Introduction ECMO for Pediatric Oncology Patients Case · Introduction Case ECMO for Pediatric...
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Hypoxemic Respiratory Arrest Requiring Extracorporreal Membrane Oxygenation in a Patient with Metastatic Alveolar Rhabdomyosarcoma Ethan L Sanford 1,2 , Traci Wolbrink 3 , Jennifer Mack 4 , Robert G Rowe 4 1 Boston Combined Residency Program in Pediatrics; 2 Brigham and Women’s Hospital Department of Anesthesiology; 3 Boston Children’s Hospital Department of Anesthesia and Critical Care; 4 Dana-Farber Boston Children’s Cancer and Blood Disorders Center Introduction Case ECMO for Pediatric Oncology Patients References 1) Gray BW, Haft JW, Hirsch JC, Annich GM, Hirschl RB, Bartlett RH.. Extracorporeall Life support: experience with 2,000 patients. Extracorporeal life support: experience with 2,000 patien 2) Zabrocki LA, Brogan TV, Statler KD, Poss WB, Rollins MD, Bratton SL. Extracorporeal membrane oxygenation for pediatric respiratory failure: survival and predictors of mortality. Crit Ca 3) 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 Support Organization experience. Pediatr Surg 2006; 41:662-667. • At initial diagnosis, diffuse bone marrow involvement (Below, panels A-C) and a FDG avid soft tissue lesion on PET scan was noted (Right). • Two days after initiation of standard chemotherapy with irinotican and vincristine patient presented in respiratory distress. Chest Xray demonstrated R>L opacification of the lung fields (Right). • Continued, rapid deterioration lead to intubation and placement of bilateral chest tubes which evacuated copious serous fluids. • Hypoxemic respiratory arrest during suctioning prompted prolonged resuscitation. Conclusion • Uncertain or poor long-term prognosis for pediatric oncology patients has led to ambiguity regarding when to offer ECMO. • Expansion of ECMO use will lead to increased perioperative implications • How practitioners assess prognosis, individual disease characteristics, prolongation of life, patient/parent wishes, and reversibility of acute illness remains an evolving topic worthy of further investigation. Our case indicates that careful selection can lead to successful outcomes. An 8 year-old male with metastatic alveolar rhabdomyosarcoma (ARMS) presented to our institution and suffered precipitous cardiopulmonary collapse with severe tumor lysis syndrome (TLS) 48 hours after initiation of chemotherapy Hypoxemic respiratory arrest prompted prolonged resuscitation efforts and ultimately extracorporreal membrane oxygenation (ECMO) was initiated. The use of ECMO in pediatric oncology patients is controversial as prognosis, morbidity, and resource limitations must be considered. • Offering ECMO to patients with cancer is controversial and there are no standardized criteria on appropriate use • Multiple considerations • Disease prognosis • Reversibility of acute illness • Morbidity associated with treatments • Appropriate use of resources • Reported mortality for pediatric patients receiving ECMO lower (27-43%) 1,2 than in adults (54%) • Higher mortality and morbidity in oncologic/immunosupressed patients (65-70%) 3 • Despite concerns for short and long term mortality/complications, 95% of centers indicated they would consider use of ECMO in pediatric malignancy 3 • VV-ECMO was established, but continued hemodynamic instability lead to cannulation to VA-ECMO • Small, atypical cells found in tracheal and chest tube aspirates (Left, panel D) • Hemodynamics and lung compliance improved over several days • Patient received chemotherapy while on ECMO • Patient taken to OR for decannulation and repair of the femoral artery • OR course complicated by hypoxemia • ICU ventilator requested, anesthesia team and respiratory therapist coordinate ventilation strategy • Decannulation successful • Patient extubated ~ 1 week later • Most recent screening PET scan and bone marrow biopsy shows remission of disease • Deconditioning and mild anxiety are most pertinent complications • There are limited guidelines regarding ECMO management in the OR setting especially in the setting of dynamic pulmonary and cardiovascular changes • Indications for ECMO use will likely continue to expand and disease states are managed more effectively • Anesthesiologist must be trained in ECMO specific considerations • In our case, the 5-year survival of metastatic ARMS is approximately 20%, but approximately 65% of such patients are alive at two years with modern treatment. • Despite concerns over prognosis single organ involvement and the opportunity for life prolongation and/or disease survival prompted use of all available resources including ECMO
Transcript of Introduction ECMO for Pediatric Oncology Patients Case · Introduction Case ECMO for Pediatric...
