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Walczak AB, Bigelow AM, Schneider B, Deitemyer M, Duffy V, Lloyd EA, Frazier WJ, Seabrook RB, Halaweish IF, McConnell PI. Experience With the Crescent• Right Atrial Jugular Dual Lumen Catheter for Pediatric Venovenous Extracorporeal Membrane Oxygenation: A Case Series. ASAIO J 2023; 69:e526-e530. [PMID: 37678262 DOI: 10.1097/mat.0000000000002004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
The Crescent dual lumen right atrial (RA) cannula has recently been introduced for the support of pediatric patients in need of venovenous extracorporeal membrane oxygenation (VV ECMO) support. We present the first pediatric case series illustrating utility of the Crescent RA cannula in the pediatric patient population at a single institution over a 10 month period. From December 2021 to August 2022, six pediatric patients were adequately supported on seven VV ECMO runs at our institution with the Crescent RA cannula. ECMO cannulation, circuit design, anticoagulation management, ECMO circuit pressures, flow rates, and recirculation were similar to our standard of care for VV ECMO. The Crescent RA cannula can be used safely and effectively to provide adequate support for pediatric patients requiring VV ECMO.
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Affiliation(s)
- Ashley B Walczak
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Amee M Bigelow
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Brian Schneider
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Matthew Deitemyer
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Vicky Duffy
- From the Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Eric A Lloyd
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Department of Critical Care, Nationwide Children's Hospital, OH
| | - W Joshua Frazier
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Department of Critical Care, Nationwide Children's Hospital, OH
| | - Ruth B Seabrook
- Division of Neonatology, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Ihab F Halaweish
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
- Department of Clinical Surgery, The Ohio State University, Columbus, OH
| | - Patrick I McConnell
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH
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2
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Felling RJ, Kamerkar A, Friedman ML, Said AS, LaRovere KL, Bell MJ, Bembea MM. Neuromonitoring During ECMO Support in Children. Neurocrit Care 2023; 39:701-713. [PMID: 36720837 DOI: 10.1007/s12028-023-01675-8] [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] [Received: 07/15/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
Extracorporeal membrane oxygenation is a potentially lifesaving intervention for children with severe cardiac or respiratory failure. It is used with increasing frequency and in increasingly more complex and severe diseases. Neurological injuries are important causes of morbidity and mortality in children treated with extracorporeal membrane oxygenation and include ischemic stroke, intracranial hemorrhage, hypoxic-ischemic injury, and seizures. In this review, we discuss the epidemiology and pathophysiology of neurological injury in patients supported with extracorporeal membrane oxygenation, and we review the current state of knowledge for available modalities of monitoring neurological function in these children. These include structural imaging with computed tomography and ultrasound, cerebral blood flow monitoring with near-infrared spectroscopy and transcranial Doppler ultrasound, and physiological monitoring with electroencephalography and plasma biomarkers. We highlight areas of need and emerging advances that will improve our understanding of neurological injury related to extracorporeal membrane oxygenation and help to reduce the burden of neurological sequelae in these children.
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Affiliation(s)
- Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Suite 2158, Baltimore, MD, USA.
| | - Asavari Kamerkar
- Department of Anesthesia Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care, Indiana School of Medicine, Indianapolis, IN, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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3
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Chernoguz A, Monteagudo J. Neonatal venoarterial and venovenous ECMO. Semin Pediatr Surg 2023; 32:151326. [PMID: 37925998 DOI: 10.1016/j.sempedsurg.2023.151326] [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: 11/07/2023]
Abstract
ECMO remains an important support tool in the treatment of neonates with reversible congenital cardiopulmonary diseases. There are specific circumstances that call for either venoarterial (VA) or venovenous (VV) ECMO in neonates. While limited by the infant's the size and gestational age, ECMO can confer exceptional survival rates to a number of neonates who can often develop without devastating complications. However, it remains a labor and time intensive endeavor, which may be impractical or unattainable in resource-limited environments. While adult and pediatric ECMO indications and equipment options have expanded in recent years, neonatal ECMO continues to be a niche subspecialty requiring specific expertise and technical skill, especially considering the ever-changing neonatal physiology in the setting of cardiopulmonary support. It is critical to recognize the unique approaches to cannulation options, imaging, vessel management, anticoagulation, and monitoring protocols to achieve optimal outcomes. Thus, it becomes nearly impossible to separate the role of pediatric surgeons from the continuous involvement with and management of neonatal ECMO patients. This necessitates that pediatric surgeons in ECMO centers continue to hone their expertise and remain heavily involved in neonatal ECMO. This section reviews the most critical current approaches and unresolved controversies in neonatal ECMO with special attention to the practical aspects and decisions a surgeon faces in initiation and termination of neonatal ECMO.
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Affiliation(s)
- Artur Chernoguz
- Department of Surgery, Division of Pediatric Surgery, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Julie Monteagudo
- Department of Surgery, Division of Pediatric Surgery, Warren Alpert Medical School at Brown University, Providence, RI, USA.
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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.
