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Introduction: Extubation of neonatal and pediatric patients supported with extracorporeal membrane oxygenation (ECMO) may avoid ventilator induced lung injury, decrease neurosedative exposure, and improve rehabilitation and mobility. Few studies have evaluated incidence and outcomes of pediatric patients extubated during ECMO. Methods: A single-center retrospective cohort study was performed to describe our experience with extubation on ECMO. All patients extubated on ECMO from 2013-2022 were included. Patients who had a tracheostomy prior to ECMO cannulation were excluded. Patients who had a tracheostomy placed during their ECMO run were included if extubation took place prior to tracheostomy placement. Results: Forty patients were extubated during their ECMO run, representing 8.6% of all ECMO patients during that time. Twenty-five patients (62.5%) were on veno-arterial (VA) ECMO, 14 (35%) veno-venous (VV) ECMO and 1 (2.5%) patient was initially on VV but converted to VA. The most common indication for ECMO was ARDS (50%), followed by pulmonary hypoplasia (12.5%), severe bronchospasm (7.5%), congenital diaphragmatic hernia (7.5%), sepsis (5%), and heart failure (5%). Median mean airway pressure prior to cannulation was 18 cm H2O, oxygenation index was 25.5 and vasoactive inotropic score was 4. Median weight was 7.3 kg, ECMO run time was 429.5 hours and extubation duration on ECMO was 7 days. The median percentage of ECMO run spent extubated was 47%. The most common form of respiratory support while extubated was heated humidified high-flow nasal cannula (67.5%). Half of all patients were on room air for some of their extubation course. Most patients were on a continuous opiate infusion (92.5%) and/or a dexmedetomidine infusion (85%) while extubated. Eleven (27.5%) patients were able to eat by mouth. Five patients (12.5%) were able to sit over the edge of the bed, two (5%) were able to be held by a caregiver, two (5%) were able to stand and one patient (2.5%) was able to walk independently with a gait aid. Five patients (12.5%) underwent ECMO decannulation while extubated. The most common reasons for reintubation were for lung recruitment (27.8%) and bronchoscopy (18.5%). Overall 85% survived to decannulation and 75% survived to ICU discharge. In comparison, survival for all ECMO patients during the same period was 62.1%. Discussion/Conclusions: Extubation on ECMO is feasible and associated with excellent outcomes. With careful titration of neurosedatives, ECMO sweep gas and respiratory support, patients on ECMO can be safely and comfortably extubated.

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Presented at the 40th Annual ECMO and the Advanced Therapies for Respiratory Failure Symposium; Keystone, Colorado; February 25-28, 2024.

Large Single Center Experience with Extubation During Neonatal and Pediatric Extracorporeal Membrane Oxygenation

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