1
|
Gil LA, Apfeld JC, Gehred A, Walczak AB, Frazier WJ, Seabrook RB, Olutoye OO, Minneci PC. A Systematic Review of Clinical Outcomes After Carotid Artery Ligation Versus Carotid Artery Reconstruction Following Venoarterial Extracorporeal Membrane Oxygenation in Infants and Children. J Surg Res 2023; 291:423-432. [PMID: 37517350 DOI: 10.1016/j.jss.2023.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/24/2023] [Accepted: 06/25/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION In pediatric and neonatal populations, the carotid artery is commonly cannulated for venoarterial (VA) extracorporeal membrane oxygenation (ECMO). The decision to ligate (carotid artery ligation [CAL]) versus reconstruct (carotid artery reconstruction [CAR]) the artery at decannulation remains controversial as long-term neurologic outcomes remain unknown. The objective of this study was to summarize current literature on clinical outcomes following CAL and CAR after Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO). METHODS PubMed (MEDLINE), Embase, Web of Science, and Cochrane databases were searched using keywords from January 1950 to October 2020. Studies examining clinical outcomes following CAL and CAR for VA-ECMO in patients <18 y of age were included. Prospective and retrospective cohort studies, case series, case-control studies, and case reports were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were performed independently by two reviewers. Assessment of risk of bias was performed. RESULTS Eighty studies were included and classified into four categories: noncomparative clinical outcomes after CAL (n = 23, 28.8%), noncomparative clinical outcomes after CAR (n = 12, 15.0%), comparative clinical outcomes after CAL and/or CAR (n = 28, 35.0%), and case reports of clinical outcomes after CAL and/or CAR (n = 17, 21.3%). Follow-up ranged from 0 to 11 y. CAR patency rates ranged from 44 to 100%. There was no substantial evidence supporting an association between CAL versus CAR and short-term neurologic outcomes. CONCLUSIONS Studies evaluating outcomes after CAL versus CAR for VA-ECMO are heterogeneous with limited generalizability. Further studies are needed to evaluate long-term consequences of CAL versus CAR, especially as the first survivors of pediatric/neonatal ECMO approach an age of increased risk of carotid stenosis and stroke.
Collapse
Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Jordan C Apfeld
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Alison Gehred
- Grant Morrow III Library, Nationwide Children's Hospital, Columbus, Ohio
| | - Ashely B Walczak
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - W Joshua Frazier
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ruth B Seabrook
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Oluyinka O Olutoye
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio.
| |
Collapse
|
2
|
Callier K, Dantes G, Johnson K, Linden AF. Pediatric ECLS Neurologic Management and Outcomes. Semin Pediatr Surg 2023; 32:151331. [PMID: 37944407 DOI: 10.1016/j.sempedsurg.2023.151331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus.
Collapse
Affiliation(s)
- Kylie Callier
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Kevin Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Allison F Linden
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| |
Collapse
|
3
|
Basgoze S, Temur B, Ozcan ZS, Gokce I, Guvenc O, Aydin S, Guzelmeric F, Altan Kus A, Erek E. The effect of extracorporeal membrane oxygenation on neurodevelopmental outcomes in children after repair of congenital heart disease: A pilot study from Turkey. Front Pediatr 2023; 11:1131361. [PMID: 37077331 PMCID: PMC10106672 DOI: 10.3389/fped.2023.1131361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/13/2023] [Indexed: 04/21/2023] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is widely used after congenital heart surgery. The purpose of this study is to analyze the neurodevelopmental (ND) outcomes in patients who receivedECMO support after congenital cardiac surgery. Methods Between January 2014 and January 2021, 111 patients (5.8%) receivedECMO support after congenital heart operations, and 29 (26,1%) of these patients were discharged. Fifteen patients who met the inclusion criteria were included. A propensity score matching (PSM) analysis model was established using eight variables (age, weight, sex, Modified Aristotle Comprehensive Complexityscores, seizures, cardiopulmonary bypass duration, number of operations, and repair method) with 1:1 matching. According to the PSM model, 15 patients who underwent congenital heart operations were selected as the non-ECMO group. The Ages & Stages Questionnaire Third Edition (ASQ-3) was used for ND screening;it includes communication, physical skills (gross and fine motor), problem-solving, and personal-social skills domains. Results There were no statistically significant differences between the patients' preoperative and postoperative characteristics. All patients were followed up for a median of 29 months (9-56 months). The ASQ-3 results revealed that communication, fine motor, and personal-social skills assessments were not statistically different between the groups. Gross motor skills (40 vs. 60), problem-solving skills (40 vs. 50), and overall scores (200 vs. 250) were better in the non-ECMO patients (P = 0.01, P = 0.03, and P = 0.03, respectively). Nine patients (%60) in the ECMO group and 3 patients (%20) in the non-ECMO group were with neurodevelopmental delay (P = 0,03). Conclusion ND delay may occur in congenital heart surgery patients who receivedECMO support. We recommend ND screening in all patients with congenital heart disease, especially those who receivedECMO support.