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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
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Perez NP, Witt EE, Masiakos PT, Layman I, Tonna JE, Ortega G, Qureshi FG. Associations of cephalad drainage in neonatal veno-venous ECMO - A mixed-effects, propensity score adjusted retrospective analysis of 20 years of ELSO data. J Pediatr Surg 2023; 58:432-439. [PMID: 36328821 DOI: 10.1016/j.jpedsurg.2022.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 09/19/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Neurologic complications can occur during neonatal Veno-Venous (VV) ECMO. The addition of a cephalad drainage cannula (i.e., VVDL+V) to dual lumen cannulation (i.e., VVDL) has been advocated to reduce such complications, but previous studies have presented mixed results. METHODS Data from the ECMO Registry of the Extracorporeal Life Support Organization was used to extract all neonates (≤28 days old) who underwent VV ECMO for respiratory support between 2000 and 2019. Primary outcomes were mortality, conversion to Veno-Arterial (VA) ECMO, pump flows, and complications. A mixed-effects, propensity score adjusted analysis was performed. RESULTS 4,275 neonates underwent VV ECMO, 581 (13.6%) via VVDL+V cannulation, and 3,694 (86.4%) via VVDL. On unadjusted analyses, VVDL+V patients had higher rates of mortality (25.5% vs 19.0%, p<0.001), conversion to VA ECMO (14.5% vs 4.1%, p<0.001), and higher pump flows at 4 h from ECMO initiation (112.7 vs 105.5 mL/Kg/min, p<0.001), but lower at 24 h (100.3 vs 104.0 mL/Kg/min, p = 0.004), and a higher proportion of them experienced hemorrhagic (29.3% vs 18.3%, p<0.001), cardiovascular (60.8% vs 45.8%, p<0.001), and mechanical (42.5% vs 32.6%, p<0.001) complications compared to VVDL patients. After adjusting for propensity scores and the multi-level nature of ELSO data, there were no differences in neurologic outcomes, pump flows, or mortality. Rather, VVDL+V cannulation was associated with higher rates of conversion to VA ECMO (adjusted odds ratio [AOR] 43.3, 95% CI 24.3 - 77.4, p<0.001), and increased mechanical (AOR 2.2, 95% CI 1.6 - 3.0, p<0.001) and hemorrhagic (AOR 2.0, 95% CI 1.4 - 3.0, p<0.001) complications. CONCLUSIONS In this analysis, VVDL+V cannulation was not associated with any improvement in neurologic outcomes, pump flows, or mortality, but was rather associated with higher rates of conversion to Veno-Arterial ECMO, mechanical, and hemorrhagic complications.
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Affiliation(s)
- Numa P Perez
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, United States of America; Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Emily E Witt
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Peter T Masiakos
- Department of Surgery, Division of Pediatric Surgery, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Ilan Layman
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Joseph E Tonna
- Extracorporeal Life Support Organization, Ann Arbor, MI, United States of America; Department of Cardiothoracic Surgery, Department of Emergency Medicine, University Hospital, University of Utah, Salt Lake City, UT, United States of America
| | - Gezzer Ortega
- Harvard Medical School, Boston, MA, United States of America; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Faisal G Qureshi
- Department of Surgery, Division of Pediatric Surgery University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Children's Medical Center Dallas, Dallas, TX, United States of America
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Rose AT, Davis J, Williams HO, Clifton M, Paden M, Keene SD. Utility of cephalic drains in infants receiving extracorporeal membrane oxygenation. Perfusion 2022; 38:747-754. [PMID: 35343293 DOI: 10.1177/02676591221080506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The addition of cephalic drains (CDs) in extracorporeal membrane oxygenation (ECMO) to augment venous drainage may offer benefit, though their use is varied. Our objective was to describe our institution's experience with CDs including flow rates and patency. We also compared complication rates between patients with and without a CD. METHODS This retrospective cohort study included infants <12 months of age cannulated for ECMO between January 1, 2010 and September 30, 2019 at a single institution. Flow data were obtained for those with a CD. Demographic and complication rates were obtained for all. RESULTS Of 264 patients in the final cohort, 220 (83%) had a CD of which 93.2% remained patent to decannulation. CDs typically provided 30% or more of ECMO flow throughout the ECMO run. The median time to CD clot was 139 h (range 48-635 h). Patients with a clotted CD had longer ECMO runs than those whose CD remained patent (median 382 h [IQR 217-538] vs 139 h [IQR 91-246], p < 0.001). Survival to discharge was lower for those with clotted versus patent CD (14% vs 70%, p < 0.001). Mechanical complications were more common in patients with CD (p = 0.005). Seizures were more common in those without a CD (p = 0.021). CONCLUSIONS In this cohort, the majority of CDs placed remained patent at decannulation and provided substantial additional venous drainage. Mechanical problems were common in patients with CDs, but without clinical sequelae. Further study is warranted to elucidate CD impact on short- and long-term outcomes.
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Affiliation(s)
- Allison T Rose
- Division of Neonatology, Department of Pediatrics, 12239Emory University School of Medicine, Atlanta, GA, USA.,138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Joel Davis
- 138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Helen O Williams
- Division of Neonatology, Department of Pediatrics, 12239Emory University School of Medicine, Atlanta, GA, USA.,138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Matthew Clifton
- 138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA.,Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew Paden
- 138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA.,Division of Critical Care, Department of Pediatrics, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah D Keene
- Division of Neonatology, Department of Pediatrics, 12239Emory University School of Medicine, Atlanta, GA, USA.,138610Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
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7
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Melbourne L, Wien MA, Whitehead MT, Ridore M, Wang Y, Short BL, Bulas D, Massaro AN. Risk Factors for Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation. Am J Perinatol 2021; 38:1557-1564. [PMID: 32674203 DOI: 10.1055/s-0040-1714208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aimed to assess the association of clinical risk factors with severity of magnetic resonance imaging (MRI) brain injury in neonatal extracorporeal membrane oxygenation (ECMO) patients. STUDY DESIGN This is a single-center retrospective study conducted at an outborn level IV neonatal intensive care unit in a free-standing academic children's hospital. Clinical and MRI data from neonates treated with ECMO between 2005 and 2015 were reviewed. MRI injury was graded by two radiologists according to a modified scoring system that assesses parenchymal injury, extra-axial hemorrhage, and cerebrospinal fluid spaces. MRI severity was classified as none (score = 0), mild/moderate (score = 1-13.5), and severe (score ≥ 14). The relationship between selected risk factors and MRI severity was assessed by Chi-square, analysis of variance, and Kruskal-Wallis tests where appropriate. Combinative predictive ability of significant risk factors was assessed by logistic regression analyses. RESULTS MRI data were assessed in 81 neonates treated with ECMO. Veno-arterial (VA) patients had more severe injury compared with veno-venous patients. There was a trend toward less severe injury over time. After controlling for covariates, duration of ECMO remained significantly associated with brain injury, and the risk for severe injury was significantly increased in patients on ECMO beyond 210 hours. CONCLUSION Risk for brain injury is increased with VA ECMO and with longer duration of ECMO. Improvements in care may be leading to decreasing incidence of brain injury in neonatal ECMO patients. KEY POINTS · Veno-arterial ECMO is associated with more brain injury by MRI compared with veno-venous ECMO.. · Longer duration of ECMO is significantly associated with severe brain injury by MRI.. · Risk for neurologic injury may be decreasing over time with advances in neonatal ECMO..
