W. Relationship of ECMO duration with outcomes after pediatric cardiac surgery: a multi-institutional analysis. Minerva Anestesiol. 2015;81(6):619–27.PubMedGoogle Scholar
  11. 11.
    Schmidt M, Burrell A, Roberts L, Bailey M, Sheldrake J, Rycus PT, Hodgson C, Scheinkestel C, Cooper DJ, Thiagarajan RR, Brodie D, Pellegrino V, Pilcher D. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J. 2015;36(33):2246–56.CrossRefGoogle Scholar
  12. 12.
    Meyer DM, Jessen ME. Results of extracorporeal membrane oxygenation in children with sepsis. The extracorporeal life support organization. Ann Thorac Surg. 1997;63(3):756–61.CrossRefGoogle Scholar
  13. 13.
    Maclaren G, Butt W, Best D, Donath S, Taylor A. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution’s experience. Pediatr Crit Care Med. 2007;8(5):447–51.CrossRefGoogle Scholar
  14. 14.
    MacLaren G, Butt W, Best D, Donath S. Central extracorporeal membrane oxygenation for refractory pediatric septic shock. Pediatr Crit Care Med. 2011;12(2):133–6.CrossRefGoogle Scholar
  15. 15.
    Smalley N, MacLaren G, Best D, Paul E, Butt W. Outcomes in children with refractory pneumonia supported with extracorporeal membrane oxygenation. Intensive Care Med. 2012;38(6):1001–7.CrossRefGoogle Scholar
  16. 16.
    Roberts N, Westrope C, Pooboni SK, Mulla H, Peek GJ, Sosnowski AW, Firmin RK. Venovenous extracorporeal membrane oxygenation for respiratory failure in inotrope dependent neonates. ASAIO J. 2003;49(5):568–71.CrossRefGoogle Scholar
  17. 17.
    Zapol WM, Snider MT, Hill JD, Fallat RJ, Bartlett RH, Edmunds LH, Morris AH, Peirce EC 2nd, Thomas AN, Proctor HJ, Drinker PA, Pratt PC, Bagniewski A, Miller RG Jr. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA. 1979;242(20):2193–6.CrossRefGoogle Scholar
  18. 18.
    Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D. CESAR trial collaboration. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351–63.CrossRefGoogle Scholar
  19. 19.
    Tajik M, Cardarelli MG. Extracorporeal membrane oxygenation after cardiac arrest in children: what do we know? Eur J Cardiothorac Surg. 2008;33(3):409–17.CrossRefGoogle Scholar
  20. 20.
    Thiagarajan RR, Laussen PC, Rycus PT, Bartlett RH, Bratton SL. Extracorporeal membrane oxygenation to aid cardiopulmonary resuscitation in infants and children. Circulation. 2007;116(15):1693–700.CrossRefGoogle Scholar
  21. 21.
    Joffe AR, Lequier L, Robertson CM. Pediatric outcomes after extracorporeal membrane oxygenation for cardiac disease and for cardiac arrest: a review. ASAIO J. 2012;58(4):297–310.CrossRefGoogle Scholar
  22. 22.
    Yu HY, Yeh HL, Wang SS, Tsai MK, Chen YS, Ko WJ, Lin FY. Ultra long cardiopulmonary resuscitation with intact cerebral performance for an asystolic patient with acute myocarditis. Resuscitation. 2007;73(2):307–8.CrossRefGoogle Scholar
  23. 23.
    Barrett CS, Bratton SL, Salvin JW, Laussen PC, Rycus PT, Thiagarajan RR. Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation. Pediatr Crit Care Med. 2009;10(4):445–51.CrossRefGoogle Scholar
  24. 24.
    Conrad SJ, Bridges BC, Kalra Y, Pietsch JB, Smith AH. Extracorporeal cardiopulmonary resuscitation among patients with structurally normal hearts. ASAIO J. 2017;63(6):781–6.CrossRefGoogle Scholar
  25. 25.
    Muntean W. Coagulation and anticoagulation in extracorporeal membrane oxygenation. Artif Organs. 1999;23(11):979–83.CrossRefGoogle Scholar
  26. 26.