Collapse
Affiliation(s)
- Serdar Basgoze
- Department of Pediatric Heart Surgery, Faculty of Medicine, Atakent Hospital, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
- Correspondence: Serdar Basgoze
| | - Bahar Temur
- Department of Cardiovascular Surgery, Faculty of Medicine, Atakent Hospital, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
| | - Zeynep Sila Ozcan
- School of Medicine, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
| | - Ibrahim Gokce
- School of Medicine, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
| | - Osman Guvenc
- Department of Pediatric Cardiology, Faculty of Medicine, Atakent Hospital, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
| | - Selim Aydin
- Department of Cardiovascular Surgery, Faculty of Medicine, Atakent Hospital, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
| | - Fusun Guzelmeric
- Department of Anesthesiology, Faculty of Medicine, Atakent Hospital, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
| | - Aylin Altan Kus
- Department of Radiology, Faculty of Medicine, Atakent Hospital, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
| | - Ersin Erek
- Department of Pediatric Heart Surgery, Faculty of Medicine, Atakent Hospital, Acibadem Mehmet Ali Aydinlar University, İstanbul, Turkey
| |
Collapse
|
4
|
Theodorou CM, Guenther TM, Honeychurch KL, Kenny L, Mateev SN, Raff GW, Beres AL. Utility of Routine Head Ultrasounds in Infants on Extracorporeal Life Support: When is it Safe to Stop Scanning? ASAIO J 2022; 68:1191-1196. [PMID: 34967783 PMCID: PMC9213574 DOI: 10.1097/mat.0000000000001641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Intracranial hemorrhage (ICH) can be a devastating complication of extracorporeal life support (ECLS); however, studies on the timing of ICH detection by head ultrasound (HUS) are from 2 decades ago, suggesting ICH is diagnosed by day 5 of ECLS. Given advancements in imaging and critical care, our aim was to evaluate if the timing of ICH diagnosis in infants on ECLS support has changed. Patients <6 months old undergoing ECLS 2011-2020 at a tertiary care children's hospital were included. Primary outcome was timing of ICH diagnosis on HUS. Seventy-four infants underwent ECLS for cardiac (54%) or pulmonary (46%) indications. Venoarterial ECLS was most common (88%). Median ECLS duration was 6 days (range 1-26). Sixteen patients were diagnosed with ICH (21.6%), at a median of 2 days postcannulation (range 1-4). Nearly all were <4 weeks old at cannulation (93.8%). In conclusion, one-fifth of infants developed ICH diagnosed by HUS while on ECLS, all within the first 4 days of ECLS, consistent with previous literature. Despite advances in critical care and imaging technology, the temporality of ICH diagnosis in infants on ECLS is unchanged.
Collapse
Affiliation(s)
- Christina M. Theodorou
- University of California Davis Medical Center, Division of Pediatric General, Thoracic, and Fetal Surgery. Sacramento, CA
| | - Timothy M. Guenther
- University of California Davis Medical Center, Department of General Surgery. Sacramento, CA
| | | | - Laura Kenny
- University of California Davis Medical Center, Department of Pediatrics, Division of Critical Care. Sacramento, CA
| | - Stephanie N. Mateev
- University of California Davis Medical Center, Department of Pediatrics, Division of Critical Care. Sacramento, CA
| | - Gary W. Raff
- University of California Davis Medical Center, Division of Pediatric Cardiothoracic Surgery. Sacramento, CA
| | - Alana L. Beres
- University of California Davis Medical Center, Division of Pediatric General, Thoracic, and Fetal Surgery. Sacramento, CA
| |
Collapse
|
5
|
Agarwal P, Natarajan G, Sullivan K, Rao R, Rintoul N, Zaniletti I, Keene S, Mietzsch U, Massaro AN, Billimoria Z, Dirnberger D, Hamrick S, Seabrook RB, Weems MF, Cleary JP, Gray BW, DiGeronimo R. Venovenous versus venoarterial extracorporeal membrane oxygenation among infants with hypoxic-ischemic encephalopathy: is there a difference in outcome? J Perinatol 2021; 41:1916-1923. [PMID: 34012056 DOI: 10.1038/s41372-021-01089-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/01/2021] [Accepted: 04/29/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Our hypothesis was that among infants with hypoxic-ischemic encephalopathy (HIE), venoarterial (VA), compared to venovenous (VV), extracorporeal membrane oxygenation (ECMO) is associated with an increased risk of mortality or intracranial hemorrhage (ICH). DESIGN/METHODS Retrospective cohort analysis of infants in the Children's Hospitals Neonatal Database from 2010 to 2016 with moderate or severe HIE, gestational age ≥36 weeks, and ECMO initiation <7 days of age. The primary outcome was mortality or ICH. RESULTS Severe HIE was more common in the VA ECMO group (n = 57), compared to the VV ECMO group (n = 53) (47.4% vs. 26.4%, P = 0.02). VA ECMO was associated with a significantly higher risk of death or ICH [57.9% vs. 34.0%, aOR 2.39 (1.08-5.28)] and mortality [31.6% vs. 11.3%, aOR 3.06 (1.08-8.68)], after adjusting for HIE severity. CONCLUSIONS In HIE, VA ECMO was associated with a higher incidence of mortality or ICH. VV ECMO may be beneficial in this population.
Collapse
Affiliation(s)
- Prashant Agarwal
- Department of Pediatrics, Children's Hospital of Michigan/Central Michigan University, Detroit, MI, USA.
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan/Central Michigan University, Detroit, MI, USA
| | - Kevin Sullivan
- Department of Pediatrics, AI duPont Hospital for Children/Thomas Jefferson University, Wilmington, DE, USA
| | - Rakesh Rao
- Department of Pediatrics, Washington University in St. Louis, St Louis, MO, USA
| | - Natalie Rintoul
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Sarah Keene
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - Ulrike Mietzsch
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - An N Massaro
- Department of Pediatrics, The George Washington University School of Medicine and Children's National Hospital, Washington DC, DC, USA
| | - Zeenia Billimoria
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Daniel Dirnberger
- Department of Pediatrics, AI duPont Hospital for Children, Wilmington, DE, USA
| | - Shannon Hamrick
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - Ruth B Seabrook
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mark F Weems
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - John P Cleary
- Department of Pediatrics, Children's Hospital of Orange County, Orange, CA, USA
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert DiGeronimo
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | | |
Collapse
|
6
|
Abstract
Predicting neurodevelopmental outcomes in high-risk neonates remains challenging despite advances in neonatal care. Early and accurate characterization of infants at risk for neurodevelopmental delays is necessary to best identify those who may benefit from existing early interventions and novel therapies that become available. Although neuroimaging is a promising biomarker in the prediction of neurodevelopmental outcomes in high-risk infants, it requires additional resources and expertise. Despite many advances in neonatal neuroimaging, there remain limitations in relating early neuroimaging findings with long-term outcomes; further studies are necessary to determine the optimal protocols to best identify high-risk patients and improve neurodevelopmental outcome prediction.
