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Thatch KA, Kays DW. Advances in pulmonary management and weaning from ECLS. Semin Pediatr Surg 2023; 32:151329. [PMID: 37866170 DOI: 10.1016/j.sempedsurg.2023.151329] [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: 10/24/2023]
Abstract
ECMO for neonatal and pediatric respiratory failure provides gas exchange to allow lung recovery from reversible pulmonary ailments. This is a comprehensive discussion on the various strategies and advances utilized by pediatric ECLS specialists today. ECMO patients require continual monitoring, serial gasses and radiographs, near-infrared spectroscopy (NIRS - to monitor oxygen delivery to regional tissue beds), and more quality ECLS directed care. As the foundation to lung recovery, good EMCO closely monitors ECLS flow rates, sweep gasses, and membrane lung function. Mixed venous oxygen saturation (Sv02) greater than 65% indicates good oxygen delivery and sweep gas adjustments maintain PaCO2 of 40-45 mm Hg. Lung recovery ventilatory settings do not fully rest the lungs but maintain normal or nontoxic pressure and oxygen levels. Neonatal recovery settings are PIP (cm H20) of 15-20, PEEP of 5-10, ventilator rate of 12-20 and an inspiratory time of 0.5-1 s, and FiO2 of 0.3-0.5. Pediatric recovery settings are PIP (cm H20) < 25, PEEP of 5-15, ventilator rate of 10-20 and an inspiratory time of 0.8-1 s, and FiO2 of <0.5. Some studies demonstrate a higher recovery PEEP level decreases duration of ECMO, but do not demonstrate a mortality difference. Multiple adjunctive therapies such as surfactant, routine pulmonary clearance and respiratory physiotherapy, iNO, prone positioning, bronchoscopy, POCUS, CT imaging, and extubation or "awake ECLS" can significantly affect pulmonary recovery. Patience is necessary as lung recovery may take weeks or even months on the nontoxic settings. On these settings, dynamic recovery will be revealed by improvement in tidal volume, minute ventilation and radiographic pulmonary aeration, prompting discussion about weaning. When this pulmonary compliance recovery becomes evident, decreasing ECLS flow while also decreasing circuit FiO2 and/or sweep gas are common components to ECMO weaning strategies.
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Affiliation(s)
- Keith A Thatch
- Department of Pediatric Surgery, John Hopkins All Children's Hospital, St. Petersburg, FL, USA.
| | - David W Kays
- Department of Pediatric Surgery, John Hopkins All Children's Hospital, St. Petersburg, FL, USA
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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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Zhang QL, Chen XH, Zhou SJ, Cao H, Chen Q. Surgical experience of extracorporeal membrane oxygenation for neonates with severe respiratory failure. BMC Surg 2023; 23:195. [PMID: 37415109 DOI: 10.1186/s12893-023-02094-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) has been increasingly used for severe neonatal respiratory failure refractory to conventional treatments. This paper summarizes our operation experience of neonatal ECMO via cannulation of the internal jugular vein and carotid artery. METHODS The clinical data of 12 neonates with severe respiratory failure who underwent ECMO via the internal jugular vein and carotid artery in our hospital from January 2021 to October 2022 were collected. RESULTS All neonates were successfully operated on. The size of arterial intubation was 8 F, and the size of venous intubation was 10 F. The operation time was 29 (22-40) minutes. ECMO was successfully removed in 8 neonates. Surgeons successfully reconstructed the internal jugular vein and carotid artery of these neonates. Arterial blood flow was unobstructed in 5 patients, mild stenosis was present in 2 patients, and moderate stenosis was present in 1 patient. Venous blood flow was unobstructed in 6 patients, mild stenosis was present in 1 patient, and moderate stenosis was present in 1 patient. The complications were as follows: 1 case had poor neck incision healing after ECMO removal. No complications, such as incisional bleeding, incisional infection, catheter-related blood infection, cannulation accidentally pulling away, vascular laceration, thrombosis, cerebral haemorrhage, cerebral infarction, or haemolysis, occurred in any of the patients. CONCLUSION Cannulation of the internal jugular vein and carotid artery can quickly establish effective ECMO access for neonates with severe respiratory failure. Careful, skilled and delicate operation was essential. In addition, during the cannulation process, we should pay special attention to the position of cannulation, firm fixation and strict aseptic operation.