    Palmer K, Ehren H, Benz R, Frenckner B. Carmeda surface heparinization in neonatal ECMO systems: long-term experiments in a sheep model. Perfusion. 1995;10(5):307–13.CrossRefGoogle Scholar
  27. 27.
    Urlesberger B, Zobel G, Rodl S, Dacar D, Friehs I, Leschnik B, Muntean W. Activation of the clotting system: heparin-coated versus non coated systems for extracorporeal circulation. Int J Artif Organs. 1997;20(12):708–12.CrossRefGoogle Scholar
  28. 28.
    Silvetti S, Koster A, Pappalardo F. Do we need heparin coating for extracorporeal membrane oxygenation? New concepts and controversial positions about coating surfaces of extracorporeal circuits. Artif Organs. 2015;39(2):176–9.CrossRefGoogle Scholar
  29. 29.
    Bembea MM, Annich G, Rycus P, Oldenburg G, Berkowitz I, Pronovost P. Variability in anticoagulation management of patients on extracorporeal membrane oxygenation: an international survey. Pediatr Crit Care Med. 2013;14(2):e77–84. PMCID: PMC3567253.CrossRefGoogle Scholar
  30. 30.
    Agati S, Ciccarello G, Salvo D, Turla G, Undar A, Mignosa C. Use of a novel anticoagulation strategy during ECMO in a pediatric population: single-center experience. ASAIO J. 2006;52(5):513–6.PubMedGoogle Scholar
  31. 31.
    Urlesberger B, Zobel G, Zenz W, Kuttnig-Haim M, Maurer U, Reiterer F, Riccabona M, Dacar D, Gallisti S, Leschnik B, Muntean W. Activation of the clotting system during extracorporeal membrane oxygenation in term newborn infants. J Pediatr. 1996;129(2):264–8.CrossRefGoogle Scholar
  32. 32.
    Green TP, Isham-Schopf B, Steinhorn RH, Smith C, Irmiter RJ. Whole blood activated clotting time in infants during extracorporeal membrane oxygenation. Crit Care Med. 1990;18(5):494–8.CrossRefGoogle Scholar
  33. 33.
    Baird CW, Zurakowski D, Robinson B, Gandhi S, Burdis-Koch L, Tamblyn J, Munoz R, Fortich K, Pigula FA. Anticoagulation and pediatric extracorporeal membrane oxygenation: impact of activated clotting time and heparin dose on survival. Ann Thorac Surg. 2007;83(3):912–9; discussion 919–20.CrossRefGoogle Scholar
  34. 34.
    O’Meara LC, Alten JA, Goldberg KG, Timpa JG, Phillips J, Laney D, Borasino S. Anti-Xa directed protocol for anticoagulation management in children supported with extracorporeal membrane oxygenation. ASAIO J. 2015;61(3):339–44.CrossRefGoogle Scholar
  35. 35.
    Oliver WC. Anticoagulation and coagulation management for ECMO. Semin Cardiothorac Vasc Anesth. 2009;13(3):154–75.CrossRefGoogle Scholar
  36. 36.
    Niebler RA, Punzalan RC, Marchan M, Lankiewicz MW. Activated recombinant factor VII for refractory bleeding during extracorporeal membrane oxygenation. Pediatr Crit Care Med. 2010;11(1):98–102.CrossRefGoogle Scholar
  37. 37.
    Warren OJ, Rogers PL, Watret AL, de Wit KL, Darzi AW, Gill R, Athanasiou T. Defining the role of recombinant activated factor VII in pediatric cardiac surgery: where should we go from here? Pediatr Crit Care Med. 2009;10(5):572–82.CrossRefGoogle Scholar
  38. 38.
    Cengiz P, Seidel K, Rycus PT, Brogan TV, Roberts JS. Central nervous system complications during pediatric extracorporeal life support: incidence and risk factors. Crit Care Med. 2005;33(12):2817–24.CrossRefGoogle Scholar
  39. 39.
