The balance between systemic anticoagulation and clotting is challenging. In normal hemostasis, the endothelium regulates the balance between anticoagulant and prothrombotic systems. It becomes particularly more challenging to maintain this physiologic hemostasis when we are faced with extracorporeal life support therapies, where blood is continuously in contact with a foreign extracorporeal circuit surface predisposing a prothrombotic state. The blood-surface interaction during extracorporeal life support therapies requires the use of systemic anticoagulation to decrease the risk of clotting. Unfractionated heparin is the most common anticoagulant agent widely used in this setting. New trends include the use of direct thrombin inhibitor agents for systemic anticoagulation; and surface modifications that aim to overcome the blood-biomaterial surface interaction by modifying the hydrophilicity or hydrophobicity of the polymer surface; and coating the circuit with substances that will mimic the endothelium or anti-thrombotic agents. To improve hemocompatibility in an extracorporeal circuit, replication of the anti-thrombotic and anti-inflammatory properties of the endothelium is ideal. Surface modifications can be classified into three major groups: biomimetic surfaces (heparin, nitric oxide, and direct thrombin inhibitors); biopassive surfaces [phosphorylcholine, albumin, and poly- 2-methoxyethylacrylate]; and endothelialization of blood contacting surface. The focus of this paper will be to review both present and future novel surface modifications that can obviate the need for systemic anticoagulation during extracorporeal life support therapies.

Background Dysnatremia is a common disorder in critically ill surgical children. The study’s aim is to determine the prevalence of dysnatremia and its association with outcomes after surgery for congenital heart disease (CHD). Methods This is a single-center retrospective cohort study of children <18 years of age undergoing surgery for CHD between January 2012 and December 2014. Multivariable logistic regression analysis was used to evaluate the relationship between dysnatremia and outcomes during the perioperative period. A total of 1345 encounters met the inclusion criteria. Results The prevalence of pre- and post-operative dysnatremia were 10.2% and 47.1%, respectively. Hyponatremia occurred in 19.1%, hypernatremia in 25.6%. Hypernatremia at 24, 48, and 72 h post-operative was associated with increased hospital mortality (odds ratios (OR) [95% confidence intervals (CI)] 3.08 [1.16–8.17], p = 0.024; 4.35 [1.58–12], p = 0.0045; 4.14 [1.32–12.97], p = 0.0148, respectively. Hypernatremia was associated with adverse neurological events 3.39 [1.12–10.23], p = 0.0302 at 48 h post-operative. Hyponatremia was not associated with any adverse outcome in our secondary analysis. Conclusions Post-operative dysnatremia is a common finding in this heterogeneous cohort of pediatric cardiac-surgical patients. Hypernatremia was more prevalent than hyponatremia and was associated with adverse early post-operative outcomes. Impact Our study has shown that dysnatremia was highly prevalent in children after congenital heart surgery with hypernatremia associated with adverse outcomes including mortality. It is important to understand fluid and sodium regulation in the post-operative period in children with congenital heart disease to better address fluid overload and associated electrolyte imbalances and acute kidney injury. While clinicians are generally very aware of the importance of hyponatremia in critically ill children, similar attention should be given to hypernatremia in this population.

Background/Objectives: Nutritional support is a critical yet challenging aspect of care for pediatric patients requiring extracorporeal membrane oxygenation (ECMO). Malnutrition is prevalent in this population and is associated with worse clinical outcomes. This review synthesizes current evidence on nutritional strategies for pediatric ECMO patients, emphasizing assessment methods, feeding routes, challenges, and clinical outcomes. Methods: A literature review was conducted using PubMed, Scopus, and Web of Science to identify relevant studies published between January 2010 and 2025. Keywords included “pediatric ECMO”, “nutrition”, “enteral feeding”, and “parenteral nutrition”. Studies addressing nutritional assessment, enteral and parenteral feeding practices, and their impact on clinical outcomes were included. Results: Malnutrition is a significant risk factor for morbidity and mortality in ECMO patients, yet nutritional support remains highly variable. While enteral nutrition (EN) is preferred, feeding intolerance and gastrointestinal dysfunction often necessitate parenteral nutrition (PN). Early EN initiation, even at trophic levels, is associated with improved gut integrity and outcomes. However, achieving full nutritional goals enterally remains a challenge, particularly in neonates. PN remains essential in cases of feeding intolerance but is linked to hepatic dysfunction and metabolic imbalances. Conclusions: Optimizing nutritional support in pediatric ECMO patients requires individualized assessment and a structured approach to enteral and parenteral feeding. Further research is needed to establish standardized feeding protocols and determine the optimal timing and composition of nutritional support to improve outcomes.

Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO), is multifactorial, and results in significant morbidity and mortality. Pulmonary hemorrhage represents a serious adverse event in pediatric patients on ECMO and remains a challenging complication to manage. Its occurrence highlights the importance of identifying treatments that address bleeding complications in this population. This retrospective cohort study, from January 2018 to August 2022, explores the use of inhaled tranexamic acid (TXA), a clot-stabilizing agent, in 53 pediatric ECMO patients with new pulmonary hemorrhage. Primary diagnoses included respiratory failure (34%) and structural abnormalities (34%), such as congenital heart defects, congenital diaphragmatic hernia, and tracheal stenosis, with viral pneumonia being the leading cause of respiratory failure (47%). Results indicated that 48 of 53 (91%) patients showed cessation of pulmonary hemorrhage within 48 hours of inhaled TXA administration as measured by a decrease in our institution-specific bleeding scale from moderate to minor or no bleeding. In ECMO-managed pediatric patients with pulmonary hemorrhage, treatment with inhaled TXA demonstrated safety, with no observed adverse effects, and showed promising signs of contributing to the cessation of bleeding.