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Affiliation(s)
- Launice Melbourne
- Division of Neonatology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia
| | - Michael A Wien
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia
| | - Matthew T Whitehead
- Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia.,Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia
| | - Michelande Ridore
- Division of Neonatology, Children's National Hospital, Washington, District of Columbia
| | - Yunfei Wang
- Division of Biostatistics and Study Methodology, Children's National Research Institute, Washington, District of Columbia
| | - Billie L Short
- Division of Neonatology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia
| | - Dorothy Bulas
- Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia.,Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia
| | - An N Massaro
- Division of Neonatology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia
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Lorusso R, Belliato M, Mazzeffi M, Di Mauro M, Taccone FS, Parise O, Albanawi A, Nandwani V, McCarthy P, Kon Z, Menaker J, Johnson DM, Gelsomino S, Herr D. Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:107. [PMID: 33731186 PMCID: PMC7968168 DOI: 10.1186/s13054-021-03533-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 03/05/2021] [Indexed: 11/23/2022]
Abstract
Background Single- (SL) and double-lumen (DL) catheters are used in clinical practice for veno-venous extracorporeal membrane oxygenation (V-V ECMO) therapy. However, information is lacking regarding the effects of the cannulation on neurological complications. Methods A retrospective observational study based on data from the Extracorporeal Life Support Organization (ELSO) registry. All adult patients included in the ELSO registry from 2011 to 2018 submitted to a single run of V-V ECMO were analyzed. Propensity score (PS) inverse probability of treatment weighting estimation for multiple treatments was used. The average treatment effect (ATE) was chosen as the causal effect estimate of outcome. The aim of the study was to evaluate differences in the occurrence and the type of neurological complications in adult patients undergoing V-V ECMO when treated with SL or DL cannulas. Results From a population of 6834 patients, the weighted propensity score matching included 6245 patients (i.e., 91% of the total cohort; 4175 with SL and 20,270 with DL cannulation). The proportion of patients with at least one neurological complication was similar in the SL (306, 7.2%) and DL (189, 7.7%; odds ratio 1.10 [95% confidence intervals 0.91–1.32]; p = 0.33). After weighted propensity score, the ATE for the occurrence of least one neurological complication was 0.005 (95% CI − 0.009 to 0.018; p = 0.50). Also, the occurrence of specific neurological complications, including intracerebral hemorrhage, acute ischemic stroke, seizures or brain death, was similar between groups. Overall mortality was similar between patients with neurological complications in the two groups. Conclusions In this large registry, the occurrence of neurological complications was not related to the type of cannulation in patients undergoing V-V ECMO. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03533-5.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mirko Belliato
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiac Surgery Unit, University of Chieti, Chieti, Italy.,UOC Anestesia e Rianimazione 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michael Mazzeffi
- Departments of Anesthesiology, University of Maryland School of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, USA.,Departments of Surgery, University of Maryland School of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, USA
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Orlando Parise
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ayat Albanawi
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Veena Nandwani
- Departments of Anesthesiology, University of Maryland School of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, USA
| | - Paul McCarthy
- Departments of Anesthesiology, University of Maryland School of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, USA
| | - Zachary Kon
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, USA
| | - Jay Menaker
- Departments of Anesthesiology, University of Maryland School of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, USA
| | - Daniel M Johnson
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Herr
- Departments of Surgery, University of Maryland School of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, USA
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Neurological Monitoring and Complications of Pediatric Extracorporeal Membrane Oxygenation Support. Pediatr Neurol 2020; 108:31-39. [PMID: 32299748 PMCID: PMC7698354 DOI: 10.1016/j.pediatrneurol.2020.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation is extracorporeal life support for life-threatening cardiopulmonary failure. Since its introduction, the use of extracorporeal membrane oxygenation has expanded to patients with more complex comorbidities without change in patient mortality rates. Although many patients survive, significant neurological complications like seizures, ischemic strokes, and intracranial hemorrhage can occur during extracorporeal membrane oxygenation care. The risks of these complications often add to the complexity of decision-making surrounding extracorporeal membrane oxygenation support. In this review, we discuss the pathophysiology and incidence of neurological complications in children supported on extracorporeal membrane oxygenation, factors influencing the incidence of these complications, commonly used neurological monitoring modalities, and outcomes for this complex patient population. We discuss the current literature on the use of electroencephalography for both seizure detection and monitoring of background electroencephalographic changes, in addition to the use of less commonly used imaging modalities like transcranial Doppler. We summarize the knowledge gaps and the lack of clinical consensus guidelines for managing these potentially life-changing neurological complications. Finally, we discuss future work to further understand the pathophysiology of extracorporeal membrane oxygenation-related neurological complications.
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10
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Yu PT, Jen HC, Rice-Townsend S, Guner YS. The role of ECMO in the management of congenital diaphragmatic hernia. Semin Perinatol 2020; 44:151166. [PMID: 31472951 DOI: 10.1053/j.semperi.2019.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is the most common indication for extra-corporeal membrane oxygenation (ECMO) for neonatal respiratory failure. CDH management is evolving with advanced prenatal diagnostic imaging modalities. The risk profiles of infants receiving ECMO for CDH are shifting towards higher risk. Many clinicians are developing and following clinical practice guidelines to standardize and optimize the care of CDH neonates. Despite these efforts, there are significant differences in the practice patterns among ECMO centers as to how and when they choose to initiate ECMO for CDH, when they believe repair is safe, as well as many other nuances that are based on center experience or style. The purpose of this report is to summarize our current understanding of the new and recent developments regarding management of infants with CDH managed with ECMO.
