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Extracorporeal membrane oxygenation offers long-term survival in childhood leukemia and acute respiratory failure

  • 1,
  • 1,
  • 1,
  • 1,
  • 1 and
  • 1Email author
Critical Care201822:222

https://doi.org/10.1186/s13054-018-2134-6

  • Received: 29 March 2018
  • Accepted: 25 July 2018
  • Published:

Keywords

  • Extracorporeal membrane oxygenation
  • Childhood leukemia
  • Acute respiratory failure

Dear Editor:

Survival for childhood cancer has dramatically improved, particularly for acute lymphoblastic leukemia, reaching over 90% overall survival in industrialized countries [1]. However, some patients may encounter severe adverse events, limiting this high success rate. ARF is one of the most serious complications and is associated with high mortality if conventional therapy fails [2]. Escalation to ECMO has rarely been used in patients with malignancy due to its limited success rates and higher risk for infectious and bleeding complications [35].

We report on a single centre experience of ECMO on patients with childhood leukemia and ARF. This retrospective study was approved by the local research ethics committee. Nine patients with childhood leukemia received ECMO in induction treatment (8/9 at first remission, 1/9 at second remission) between January 2004 and June 2017. Details on these patients are provided in Table 1. ARF resulted from pulmonary infections (two patients with Candida albicans, one patient with Aspergillus terreus, four patients with no organisms identified) and pulmonary non-infectious complications (one patient with transfusion-related acute lung injury and one patient with leukemic infiltration). Median duration of mechanical ventilation before ECMO was 3 days (range 0.4–14). The median duration of ECMO support was 14 days (range 2–24). Five (56%) patients survived ECMO und four (44%) survived to hospital discharge. When compared to survivors, non-survivors had a significantly higher vasoactive inotrope score (VIS) at ECMO initiation (85 vs. 11; p = 0.032), including two patients requiring veno-arterial cannulation. Time on ECMO support was shorter (5 vs. 15 days; p = 0.032) in non-survivors and was stopped because of multiorgan failure (22%), intracranial bleeding (11%) and progressive leukemia (11%). One patient (11%) recovered from hematopoietic stem cell transplantation performed on ECMO, but died two months later of septic shock. Moreover, non-survivors had significantly lower platelet count on ECMO (30 ×  103/μL vs 98 × 103/μL; p = 0.041). Eight (89%) patients received chemotherapy in the four weeks prior to and five (56%) were neutropenic at ECMO cannulation. Neutropenic patients did not have higher mortality compared to those without neutropenia (3/5 vs 2/4).
Table 1

Clinical characteristics and demographics of patients on ECMO

Clinical characteristics

N

Demographics

All

Survivors

Non-survivors

p-value

Diagnosis

 

Age (years)

14 (1–18)

9 (4–16)

16 (1–18)

0.286

 ALL

5

Weight (kg)

47 (7–74)

26 (12–50)

56 (7–74)

0.286

 AML

3

Pre ECMO

    

 JMML

1

pH

7.2 (7.0–7.6)

7.3 (7.0–7.6)

7.2 (7.0–7.4)

0.413

Reason for ARF

 

Lactate (mg/dL)

17 (7–68)

17 (7–24)

17 (8–68)

0.556

 Fungal infection

3

pO2/FiO2

47 (32–67)

66 (32–67)

44 (34–50)

0.286

 Pulmonary infectiona

4

VIS score

45 (5–160)

11 (5–45)

85 (22–160)

0.032

 TRALI

1

Platelet count (×  103/μL)

27 (14–214)

145 (26–214)

27 (14–53)

0.111

 Leukemic infiltration

1

Ventilation days

3 (0.4–14)

4.5 (1–13)

2 (0.4–12)

0.556

Causes of death on ECMO

 

During ECMO

    

 Intracranial hemorrhage

1

Platelet count (×  103/μL)

35 (19–106)

98 (22–106)

30 (19–48)

0.041

 Multiorgan failure

2

Platelets transfusions / day

2.2 (0.2–3.8)

0.5 (0.2–2.2)

3.3 (1.7–4.7)

0.111

 Leukemic infiltration

1

VV Cannulation

7

5

2

 

Outcome on ECMO

 

VA Cannulation

2

0

2

 

 Survived on ECMO

5

Major bleeding

4

0

4

 

 Discharged from hospital

4

Need for CRRT

3

0

3

 

 Survived long-term

4

ECMO Duration (days)

14 (2–24)

15 (9–24)

5 (2–17)

0.032

ano organism detected

ALL acute lymphoblastic leukemia, AML acute myeloid leukemia, JMML juvenile myelomonocytic leukemia, ARF acute respiratory failure, ano organism detected, ECMO extracorporeal membrane oxygenation, TRALI transfusion-related acute lung injury, VIS vasoactive inotrope score = dose of dopamine (μg/kg/min) + dose of dobutamine (μg/kg/min) + 100 x dose of adrenaline (μg/kg/min) + 100 x dose of noradrenaline (μg/kg/min) + 10 x milrinone dose (μg/kg/min) + 10,000 x dose of vasopressin (U/kg/min), VV veno-venous, VA veno-arterial, CRRT continuous renal replacement therapy

All four survivors are in complete oncologic remission at a median follow-up of 8.4 years (range 1.8–13.1), are restored to full health, and are all engaged to full-time study or work. Our data is limited by a small sample size and by its retrospective analysis. Nevertheless, it indicates that ECMO provides an effective rescue therapy in childhood leukemic patients with ARF.

Abbreviations

ARF: 

Acute respiratory failure

ECMO: 

Extracorporeal membrane oxygenation

Declarations

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

GC, GK and RC conceived the study and collected the data. GC and RC performed the statistical analyses. GC and RC interpreted the data and wrote the first draft of the manuscript. All authors critically reviewed and edited the manuscript and all authors read and approved the final version.

Ethics approval and consent to participate

The study was conducted in accordance with Good Clinical Practice (Declaration of Helsinki 2002) and was approved by the Ethics Committee of the Medical University of Innsbruck (Reference Number 34266 A). Consent for patient participation was waived.

Consent for publication

No consent for publication was needed.

Competing interests

The authors declare that they have no competing interests.

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Pediatrics, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria

References

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Copyright

© The Author(s). 2018

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