It is unclear how extracorporeal membrane oxygenation use varies across paediatric cardiac surgical programmes and how it relates to post-operative mortality. We aimed to determine hospital-level variation in post-operative extracorporeal membrane oxygenation use and its association with case-mix adjusted mortality.

Retrospective analysis of 37 hospitals contributing to the Pediatric Cardiac Critical Care Consortium clinical registry from 1 August 2014 to 31 December 2019. Hospitalisations including cardiothoracic surgery and post-operative admission to paediatric cardiac ICUs were included. Two-level multivariable logistic regression with hospital random effect was used to determine case-mix adjusted post-operative extracorporeal membrane oxygenation use rates and in-hospital mortality. Hospitals were grouped into extracorporeal membrane oxygenation use tertiles, and mortality was compared across tertiles.

There were 43,640 eligible surgical hospitalisations; 1397 (3.2%) included at least one post-operative extracorporeal membrane oxygenation run. Case-mix adjusted extracorporeal membrane oxygenation rates varied more than sevenfold (0.9–6.9%) across hospitals, and adjusted mortality varied 10-fold (0–5.5%). Extracorporeal membrane oxygenation rates were 2.0%, 3.5%, and 5.2%, respectively, for low, middle, and high extracorporeal membrane oxygenation use tertiles (P < 0.0001), and mortality rates were 1.9%, 3.0%, and 3.1% (p < 0.0001), respectively. High extracorporeal membrane oxygenation use hospitals were more likely to initiate extracorporeal membrane oxygenation support intraoperatively (1.6% vs. 0.6% low and 1.1% middle, p < 0.0001). Extracorporeal membrane oxygenation indications were similar across hospital tertiles. When extracorporeal cardiopulmonary resuscitation was excluded, variation in extracorporeal membrane oxygenation use rates persisted (1.5%, 2.6%, 3.8%, p < 0.001).

There is hospital variation in adjusted post-operative extracorporeal membrane oxygenation use after paediatric cardiac surgery and a significant association with adjusted post-operative mortality. These findings suggest that post-operative extracorporeal membrane oxygenation use could be a complementary quality metric to mortality to assess performance of cardiac surgical programmes.

The safety of early post-operative cardiac catheterisation has been described following congenital heart surgery. Optimal timing of early post-operative cardiac catheterisation remains uncertain. The aim of this study was to describe the safety of early post-operative cardiac catheterisation and its impact on cardiac ICU and hospital length of stay, duration of mechanical ventilation, and extracorporeal support.

This single-centre retrospective cohort study compared clinical and outcome variables between “early” early post-operative cardiac catheterisation (less than 72 hours after surgery) and “late” early post-operative cardiac catheterisation (greater than 72 hours after surgery) groups using Chi-squared, Student’s t, and log-rank test (or appropriate nonparametric test).

In total, 132 patients were included, 22 (16.7%) “early” early post-operative cardiac catheterisation, and 110 (83.3%) “late” early post-operative cardiac catheterisation. Interventions were performed in 63 patients (51.5%), 7 (11.1%) early and 56 (88.9%) late. Complications of catheterisation occurred in seven (5.3%) patients, two early and five late. There were no major complications. Patients in the late group trended towards a longer stay in the cardiac ICU (19 days [7, 62] versus 11.5 days [7.2, 31.5], p = 0.6) and in the hospital (26 days [9.2, 68] versus 19 days [13.2, 41.8], p = 0.8) compared to the earlier group.

“Early” early post-operative cardiac catheterisation was associated with an overall low rate of complications. Earlier catheterisations trended towards shorter cardiac ICU and hospital length of stays. Earlier catheterisations may lead to earlier recovery for patients not following an expected post-operative course.

The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland’s (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care.

The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation.

Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide.

The C4 has played an integral role in the State of Maryland’s pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU.

Retrospective review of clinical characteristics and outcomes of children (aged 0–21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation.

One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation.

Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.

Bronchoscopic removal of a foreign body is a common emergency procedure in paediatric otolaryngology. It is potentially life-threatening, as complete airway obstruction caused by the foreign body can lead to hypoxic cardiac arrest during the manipulation of the object.

This paper presents a child who had aspirated a foreign body that could not be extracted conventionally via rigid bronchoscopy in the first instance. Subsequently, it was extracted at repeat bronchoscopy under controlled respiratory conditions maintained by an extracorporeal gas exchange circuit – extracorporeal membrane oxygenation, using a polypropylene hollow fibre oxygenator commonly employed in cardiac surgery (rather than a more expensive polymethyl pentene oxygenator commonly used in extracorporeal membrane oxygenation).

