The Contemporary Landscape of Pediatric Extracorporeal Life Support: Indications, Volume, and Mortality in the United States, 2016-2023
Giselle Porter1, Zihan Gao1, Kruti Desai1, Troy Coaston1, Sara Sakowitz2, Peyman Benharash1, Yas Sanaiha1
1University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, 2Massachusetts General Hospital, Boston, MA
Background:
Extracorporeal life support (ECLS) serves as a temporary bridge therapy for critically ill pediatric patients. As ECLS utilization continues to expand with evolving clinical practice, contemporary analyses evaluating the indications and utilization patterns within the pediatric population remain limited. Therefore, this study aimed to characterize national trends in the indications of and outcomes following ECLS in a contemporary cohort of pediatric patients.
Methods:
All pediatric patients (<18 years) who received ECLS were identified in the 2016 - 2023 National Inpatient Sample. Patients with neonatal indications for ECLS support, such as congenital diaphragmatic hernia, meconium aspiration, and primary pulmonary hypertensionwere excluded from analysis. Indications for ECLS were categorized as postcardiotomy syndrome (PCS), cardiogenic shock (CS), respiratory failure (RF), mixed cardiopulmonary failure (CPF), and post-heart or lung transplant dysfunction (TD). Yearly center-level caseload was calculated as the annual number of ECLS procedures performed at each institution.
Outcomes of interest included temporal trends in ECLS utilization, mortality, and indications as well as length of stay (LOS) and hospitalization costs. Complications were pooled as a composite variable to include cardiac, infectious, neurologic, renal, and respiratory causes. All trends were evaluated using Cuzick's test (nptrend). Patient, procedural, and clinical characteristics were compared using Pearson's Chi-square, and Mann-Whitney U tests, as appropriate. Multivariate logistic regression models were developed to evaluate factors associated with the use of ECLS, including indications and institution caseload.
Results:
Of an estimated 11,895 pediatric ECLS hospitalizations from 2016-2023, RF was the most common indication (42.6%). Over the study period, ECLS utilization rose 33.5%, increasing from 1,270 to 1,695 annual cases (nptrend<0.001), with RF consistently representing the most common indication. Furthermore, median per-patient costs increased significantly from $451,012 in 2016 to $525,759 in 2023 (Figure 1B, nptrend=0.014).
Overall, in-hospital mortality among pediatric ECLS patients was 39.6%. Mortality varied by ECLS indication, with the highest mortality rate observed among CPF (50.6%) and the lowest among those with TD (17.7%; p<0.001). CS and PCS had intermediate mortality rates. Notably, despite marked differences in mortality rates across indications, mortality within each indication group remained stable over the study period (Figure 2)
At the hospital level, median ECLS volume increased from 20 to 30 cases per center (nptrend<0.001). The number of hospitals performing pediatric ECLS remained relatively stable over the study period, ranging from 90-110 centers annually. Regionally, ECLS utilization was highest in the Southern United States, accounting for the greatest proportion of cases (39.8%), while the Northeast had the lowest proportion of ECLS cases (13.7%, p<0.001) (Figure 3). Resource utilization also varied significantly by indication, ranging from $392,645 for cardiogenic shock to $1,182,326 for transplant dysfunction (p<0.001).
Conclusion:
In the present contemporary analysis, utilization of pediatric ECLS increased significantly between 2016-2023, accompanied by a substantial escalation in resource utilization. Despite expanding utilization across clinical indications for ECLS, mortality remained stable over the study period. Additionally, observed variation in center-level caseloads and utilization patterns suggests a potential role for regionalized ECLS care models, whereby concentration of expertise and resources at high-volume centers may improve efficiency and outcomes for critical pediatric patients. Our findings highlight the rising clinical and financial burden of pediatric ECLS in the contemporary era and emphasize the opportunity for systems-level frameworks to optimize outcomes in this population.
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