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268: EFFECTS OF INHALED NO COMBINED WITH HIGH-FLOW NASAL CANNULA AFTER TOTAL CAVOPULMONARY CONNECTION

Learning Objectives: Prone positioning can improve lung condition by promoting alveolar recruitment. Furthermore, it may optimize cardiac function via cardiopulmonary interaction. Therefore, prone positioning during extracorporeal membrane oxygenation (ECMO), whether it’s for respiratory or cardiac support, may shorten the duration of ECMO and improve outcome. Prone positioning during ECMO without neuromuscular blockade in pediatric patients, however, has not been well described. Here, we report its feasibility and safety. Methods: All ECMO runs from January 2016 to June 2018 in the PICU at a tertiary children’s hospital in Japan were retrospectively reviewed using the institutional database. After excluding from analysis 4 ECMO runs where transfer of the patient to another hospital or withdrawal of care was done within 24 hours, 22 ECMO runs involving 20 patients were analyzed with respect to age, weight, indications for ECMO, duration of prone positioning and ECMO run, and requirement of neuromuscular blockade and sedatives. Results: Prone positioning was not performed in 13 runs because of central cannulation in 10, no lung pathology in 1, dismal prognosis with early withdrawal in 1, and trouble with venous drainage in 1. Prone positioning was performed in the remaining 9 runs, all of which were venoarterial ECMO with cervical cannulation, but indicated for variety of reasons: persistent pulmonary hypertension of the newborn in 2, respiratory failure in 3, and hypoxemia or heart failure in the operating room after congenital heart surgery in 5. One had the sternum open. Median age and weight at ECMO initiation was 1 [0–7.5] month and 3.8 [3.3–5.9] kg, respectively. A median of 3 [1.5–6] flips to prone were performed and prone position was kept for a total of 44.5 [18.9–86.2] hours out of 9 [5–21.5] days of ECMO run. During prone positioning, no one received continuous neuromuscular blockade and only one needed escalation of continuous sedative administration. At the end of prone positioning, median doses of continuous infusion of midazolam, fentanyl, morphine, dexmedetomidine, and chlorpromazine were 0.11 [0.075–0.14] mg/kg/h, 1.0 [0.48–1.45] mcg/kg/h, 61 [27–71] mcg/kg/h, 0.71 [0.63–0.98] mcg/kg/h, and 0.20 [0.17–0.21] mg/kg/h, respectively. Prone positioning was discontinued early (in 3 hours) only in one case due to unstable ECMO blood flow. No major complications occurred. Conclusions: Prone positioning during ECMO without neuromuscular blockade in pediatric patients are feasible and safe.