Collapse
|
7
|
Geven W, Nabuurs-Korhman L, van Kessel-Feddema J, Festen C. Follow-up in Neonatal Extracorporeal Membrane Oxygenation (ECMO). Int J Artif Organs 2018. [DOI: 10.1177/039139889501801007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 34 survivors of the first 43 ECMO patients from our institution before discharge to another hospital or home an EEG, BAER, Head Ultrasonography, cerebral CT scan, Dubowitz score and ophthalmological inspection were performed. At one year of age Mental Developmental Index of the Bayley scales, Motor Quotient as well as pulmonary and neurological status were assessed. In 29 patients follow-up took place in our hospital. In 17 of them (59%) all tests before discharge were normal, 2 patients (7%) showed an abnormal BAER, an additional 5 patients (17%) had abnormal EEG and 2 patients (7%) had abnormal HUS in combination with abnormal cerebral CT scan. In 19 patients (33%) the Dubowitz score was abnormal at discharge. At one year of age neurological status was normal in 25 (86%) patients, respiratory status was normal in 22 (76%) and Mental Development Index was > 80 in 23 of the patients (79%). A significant correlation between Mental Development Index and Motor Quotient was found r=0.50, p=0.0065. It is concluded that more than one abnormal neurophysiological test before discharge may identify patients with additional risks for adverse outcome and that the respiratory status influenced psychomotor development at one year of age.
Collapse
Affiliation(s)
- W.B. Geven
- Department of Neonatology Nijmegen - The Netherlands
| | | | | | - C. Festen
- Paediatric Surgery, University Hospital Nijmegen, Nijmegen - The Netherlands
| |
Collapse
|
8
|
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with respiratory and cardiac failure refractory to maximal medical management. The extracorporeal life support organization registry is the largest available resource for describing the population and outcomes of patients treated with this therapy. The use of ECMO for neonatal patients is decreasing in proportion to the total annual ECMO runs most likely due to advancements in medical management. Although the overall survival for neonatal ECMO has decreased, this is likely a reflection of the increasingly complex neonatal patients treated with this therapy. Although many patient and mechanical complications are decreasing over time, there remains a high percentage of morbidities and risks associated with ECMO. Continued refinements in management strategies are important to improving overall patient outcomes.
Collapse
Affiliation(s)
- Burhan Mahmood
- Department of Pediatrics, Division of Newborn Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, One Children's Hospital Dr, 2133 Faculty Pavilion, 4401 Penn Ave, Pittsburgh, PA 15224.
| | - Debra Newton
- Extracorporeal Support Department, Children's Mercy Kansas City, Kansas City, MO
| | - Eugenia K Pallotto
- Extracorporeal Support Department, Children's Mercy Kansas City, Kansas City, MO; Department of Pediatrics, University of Missouri School of Medicine, Intensive Care Nursery and Neonatal ECMO Children's Mercy, Kansas City, MO
| |
Collapse
|
9
|
Abstract
Utilization of extraocorporeal membrane oxygenation (ECMO) has become increasingly widespread as a bridging therapy for neonates with severe, reversible respiratory or cardiac diseases. While significant risks remain, due to advances in medical and surgical management, overall mortality has decreased. However, short and long-term neurological morbidity has remained high. Therefore, increasing attention has been focused on multimodal neuromonitoring to track and optimally, minimize or prevent intracranial injury. This review will explore the the indications, advantages, disadvantages, timing, frequency, duration, and any known correlation with neurodevelopmental outcomes of common types of neuromonitoring in the neonatal ECMO population. Investigational monitoring techniques such as NIRS will be briefly reviewed.
Collapse
Affiliation(s)
- Nan Lin
- Division of Neurology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - John Flibotte
- Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
| |
Collapse
|
10
|
Wien MA, Whitehead MT, Bulas D, Ridore M, Melbourne L, Oldenburg G, Short BL, Massaro AN. Patterns of Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation. AJNR Am J Neuroradiol 2017; 38:820-826. [PMID: 28209579 DOI: 10.3174/ajnr.a5092] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/05/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Neonates treated with extracorporeal membrane oxygenation are at risk for brain injury and subsequent neurodevelopmental compromise. Advances in MR imaging and improved accessibility have led to the increased use of routine MR imaging after extracorporeal membrane oxygenation. Our objective was to describe the frequency and patterns of extracorporeal membrane oxygenation-related brain injury based on MR imaging findings in a large contemporary cohort of neonates treated with extracorporeal membrane oxygenation. MATERIALS AND METHODS This was a retrospective study of neonatal patients treated with extracorporeal membrane oxygenation from 2005-2015 who underwent MR imaging before discharge. MR imaging and ultrasound studies were reviewed for location and type of parenchymal injury, ventricular abnormalities, and increased subarachnoid spaces. Parenchymal injury frequencies between patients treated with venoarterial and venovenous extracorporeal membrane oxygenation were compared by χ2 tests. RESULTS Of 81 neonates studied, 46% demonstrated parenchymal injury; 6% showed infarction, mostly in vascular territories (5% anterior cerebral artery, 5% MCA, 1% posterior cerebral artery); and 20% had hemorrhagic lesions. The highest frequency of injury occurred in the frontal (right, 24%; left, 25%) and temporoparietal (right, 14%; left, 19%) white matter. Sonography had low sensitivity for these lesions. Other MR imaging findings included volume loss (35%), increased subarachnoid spaces (44%), and ventriculomegaly (17% mild, 5% moderate, 1% severe). There were more parenchymal injuries in neonates treated with venoarterial (49%) versus venovenous extracorporeal membrane oxygenation (29%, P = .13), but the pattern of injury was consistent between both modes. CONCLUSIONS MR imaging identifies brain injury in nearly half of neonates after treatment with extracorporeal membrane oxygenation. The frontal and temporoparietal white matter are most commonly affected, without statistically significant laterality. This pattern of injury is similar between venovenous and venoarterial extracorporeal membrane oxygenation, though the frequency of injury may be higher after venoarterial extracorporeal membrane oxygenation.