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Affiliation(s)
- Qi-Liang Zhang
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xiu-Hua Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Si-Jia Zhou
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
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Cannulation approach and mortality in neonatal ECMO. J Perinatol 2023; 43:196-202. [PMID: 36076033 DOI: 10.1038/s41372-022-01503-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Identify associations between cannulation approach and mortality in neonates who received ECMO support for respiratory failure. STUDY DESIGN A retrospective analysis of neonates receiving ECMO for respiratory indications at a single quaternary-referral NICU. Associations between cannulation approach and mortality were assessed after adjustment for Neo-RESCUERS score. Cox Proportional Hazards (CPH) model was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for each variable and outcome. RESULTS Among 244 neonates, overall survival was 88%, with 71% undergoing VV cannulation. After adjusting for Neo-RESCUERS score, VA cannulation was associated with higher mortality during ECMO when compared with VV cannulation (HR 4.189, 95% CI 1.480-11.851, P = 0.0069). Disease-specific comparisons revealed no statistical difference in Neo-RESCUERS score between VA and VV cohorts; however, VA cannulation was associated with higher ECMO mortality for neonates with congenital diaphragmatic hernia (50% vs. 5.5%, Χ2 = 8.5965, P = 0.0034) and PPHN (20% vs. 1.8%, Χ2 = 9.1047, P = 0.0025) when compared with VV cannulation. CONCLUSION VA cannulation was associated with increased mortality in neonates while on ECMO for respiratory failure, which was independent of illness severity.
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Perioperative extracorporeal membrane oxygenation in pediatric congenital heart disease: Chinese expert consensus. World J Pediatr 2023; 19:7-19. [PMID: 36417081 PMCID: PMC9832091 DOI: 10.1007/s12519-022-00636-z] [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: 07/24/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Congenital heart disease (CHD) is one of the main supportive diseases of extracorporeal membrane oxygenation in children. The management of extracorporeal membrane oxygenation (ECMO) for pediatric CHD faces more severe challenges due to the complex anatomical structure of the heart, special pathophysiology, perioperative complications and various concomitant malformations. The survival rate of ECMO for CHD was significantly lower than other classifications of diseases according to the Extracorporeal Life Support Organization database. This expert consensus aims to improve the survival rate and reduce the morbidity of this patient population by standardizing the clinical strategy. METHODS The editing group of this consensus gathered 11 well-known experts in pediatric cardiac surgery and ECMO field in China to develop clinical recommendations formulated on the basis of existing evidences and expert opinions. RESULTS The primary concern of ECMO management in the perioperative period of CHD are patient selection, cannulation strategy, pump flow/ventilator parameters/vasoactive drug dosage setting, anticoagulation management, residual lesion screening, fluid and wound management and weaning or transition strategy. Prevention and treatment of complications of bleeding, thromboembolism and brain injury are emphatically discussed here. Special conditions of ECMO management related to the cardiovascular anatomy, haemodynamics and the surgical procedures of common complex CHD should be considered. CONCLUSIONS The consensus could provide a reference for patient selection, management and risk identification of perioperative ECMO in children with CHD. Video abstract (MP4 104726 kb).
