Extracorporeal membrane oxygenation and cerebral blood flow velocity in children

Nicole F O'Brien, Mark W Hall
Pediatric Critical Care Medicine 2013, 14 (3): e126-34

OBJECTIVE: To determine how extracorporeal membrane oxygenation affects cerebral blood flow velocity and to determine whether specific changes in cerebral blood flow velocity may be associated with neurologic injury.

DESIGN: Prospective, observational study.

SETTING: PICU in a tertiary care academic center.

PATIENTS: Children (age less than or equal to 18 yr) requiring extracorporeal membrane oxygenation support.


MEASUREMENTS AND MAIN RESULTS: Eighteen patients (age 3.8 ± 7.2 years; venovenous neck, n = 5; venoarterial neck, n = 8; venoarterial chest, n = 5) requiring extracorporeal membrane oxygenation underwent daily transcranial Doppler ultrasound measurements of cerebral blood flow velocity in bilateral middle cerebral arteries. Cerebral blood flow velocity measurements were recorded as a percentage of age and gender normal value. On extracorporeal membrane oxygenation, cerebral blood flow velocities in patients not suffering clinically evident neurologic injury were decreased with systolic flow velocity (Vs) 54% ± 3% predicted and mean flow velocity (Vm) 52% ± 4% predicted. After decannulation, Vs and Vm were higher than while on extracorporeal membrane oxygenation at 73% ± 3% predicted (p = 0.0007 vs. value on extracorporeal membrane oxygenation) and 64% ± 4% predicted (p = 0.01 vs. value on extracorporeal membrane oxygenation).Patients who developed clinically evident cerebral hemorrhage had higher Vs, diastolic flow velocity (Vd), and Vm compared with those who did not: 123% ± 8% predicted, 130% ± 18% predicted, 127% ± 9% predicted (p < compared to values in children not suffering neurological injury). Supranormal flow velocities were noted 2-6 days before clinical recognition of cerebral hemorrhage in all four patients. There were no significant differences in mean arterial blood pressure, circuit flow, or hematocrit between the children who suffered cerebral hemorrhage and those who did not. Partial pressure of carbon dioxide was lower in the group of patients who experienced cerebral hemorrhage than in those who did not (38 ± 2 vs. 44 ± 1 mm Hg, p = 0.03).

CONCLUSION: In children who did not suffer clinically apparent neurologic injury, cerebral blood flow velocities were lower than normal while on extracorporeal membrane oxygenation support and increased after decannulation. However, children who developed cerebral hemorrhage had higher than normal cerebral blood flow velocities noted for days prior to clinical recognition of bleeding. Cerebral blood flow velocity measurement may represent a portable, noninvasive way to predict cerebral complications of extracorporeal membrane oxygenation and deserves further study.

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