Collapse
Affiliation(s)
- M A Wien
- From the Divisions of Diagnostic Imaging and Radiology (M.A.W., M.T.W., D.B.)
| | - M T Whitehead
- From the Divisions of Diagnostic Imaging and Radiology (M.A.W., M.T.W., D.B.)
- The George Washington University School of Medicine (M.T.W., D.B., L.M., A.N.M.), Washington, DC
| | - D Bulas
- From the Divisions of Diagnostic Imaging and Radiology (M.A.W., M.T.W., D.B.)
- Neonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
- The George Washington University School of Medicine (M.T.W., D.B., L.M., A.N.M.), Washington, DC
| | - M Ridore
- Neonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
| | - L Melbourne
- Neonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
- The George Washington University School of Medicine (M.T.W., D.B., L.M., A.N.M.), Washington, DC
| | - G Oldenburg
- the ECMO Program (G.O.), Children's National Health System, Washington, DC
| | - B L Short
- Neonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
| | - A N Massaro
- Neonatology (D.B., M.R., L.M., B.L.S., A.N.M.)
- The George Washington University School of Medicine (M.T.W., D.B., L.M., A.N.M.), Washington, DC
| |
Collapse
|
11
|
Neuromonitoring During Extracorporeal Membrane Oxygenation: A Systematic Review of the Literature. Pediatr Crit Care Med 2015; 16:558-64. [PMID: 25828783 DOI: 10.1097/pcc.0000000000000415] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Neurologic injury remains a significant morbidity and risk factor for mortality in critically ill patients undergoing extracorporeal membrane oxygenation. Our goal was to systematically review the literature on the use of neuromonitoring methods during extracorporeal membrane oxygenation. DATA SOURCES Electronic searches of PubMed, CINAHL, EMBASE, Web of Science, Cochrane, and Scopus were conducted in March 2014, using a combination of medical subject heading terms and text words to define concepts of extracorporeal life support, neurologic monitoring techniques, evaluation, and outcomes. STUDY SELECTION Studies were selected based on inclusion and exclusion criteria defined a priori. DATA EXTRACTION Two authors reviewed all citations independently. A standardized data extraction form was used to construct evidence tables by neuromonitoring method. Evidence was graded using the Oxford Evidence-Based Medicine scoring system. DATA SYNTHESIS Of 3,459 unique citations, 39 studies met the inclusion criteria. Study designs were retrospective observational cohort studies (n = 20), prospective observational studies (n = 17), case-control studies (n = 2), and no interventional studies. Most studies evaluated newborns (n = 30). Extracorporeal membrane oxygenation neuromonitoring methods included neuroimaging (head ultrasound) (n = 12); intermittent, conventional, multichannel electroencephalography (n = 5); 1- to 2-channel amplitude-integrated electroencephalography (n = 2); Doppler ultrasound (n = 7); cerebral oximetry (n = 6); plasma brain injury biomarkers (n = 4); and other (n = 3). All evidence was graded 2B-4, with the majority of studies graded 3B (20/39 studies) and 4 (10/39 studies). Due to the heterogeneity of the studies included, aggregate analysis was not possible. CONCLUSIONS Data supporting the use and effectiveness of current neuromonitoring methods are limited. Most studies have modest sample sizes, are observational in nature, and include patient populations that are of different ages and pathologies, with very limited data for pediatric and adult ages. Well-designed studies with adequate power and standardized short- and long-term outcomes are needed to develop guidelines for neuromonitoring and ultimately neuroprotection in patients on extracorporeal membrane oxygenation.
Collapse
|
12
|
Abstract
MRI performed in the neonatal period has become a tool widely used by clinicians and researchers to evaluate the developing brain. MRI can provide detailed anatomical resolution, enabling identification of brain injuries due to various perinatal insults. This review will focus on the link between neonatal MRI findings and later neurodevelopmental outcomes in high-risk term infants. In particular, the role of conventional and advanced MR imaging in prognosticating outcomes in neonates with hypoxic-ischemic encephalopathy, ischemic perinatal stroke, need for extracorporeal membrane oxygenation life support, congenital heart disease, and other neonatal neurological conditions will be discussed.
Collapse
Affiliation(s)
- An N Massaro
- Department of Pediatrics, The George Washington University School of Medicine, 111 Michigan Ave, NW Washington, DC 20010.
| |
Collapse
|
13
|
Abstract
Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for newborns with severe but reversible respiratory failure. Although ECMO has significantly improved survival, it is associated with substantial complications, of which intracranial injuries are the most important. These injuries consist of hemorrhagic and non-hemorrhagic, ischemic lesions. Different from the classical presentation of hemorrhages in preterm infants, hemorrhages in ECMO-treated newborns are mainly parenchymal and with a high percentage in the posterior fossa area. There are conflicting data on the predominant occurrence of cerebral lesions in the right hemisphere. The existence of intracerebral injuries and the classification of its severity are the major predictors of neurodevelopmental outcome. This section will discuss the known data on intracranial injury in the ECMO population and the effect of ECMO on the brain.
