Neonatal extracorporeal membrane oxygenation: how not to assess novel technologies

Clinical Research in Acute Fatal Illness

Clinical research to evaluate the effectiveness of life support systems in acute fatal illness has unique problems of logistics, ethics, and consent. There have been 10 prospective comparative trials of extracorporeal membrane oxygenation in acute fatal respiratory failure, utilizing different study designs. The trial designs were prospective controlled randomized, prospective adaptive randomized, sequential, and matched pairs. The trials were reviewed with regard to logistics, ethics, consent, statistical methods, economics, and impact. The matched pairs method is the best study design for evaluation of life support systems in acute fatal illness.

Off-label use of inhaled nitric oxide after release of NIH consensus statement

BACKGROUND

Inhaled nitric oxide (iNO) therapy is an off-label medication in infants <34 weeks' gestational age. In 2011, the National Institutes of Health released a statement discouraging routine iNO use in premature infants. The objective of this study was to describe utilization patterns of iNO in American NICUs in the years surrounding the release of the National Institutes of Health statement. We hypothesized that iNO prescription rates in premature infants have remained unchanged since 2011.

METHODS

The Pediatrix Medical Group Clinical Data Warehouse was queried for the years 2009-2013 to describe first exposure iNO use among all admitted neonates stratified by gestational age.

RESULTS

Between 2009 and 2013, the rate of iNO utilization in 23- to 29-week neonates increased from 5.03% to 6.19%, a relative increase of 23% (confidence interval: 8%-40%; P = .003). Of all neonates who received iNO therapy in 2013, nearly half were <34 weeks' gestation, with these infants accounting for more than half of all first exposure iNO days each year of the study period.

CONCLUSIONS

The rates of off-label iNO use in preterm infants continue to rise despite evidence revealing no clear benefit in this population. This pattern of iNO prescription is not benign and comes with economic consequences.

The development and use of extracorporeal membrane oxygenation in neonates

Extracorporeal membrane oxygenation (ECMO) is the utilization of a modified heart-lung machine to provide temporary support for patients with severe respiratory or cardiac failure. In contrast to patients managed with traditional cardiopulmonary bypass, patients on ECMO undergo cannulation of relatively accessible blood vessels, are maintained at normal body temperature, and only require partial anticoagulation with heparin. Although first developed for use in adults, ECMO has been most successful in the treatment of newborn infants with life-threatening pulmonary failure. Since 1974, over 17,000 infants have received ECMO with a 78% survival rate. There is a 15%-20% incidence of neurodevelopmental disabilities among ECMO survivors.

Evaluation of ethical conflicts associated with randomized, controlled trials in critically ill children

OBJECTIVE

To determine whether randomized, controlled trials (RCTS) of potentially life-sustaining therapies in critically ill infants and children cause an ethical conflict for physician investigators and if ethical conflicts affect protocol implementation.

DESIGN

Descriptive survey.

SUBJECTS

A convenience sample of 1,050 physicians from a national pediatric critical care meeting mailing list.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The survey return rate was 41% (n = 415). Of the returned surveys, 81% (n = 331) were answered by pediatric intensivists and fellows. The remaining 19% (n = 84) were completed by other physician subspecialists. Overall, 74% had experience with RCTs involving a potentially life-saving therapy (25% had experience with three or more trials, and 26% had never participated in this type of study). The vast majority of the respondents (96%) indicated that they believe RCTs of potentially life-sustaining therapies are ethical; however, only 10% stated that they never experienced an ethical conflict with these types of studies. Most respondents (84%) indicated that published data from uncontrolled trials may bias them toward an investigational therapy. Furthermore, only 35% of the respondents indicated that they always maintain strict protocol adherence when the condition of a control patient deteriorates and parents request the experimental treatment. There was a significant association between physicians who experienced an ethical conflict and the likelihood that they would do the following if the condition of a control patient deteriorated: fail to maintain strict protocol adherence (p = .05); alter the protocol in response to parental requests for the experimental treatment (p < .01); or seek compassionate use of the experimental treatment (p < .01).

CONCLUSIONS

Although physicians consider RCTs of potentially life-sustaining therapies ethical, they acknowledge that this type of study sometimes creates an ethical conflict. Published results of uncontrolled trials lead to investigator bias in randomized trials and preclude equipoise. Our results indicate that RCTs involving life-sustaining therapies may be biased, lack consistent protocol implementation, and raise concern that data from these studies are potentially flawed.

Health care technology as a policy issue

Health care technology has become an increasingly visible issue in many countries, primarily because of the rising costs of health care. In addition, many questions concerning quality of care are being raised. Health care technology assessment has been seen as an aid in addressing questions concerning technology, including benefits and costs. A number of industrialized countries have developed active programs of health care technology assessment during the past two decades. Eight countries at similar levels of socio-economic and health development--Australia, Canada, France, Germany, the Netherlands, Sweden, the United Kingdom and the United States--have been examined to gain insights into how they manage health care technology and what place technology assessment has in such management. In addition to seeking general information, specific cases--treatment for coronary artery disease, medical imaging, laparoscopic surgery, treatment of end-stage renal disease, neonatal intensive care, and breast cancer screening--were examined in each country.