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Johnson B, Dobkin SL, Josephson M. Extracorporeal membrane oxygenation as a bridge to transplant in neonates with fatal pulmonary conditions: A review. Paediatr Respir Rev 2022; 44:31-39. [PMID: 36464576 DOI: 10.1016/j.prrv.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2022]
Abstract
Neonates with progressive respiratory failure should be referred early for subspecialty evaluation and lung transplantation consideration. ECMO should be considered for patients with severe cardiopulmonary dysfunction and a high likelihood of death while on maximal medical therapy, either in the setting of reversible medical conditions or while awaiting lung transplantation. While ECMO offers hope to neonates that experience clinical deterioration while awaiting transplant, the risks and benefits of this intervention should be considered on an individual basis. Owing to the small number of infant lung transplants performed yearly, large studies examining the outcomes of various bridging techniques in this age group do not exist. Multiple single-centre experiences of transplanted neonates have been described and currently serve as guidance for transplant teams. Future investigation of outcomes specific to neonatal transplant recipients bridged with advanced devices is needed.
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Affiliation(s)
- Brandy Johnson
- Division of Pediatric Pulmonary Medicine, UF Health Shands Children's Hospital, Gainesville, FL, USA; Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA.
| | - Shoshana Leftin Dobkin
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Maureen Josephson
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Mahmood B. Persistent pulmonary hypertension of newborn. Semin Pediatr Surg 2022; 31:151202. [PMID: 36038220 DOI: 10.1016/j.sempedsurg.2022.151202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Burhan Mahmood
- Division of Newborn Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pennsylvania, USA.
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Bakoš M, Braovac D, Barić H, Belina D, Željko Đurić, Dilber D, Novak M, Matić T. Extracorporeal membrane oxygenation in children: An update of a single tertiary center 11-Year experience from Croatia. Perfusion 2022:2676591221093204. [PMID: 35543369 DOI: 10.1177/02676591221093204] [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: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is an important treatment option for organ support in respiratory insufficiency, cardiac failure, or as an advanced tool for cardiopulmonary resuscitation. Reports on pediatric ECMO use in our region are lacking. METHODS This study is a retrospective review of all pediatric cases that underwent a veno-arterial (VA) or veno-venous (VV) ECMO protocol between November 2009 and August 2020 at the Department of Pediatrics, University Hospital Center Zagreb, Croatia. RESULTS Fifty-two ECMO runs identified over the period; data were complete for 45 cases, of which 23 (51%) were female, and median age was 8 months. Thirty-eight (84%) patients were treated using the VA-and 7 (16%) using VV-ECMO. The overall survival rate was 51%. Circulatory failure was the most common indication for ECMO (N = 38, 84%), and in 17 patients ECMO was started after cardiopulmonary resuscitation (E-CPR). Among survivors, 74% had no or minor neurological sequelae. Variables associated with poor outcome were renal failure with renal replacement therapy (p < .001) and intracranial injury (p < .001). CONCLUSION Overall survival rate in our cohort is comparable to the data published in the literature. The use of hemodialysis was shown to be associated with higher mortality. High rates of full neurological recovery among survivors are a strong case for further ECMO program development in our institution.
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Affiliation(s)
- Matija Bakoš
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia
| | - Duje Braovac
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia
| | - Hrvoje Barić
- Department of Neurosurgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dražen Belina
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Željko Đurić
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Daniel Dilber
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Milivoj Novak
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Toni Matić
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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Jin C, Lin N, Yang S, Yan C, Li S, Wu X, Zhu J. Postoperative nursing care of a child with pulmonary artery displacement combined with slide tracheobronchial plasty. Nurs Crit Care 2022; 28:446-453. [PMID: 35534433 DOI: 10.1111/nicc.12774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Generally, pulmonary artery sling operation involves the pulmonary artery transplantation to be cut off. Nursing care is focused on the postoperative pulmonary vascular anastomosis, respiratory tract, and blood pressure after surgery. We report the case of an infant who underwent pulmonary artery tracheal transposition combined with Slide keratoplasty, where the pulmonary artery transplantation was not cut off. We highlight that postoperative pulmonary artery blood flow to the unobstructed airway and airway reconstruction surgery should be focused on to help children recover and ensure successful surgery. METHODS To report the postoperative nursing experience of one patient with pulmonary artery sling undergoing pulmonary tracheal transposition combined with Slide arthroplasty. RESULTS Throughout the postoperative care, airway management should be focused on to maintain circulation stability in the early postoperative period, and corresponding measures such as posture management, atomization inhalation, and improved chest physical therapy should be applied according to the special surgical method of the case in order to reduce airway complications and to improve the surgical success rate of children with pulmonary artery sling undergoing pulmonary tracheal transposition combined with Slide arthroplasty. CONCLUSION In similar cases, after pulmonary tracheal transposition and Slide angioplasty, the doctors and nurses should pay attention to early circulation stability and focus on airway management through careful treatment and nursing, so as to promote the child's recovery.
