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Excerpt
The authors report on their experience in the use of extracorporeal membrane oxygenation (ECMO) in the management of children with severe meningococcemia. Four centers in the United Kingdom and one in Australia contributed cases. Children included were those with either septic shock refractory to conventional therapy or patients with respiratory failure despite maximum ventilatory support. Twelve patients (median age, 26 months) were treated with ECMO from 1989 until 1996 at the five centers; seven children had intractable shock and five respiratory failure. The median predicted risk of mortality based on the pediatric risk of mortality score before ECMO was 72%.
The median duration of ECMO was 76 (range, 20 to 263) h. Eight of the 12 patients survived, one with loss of all fingers from gangrene before ECMO and one with functionally mild hemiplegia and mild visual impairment from a vitreous hemorrhage. Four patients died; two developed brain death during treatment with ECMO and 2 after discontinuation of life support at the request of the families (both children had developed ischemia in all their extremities).
Comment by Jaime E. Fergie, M.D., Corpus Christi, TX: This group of children is highly selected and represents the more severe end of the meningococcemia spectrum. Considering their predicted risk of mortality, most of them should have died. This study is not a randomized placebo-controlled trial, but considering historic data the results are very impressive. Meningococcemia is one of the most rapidly devastating infections affecting humans. At present eradication of meningococci from the blood is not a major problem and occurs rapidly after initiation of appropriate therapy. Major efforts are now directed toward controlling the inflammatory cascade and allowing the body time to return to its homeostatic balance. In addition to ECMO a recent development in the management of invasive meningococcal disease is the investigational use of bactericidal/permeability-increasing protein, an antiendotoxin modality that inhibits a number of responses to endotoxin in vitro. Results of a Phase I/II trial presented at the 1997 annual meeting of the Infectious Diseases Society in San Francisco (B Giroir, et al. Clin Infect Dis 1997;25:431) indicated that only 1 (4%) of 26 children with meningococcemia treated with bactericidal/permeability-increasing protein died, compared to a case fatality rate of 20 to 50% in historic controls.