Collapse
Affiliation(s)
- Arno F J van Heijst
- Department of Pediatrics, Division of Neonatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - Amerik C de Mol
- Department of Pediatrics, Albert Sweitzer Hospital, Dordrecht, Rotterdam, The Netherlands
| | - Hanneke Ijsselstijn
- Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
14
|
Ijsselstijn H, van Heijst AFJ. Long-term outcome of children treated with neonatal extracorporeal membrane oxygenation: increasing problems with increasing age. Semin Perinatol 2014; 38:114-21. [PMID: 24580767 DOI: 10.1053/j.semperi.2013.11.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
As more and more critically ill neonates survive, it becomes important to evaluate long-term morbidity. This review aims to provide an up-to-date overview of medical and neurodevelopmental outcomes in children who as neonates received treatment with extracorporeal membrane oxygenation (ECMO). Most patients-except those with congenital diaphragmatic hernia-have normal lung function and normal growth at older age. Maximal exercise capacity is below normal and seems to deteriorate over time in the CDH population. Gross motor function problems have been reported until school age. Although mental development is usually favorable within the first years and cognition is normal at school age, many children experience problems with working speed, spatial ability tasks, and memory. In conclusion, children who survived neonatal treatment with ECMO often encounter neurodevelopmental problems at school age. Long-term follow-up is needed to recognize problems early and to offer appropriate intervention.
Collapse
Affiliation(s)
- Hanneke Ijsselstijn
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Dr. Molewaterplein 60, Rotterdam NL-3015 GJ, The Netherlands.
| | - Arno F J van Heijst
- Department of Neonatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
15
|
de Los Reyes E, Roach ES. Neurologic complications of congenital heart disease and its treatment. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:49-59. [PMID: 24365288 DOI: 10.1016/b978-0-7020-4086-3.00005-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Advances in surgical and medical management have dramatically improved the survival of individuals with congenital cardiac anomalies. Various neurologic complications occur in association with congenital heart disease, including cognitive impairment and ischemic stroke. The likelihood of stroke is greatest in individuals with severe structural cardiac defects such as tetralogy of Fallot, transposition of the great arteries, or hypoplastic left heart syndrome. A persistent foramen ovale adds little or no additional stroke risk unless it is associated with an atrial septal aneurysm or other anomaly. Individuals with congenital heart disease caused by genetic abnormalities are apt to have other anomalies as well. Complications related to correction of cardiac anomalies include seizures, ischemia, stroke, and movement disorders.
Collapse
Affiliation(s)
| | - E Steve Roach
- Division of Child Neurology, Ohio State University, Columbus, OH, USA
| |
Collapse
|
16
|
Brain injury associated with neonatal extracorporeal membrane oxygenation in the Netherlands: a nationwide evaluation spanning two decades. Pediatr Crit Care Med 2013; 14:884-92. [PMID: 24121484 DOI: 10.1097/pcc.0b013e3182a555ac] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine the prevalence of and to classify ultrasound-proven brain injury during neonatal extracorporeal membrane oxygenation in The Netherlands. DESIGN Retrospective nationwide study (Rotterdam and Nijmegen), spanning two decades. SETTING Level III university hospitals. SUBJECTS All neonates who underwent neonatal extracorporeal membrane oxygenation from 1989 to 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cranial ultrasound images were reviewed independently by two investigators without knowledge of primary diagnosis, outcome, type of extracorporeal membrane oxygenation, or statistics. The scans were reviewed for lesion type and timing, with the use of a refined classification method for focal brain injury. Extracorporeal membrane oxygenation type was venoarterial in 88%. Brain abnormalities were detected in 17.3%: primary hemorrhage was most frequent (8.8%). Stroke was identified in 5% of the total group, with a notable significant preference for the left hemisphere (in 70%). Lobar hematoma (prevalence 2.2 %) was also significantly left predominant. CONCLUSION The incidence of brain injury found with cranial ultrasound in The Netherlands of the patients treated with extracorporeal membrane oxygenation during the neonatal period was 17.3%. Primary hemorrhage was the largest group of lesions, not clearly side-specific except for lobar bleeding, most probably related to changes in venous flow. Arterial ischemic stroke occurred predominant in the left hemisphere.
Collapse
|
17
|
Utility of neuroradiographic imaging in predicting outcomes after neonatal extracorporeal membrane oxygenation. J Pediatr Surg 2012; 47:76-80. [PMID: 22244396 DOI: 10.1016/j.jpedsurg.2011.10.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/06/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND The need for routine neuroimaging after extracorporeal membrane oxygenation (ECMO) and the optimal radiographic study remains unclear. We sought to evaluate the correlation between findings on head ultrasound (HUS) and magnetic resonance imaging (MRI) and determine the association of these findings to neurodevelopmental outcome. METHODS A retrospective review was performed (2003-2010) to identify neonates who had a MRI after ECMO. Each MRI was reviewed by a single pediatric neuroradiologist. Neurodevelopmental data was collected from the high-risk neonatal follow-up clinic. RESULTS Fifty neonates had a MRI (venoarterial 37, venovenous 13) after ECMO. HUS was abnormal in 24%, whereas MRI was abnormal in 62%. All infants with an abnormal HUS had an abnormal MRI, but an additional 50% of patients with a normal HUS had an abnormal MRI. Venoarterial ECMO was significantly associated with an abnormal MRI. Follow-up data was available for 26 neonates. The only predictor of abnormal neurodevelopment was the need for supplemental tube feeds at discharge. CONCLUSIONS MRI identified significantly more abnormalities compared to routine HUS after neonatal ECMO. However, neither MRI nor HUS findings correlated with early neurodevelopmental outcome. Feeding ability at discharge was the overall best predictor of neurologic impairment in survivors.