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Affiliation(s)
- Chendi Jin
- Cardiac Intensive Care Unit, the Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Nan Lin
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Shanfeng Yang
- Cardiac Intensive Care Unit, the Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Chuanchuan Yan
- Cardiac Intensive Care Unit, the Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Shuaini Li
- Cardiac Intensive Care Unit, the Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xiujing Wu
- Cardiac Intensive Care Unit, the Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jihua Zhu
- Nursing Department, the Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Cui Y, Zhang Y, Dou J, Shi J, Zhao Z, Zhang Z, Chen Y, Cheng C, Zhu D, Quan X, Zhu X, Huang W. Venovenous vs. Venoarterial Extracorporeal Membrane Oxygenation in Infection-Associated Severe Pediatric Acute Respiratory Distress Syndrome: A Prospective Multicenter Cohort Study. Front Pediatr 2022; 10:832776. [PMID: 35391748 PMCID: PMC8982932 DOI: 10.3389/fped.2022.832776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been increasingly used as rescue therapy for severe pediatric acute respiratory distress syndrome (PARDS) over the past decade. However, a contemporary comparison of venovenous (VV) and venoarterial (VA) ECMO in PARDS has yet to be well described. Therefore, the objective of our study was to assess the difference between VV and VA ECMO in efficacy and safety for infection-associated severe PARDS patients. METHODS This prospective multicenter cohort study included patients with infection-associated severe PARDS who received VV or VA ECMO in pediatric intensive care units (PICUs) of eight university hospitals in China between December 2018 to June 2021. The primary outcome was in-hospital mortality. Secondary outcomes included ECMO weaning rate, duration of ECMO and mechanical ventilation (MV), ECMO-related complications, and hospitalization costs. RESULTS A total of 94 patients with 26 (27.66%) VV ECMO and 68 (72.34%) VA ECMO were enrolled. Compared to the VA ECMO patients, VV ECMO patients displayed a significantly lower in-hospital mortality (50 vs. 26.92%, p = 0.044) and proportion of neurologic complications, shorter duration of ECMO and MV, but the rate of successfully weaned from ECMO, bleeding, bloodstream infection complications and pump failure were similar. By contrast, oxygenator failure was more frequent in patients receiving VV ECMO. No significant intergroup difference was observed for the hospitalization costs. CONCLUSION These positive findings showed the conferred survival advantage and safety of VV ECMO compared with VA ECMO, suggesting that VV ECMO may be an effective initial treatment for patients with infection-associated severe PARDS.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaying Dou
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Zhe Zhao
- Pediatric Intensive Care Unit, Senior Department of Pediatrics, The Seventh Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhen Zhang
- Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
| | - Yingfu Chen
- Critical Care Medicine, Children's Hospital Affiliated to Chongqing Medical University, Chongqing, China
| | - Chao Cheng
- Pediatric Intensive Care Unit, Shengjing Hospital Affiliated to China Medical University, Shenyang, China
| | - Desheng Zhu
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, China
| | - Xueli Quan
- Surgical Intensive Care Unit of Henan Children's Hospital, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xuemei Zhu