Health care technology in the United States

The US health care system reflects the free market of the US economy--there is no fixed budget and no limit on expenditures in the loosely structured matrix of largely private-sector health industry components. Mainly because of the inaccessibility of adequate health care for a large segment of the population, and because of the enormous cost of care threatens financial ruin for many more people, the first major reform of the system was debated in Congress for most of 1994, though, in the end, no leglislation was passed. One focus of the debate on spending has been the problem of excessive use of expensive medical technology and the need for some control, which, by and large, is lacking in the existing system. Health care technology assessment itself is a thriving industry in the United States, used by government, insurers, medical societies, hospitals, and other groups for their own purposes. At the national policy level, few opportunities for technology assessment to affect the health care industry exist, so most effort is directed at trying to affect medical practice at the level of the individual hospital and practitioner. The discernible effect of technology assessment has been minimal.

Varicella pneumonitis: a role for extra-corporeal membrane oxygenation?

Pneumonitis is the most serious complication of varicella zoster infection and may be fatal despite antiviral therapy and assisted ventilation. We report two cases of varicella pneumonitis which were complicated by severe pneumonitis. Both patients deteriorated on maximal ventilatory support and were then given extra-corporeal membrane oxygenation (ECMO) and recovered. One patient subsequently developed lymphoma and the other was found to have an immunoglobulin subclass deficiency. ECMO should be considered for patients with varicella pneumonitis who do not respond to conventional treatment. Those with severe pneumonitis should be investigated for underlying immunodeficiency.

Neonatal extracorporeal membrane oxygenation (ECMO): clinical trials and the ethics of evidence

Neonatal extracorporeal membrane oxygenation (ECMO), a technology for the treatment of respiratory failure in newborns, is used as a case study to examine statistical and ethical aspects of clinical trials and to illustrate a proposed 'ethics of evidence', an approach to medical uncertainty within the context of contemporary biomedical ethics. Discussion includes the twofold aim of the ethics of evidence: to clarify the role of uncertainty and scientific evidence in medical decision-making, and to call attention to the need to confront the irreducible nature of uncertainty.

Extracorporeal life support in paediatrics

Extracorporeal membrane oxygenation (ECMO) is a life support technique based on modifications of heart-lung bypass technology. It is used to support severe but potentially reversible pulmonary or cardiopulmonary failure. There is increasing use of the technique for neonates and a return of interest in its use for adults. The number of non-neonatal paediatric patients receiving pulmonary support with ECMO worldwide is, however, small, and survival rates average less than 50%. Initial experience in 15 patients aged 3 months to 5 years with a high survival and low morbidity is reported.

Evaluation and policy considerations in the introduction of extracorporeal membrane oxygenation

The introduction of extracorporeal membrane oxygenation (ECMO) in Australia was associated with establishment of the technology at two teaching hospitals followed by appraisal through a consensus conference and a subsequent synthesis report and cost analysis. The assessments and associated policy processes have helped to define the place of the technology, but many uncertainties remain due to limited relevance of results from other countries, the preliminary nature of local data and absence of controlled trials. This experience raises questions concerning approaches by professional groups, funding authorities and assessment agencies in dealing with specialised new techniques which are associated with a small national caseload.

UK experience in neonatal extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is a life support technique capable of supporting pulmonary, cardiac, or cardiopulmonary function. It has proved most successful in neonatal respiratory failure. We report the initial UK experience with a survival rate of 80% in 15 neonates (gestations 36-41 weeks, birth weights 2690-3990 g) whose condition exceeded American criteria for ECMO treatment for a prolonged period before referral. Ages at referral varied from 11 to 240 hours and the duration of bypass required varied from 30 to 240 hours respectively.

The perinatal autopsy: a contemporary approach

As autopsy rates in general hospitals decline, interest in the perinatal autopsy continues to rise, reflecting the emergence of a vigorous specialty growing in parallel with fetal medicine, prenatal diagnosis and clinical genetics. Perinatal autopsies are best carried out in tertiary centres which provide these services. Meticulous documentation, flexibility of technique, intelligent use of laboratory tests and wide systematic histopathologic sampling are emphasized. Microbiologic examination is of particular value when carried out by a laboratory having a special interest in genital tract and perinatal pathogens. Karyotyping must be selective if resources are to be conserved and is most productive when there are multiple malformations. Perinatal autopsy is not complete without examination of the placenta and significant lesions should be clearly distinguished from curiosities and from changes secondary to fetal death. The pathologist's wider contribution to perinatal medicine includes providing high quality data to epidemiology units and auditing committees, contributing to the multidisciplinary management of prenatally diagnosed fetal abnormalities, monitoring iatrogenic disease patterns and supporting the process of perinatal grief management. Special problems and diagnostic challenges are to be found when investigating sudden, unexplained intrauterine fetal death, hydrops, bone dysplasias and complicated multiple pregnancies.

Neonatal intensive care. When and where is it justified?

There is a wide panorama of disorders in the newborn infant where neonatal intensive care has been proven effective in reducing mortality. Although modern neonatal intensive care can be very costly, short and simple interventions for support and resuscitation still can be highly beneficial. In reviewing the field of neonatal intensive care during the 1980s, it becomes evident that a major challenge for the future will be to apply physiological principles of great and proven value for the newborn baby to more simple devices. Only thereby can the technology of neonatal care defined as a complex of actions-not only equipment and techniques-become justified for future generations.

Statistics in medical journals: developments in the 1980s

This paper reviews changes in the use of statistics in medical journals during the 1980s. Aspects considered are research design, statistical analysis, the presentation of results, medical journal policy (including statistical refereeing), and the misuse of statistics. Despite some notable successes, the misuse of statistics in medical papers remains common.