Extracorporeal membrane oxygenation use can be considered in exceptional cases of upper airway emergencies, even in resource-poor settings, and can avoid more hazardous thoracotomy and bronchotomy procedures.

To evaluate how key aspects of New York State Ventilator Allocation Guidelines (NYSVAG)—Sequential Organ Failure Assessment score criteria and ventilator time trials —might perform with respect to the frequency of ventilator reallocation and survival to hospital discharge in a simulated cohort of coronavirus disease (COVID-19) patients.

Single center retrospective observational and simulation cohort study of 884 critically ill COVID-19 patients undergoing ventilator allocation per NYSVAG.

In total, 742 patients (83.9%) would have had their ventilator reallocated during the 11-day observation period, 280 (37.7%) of whom would have otherwise survived to hospital discharge if provided with a ventilator. Only 65 (18.1%) of the observed surviving patients would have survived by NYSVAG. Extending ventilator time trials from 2 to 5 days resulted in a 49.2% increase in simulated survival to discharge.

In the setting of a protracted respiratory pandemic, implementation of NYSVAG or similar protocols could lead to a high degree of ventilator reallocation, including withdrawal from patients who might otherwise survive. Longer ventilator time trials might lead to improved survival for COVID-19 patients given their protracted respiratory failure. Further studies are needed to understand the survival of patients receiving reallocated ventilators to determine whether implementation of NYSVAG would improve overall survival.

We investigated the risk of increased nosocomial infections and the associated pathogens in patients who underwent paediatric cardiovascular surgery and were put on extracorporeal membrane oxygenation support. We studied the duration of extracorporeal membrane oxygenation use and other variables that may be associated with increased nosocomial infection risk.

Patients who were treated with an extracorporeal membrane oxygenation in paediatric cardiovascular surgery ICU between 2010 and 2020 were included in this retrospective study. We analysed the site of infection and microbiological profile of infections occurring in these patients according to CDC and National Healthcare Safety Network criteria.

The onset of infection development in patients after extracorporeal membrane oxygenation was found to be median 8 (3–15, 25–75 IQR) days in the whole group, and median 11 (3–16, 25–75 IQR) days in those who developed infection without being put on extracorporeal membrane oxygenation. When patients were divided into those with and without infection, duration of ICU was found to be 19 (16–28, IQR 25–75) days in patients with infection vs. 8 (2–16, IQR 25–75; p: <0.001) days in patients without infection. Duration of extracorporeal membrane oxygenation support was found to be 14 (10–25, IQR 25–75) days in patients with infection versus 5 (2–10, IQR 25–75; p: <0.001) days in patients without infection and total hospital stay was 26 (18–33, IQR 25–75) days in patients with infection versus 8 (2–23, IQR 25–75) days in those without infection. A total of 24 patients out of the 70 patients experienced 32 infectious episodes during extracorporeal membrane oxygenation support. Culture-positive infections were detected at a single site in 19 patients, and multiple sites in 5 patients.

We propose that prolonged extracorporeal membrane oxygenation support is associated with an increased risk of infection. Although extracorporeal membrane oxygenation is a life-saving treatment method, prolonged extracorporeal membrane oxygenation may increase the development of infectious complications and the associated mortality and morbidity of the patient.

Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a “hub and spoke” model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport. However, as ECMO centers and networks grow, the increasing number of transports will be limited by this mandate.

The aim of this study was to compare rates of adverse events occurring during transport of ECMO patients with and without an additional clinician, defined as a physician, nurse practitioner (NP), or physician assistant (PA).

This is a retrospective cohort study of all adults transported while cannulated on ECMO from 2011-2018 via ground and air between 21 hospitals in the northeastern United States, comparing transports with and without additional clinicians. The primary outcome was the rate of major adverse events, and the secondary outcome was minor adverse events.

Over the seven-year study period, 93 patients on ECMO were transported. Twenty-three transports (24.7%) were accompanied by a physician or other additional clinician. Major adverse events occurred in 21.5% of all transports. There was no difference in the total rate of major adverse events between accompanied and unaccompanied transports (P = .91). Multivariate analysis did not demonstrate any parameter as being predictive of major adverse events.

In a retrospective cohort study of transports of ECMO patients, there was no association between the overall rate of major adverse events in transport and the accompaniment of an additional clinician. No variables were associated with major adverse events in either cohort.