Collapse
|
18
|
Buesing KA, Kilian AK, Schaible T, Loff S, Sumargo S, Neff KW. Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia: follow-up MRI evaluating carotid artery reocclusion and neurologic outcome. AJR Am J Roentgenol 2007; 188:1636-42. [PMID: 17515387 DOI: 10.2214/ajr.06.1319] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The purpose of our study was to prospectively assess, using MRI and MR angiography, the cerebral and vascular status of 2-year-old children with congenital diaphragmatic hernia (CDH) in whom carotid artery reconstruction was performed after neonatal extra-corporeal membrane oxygenation (ECMO) therapy and to compare the neurologic development of children with vascular reocclusion with that of CDH children with successful repair and with non-ECMO controls. SUBJECTS AND METHODS A total of 30 infants (17 boys, 13 girls; 2 +/- 0.26 years) were included. Of these, 18 (60%) infants received arteriovenous ECMO therapy with subsequent reconstruction of the right common carotid artery (RCCA). Two years postoperatively, the children were examined with cerebral MRI, including 3D time-of-flight and contrast-enhanced 3D MR angiography of the intra- and extracranial brain-supplying arteries. The pathologic findings were analyzed for the ability to predict impaired neurologic development. RESULTS The RCCA was occluded or highly stenotic in 13 (72%) of 18 children. All infants showed intra- and extracranial collaterals and a patent internal carotid artery. The average duration of ECMO was not longer than in cases of successful reconstruction (p = 1). The ECMO group showed a significantly greater incidence of cerebral injuries (p = 0.007) but no relevant impairment in neurologic development compared with controls (p = 0.26). Unsuccessful RCCA repair had no predictive value for a poor neurologic outcome (p = 1). CONCLUSION The outcome of RCCA repair after ECMO is possibly poorer than expected, with vascular occlusion or high-grade stenosis occurring in almost three quarters of patients. Although reocclusion of the RCCA does not increase the risk for cerebral lesions or an impaired neurologic development during the first 2 years postoperatively, the overall benefit of RCCA repair remains doubtful, and the potential long-term risk arising from these plaques has yet to be assessed.
Collapse
Affiliation(s)
- Karen A Buesing
- Department of Clinical Radiology, University Hospital Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, Mannheim 68167, Germany.
| | | | | | | | | | | |
Collapse
|
19
|
Khan AM, Shabarek FM, Zwischenberger JB, Warner BW, Cheu HW, Jaksic T, Goretsky MJ, Meyer TA, Doski J, Lally KP. Utility of daily head ultrasonography for infants on extracorporeal membrane oxygenation. J Pediatr Surg 1998; 33:1229-32. [PMID: 9721992 DOI: 10.1016/s0022-3468(98)90156-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Intracranial hemorrhage (ICH) is a major concern during extracorporeal membrane oxygenation (ECMO). Daily cranial ultrasonography has been used by many ECMO centers as a diagnostic tool for both detecting and following ICH while infants are on bypass. The purpose of this patient review was to look at the usefulness of performing daily cranial ultrasonography (HUS) in infants on ECMO in detecting intraventricular hemorrhage of a magnitude sufficient to alter patient treatment. METHODS The authors reviewed retrospectively all of the records of all neonates treated with ECMO at the Hermann Children's Hospital, Wilford Hall USAF Medical Center, Cincinnati Children's Hospital, The University of Texas Medical Branch at Galveston, and Texas Children's Hospital between February 1986 to March 1995. Two hundred ninety-eight patients were placed on ECMO during this period. All patients had HUS before, and daily while on ECMO, and all were reviewed by the staff radiologists. A total of 2,518 HUS examinations were performed. RESULTS Fifty-two of 298 patients (17.5%) had an intraventricular hemorrhage seen on ultrasound scan. Nine of 52 patients (17.3%) had an ICH seen on the initial HUS examination before ECMO, all of which were grade I, and 43 of 52 patients (82.7%) had ICH while on ECMO. Of these ICH, 15 were grade I, 10 were grade II, 10 were grade III, and eight were grade IV. Forty of these ICH (93%) were diagnosed by HUS during the first 5 days of the ECMO course. Seven hundred eighty-six HUS were performed after day 5, at an estimated cost of $300,000 to $450,000 (charges), demonstrating three new intraventricular hemorrhages, one grade I, and one grade IV on day 7 and one grade I on day 8. Eight patients were taken off ECMO because of ICH diagnosed within the first 5 days. One patient was taken off ECMO because of ICH diagnosed after 5 days. This patient had clinical symptoms suggestive of ICH. CONCLUSIONS Almost all ICH occur during the first 5 days of an ECMO course. Unless there is a clinical suspicion, it is not cost effective to perform HUS after the fifth day on ECMO, because subsequent HUS examinations are unlikely to yield information significant enough to alter management.
