Date Published: April 26, 2019
Publisher: Public Library of Science
Author(s): Katharine Robb, Aditya Badheka, Tong Wang, Sankeerth Rampa, Veerasathpurush Allareddy, Veerajalandhar Allareddy, Andrea Ballotta.
The American College of Critical Care Medicine recommends that children with persistent fluid, catecholamine, and hormone-resistant septic shock be considered for extracorporeal membrane oxygenation (ECMO) support. Current national estimates of ECMO use in hospitalized children with sepsis are unknown. We sought to examine the use of ECMO in these children and to examine the overall outcomes such as in-hospital mortality, length of stay (LOS), and hospitalization charges (HC).
A retrospective analysis of the National Inpatient Sample, which approximates a 20% stratified sample of all discharges from United States community hospitals, was performed. All children (≤ 17 years) who were hospitalized for sepsis between 2012 and 2014 were included. The associations between ECMO and outcomes were examined by multivariable linear and logistic regression models.
A total of 62,310 children were included in the study. The mean age was 4.2 years. ECMO was provided to 415 of the children (0.67% of the cohort with sepsis). Comparative outcomes of sepsis in children who received ECMO versus those who did not included in-hospital mortality rate (41% vs 2.8%), mean HC ($749,370 vs $90,568) and mean LOS (28.8 vs 9.1 days). After adjusting for confounding factors, children receiving ECMO had higher odds of mortality (OR 11.15, 95% CI 6.57–18.92, p < 0.001), longer LOS (6.6 days longer, p = 0.0004), and higher HC ($510,523 higher, p < 0.0001). Use of ECMO in children with sepsis is associated with considerable resource utilization but has 59% survival to discharge. Further studies are needed to examine the post discharge and neurocognitive outcomes in survivors.
Sepsis is a leading cause of morbidity and mortality among children worldwide [1–5]. In the United States, pediatric sepsis results in more than 75,000 hospitalizations and 6,800 deaths each year [6–9]. Children hospitalized with sepsis have mortality rates of 6–14% [6, 8, 10]. In children with septic shock, however, mortality rates increase to 17% . The factor most strongly associated with increased mortality in sepsis in the development of refractory shock [12, 13].
From 2012 to 2014, 62,310 children ≤ 17 years of age were hospitalized for sepsis in the United States (Table 1). These 62,310 patients who were admitted for sepsis represent the entire cohort of 100% of hospitalizations that occurred in the USA over the study period. The mean age of the cohort was 4.2 years. Over half (52.3%) of patients were male. Most patients (47.1%) were white, 25.3% Hispanic, and 16.6% black, with other races constituting the remaining 11%. The in-hospital mortality rate was 3.1% (1,930 patients). Nearly half (46.8%) of the patients did not have any comorbid conditions. ECMO support was provided to a total of 415 patients, or 0.67% of the cohort (1 in 145 of those who had sepsis). Of these, 375 (90%) had only one run, while the remaining 40 (10%) received two or more ECMO runs. The majority of patients (77.9%) were treated in urban teaching hospitals.
In our study, less than 1% of pediatric patients with sepsis received ECMO. We found that use of ECMO in children with sepsis is associated with considerable resource utilization but acceptable survival rate to discharge (59%). After adjusting for potential confounders, patients who received ECMO had an increased risk of in-hospital mortality, longer LOS, and higher hospitalization charges compared to those who did not.
Use of ECMO in children hospitalized for sepsis is associated with acceptable survival rates to discharge (59%) and should be considered a viable strategy in children with refractory septic shock. Further studies are needed to examine post discharge and neurocognitive outcomes in survivors.