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Affiliation(s)
- Peter T Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, 505 S. Main St, #225, Orange, CA 92868, United States
| | - Howard C Jen
- David Geffen School of Medicine at UCLA, Mattel Children's Hospital at UCLA, Los Angeles, CA, United States
| | - Samuel Rice-Townsend
- Department of Pediatric Surgery, Children's Hospital Boston-Harvard Medical School, Boston, MA, United States
| | - Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, 505 S. Main St, #225, Orange, CA 92868, United States.
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11
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Is peripheral venovenous-arterial ECMO a feasible alternative to central cannulation for pediatric refractory septic shock? Intensive Care Med 2019; 45:1658-1660. [PMID: 31529351 DOI: 10.1007/s00134-019-05720-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
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12
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Conrad SA, Broman LM, Taccone FS, Lorusso R, Malfertheiner MV, Pappalardo F, Di Nardo M, Belliato M, Grazioli L, Barbaro RP, McMullan DM, Pellegrino V, Brodie D, Bembea MM, Fan E, Mendonca M, Diaz R, Bartlett RH. The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization. Am J Respir Crit Care Med 2019; 198:447-451. [PMID: 29614239 DOI: 10.1164/rccm.201710-2130cp] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Extracorporeal life support (ECLS) was developed more than 50 years ago, initially with venoarterial and subsequently with venovenous configurations. As the technique of ECLS significantly improved and newer skills developed, complexity in terminology and advances in cannula design led to some misunderstanding of and inconsistency in definitions, both in clinical practice and in scientific research. This document is a consensus of multispecialty international representatives of the Extracorporeal Life Support Organization, including the North America, Latin America, EuroELSO, South West Asia and Africa, and Asia-Pacific chapters, imparting a global perspective on ECLS. The goal is to provide a consistent and unambiguous nomenclature for ECLS and to overcome the inconsistent use of abbreviations for ECLS cannulation. Secondary benefits are ease of multicenter collaboration in research, improved registry data quality, and clear communication among practitioners and researchers in the field.
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Affiliation(s)
- Steven A Conrad
- 1 Department of Medicine.,2 Department of Emergency Medicine, and.,3 Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - L Mikael Broman
- 4 ECMO Center, Karolinska University Hospital, and.,5 Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Fabio S Taccone
- 6 Department of Intensive Care, Hôpital Erasme, Brussels, Belgium
| | - Roberto Lorusso
- 7 Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Federico Pappalardo
- 9 Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Matteo Di Nardo
- 10 Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Mirko Belliato
- 11 U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lorenzo Grazioli
- 12 Department of Anesthesiology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - D Michael McMullan
- 14 Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Vincent Pellegrino
- 15 Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Daniel Brodie
- 16 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Melania M Bembea
- 17 Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eddy Fan
- 18 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Malaika Mendonca
- 19 Division of Pediatric Critical Care, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates; and
| | - Rodrigo Diaz
- 20 Division of Cardiovascular Anesthesiology, Clinica las Condes, Santiago, Chile
| | - Robert H Bartlett
- 21 Department of Surgery, University of Michigan, Ann Arbor, Michigan
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13
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El-Sabbagh AM, Gray BW, Shaffer AW, Bryner BS, Church JT, McLeod JS, Zakem S, Perkins EM, Shellhaas RA, Barks JDE, Rojas-Peña A, Bartlett RH, Mychaliska GB. Cerebral Oxygenation of Premature Lambs Supported by an Artificial Placenta. ASAIO J 2019; 64:552-556. [PMID: 28937410 PMCID: PMC5860928 DOI: 10.1097/mat.0000000000000676] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
An artificial placenta (AP) using venovenous extracorporeal life support (VV-ECLS) could represent a paradigm shift in the treatment of extremely premature infants. However, AP support could potentially alter cerebral oxygen delivery. We assessed cerebral perfusion in fetal lambs on AP support using near-infrared spectroscopy (NIRS) and carotid arterial flow (CAF). Fourteen premature lambs at estimated gestational age (EGA) 130 days (term = 145) underwent cannulation of the right jugular vein and umbilical vein with initiation of VV-ECLS. An ultrasonic flow probe was placed around the right carotid artery (CA), and a NIRS sensor was placed on the scalp. Lambs were not ventilated. CAF, percentage of regional oxygen saturation (rSO2) as measured by NIRS, hemodynamic data, and blood gases were collected at baseline (native placental support) and regularly during AP support. Fetal lambs were maintained on AP support for a mean of 55 ± 27 hours. Baseline rSO2 on native placental support was 40% ± 3%, compared with a mean rSO2 during AP support of 50% ± 11% (p = 0.027). Baseline CAF was 27.4 ± 5.4 ml/kg/min compared with an average CAF of 23.7 ± 7.7 ml/kg/min during AP support. Cerebral fractional tissue oxygen extraction (FTOE) correlated negatively with CAF (r = -0.382; p < 0.001) and mean arterial pressure (r = -0.425; p < 0.001). FTOE weakly correlated with systemic O2 saturation (r = 0.091; p = 0.017). Cerebral oxygenation and blood flow in premature lambs are maintained during support with an AP. Cerebral O2 extraction is inversely related to carotid flow and is weakly correlated with systemic O2 saturation.