    Luyt CE, Brechot N, Demondion P, Jovanovic T, Hekimian G, Lebreton G, Nieszkowska A, Schmidt M, Trouillet JL, Leprince P, Chastre J, Combes A. Brain injury during venovenous extracorporeal membrane oxygenation. Intensive Care Med. 2016;42(5):897–907.CrossRefGoogle Scholar
  40. 40.
    Nasr DM, Rabinstein AA. Neurologic complications of extracorporeal membrane oxygenation. J Clin Neurol. 2015;11(4):383–9. PMCID: PMC4596114.CrossRefGoogle Scholar
  41. 41.
    Lorusso R, Gelsomino S, Parise O, Di Mauro M, Barili F, Geskes G, Vizzardi E, Rycus PT, Muellenbach R, Mueller T, Pesenti A, Combes A, Peek G, Frenckner B, Di Nardo M, Swol J, Maessen J, Thiagarajan RR. Neurologic injury in adults supported with veno-venous extracorporeal membrane oxygenation for respiratory failure: findings from the extracorporeal life support organization database. Crit Care Med. 2017;45(8):1389–97.CrossRefGoogle Scholar
  42. 42.
    Heard ML, Clark RH, Pettignano R, Dykes FD. Daily cranial ultrasounds during ECMO: a quality review/cost analysis project. J Pediatr Surg. 1997;32(8):1260–1.CrossRefGoogle Scholar
  43. 43.
    Khan AM, Shabarek FM, Zwischenberger JB, Warner BW, Cheu HW, Jaksic T, Goretsky MJ, Meyer TA, Doski J, Lally KP. Utility of daily head ultrasonography for infants on extracorporeal membrane oxygenation. J Pediatr Surg. 1998;33(8):1229–32.CrossRefGoogle Scholar
  44. 44.
    Bembea MM, Felling R, Anton B, Salorio CF, Johnston MV. Neuromonitoring during extracorporeal membrane oxygenation: a systematic review of the literature. Pediatr Crit Care Med. 2015;16(6):558–64.CrossRefGoogle Scholar
  45. 45.
    Gow KW, Lao OB, Leong T, Fortenberry JD. Extracorporeal life support for adults with malignancy and respiratory or cardiac failure: the extracorporeal life support experience. Am J Surg. 2010;199(5):669–75.CrossRefGoogle Scholar
  46. 46.
    Wohlfarth P, Ullrich R, Staudinger T, Bojic A, Robak O, Hermann A, Lubsczyk B, Worel N, Fuhrmann V, Schoder M, Funovics M, Rabitsch W, Knoebl P, Laczika K, Locker GJ, Sperr WR, Schellongowski P. Arbeitsgruppe fur hamato-onkologische Intensivmedizin der Osterreichischen Gesellschaft fur Internistische und Allgemeine Intensivmedizin und Notfallmedizin (OGIAIN). Extracorporeal membrane oxygenation in adult patients with hematologic malignancies and severe acute respiratory failure. Crit Care. 2014;18(1):R20. PMCID: PMC4055976CrossRefGoogle Scholar
  47. 47.
    Schmidt M, Schellongowski P, Patroniti N, Taccone FS, Reis Miranda D, Reuter J, Prodanovic H, Pierrot M, Dorget A, Park S, Balik M, Demoule A, Crippa IA, Mercat A, Wohlfarth P, Sonneville R, Combes A, International ECMO Network (ECMONet), the REVA Research Network and the IDEA Study Group. Six-month outcome of immunocompromised severe ARDS patients rescued by ECMO. An international multicenter retrospective study. Am J Respir Crit Care Med. 2018 Jan 3.Google Scholar
  48. 48.
    Smith S, Butt W, Best D, MacLaren G. Long-term survival after extracorporeal life support in children with neutropenic sepsis. Intensive Care Med. 2016;42(5):942–3.CrossRefGoogle Scholar
  49. 49.
    Huang M, Owen E, Myers S, Raj A. Cardiopulmonary failure requiring ECMO bypass resulting from leukemia cell lysis in a patient with childhood acute myelomonocytic leukemia. Case Rep Hematol. 2015;2015:640528. PMCID: PMC4466370.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Lueck C, Kuehn C, Hoeper MM, Ganser A, Eder M, Beutel G. Successful use of extracorporeal membrane oxygenation during induction chemotherapy in a patient with mediastinal tumor mass of a T lymphoblastic lymphoma. Ann Hematol. 2016;95(10):1719–21.CrossRefGoogle Scholar
  51. 51.
