OUR CARE
Teamwork equals excellence in pediatric extracorporeal resuscitation
From left to right: Nancy Ghanayem, MD; Hannah Gorman; Rebecca Rose, BA, RRT-NPS
The call came from a Chicago community hospital late one January night. A 15-year-old boy was in the hospital’s emergency department (ED) in severe respiratory distress, potentially infected with COVID-19. The hospital had no pediatric intensive care unit (PICU), so would Comer Children’s accept him as a patient? The second surge of COVID-19 was at its peak, the University of Chicago Medicine Comer Children’s Hospital PICU was nearly at capacity, and many medical staffers were out sick with the virus. But pediatric intensivist Nancy Ghanayem, MD, Chief of Pediatric Critical Care, and UChicago Medicine’s Transfer Center assured the ED physician that they would move mountains to find a PICU bed for the teen — and they did.
When Angel arrived at Comer Children’s, he was met by pediatric intensivists Grace Chong, MD, and Rebecca Propper, MD. Angel did not have COVID-19, but he continued to deteriorate rapidly, with acute respiratory failure and pneumonia, severe arrhythmia, and myocarditis, later found to be the result of infection with adenovirus.
“Angel needed to be put on a ventilator, but intubating him was very high risk because of his poor heart function and the likelihood that he would have a cardiac arrest,” said Ghanayem, who has expertise in cardiac critical care and pediatric mechanical circulatory support. The critical care team quickly called cardiac surgeon Narutoshi Hibino, MD, PhD, and the pediatric extracorporeal membrane oxygenation (ECMO) team to be at the ready to perform extracorporeal cardiopulmonary resuscitation (ECPR) should Angel have a cardiac arrest while he was intubated.
But even with ECPR, the odds of Angel surviving to hospital discharge were only 42%, based on national data. What Angel did have on his side, however, was a team of clinicians who had continually demonstrated excellence in performing CPR. For several consecutive years, Comer Children’s has received the highest award in pediatric cardiopulmonary resuscitation from the American Heart Association (AHA) for complying with the association’s Get With The Guidelines Resuscitation quality metrics for CPR in children.
“We have a very tight focus at Comer on high-quality CPR to optimize neurologic and organ recovery in our patients,” said Priti Jani, MD, MPH, Director of Simulation and Resuscitation for the PICU and Chair of the Pediatric CPR Committee. “PICU staff stay at the top of their skills by frequently participating in simulation-based training, including use of defibrillators that provide feedback on CPR quality, and in the AHA’s Pediatric Advanced Life Support program.”
As the anesthesiologist intubated Angel, he had a cardiac arrest as expected. In less than four minutes after the PICU team began CPR, Angel regained spontaneous circulation. With every second crucial in cannulating Angel onto ECMO to avoid recurrent cardiac arrests, Hibino, who has extensive experience in pediatric cardiac surgery, initiated the procedure. Within 30 minutes, Angel was on ECMO. “Placing a patient on ECMO requires a rapid and well-coordinated effort, requiring not only the surgeon and intensivists, but also the perfusionist team, OR team, ICU nurses, pharmacists and respiratory therapists,” said Jani.
In collaboration with pediatric heart failure specialist Stephen Pophal, MD, and electrophysiologist Frank Zimmerman, MD, Angel’s arrythmias were controlled and his myocarditis treated. Four days after being rescued onto ECMO, Angel was successfully removed from mechanical circulatory support with normal cardiac rhythm and markedly improved heart function.
Despite the severity of Angel’s illnesses, he recovered fully and was discharged from the hospital after 14 days. “Angel had a truly amazing recovery, which speaks to the preparedness of the team and the extent of our specialist resources,” said Ghanayem. “When we in the PICU ask for help in rescuing patients, there is never any hesitation from any member of our team, including our ECMO specialists, to provide it.”
Adds Hannah Gorman, PICU patient care manager: “Not every PICU can provide ECMO, and even fewer can provide ECPR. What was remarkable here is that we cannulated Angel on ECMO swiftly and he was discharged healthy in such a short time.”
The extensive cardiac expertise among critical care physicians at Comer Children’s and their exceptional management of patients contribute to the success of kids on ECMO, decreasing their length of stay and reducing their comorbidities, said Rebecca Rose, BA, RRT-NPS, ECMO manager for UChicago Medicine. “Multiple PICU nurses also took care of Angel, and their seasoned assessment of his critical needs meant that they could prioritize tasks, such as expediting diagnostic testing and lifesaving interventions. Every single person on Angel’s team was prepared and at the right place at the right time,” she said.