- Critical Care Medicine, Children's Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenyan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Choi BH, Verma S, Cicalese E, Dapul H, Toy B, Chopra A, Fisher JC. Morbidity of conversion from venovenous to venoarterial ECMO in neonates with meconium aspiration or persistent pulmonary hypertension. J Pediatr Surg 2021; 56:459-464. [PMID: 33645507 DOI: 10.1016/j.jpedsurg.2020.09.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 09/15/2020] [Accepted: 09/24/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Outcomes in neonates receiving extracorporeal membrane oxygenation (ECMO) for meconium aspiration syndrome (MAS) and/or persistent pulmonary hypertension (PPHN) are favorable. Infants with preserved perfusion are often offered venovenous (VV) support to spare morbidities of venoarterial (VA) ECMO. Worsening perfusion or circuit complications can prompt conversion from VV-to-VA support. We examined whether outcomes in infants requiring VA ECMO for MAS/PPHN differed if they underwent VA support initially versus converting to VA after a VV trial, and what factors predicted conversion. METHODS We reviewed the Extracorporeal Life Support Organization registry from 2007 to 2017 for neonates with primary diagnoses of MAS/PPHN. Propensity score analysis matched VA single-runs (controls) 4:1 against VV-to-VA conversions based on age, pre-ECMO pH, and precannulation arrests. Primary outcomes were complications and survival. Data were analyzed using Mann-Whitney U and Fisher's exact testing. Multivariate regression identified independent predictors of conversion for VV patients. RESULTS 3831 neonates underwent ECMO for MAS/PPHN, including 2129 (55%) initially requiring VA support. Of 1702 patients placed on VV ECMO, 98 (5.8%) required VV-to-VA conversion. Compared with 364 propensity-matched isolated VA controls, conversion runs were longer (190 vs. 127 h, P < 0.001), were associated with more complications, and decreased survival to discharge (70% vs. 83%, P = 0.01). On multivariate regression, conversion was more likely if neonates on VV ECMO did not receive surfactant (OR = 1.7;95%CI = 1.1-2.7;P = 0.03) or required high-frequency ventilation (OR = 1.9;95%CI = 1.2-3.3;P = 0.01) before ECMO. CONCLUSION Conversion from VV-to-VA ECMO in infants with MAS/PPHN conveys increased morbidity and mortality compared to similar patients placed initially onto VA ECMO. VV patients not receiving surfactant or requiring high-frequency ventilation before cannulation may have increased risk of conversion. While conversions remain rare, decisions to offer VV ECMO for MAS/PPHN must be informed by inferior outcomes observed should conversion be required. LEVEL OF EVIDENCE Level of evidence 3 Retrospective comparative study.
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Affiliation(s)
- Beatrix Hyemin Choi
- Division of Pediatric Surgery and Department of Surgery, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Sourabh Verma
- Divisions of Neonatology and NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Erin Cicalese
- Divisions of Neonatology and NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Heda Dapul
- Pediatric Critical Care and Department of Pediatrics, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Bridget Toy
- Transplant Institute, NYU Langone Health, New York, NY
| | - Arun Chopra
- Pediatric Critical Care and Department of Pediatrics, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Jason C Fisher
- Division of Pediatric Surgery and Department of Surgery, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone.