    Gow KW, Wulkan ML, Heiss KF, Haight AE, Heard ML, Rycus P, Fortenberry JD. Extracorporeal membrane oxygenation for support of children after hematopoietic stem cell transplantation: the extracorporeal life support organization experience. J Pediatr Surg. 2006;41(4):662–7.CrossRefGoogle Scholar
  52. 52.
    Di Nardo M, Locatelli F, Palmer K, Amodeo A, Lorusso R, Belliato M, Cecchetti C, Perrotta D, Picardo S, Bertaina A, Rutella S, Rycus P, Di Ciommo V, Holzgraefe B. Extracorporeal membrane oxygenation in pediatric recipients of hematopoietic stem cell transplantation: an updated analysis of the extracorporeal life support organization experience. Intensive Care Med. 2014;40(5):754–6.PubMedGoogle Scholar
  53. 53.
    Wohlfarth P, Beutel G, Lebiedz P, Stemmler HJ, Staudinger T, Schmidt M, Kochanek M, Liebregts T, Taccone FS, Azoulay E, Demoule A, Kluge S, Svalebjorg M, Lueck C, Tischer J, Combes A, Boll B, Rabitsch W, Schellongowski P. Intensive Care in Hematologic and Oncologic Patients (iCHOP), Caring for critically ill immunocompromised patients Multinational Network (NINE-I). Characteristics and outcome of patients after allogeneic hematopoietic stem cell transplantation treated with extracorporeal membrane oxygenation for acute respiratory distress syndrome. Crit Care Med. 2017;45(5):e500–7.CrossRefGoogle Scholar
  54. 54.
    Di Nardo M, Li Pira G, Amodeo A, Cecchetti C, Giorda E, Ceccarelli S, Brescia LP, Pirozzi N, Rutella S, Locatelli F, Bertaina A. Adoptive immunotherapy with antigen-specific T cells during extracorporeal membrane oxygenation (ECMO) for adenovirus-related respiratory failure in a child given haploidentical stem cell transplantation. Pediatr Blood Cancer. 2014;61(2):376–9.CrossRefGoogle Scholar
  55. 55.
    Di Nardo M, Locatelli F, Di Florio F, Cecchetti C, Amodeo A, Rutella S, Bertaina A. Extracorporeal membrane oxygenation as a bridge to allogeneic T-cell depleted hematopoietic stem cell transplantation in infants with severe combined immune deficiency: is it feasible? Intensive Care Med. 2014;40(10):1600–1.CrossRefGoogle Scholar
  56. 56.
    Schmidt M, Brodie D, Combes A. Patients with hematologic malignancies have many reasons to die during extracorporeal membrane oxygenation. Crit Care. 2014; 18(5): 522-014-0522-0. PMCID: PMC4163603.Google Scholar
  57. 57.
    Bailly DK, Reeder RW, Zabrocki LA, Hubbard AM, Wilkes J, Bratton SL, Thiagarajan RR. Extracorporeal life support organization member centers. Development and validation of a score to predict mortality in children undergoing extracorporeal membrane oxygenation for respiratory failure: pediatric pulmonary rescue with extracorporeal membrane oxygenation prediction score. Crit Care Med. 2017;45(1):e58–66. PMCID: PMC5532876.CrossRefGoogle Scholar
  58. 58.
    Wolfson RK, Kahana MD, Nachman JB, Lantos J. Extracorporeal membrane oxygenation after stem cell transplant: clinical decision-making in the absence of evidence. Pediatr Crit Care Med. 2005;6(2):200–3.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing 2019

Authors and Affiliations

  1. 1.Department of Pediatrics, Section of Critical CareMedical College of WisconsinMilwaukeeUSA
  2. 2.Department of Pediatric OncologyDana-Farber Cancer Institute/Boston Children’s HospitalBostonUSA

Personalised recommendations