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Affiliation(s)
- Ahmed M El-Sabbagh
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Department of Pediatrics & Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - Brian W Gray
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew W Shaffer
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Benjamin S Bryner
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Joseph T Church
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jennifer S McLeod
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Sara Zakem
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Elena M Perkins
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Renée A Shellhaas
- Department of Pediatrics & Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - John D E Barks
- Department of Pediatrics & Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - Alvaro Rojas-Peña
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Robert H Bartlett
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - George B Mychaliska
- From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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14
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Broman LM, Taccone FS, Lorusso R, Malfertheiner MV, Pappalardo F, Di Nardo M, Belliato M, Bembea MM, Barbaro RP, Diaz R, Grazioli L, Pellegrino V, Mendonca MH, Brodie D, Fan E, Bartlett RH, McMullan MM, Conrad SA. The ELSO Maastricht Treaty for ECLS Nomenclature: abbreviations for cannulation configuration in extracorporeal life support - a position paper of the Extracorporeal Life Support Organization. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:36. [PMID: 30736845 PMCID: PMC6367794 DOI: 10.1186/s13054-019-2334-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 01/23/2019] [Indexed: 01/21/2023]
Abstract
Background The Extracorporeal Life Support Organization (ELSO) Maastricht Treaty for Nomenclature in Extracorporeal Life Support (ECLS) established consensus nomenclature and abbreviations for ECLS to ensure accurate, concise communication. Methods We build on this consensus nomenclature by layering a framework of precise and efficient abbreviations for cannula configuration that describe flow direction, number of cannulae used, any additional ECLS-related catheters, and cannulation sites. This work is a consensus of international representatives of the ELSO, including those from the North American, Latin American, European, South and West Asian, and Asian-Pacific chapters of ELSO. Results The classification increases in descriptive capability by introducing a third (cannula tip position) and fourth (cannula dimension) level to those provided in the previous consensus on ECLS cannulation configuration nomenclature. This expansion offers the simplest level needed to convey cannulation information yet allows for more details when required. Conclusions A complete nomenclature for ECLS cannulation configurations accommodating future revisions was developed to facilitate ability to compare practices and results, to promote efficient communication, and to improve quality of registry data. Electronic supplementary material The online version of this article (10.1186/s13054-019-2334-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden. .,European ECMO Advisory board, Pavia, Italy.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, ULB, Brussels, Belgium.,European ECMO Advisory board, Pavia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department - Heart & Vascular Centre, Maastricht University Medical Hospital, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Maximilian Valentin Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, University Medical Center Regensburg, Regensburg, Germany.,European ECMO Advisory board, Pavia, Italy
| | - Federico Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Hospital, Vita Salute University, Milan, Italy.,European ECMO Advisory board, Pavia, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy.,European ECMO Advisory board, Pavia, Italy
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,European ECMO Advisory board, Pavia, Italy
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan P Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Steven A Conrad
- Louisiana State University Health Sciences Center, Shreveport, LA, USA
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15
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Grover TR, Rintoul NE, Hedrick HL. Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia. Semin Perinatol 2018; 42:96-103. [PMID: 29338874 DOI: 10.1053/j.semperi.2017.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly which impairs normal pulmonary development leading to acute and chronic respiratory failure, pulmonary hypoplasia, pulmonary hypertension, and mortality. CDH is the most common non-cardiac indication for neonatal ECMO. Prenatal and postnatal predictors of CDH severity aid in patient selection. Centers vary in preferred mode of ECMO and timing of CDH repair. Survivors of severe CDH with ECMO are at risk for long-term sequelae including neurodevelopmental delays.
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Affiliation(s)
- Theresa R Grover
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, 13121 E 17th Ave, MS 8402, Aurora, CO, 80045.
| | - Natalie E Rintoul
- Department of Pediatrics, Division of Neonatology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Holly L Hedrick
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
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16
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Reeb J, Olland A, Renaud S, Kindo M, Santelmo N, Massard G, Falcoz PE. Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica. EMC - TECNICHE CHIRURGICHE - CHIRURGIA GENERALE 2017. [PMCID: PMC7164803 DOI: 10.1016/s1636-5577(17)82113-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In origine, l’extracorporeal membrane oxygenation (ECMO) era una tecnica di assistenza respiratoria che utilizzava uno scambiatore gassoso a membrana. Per estensione, l’ECMO è diventata una tecnica respiratoria e cardiopolmonare utilizzata in caso di deficit respiratorio e/o cardiaco nell’attesa della restaurazione della funzione deficitaria o di un eventuale trapianto. Il supporto emodinamico può essere parziale o totale. Gli accessi vascolari possono essere periferici o centrali. Questo tipo di assistenza utilizza il concetto di circolazione extracorporea (CEC) sanguigna che in epoca moderna si è estesa con l’utilizzo di polmoni artificiali a membrana. Il circuito di base è semplice e comprende una pompa, un ossigenatore (che permette al sangue di caricarsi di O2 e di eliminare CO2) e delle vie d’accesso (una di drenaggio e una di reinfusione). La sua attuazione è facile, veloce e può essere avviata al letto del malato. Il miglioramento delle attrezzature, una migliore conoscenza delle tecniche e delle indicazioni, e le politiche di salute pubblica hanno reso popolare questa tecnica. Alcuni centri di chirurgia toracica la utilizzano di routine come assistenza alla realizzazione di un intervento terapeutico (soprattutto trapianto) assieme a team di rianimazione per il trattamento della sindrome da distress respiratorio acuto. Nel quadro della malattia polmonare dell’adulto, l’idea principale è quella di sviluppare il concetto di strategia minimalista con l’uso di una CEC adiuvante parziale – più che sostitutiva totale – che permetterebbe il recupero metabolico ad integrum del paziente. Nei prossimi anni, i progressi della tecnologia e dell’ingegneria così come le conoscenze approfondite permetteranno il miglioramento della prognosi dei pazienti colpiti da deficit respiratorio sotto assistenza meccanica.