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Persad E, Sibrecht G, Ringsten M, Karlelid S, Romantsik O, Ulinder T, Borges do Nascimento IJ, Björklund M, Arno A, Bruschettini M. Interventions to minimize blood loss in very preterm infants-A systematic review and meta-analysis. PLoS One 2021; 16:e0246353. [PMID: 33556082 PMCID: PMC7870155 DOI: 10.1371/journal.pone.0246353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/18/2021] [Indexed: 12/25/2022] Open
Abstract
Blood loss in the first days of life has been associated with increased morbidity and mortality in very preterm infants. In this systematic review we included randomized controlled trials comparing the effects of interventions to preserve blood volume in the infant from birth, reduce the need for sampling, or limit the blood sampled. Mortality and major neurodevelopmental disabilities were the primary outcomes. Included studies underwent risk of bias-assessment and data extraction by two review authors independently. We used risk ratio or mean difference to evaluate the treatment effect and meta-analysis for pooled results. The certainty of evidence was assessed using GRADE. We included 31 trials enrolling 3,759 infants. Twenty-five trials were pooled in the comparison delayed cord clamping or cord milking vs. immediate cord clamping or no milking. Increasing placental transfusion resulted in lower mortality during the neonatal period (RR 0.51, 95% CI 0.26 to 1.00; participants = 595; trials = 5; I2 = 0%, moderate certainty of evidence) and during first hospitalization (RR 0.70, 95% CI 0.51, 0.96; 10 RCTs, participants = 2,476, low certainty of evidence). The certainty of evidence was very low for the other primary outcomes of this review. The six remaining trials compared devices to monitor glucose levels (three trials), blood sampling from the umbilical cord or from the placenta vs. blood sampling from the infant (2 trials), and devices to reintroduce the blood after analysis vs. conventional blood sampling (1 trial); the certainty of evidence was rated as very low for all outcomes in these comparisons. Increasing placental transfusion at birth may reduce mortality in very preterm infants; However, extremely limited evidence is available to assess the effects of other interventions to reduce blood loss after birth. In future trials, infants could be randomized following placental transfusion to different blood saving approaches. Trial registration: PROSPERO CRD42020159882.
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Affiliation(s)
- Emma Persad
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria
- Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | | | | | | | | | - Tommy Ulinder
- Department of Pediatrics, Lund University, Lund, Sweden
| | - Israel Júnior Borges do Nascimento
- University Hospital and School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- School of Medicine, Milwaukee Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Maria Björklund
- Library & ICT, Faculty of Medicine, Lund University, Lund, Sweden
| | - Anneliese Arno
- Eppi-Centre, Institute of Education, University College London, London, United Kingdom
| | - Matteo Bruschettini
- Department of Pediatrics, Lund University, Lund, Sweden
- Cochrane Sweden, Research and Development, Skåne University Hospital, Lund, Sweden
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Chemonges S. Cardiorespiratory physiological perturbations after acute smoke-induced lung injury and during extracorporeal membrane oxygenation support in sheep. F1000Res 2020; 9:769. [PMID: 32953091 PMCID: PMC7481850 DOI: 10.12688/f1000research.24927.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 01/19/2023] Open
Abstract
Background: Numerous successful therapies developed for human medicine involve animal experimentation. Animal studies that are focused solely on translational potential, may not sufficiently document unexpected outcomes. Considerable amounts of data from such studies could be used to advance veterinary science. For example, sheep are increasingly being used as models of intensive care and therefore, data arising from such models must be published. In this study, the hypothesis is that there is little information describing cardiorespiratory physiological data from sheep models of intensive care and the author aimed to analyse such data to provide biological information that is currently not available for sheep that received extracorporeal life support (ECLS) following acute smoke-induced lung injury. Methods: Nineteen mechanically ventilated adult ewes undergoing intensive care during evaluation of a form of ECLS (treatment) for acute lung injury were used to collate clinical observations. Eight sheep were injured by acute smoke inhalation prior to treatment (injured/treated), while another eight were not injured but treated (uninjured/treated). Two sheep were injured but not treated (injured/untreated), while one received room air instead of smoke as the injury and was not treated (placebo/untreated). The data were then analysed for 11 physiological categories and compared between the two treated groups. Results: Compared with the baseline, treatment contributed to and exacerbated the deterioration of pulmonary pathology by reducing lung compliance and the arterial oxygen partial pressure to fractional inspired oxygen (PaO 2/FiO 2) ratio. The oxygen extraction index changes mirrored those of the PaO 2/FiO 2 ratio. Decreasing coronary perfusion pressure predicted the severity of cardiopulmonary injury. Conclusions: These novel observations could help in understanding similar pathology such as that which occurs in animal victims of smoke inhalation from house or bush fires, aspiration pneumonia secondary to tick paralysis and in the management of the severe coronavirus disease 2019 (COVID-19) in humans.