Collapse
Affiliation(s)
- A M Khan
- Department of Pediatrics, University of Texas Medical School and Hermann Children's Hospital, Houston, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Klein MD, Lessin MS, Whittlesey GC, Chang CH, Becker CJ, Meyer SL, Smith AM. Carotid artery and jugular vein ligation with and without hypoxia in the rat. J Pediatr Surg 1997; 32:565-70. [PMID: 9126755 DOI: 10.1016/s0022-3468(97)90708-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A continuing concern about the use of extracorporeal membrane oxygenation (ECMO) is the cannulation of the common carotid artery or the internal jugular vein. The authors investigated the changes that might occur in the brain with neck vessel ligation in the normal and the hypoxic rat. Two groups of 60 rats each were studied. The first group was divided into three subgroups of 20 animals each. Subgroup 1 (HH) was hypoxic both 24 hours before and 24 hours after operation. Subgroup 2 (HN) (the ECMO model) was hypoxic before operation and recovered for 24 hours in room air. Subgroup 3 (NN) underwent the entire procedure in room air. For each oxygen environment, four different operations were performed: carotid artery ligation, jugular vein ligation, carotid artery and jugular vein ligation, and dissection of the vessels without ligation (sham). Thus each subgroup was further divided into four sub-subgroups based on the operation performed. Rats were again anesthetized after a 24-hour recovery period and killed using low, blunt cervical dislocation. In the first group of 60 rats, the skull was opened and the brain was carefully removed from the cranial vault and placed in a fixative. The brains were placed in a small magnetic resonance imaging (MRI) head coil in groups of five and scans were obtained to provide T1 and T2 images that correlated with histological sections. MRI scans were reviewed in random, blinded fashion by an imager unaware of how these animals had been treated. The brains were then sectioned coronally at six corresponding levels: frontal, mid and posterior cerebrum, midbrain, pons, and medulla. Histological examination was performed in blinded fashion. The number of lesions (usually ischemic as noted by a decrease in the number of neurons) was totaled for each area of the brain. There were no differences that were consistent or statistically significant in the MR images of brains removed from the head, although it would appear that rats with jugular vein and carotid artery ligation were relatively protected. In the HN group jugular vein ligation was worst, and adding carotid artery ligation was best. In the histological studies the NN group had significantly more lesions than the HH group (P < .01). The second group of 60 rats was divided and treated as the first group in all respects except that MRI was conducted immediately after death on intact heads, and no histological studies were performed. This was done to control for lesions that might have been produced by removal of the brains from the skulls. In this group all findings were right sided. One animal in the HN group showed midcerebral white matter edema after jugular and carotid ligation. Focal anterior cerebral edema was seen in another animal (HH) after isolated carotid ligation. An occipital infarct was found in one animal (HH) after both carotid and jugular ligation. The authors conclude that neck vessel ligation in the hypoxic or normoxic rat causes only occasional and sporadic brain injury much as is seen clinically in newborn ECMO patients.
Collapse
Affiliation(s)
- M D Klein
- Department of Surgery, Wayne State University School of Medicine and the Children's Hospital of Michigan, Detroit 48201, USA
| | | | | | | | | | | | | |
Collapse
|
21
|
Howard S, Mugford M, Normand C, Elbourne D, Grant A, Field D, Johnson A. A cost-effectiveness analysis of neonatal ECMO using existing evidence. Int J Technol Assess Health Care 1996; 12:80-92. [PMID: 8690565 DOI: 10.1017/s0266462300009417] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A cost-effectiveness analysis is part of the U.K. ECMO Trial. In preparation for this analysis, existing evidence on the costs and effectiveness of neonatal ECMO was evaluated. ECMO appears to be more costly but may be more or less effective than conventional treatment. No case can be made for introducing ECMO before trial results are available.
Collapse
Affiliation(s)
- S Howard
- London School of Hygiene and Tropical Medicine
| | | | | | | | | | | | | |
Collapse
|
22
|
Glass P, Wagner AE, Papero PH, Rajasingham SR, Civitello LA, Kjaer MS, Coffman CE, Getson PR, Short BL. Neurodevelopmental status at age five years of neonates treated with extracorporeal membrane oxygenation. J Pediatr 1995; 127:447-57. [PMID: 7544826 DOI: 10.1016/s0022-3476(95)70082-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To determine the neurodevelopmental status at age 5 years among children who received extracorporeal membrane oxygenation (ECMO) in the newborn period as a treatment for severe cardiorespiratory failure. METHODS We conducted a prospective cohort study of 103 five-year-old ECMO-treated children born between June 1984 and July 1988, and treated at our institution. Thirty-seven healthy control children were recruited locally. The assessment protocol included a complete neuropsychologic assessment, psychosocial assessment with parent questionnaires, a standard neurologic evaluation, assessment of gross motor and fine motor function, a medical history, and physical examination. RESULTS Major disability was present in 17 of the ECMO cohort. Eleven ECMO-treated children (11%) were mentally retarded, one of whom was profoundly impaired. Two additional children had severe learning disabilities. Cerebral palsy was diagnosed in 5 (5%) ECMO-treated children, but all cases were mild in nature and the patients were walking unaided. One child has paraplegia. The mean Full Scale, Verbal, and Performance IQs of the EMCO-treated children were within the normal range, but as a group were significantly lower than in control children (96 vs 115, p < 0.001). Children treated with ECMO had increased risk relative to the control children for academic difficulties at school age (49% VS 22%, P < 0.01) and a higher rate of behavioral problems reported by parents (42% vs 16%, p = 0.01). CONCLUSIONS The rate of major disability was comparable to that in other high-risk populations. The high rate of behavioral problems and increased risk of subsequent school failure among nonretarded ECMO-treated children supports the need for close follow-up of these children after hospital discharge.
Collapse
Affiliation(s)
- P Glass
- Department of Behavioral Sciences, Children's National Medical Center, Washington, D.C. 20010, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Lago P, Rebsamen S, Clancy RR, Pinto-Martin J, Kessler A, Zimmerman R, Schmelling D, Bernbaum J, Gerdes M, D'Agostino JA. MRI, MRA, and neurodevelopmental outcome following neonatal ECMO. Pediatr Neurol 1995; 12:294-304. [PMID: 7546003 DOI: 10.1016/0887-8994(95)00047-j] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cranial magnetic resonance imaging (MRI) of 31 newborn infants treated with venoarterial cardiopulmonary bypass for severe but reversible respiratory failure, revealed major focal parenchymal lesions in 7 of 31 infants (23%) and demonstrated abnormal enlargement of extra-axial and ventricular cerebrospinal fluid spaces in 16 of 31 (51%). No preferential left versus right lateralization of focal injury was observed in conjunction with right common carotid artery and jugular vein ligation. No statistically significant relationships were found between major brain lesions on MRI scans and the clinical characteristics of the pre-extracorporeal membrane oxygenation (ECMO), ECMO, and post-ECMO course. Major focal brain lesions were significantly associated with an asymmetric cerebrovascular response to carotid ligation of the right versus left middle cerebral arteries as detected by magnetic resonance angiography (P < .05). Enlarged cerebrospinal fluid spaces were not significantly related to the presence of parenchymal MRI lesions, but were associated with lower Bayley neurodevelopmental scores for mental (MDI) and psychomotor evaluations (PDI) at 6 and 12 months (P < .05). It is concluded that asymmetries of cerebral vascular adaptation detected by magnetic resonance angiography after ECMO may be associated with major brain lesions revealed by MRI. Thereafter, the presence of enlarged cerebrospinal fluid spaces on MRI is associated with a poor shortterm developmental outcome.
