THE IMPACT OF EXTRACORPOREAL MEMBRANE-OXYGENATION ON SURVIVAL IN PEDIATRIC-PATIENTS WITH ACUTE RESPIRATORY-FAILURE

Objective: Extracorporeal membrane oxygenation (ECMO) has been used wi th increasing frequency in the treatment of acute respiratory failure in pediatric patients. Our objective in this study was to test the hyp othesis that ECMO improves outcome in pediatric patients with acute re spiratory failure. Design: Multicenter, retrospective cohort analysis. Setting: Forty one pediatric intensive care units participated in the study under the auspices of the Pediatric Critical Care Study Group. Patients: All pediatric patients admitted to the participating institu tions with acute respiratory failure during 1991 were included. Patien ts with congenital heart disease, contraindications to ECMO, or incomp lete data were excluded, yielding a data set of 331 patients from 32 h ospitals. Interventions: Conventional mechanical ventilation, high-fre quency ventilation, and extracorporeal membrane oxygenation. Measureme nts and Main Results: Multivariate logistic regression analysis was us ed to identify factors associated with survival, In a second analysis, pairs of ECMO and non-ECMO patients, matched by severity of disease a nd respiratory diagnosis, were compared. The use of ECMO (p =.0082), b ut not the use of high-frequency ventilation, was associated with a re duction in mortality. Other factors independently associated with mort ality included oxygenation index (p < .0001). Pediatric Risk of Mortal ity score (PRISM) (p < .0001) and the Pace(2) (p = .045). In 53 diagno sis- and risk-matched pairs, there was a significantly lower mortality rate (26.4% vs. 47.2%; p < .01) in the ECMO-treated patients. When al l patients were stratified into mortality risk quartiles on the basis of oxygenation index and PRISM score, the proportion of deaths among E CMO treated patients in the 50% to 75% mortality risk quartile was les s than half the proportion in the non-ECMO treated patients (28.6% vs, 71.4%; p < .05). No effect was seen in the other quartiles. Conclusio ns: The use of ECMO was associated with an improved survival in pediat ric patients with respiratory failure. The lack of association of outc ome with treatment in the ECMO-capable hospital or with another tertia ry technology (i.e., high-frequency ventilation) suggests that ECMO it self was responsible for the improved outcome. Further studies of this procedure are warranted but require broad-based multi-institutional p articipation to provide sufficient statistical power and sensitivity t o demonstrate efficacy.