P1.059: Modified Delphi Consensus Study on the Usage of Extracorporeal Membrane Oxygenation in Pediatric Trauma

Background: Trauma is leading cause of death of children in all age groups, yet resuscitation of critically injured children, namely the role of extracorporeal membrane oxygenation (ECMO), has not been well studied. We sought to achieve consensus on indications and contraindications for the use of ECMO in pediatric trauma among pediatric and adult trauma surgeons, pediatric critical care physicians, and pediatric emergency medicine physicians through a modified Delphi consensus process.

Methods: After development of candidate statements by a multi-institutional working group consisting of pediatric surgeons and pediatric critical care medicine physicians, we conducted a modified Delphi consensus process. The process consisted of 3 rounds with consensus defined a priori as a Cronbach’s alpha >0.8 and >80% panel agreement. Statements were reviewed and rated using a 1-5 Likert scale by an expert panel consisting of pediatric surgeons, pediatric critical care medicine physicians, pediatric emergency medicine physicians, and adult trauma surgeons (Figure 1). Members of the working group did not participate in the rating of statements.

Results: The expert panel consisted of fifty-five physicians took part in the study as a member of the expert panel. This consisted of 19 pediatric critical care medicine physicians, 12 pediatric surgeons, 10 adult trauma surgeons, and 8 pediatric emergency medicine physicians from 22 American states and 6 European countries. Of the initial 47 statements proposed, 19 reached consensus. Internal consistency was excellent with alpha=0.97. Agreement was highest for ECMO indications including accidental hypothermia (100%), cold water drowning (95.8%), and respiratory failure (95.8%), and for the ECMO relative indication of acute respiratory distress syndrome (ARDS) refractory to medical management in a polytrauma patient (97.9%). Agreement on contraindications for ECMO was highest for loss of pulses with no signs of life for >15 minutes (93.7%) and severe/irreversible neurological injury (97.9%). Warm water drowning and major burn < 80% of total body surface area were not considered contraindications (Table 1). Statements which did not reach consensus included: the presence of intracranial bleeding is a relative contraindication for ECMO (excluded round 3); and a pediatric patient presenting with either a blunt abdominal or thoracic injury, or a penetrating abdominal or thoracic injury with signs of life with loss of pulses for < 15 minutes is not a contraindication for ECMO (excluded round 2).

Conclusion: In this large national modified Delphi study, consensus was reached among key stakeholders on multiple indications and contraindications to the use of ECMO in pediatric trauma. Areas which did not reach consensus require further study. This study is important for furthering the national dialogue on the use of ECMO in pediatric trauma patients.