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      Kinetics of Procalcitonin in Pediatric Patients on Extracorporeal Membrane Oxygenation

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          Abstract

          Objectives:

          To assess the kinetics of procalcitonin (PCT) and C-reactive protein (CRP) in pediatric patients who required extracorporeal membrane oxygenation (ECMO) and to analyze its relationship with morbidity and mortality.

          Patients and methods:

          Prospective observational study including pediatric patients who required ECMO. Both PCT and CRP were sequentially drawn before ECMO (P0) and until 72 hours after ECMO.

          Results:

          A total of 40 patients were recruited. Two cohorts were established based on the value of the P0 PCT (>10 ng/mL). Comparing the kinetics of PCT and CRP in these cohorts, the described curves were the expected for each clinical situation. The cutoff for P0 PCT to predict multiple organ dysfunction syndrome was 2.55 ng/mL (sensibility 83%, specificity 100%). Both PCT and CRP did not predict risk of neurologic sequelae or mortality in any group.

          Conclusions:

          Procalcitonin does not seem to be modified by ECMO and could be a good biomarker of evolution.

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          Most cited references23

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          The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology

          Jonathan Millar, Jonathon P Fanning, Charles Mcdonald … (2016)
          Extracorporeal membrane oxygenation (ECMO) is a technology capable of providing short-term mechanical support to the heart, lungs or both. Over the last decade, the number of centres offering ECMO has grown rapidly. At the same time, the indications for its use have also been broadened. In part, this trend has been supported by advances in circuit design and in cannulation techniques. Despite the widespread adoption of extracorporeal life support techniques, the use of ECMO remains associated with significant morbidity and mortality. A complication witnessed during ECMO is the inflammatory response to extracorporeal circulation. This reaction shares similarities with the systemic inflammatory response syndrome (SIRS) and has been well-documented in relation to cardiopulmonary bypass. The exposure of a patient’s blood to the non-endothelialised surface of the ECMO circuit results in the widespread activation of the innate immune system; if unchecked this may result in inflammation and organ injury. Here, we review the pathophysiology of the inflammatory response to ECMO, highlighting the complex interactions between arms of the innate immune response, the endothelium and coagulation. An understanding of the processes involved may guide the design of therapies and strategies aimed at ameliorating inflammation during ECMO. Likewise, an appreciation of the potentially deleterious inflammatory effects of ECMO may assist those weighing the risks and benefits of therapy.
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            Infections during extracorporeal membrane oxygenation: epidemiology, risk factors, pathogenesis and prevention.

            Stefano Biffi, Stefano Di Bella, Vittorio Scaravilli … (2017)
            Extracorporeal membrane oxygenation (ECMO) is a life support technique used in patients with respiratory and/or cardiac failure. The ECMO circuit consists of vascular cannulae, a pump and an artificial lung. Infections are among the most common complications associated with ECMO and have a significant impact on the mortality rate. Here we present a narrative literature review regarding the epidemiology, risk factors, pathogenesis and prevention of infectious complications during ECMO support. The prevalence of hospital-acquired infections during ECMO is 10-12% and their occurrence is likely to be more frequent compared with other critically ill patients. Coagulase-negative staphylococci, Candida spp., Enterobacteriaceae and Pseudomonas aeruginosa are the most frequently involved pathogens. A high incidence of ventilator-associated pneumonia was reported (24.4 cases/1000 ECMO days), with a major role unexpectedly played by Enterobacteriaceae. The infectious risk was shown to increase along the duration of the ECMO run, which represents the most important risk factor for the development of infections. Other ECMO-specific factors predisposing to infections include: the severity of illness in ECMO patients; the high risk of bacterial translocation from the gut; and ECMO-related impairment of the immune system. Another important issue could be microbial colonisation of catheters, ECMO cannulae and the oxygenator, which is consistent with most commonly observed aetiologies.
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              Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation

              Fillipo Corsi, Guillaume Lebreton, Nicolas Bréchot … (2017)
              Background Despite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Others have absolute contraindication to receive reperfusion therapies. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation. Methods ECMO-related complications and 90-day mortality were analyzed for 17 highly unstable, ECMO-treated, massive PE patients admitted to a tertiary-care center (2006–2015). Hospital- discharge survivors were assessed for long-term health-related quality of life. A systematic review of this topic was also conducted. Results Seventeen high-risk PE patients [median age 51 (range 18–70) years, Simplified Acute Physiology Score II (SAPS II) 78 (45–95)] were placed on VA-ECMO for 4 (1–12) days. Among 15 (82%) patients with pre-ECMO cardiac arrest, seven (41%) were cannulated during cardiopulmonary resuscitation, and eight (47%) underwent pre-ECMO thrombolysis. Pre-ECMO median blood pressure, pH, and blood lactate were, respectively: 42 (0–106) mmHg, 6.99 (6.54–7.37) and 13 (4–19) mmol/L. Ninety-day survival was 47%. Fifteen (88%) patients suffered in-ICU severe hemorrhages with no impact on survival. Like other ECMO-treated patients, ours reported limitations of all physical domains but preserved mental health 19 (4–69) months post-ICU discharge. Conclusions VA-ECMO could be a lifesaving rescue therapy for patients with high-risk, acute, massive PE when thrombolytic therapy fails or the patient is too sick to benefit from surgical thrombectomy. Because heparin-induced clot dissolution and spontaneous fibrinolysis allows ECMO weaning within several days, future studies should investigate whether VA-ECMO should be the sole therapy or completed by additional mechanical clot-removal therapies in this setting. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1655-8) contains supplementary material, which is available to authorized users.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Biomark Insights
                Journal ID (iso-abbrev): Biomark Insights
                Journal ID (publisher-id): BMI
                Journal ID (hwp): spbmi
                Title: Biomarker Insights
                Publisher: SAGE Publications (Sage UK: London, England )
                ISSN (Electronic): 1177-2719
                Publication date (Electronic): 08 January 2018
                Publication date Collection: 2018
                Volume: 13
                Electronic Location Identifier: 1177271917751900
                Affiliations
                [1 ]Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
                [2 ]Neonatal Intensive Care Unit Service, Maternal, Fetal and Neonatology Center Barcelona (BCNatal), Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
                [3 ]Pediatric Intensive Care Unit, Paediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain
                Author notes
                [*]Iolanda Jordan, Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu Number 2, Barcelona 08950, Spain. Email: ijordan@ 123456sjdhospitalbarcelona.org
                Article
                Publisher ID: 10.1177_1177271917751900 Publisher-manuscript ID: BMI-0042796
                DOI: 10.1177/1177271917751900
                PMC ID: 5764148
                SO-VID: 8e0bd58d-59a9-4532-9595-aafb3a28e67a
                Copyright © © The Author(s) 2018
                License:

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Date received : 8 August 2017
                Date accepted : 11 December 2017
                Categories
                Subject: Review
                Custom metadata
                cover-date January-December 2018

                ScienceOpen disciplines: Clinical chemistry
                Keywords: ecmo,procalcitonin,c-reactive protein,infection,multiple organ dysfunction syndrome,outcome
                Data availability:
                ScienceOpen disciplines: Clinical chemistry
                Keywords: ecmo, procalcitonin, c-reactive protein, infection, multiple organ dysfunction syndrome, outcome

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