Collapse
Affiliation(s)
- P Lago
- Division of Neonatology, Children's Hospital of Philadelphia, PA 19104, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
D'Agostino JA, Bernbaum JC, Gerdes M, Schwartz IP, Coburn CE, Hirschl RB, Baumgart S, Polin RA. Outcome for infants with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: the first year. J Pediatr Surg 1995; 30:10-5. [PMID: 7722808 DOI: 10.1016/0022-3468(95)90598-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Congenital diaphragmatic hernia (CDH) has been associated with a high mortality rate. The purposes of this study were to determine the impact of extracorporeal membrane oxygenation (ECMO) on the survival of infants with CDH and to document the sequelae and 1-year neurodevelopmental outcome for CDH infants who required ECMO. Thirty neonates with CDH were admitted between May 7, 1990 and October 1, 1992. Twenty required ECMO and were enrolled in our neonatal follow-up program. Information about the infants' neonatal course was obtained from chart review, and the infants were seen at 3, 6, and 12 months of age for medical and neurodevelopmental follow-up. Primary diaphragmatic repair was performed in 13 infants. Five required Goretex graft reconstruction (GGR), and two did not have repair. Sixteen (80%) of the 20 infants who required ECMO survived. The overall survival rate increased from 31% (10 of 32) in the 5 years previous to the start of the ECMO program to 63% (19 of 30) since then (P = .01). The most common sequelae noted by the time of discharge included gastroesophageal reflux (GER; 81%), the need for tube feeding (69%), and chronic lung disease (CLD; 62%). At 1 year of age, mean cognitive skills were average (87 +/- 23) and motor skills were borderline (75 +/- 24) according to the Bayley Scales of Infant Development. Hypotonia was present in 10 of 13 patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- J A D'Agostino
- Division of Neonatology, Children's Hospital of Philadelphia, PA 19104
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
Over the past 2 decades, 110 patients with congenital diaphragmatic hernia (CDH) were treated in the authors' hospital. Eighty-six survived; of these, 10 patients (11.6%) had gastroesophageal reflux (GER) after repair of CDH. Seven occurred in the past 5 years, during which time advanced intensive care including extracorporeal membrane oxygenation (ECMO) was used. Vomiting started within 4 weeks after repair of CDH in eight cases, and hiatal hernia was demonstrated in six cases. Three patients responded to conservative therapy; the other seven required antireflux surgery. Several factors are believed to be possible causes of the development of GER in CDH cases. Among them, slow pulmonary expansion of the affected side was thought to be the most important. Namely, in a case of CDH associated with severe hypoplastic lung, the esophagus may be deviated to the affected side before the lung is expanded. After expansion, the abdominal esophagus shortens, and GER or a hiatal hernia can occur in severe cases. There were seven such patients in our series of 10. With the increase in the survival rate of CDH cases associated with severe hypoplastic lung, the number of such patients also may increase. Therefore, some additional procedure to prevent the lower esophagus from sliding will be necessary in the repair of diaphragmatic hernia.
Collapse
Affiliation(s)
- M Nagaya
- Department of Pediatric Surgery, Central Hospital, Kasugai, Japan
| | | | | |
Collapse
|
26
|
Abstract
From 1973-1985 to 1988 the average patient complications per case were 1.44 per case and significantly increased during 1990 to 1992 to 2.10 per case (Figure 3). During the same periods patient survival significantly decreased from 84% (1973-1985 to 1988, n = 2463) to 80% (1990 to 1992, n = 4005) (Figure 4). The association between total complication rates and survival rate was examined by regression analysis (Table 5). The correlation of patient complication rate and total complication rate with survival is highly significant; however, causality cannot be established. When comparing different entry criteria (Table 2) for incidence of mechanical and patient complications, no significant differences are apparent. This is not surprising since each of the entry criteria were designed to identify the same patient population. When premature neonates (> 35 weeks) were placed on ECMO, 36% of them had intracranial haemorrhage (ICH) with 62% mortality while only 12% of the neonates < 35 weeks had ICH and a 49% mortality. Similar findings were noted with low birthweight neonates (< 2.2 kg), 28% had ICH with 64% mortality while only 12% of the neonates > 2.2 kg had ICH with a 50% mortality. Selection criteria remain problematic for a variety of reasons. They cannot be viewed as absolute because of variability between centres. What represents likely 80% mortality in one centre may not apply to another. Historical controls are misleading because changing respiratory therapy strategies make historical populations difficult to compare. Also, once an ECMO centre becomes established, a more challenging group of patients will be attracted than previously was the case. Further, a single entry criterion cannot be generalized for all entry diagnoses. Criteria for an 80% predicted mortality is probably not the same for MAS, CHN, PPHN, and sepsis. Subsequent patients registered in the Neonatal ECMO Registry of the Extracorporeal Life Support Organization will address these issues more thoroughly, as specific details of the pre-ECMO condition and therapeutic strategies are collected. This collective review should help to identify trends which require reassessment of technique or patient management.
Collapse
|
27
|
Abstract
Despite an association with meconium and blood aspiration, pneumonia, sepsis, pneumothorax, prematurity, and congenital diaphragmatic hernia, no cause for persistent pulmonary hypertension of the newborn can be found in many cases. This article discusses the advances in current therapies including the promising new therapy of inhaled nitric oxide.
Collapse
Affiliation(s)
- J D Roberts
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|