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Affiliation(s)
- J. Reeb
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
- The Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, 200, Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - A. Olland
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - S. Renaud
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - M. Kindo
- Service de chirurgie cardiovasculaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - N. Santelmo
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - G. Massard
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - P.-E. Falcoz
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
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17
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Clair MP, Rambaud J, Flahault A, Guedj R, Guilbert J, Guellec I, Durandy A, Demoulin M, Jean S, Mitanchez D, Chalard F, Sileo C, Carbajal R, Renolleau S, Léger PL. Prognostic value of cerebral tissue oxygen saturation during neonatal extracorporeal membrane oxygenation. PLoS One 2017; 12:e0172991. [PMID: 28278259 PMCID: PMC5344369 DOI: 10.1371/journal.pone.0172991] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 12/02/2022] Open
Abstract
Objectives Extracorporeal membrane oxygenation support is indicated in severe and refractory respiratory or circulatory failures. Neurological complications are typically represented by acute ischemic or hemorrhagic lesions, which induce higher morbidity and mortality. The primary goal of this study was to assess the prognostic value of cerebral tissue oxygen saturation (StcO2) on mortality in neonates and young infants treated with ECMO. A secondary objective was to evaluate the association between StcO2 and the occurrence of cerebral lesions. Study design This was a prospective study in infants < 3 months of age admitted to a pediatric intensive care unit and requiring ECMO support. Measurements The assessment of cerebral perfusion was made by continuous StcO2 monitoring using near-infrared spectroscopy (NIRS) sensors placed on the two temporo-parietal regions. Neurological lesions were identified by MRI or transfontanellar echography. Results Thirty-four infants <3 months of age were included in the study over a period of 18 months. The ECMO duration was 10±7 days. The survival rate was 50% (17/34 patients), and the proportion of brain injuries was 20% (7/34 patients). The mean StcO2 during ECMO in the non-survivors was reduced in both hemispheres (p = 0.0008 right, p = 0.03 left) compared to the survivors. StcO2 was also reduced in deceased or brain-injured patients compared to the survivors without brain injury (p = 0.002). Conclusion StcO2 appears to be a strong prognostic factor of survival and of the presence of cerebral lesions in young infants during ECMO.
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Affiliation(s)
- Marie-Philippine Clair
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Jérôme Rambaud
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Adrien Flahault
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology (CIRB), INSERM, U1050, Paris, France
- CNRS, UMR 7241, Paris, France
| | - Romain Guedj
- Department of Emergency medicine, Trousseau Hospital, AP-HP, Paris, France
| | - Julia Guilbert
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Isabelle Guellec
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Amélie Durandy
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Maryne Demoulin
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Sandrine Jean
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | | | - François Chalard
- Department of Pediatric Radiology, Trousseau Hospital, AP-HP, Paris, France
| | - Chiara Sileo
- Department of Pediatric Radiology, Trousseau Hospital, AP-HP, Paris, France
| | - Ricardo Carbajal
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
- Department of Emergency medicine, Trousseau Hospital, AP-HP, Paris, France
- UPMC Pierre et Marie Curie University, Paris VI, France
| | - Sylvain Renolleau
- Department of Pediatric intensive care unit, Necker Hospital, AP-HP, Paris, France
| | - Pierre-Louis Léger
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
- * E-mail:
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18
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Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica. EMC - TECNICHE CHIRURGICHE TORACE 2016. [PMCID: PMC7159017 DOI: 10.1016/s1288-3336(16)79382-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
In origine, l’extracorporeal membrane oxygenation (ECMO) era una tecnica di assistenza respiratoria che utilizzava uno scambiatore gassoso a membrana. Per estensione, l’ECMO è diventata una tecnica respiratoria e cardiopolmonare utilizzata in caso di deficit respiratorio e/o cardiaco nell’attesa della restaurazione della funzione deficitaria o di un eventuale trapianto. Il supporto emodinamico può essere parziale o totale. Gli accessi vascolari possono essere periferici o centrali. Questo tipo di assistenza utilizza il concetto di circolazione extracorporea (CEC) sanguigna che in epoca moderna si è estesa con l’utilizzo di polmoni artificiali a membrana. Il circuito di base è semplice e comprende una pompa, un ossigenatore (che permette al sangue di caricarsi di O2 e di eliminare CO2) e delle vie d’accesso (una di drenaggio e una di reinfusione). La sua attuazione è facile, veloce e può essere avviata al letto del malato. Il miglioramento delle attrezzature, una migliore conoscenza delle tecniche e delle indicazioni, e le politiche di salute pubblica hanno reso popolare questa tecnica. Alcuni centri di chirurgia toracica la utilizzano di routine come assistenza alla realizzazione di un intervento terapeutico (soprattutto trapianto) assieme a team di rianimazione per il trattamento della sindrome da distress respiratorio acuto. Nel quadro della malattia polmonare dell’adulto, l’idea principale è quella di sviluppare il concetto di strategia minimalista con l’uso di una CEC adiuvante parziale – più che sostitutiva totale – che permetterebbe il recupero metabolico ad integrum del paziente. Nei prossimi anni, i progressi della tecnologia e dell’ingegneria così come le conoscenze approfondite permetteranno il miglioramento della prognosi dei pazienti colpiti da deficit respiratorio sotto assistenza meccanica.
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19
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Roberts J, Keene S, Heard M, McCracken C, Gauthier TW. Successful primary use of VVDL+V ECMO with cephalic drain in neonatal respiratory failure. J Perinatol 2016; 36:126-31. [PMID: 26562372 DOI: 10.1038/jp.2015.163] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 09/28/2015] [Accepted: 10/01/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the use of double-lumen venovenous (VVDL) extracorporeal membrane oxygenation (ECMO) with cephalic draining cannula (VVDL+V) as a primary approach for all neonatal respiratory diagnoses and to compare our single-center experience with data as collected in the Extracorporeal Life Support Organization (ELSO) database. STUDY DESIGN We retrospectively reviewed all cases of ECMO for neonatal respiratory failure performed in the neonatal intensive-care unit at a large referral children's hospital, the Children's Healthcare of Atlanta at Egleston (CHOA-E). Comparisons were then made to neonatal respiratory ECMO data retrieved from the ELSO database. RESULTS At CHOA-E 162 of 189 cases were completed with the VVDL+V approach. Survival in the VVDL+V cohort was 89.1% versus 68.7% from ELSO, P<0.001. For those complications considered, the overall risk of complication favored the CHOA-E VVDL+V group as compared with ELSO (odds ratio (OR) 0.71 (0.52-0.7)) as did the risk of neurologic complications (OR 0.29, (0.15-0.58)), including intracranial hemorrhage (OR 0.39 (0.18-0.97), P=0.011). CONCLUSION The VVDL+V approach can be used successfully as the primary approach for ECMO for neonatal respiratory failure of various etiologies and in this single-center cohort this approach was associated with improved survival and lower rates of complication as compared with the ELSO database.