Hypoxemic Respiratory Arrest Requiring Extracorporreal Membrane Oxygenation in a Patient with Metastatic Alveolar Rhabdomyosarcoma Ethan L Sanford1,2, Traci Wolbrink3, Jennifer Mack4, Robert G Rowe4
1Boston Combined Residency Program in Pediatrics; 2Brigham and Women’s Hospital Department of Anesthesiology; 3Boston Children’s Hospital Department of Anesthesia and Critical Care; 4Dana-Farber Boston Children’s Cancer and Blood Disorders Center
Introduction
Case
ECMO for Pediatric Oncology Patients
References 1) Gray BW, Haft JW, Hirsch JC, Annich GM, Hirschl RB, Bartlett RH.. Extracorporeall Life support: experience with 2,000 patients. Extracorporeal life support: experience with 2,000 patients. ASAIO J 2015; 61:2-7. 2) Zabrocki LA, Brogan TV, Statler KD, Poss WB, Rollins MD, Bratton SL. Extracorporeal membrane oxygenation for pediatric respiratory failure: survival and predictors of mortality. Crit Care Med. 2011; 39:364-370.
3) 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. Pediatr Surg 2006; 41:662-667.
• At initial diagnosis, diffuse bone marrow involvement (Below, panels A-C) and a FDG avid soft tissue lesion on PET scan was noted (Right).
• Two days after initiation of standard chemotherapy with irinotican and vincristine patient presented in respiratory distress. Chest Xray demonstrated R>L opacification of the lung fields (Right).
• Continued, rapid deterioration lead to intubation and placement of bilateral chest tubes which evacuated copious serous fluids.
• Hypoxemic respiratory arrest during suctioning prompted prolonged resuscitation.
Conclusion • Uncertain or poor long-term prognosis for pediatric oncology patients has led to ambiguity regarding when to offer ECMO. • Expansion of ECMO use will lead to increased perioperative implications • How practitioners assess prognosis, individual disease characteristics, prolongation of life, patient/parent wishes, and
reversibility of acute illness remains an evolving topic worthy of further investigation. Our case indicates that careful selection can lead to successful outcomes.
An 8 year-old male with metastatic alveolar rhabdomyosarcoma (ARMS) presented to our institution and suffered precipitous cardiopulmonary collapse with severe tumor lysis syndrome (TLS) 48 hours after initiation of chemotherapy Hypoxemic respiratory arrest prompted prolonged resuscitation efforts and ultimately extracorporreal membrane oxygenation (ECMO) was initiated. The use of ECMO in pediatric oncology patients is controversial as prognosis, morbidity, and resource limitations must be considered.
• Offering ECMO to patients with cancer is controversial and there are no standardized criteria on appropriate use
• Multiple considerations • Disease prognosis • Reversibility of acute illness • Morbidity associated with treatments • Appropriate use of resources
• Reported mortality for pediatric patients receiving ECMO lower (27-43%)1,2 than in adults (54%) • Higher mortality and morbidity in oncologic/immunosupressed patients (65-70%)3
• Despite concerns for short and long term mortality/complications, 95% of centers indicated they would consider use of ECMO in pediatric malignancy3
• VV-ECMO was established, but continued hemodynamic instability lead to cannulation to VA-ECMO
• Small, atypical cells found in tracheal and chest tube aspirates (Left, panel D)
• Hemodynamics and lung compliance improved over several days • Patient received chemotherapy while on ECMO • Patient taken to OR for decannulation and repair of the femoral artery • OR course complicated by hypoxemia • ICU ventilator requested, anesthesia team and respiratory therapist
coordinate ventilation strategy • Decannulation successful • Patient extubated ~ 1 week later • Most recent screening PET scan and bone marrow biopsy shows
remission of disease • Deconditioning and mild anxiety are most pertinent complications
• There are limited guidelines regarding ECMO management in the OR setting especially in the setting of dynamic pulmonary and cardiovascular changes
• Indications for ECMO use will likely continue to expand and disease states are managed more effectively
• Anesthesiologist must be trained in ECMO specific considerations
• In our case, the 5-year survival of metastatic ARMS is approximately 20%, but approximately 65% of such patients are alive at two years with modern treatment.
• Despite concerns over prognosis single organ involvement and the opportunity for life prolongation and/or disease survival prompted use of all available resources including ECMO