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Affiliation(s)
- J Roberts
- Department of Pediatrics, Emory Children's Center, Emory University, School of Medicine, Atlanta, GA, USA
| | - S Keene
- Department of Pediatrics, Emory Children's Center, Emory University, School of Medicine, Atlanta, GA, USA
| | - M Heard
- ECMO and Advanced Technologies Department, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - C McCracken
- Department of Pediatrics, Emory Children's Center, Emory University, School of Medicine, Atlanta, GA, USA
| | - T W Gauthier
- Department of Pediatrics, Emory Children's Center, Emory University, School of Medicine, Atlanta, GA, USA
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20
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Rambaud J, Guellec I, Guilbert J, Léger PL, Renolleau S. Calcium homeostasis disorder during and after neonatal extracorporeal membrane oxygenation. Indian J Crit Care Med 2015; 19:513-7. [PMID: 26430336 PMCID: PMC4578194 DOI: 10.4103/0972-5229.164797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND AIMS Extracorporeal membrane oxygenation (ECMO) is used during pediatric resuscitation in case of refractory hypoxemia or septic shock under maximum therapy. Previous studies describe calcium homeostasis dysregulation. The aim of this study was to confirmed of calcium homeostasis dysregulation in neonates under ECMO and supposed news explanation. SUBJECTS AND METHODS From November 2012 to July 2013, we performed a prospective single center observational study. Eleven neonatal patients were included. Blood was obtained before and during ECMO (day 7, 14 and 21) for parathyroid hormone (PTH), protein adjusted serum calcium, ionized calcium, magnesium, and calcitriol levels. All surviving patients underwent a consultation up to 6 months after ECMO weaning. RESULTS During ECMO PTH was inadequately high with normal serum calcium on day 7 (PTH: 73.54 ± 40 ng/l; calcemia: 2.33 ± 0.21 mmol/l), day 14 (PTH: 57.63 ± 29.57 ng/l; calcemia: 2.44 ± 0.43 mmol/l) and day 21 (PTH: 54.93 ± 8.43 ng/l; calcemia: 2.13 ± 0.09 mmol/l). The absence of correlation between serum calcium and PTH levels seem to confirm the dysregulation of PTH - serum calcium metabolism during ECMO. Six months after ECMO weaning, we noticed hypercalcemia with normal PTH. CONCLUSIONS We confirmed the existence of severe disturbances of calcium homeostasis in neonates on ECMO and supposed the possible damage of calcium regulation. We did not succeed in finding clear explanations of these disturbances.
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Affiliation(s)
- Jerome Rambaud
- From: Paediatric Intensive Care Unit, Armand-Trousseau Hospital APHP (Paris Hospitals Public Assistance), UPMC (Pierre and Marie Curie University, Paris VI), Paris, France
| | - Isabelle Guellec
- From: Paediatric Intensive Care Unit, Armand-Trousseau Hospital APHP (Paris Hospitals Public Assistance), UPMC (Pierre and Marie Curie University, Paris VI), Paris, France
| | - Julia Guilbert
- From: Paediatric Intensive Care Unit, Armand-Trousseau Hospital APHP (Paris Hospitals Public Assistance), UPMC (Pierre and Marie Curie University, Paris VI), Paris, France
| | - Pierre-Louis Léger
- From: Paediatric Intensive Care Unit, Armand-Trousseau Hospital APHP (Paris Hospitals Public Assistance), UPMC (Pierre and Marie Curie University, Paris VI), Paris, France
| | - Sylvain Renolleau
- From: Paediatric Intensive Care Unit, Armand-Trousseau Hospital APHP (Paris Hospitals Public Assistance), UPMC (Pierre and Marie Curie University, Paris VI), Paris, France
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Werho DK, Pasquali SK, Yu S, Donohue J, Annich GM, Thiagarajan RR, Hirsch-Romano JC, Gaies MG. Hemorrhagic complications in pediatric cardiac patients on extracorporeal membrane oxygenation: an analysis of the Extracorporeal Life Support Organization Registry. Pediatr Crit Care Med 2015; 16:276-88. [PMID: 25651048 PMCID: PMC4668708 DOI: 10.1097/pcc.0000000000000345] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To determine the prevalence of and risk factors for hemorrhagic complications in children with cardiac disease requiring extracorporeal membrane oxygenation. DESIGN Retrospective review of the Extracorporeal Life Support Organization Registry (2002-2013). SETTING Participating Extracorporeal Life Support Organization centers. PATIENTS Patients less than 18 years old on extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 21,845 patients requiring extracorporeal membrane oxygenation during the study period, 8,905 (41%) had cardiac disease, and 79% of whom (6,995) had cardiac surgery. Hemorrhagic complications occurred in 8,480 patients (39% of overall cohort), with higher rates in cardiac versus noncardiac patients (49% vs 32%; p < 0.0001) related to cannulation and surgical site bleeding. Cardiac surgical patients had higher rates of hemorrhage compared with cardiac medical patients (57% vs 38%; p < 0.0001), and cardiac patients with hemorrhage had higher extracorporeal membrane oxygenation mortality compared with those without (42% vs 22% in medical patients and 34% vs 20% in surgical patients; both p < 0.0001). In multivariable analysis in both the cardiac medical and surgical groups, hemorrhage risk was higher in children greater than 1 year old and in patients with longer extracorporeal membrane oxygenation duration. Additional independent risk factors for hemorrhage in cardiac surgical patients included pre-extracorporeal membrane oxygenation mediastinal exploration (odds ratio, 3.6; 95% CI, 2.1-6.3), Society of Thoracic Surgeons morbidity category 4-5 (odds ratio, 1.2; 95% CI, 1.03-1.5), cannulation less than 24 hours after surgery (odds ratio, 1.6; 95% CI, 1.3-1.9), and longer cardiopulmonary bypass time (≥ 282 min [upper quartile]; odds ratio, 1.5; 95% CI, 1.3-1.9). CONCLUSIONS In this large, multicenter analysis, hemorrhagic complications occurred in nearly half of children with heart disease on extracorporeal membrane oxygenation and were associated with a significant mortality risk. Several factors were associated with hemorrhagic complications in cardiac surgical patients including pre-extracorporeal membrane oxygenation mediastinal exploration, greater surgical complexity, early postoperative cannulation, and longer bypass times. Whether these risks can be mitigated by modifying or delaying systemic anticoagulation requires further investigation.
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Affiliation(s)
- David K Werho
- 1University of Michigan, Ann Arbor, MI. 2Toronto Hospital for Sick Children, Toronto, Canada. 3Boston Children's Hospital, Boston, MA
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Abstract
Extracorporeal membrane oxygenation (ECMO) continues to be an important rescue therapy for newborns with a variety of causes of cardio-respiratory failure unresponsive to high-frequency ventilation, surfactant replacement, and inhaled nitric oxide. There are approximately 800 neonatal respiratory ECMO cases reported annually to the Extracorporeal Life Support Organization; venoarterial ECMO has been used in approximately 72% with a cumulative survival of 71% and venovenous has been used in 28% with a survival of 84%. Congenital diaphragmatic hernia is now the most common indication for ECMO. This article reviews the development of the two types of extracorporeal support, venoarterial and venovenous ECMO, and discusses the advantages of each method, the current selection criteria, the procedure, and the clinical management of neonates on ECMO.
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Affiliation(s)
- Khodayar Rais-Bahrami
- Department of Neonatology, Children's National Medical Center, The George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010.
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA; Medical Director, Neonatal ECMO Program, Lucile Salter Packard Children's Hospital, Palo Alto, CA
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Renolleau S. [Particularities of ECMO in acute respiratory distress syndrome in pediatrics]. MEDECINE INTENSIVE REANIMATION 2013; 22:654-662. [PMID: 32288736 PMCID: PMC7117835 DOI: 10.1007/s13546-014-0876-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Les techniques de circulation extracorporelle sont utilisées en pédiatrie dans les syndromes de détresse respiratoire aiguë (SDRA) les plus graves depuis les années 1980. Les données du registre international de l’Extracorporeal Life Support Organization révèlent plus 5 000 enfants placés en extracorporeal membrane oxygenation (ECMO) en 2012 avec une augmentation du nombre de cas annuels depuis l’épidémie de 2009. La survie, de 56 %, est stable alors que le nombre d’enfants avec des comorbidités augmente grâce aux améliorations apportées au matériel. Bien que nous ne disposions pas d’études randomisées, ces résultats encouragent à proposer l’ECMO dans l’arsenal thérapeutique du SDRA de l’enfant. Si les techniques veinoveineuses doivent être privilégiées dans les affections respiratoires, l’ECMO veinoartérielle peut être nécessaire et reste d’une utilisation fréquente chez l’enfant (50 % des cas). En pédiatrie, les particularités techniques sont liées d’une part aux particularités physiologiques de l’enfant et d’autre part aux contraintes dues au matériel proposé selon les différentes catégories d’âge. L’ECMO est une technique de recours lourde qui nécessite une expertise à la fois technique et pédiatrique spécialisée en raison de ce terrain particulier.
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Affiliation(s)
- S Renolleau
- Service de réanimation néonatale et pédiatrique, groupe hospitalier Armand-Trousseau-La-Roche-Guyon, AP-HP, université Pierre-et-Marie-Curie-Paris-VI, 26, avenue du Docteur-Arnold-Netter, F-75012 Paris, France
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Hanekamp MN, Mazer P, van der Cammen-van Zijp MHM, van Kessel-Feddema BJM, Nijhuis-van der Sanden MWG, Knuijt S, Zegers-Verstraeten JLA, Gischler SJ, Tibboel D, Kollée LAA. Follow-up of newborns treated with extracorporeal membrane oxygenation: a nationwide evaluation at 5 years of age. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:R127. [PMID: 16961935 PMCID: PMC1751085 DOI: 10.1186/cc5039] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Revised: 08/03/2006] [Accepted: 09/11/2006] [Indexed: 11/13/2022]
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) is a supportive cardiopulmonary bypass technique for babies with acute reversible cardiorespiratory failure. We assessed morbidity in ECMO survivors at the age of five years, when they start primary school and major decisions for their school careers must be made. Methods Five-year-old neonatal venoarterial-ECMO survivors from the two designated ECMO centres in The Netherlands (Erasmus MC – Sophia Children's Hospital in Rotterdam, and University Medical Center Nijmegen) were assessed within the framework of an extensive follow-up programme. The protocol included medical assessment, neuromotor assessment, and psychological assessment by means of parent and teacher questionnaires. Results Seventeen of the 98 children included in the analysis (17%) were found to have neurological deficits. Six of those 17 (6% of the total) showed major disability. Two of those six children had a chromosomal abnormality. Three were mentally retarded and profoundly impaired. The sixth child had a right-sided hemiplegia. These six children did not undergo neuromotor assessment. Twenty-four of the remaining 92 children (26%) showed motor difficulties: 15% actually had a motor problem and 11% were at risk for this. Cognitive delay was identified in 11 children (14%). The mean IQ score was within the normal range (IQ = 100.5). Conclusion Neonatal ECMO in The Netherlands was found to be associated with considerable morbidity at five years of age. It appeared feasible to have as many as 87% of survivors participate in follow-up assessment, due to cooperation between two centres and small travelling distances. Objective evaluation of the long-term morbidity associated with the application of this highly invasive technology in the immediate neonatal period requires an interdisciplinary follow-up programme with nationwide consensus on timing and actual testing protocol.
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Affiliation(s)
- Manon N Hanekamp
- Department of Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital. Rotterdam, The Netherlands
| | - Petra Mazer
- Department of Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital. Rotterdam, The Netherlands
| | - Monique HM van der Cammen-van Zijp
- Department of Physical Therapy, Subdivision Peadiatric Physiotherapy, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherland
| | | | | | - Simone Knuijt
- Department of Allied Health Care, Speech and Language Pathology, Radboud University Nijmegen Medical Centre, The Netherlands
| | | | - Saskia J Gischler
- Department of Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital. Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital. Rotterdam, The Netherlands
| | - Louis AA Kollée
- Department of Neonatology, Radboud University Nijmegen Medical Centre, The Netherlands
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