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Affiliation(s)
- Saul Chemonges
- School of Veterinary Science, The University of Queensland, Gatton, Queensland 4343, Australia
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Hong X, Zhao Z, Liu Z, Liu C, Wang J, Quan X, Wu H, Ji Q, Sun J, Cheng D, Feng Z, Shi Y. Venoarterial Extracorporeal Membrane Oxygenation for Severe Neonatal Acute Respiratory Distress Syndrome in a Developing Country. Front Pediatr 2020; 8:227. [PMID: 32548079 PMCID: PMC7270410 DOI: 10.3389/fped.2020.00227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/15/2020] [Indexed: 01/19/2023] Open
Abstract
Objective: Extracorporeal membrane oxygenation (ECMO) has supported oxygen delivery and carbon dioxide removal in neonatal severe respiratory failure for more than 4 decades. The definition and diagnosis of neonatal acute respiratory distress syndrome (ARDS) was made according to the criteria first established by a Montreux Conference in 2017. By far, there has been no ECMO efficiency studies in neonatal ARDS. We aimed to compare the outcomes of neonates with severe ARDS supported with and without ECMO. Design: Retrospective pair-matched study. Setting: In the present retrospective pair-matched study, the outcomes of severe ARDS with ECMO support and without ECMO support were analyzed and compared. Propensity score matching was conducted. The study subjects were selected from a China Neonatal ECMO (CNECMO) study. In total, five hospitals were included in the CNECMO study. The patients were matched with demographic and clinical data. The primary endpoint was in-hospital mortality. Secondary outcomes included ventilator-time, ICU stay, hospitalization costs and cranial MRI results. Patients: 145 neonates with severe ARDS (Oxygenation Index, OI ≥16) from 5 hospitals. Interventions: No interventions. Measurements and Main Results: We collected the data of 145 neonates with severe ARDS (Oxygenation Index, OI≥16) from 5 hospitals. Among them, 42 neonates received venoarterial (VA) ECMO support, and the remaining 103 neonates were treated with conventional mechanical ventilation. The mortality of ECMO-supported neonates was not significantly different compared with the ESLO neonatal respiratory-supported from 2012 to 2018 (23.8 vs. 32.5%, p = 0.230). After matching with the propensity score we got 31 pairs. The ECMO-supported neonates had a lower in-hospital mortality (6 of 31, 19.4%) vs. non ECMO-supported patients (18 of 31, 58.1%) (p = 0.002). Hospitalization costs of survivors in ECMO-supported neonates were significantly higher than that of non-ECMO-supported neonates (p < 0.001). There was no difference of ventilator-times (p = 0.206), ICU stay (p = 0.879) and cranial MRI (p = 0.899) between the survivors of ECMO-supported and non-ECMO-supported neonates with ARDS. Conclusions: By far, there has been no ECMO efficiency studies in neonatal ARDS. This study found that ECMO-support have superior outcomes compared with non-ECMO-support in neonates with severe ARDS.
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Affiliation(s)
- Xiaoyang Hong
- Pediatric Intensive Care Unit, Affiliated Bayi Children's Hospital, The Seventh Medical Center, PLA General Hospital, Beijing, China
| | - Zhe Zhao
- Pediatric Intensive Care Unit, Affiliated Bayi Children's Hospital, The Seventh Medical Center, PLA General Hospital, Beijing, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Zhenqiu Liu
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Change Liu
- Pediatric Intensive Care Unit, Affiliated Bayi Children's Hospital, The Seventh Medical Center, PLA General Hospital, Beijing, China
| | - Jie Wang
- Surgical Pediatric Intensive Care Unit, Children's Hospital Affiliated of Zhengzhou University, Zhengzhou, China
| | - Xueli Quan
- Surgical Pediatric Intensive Care Unit, Children's Hospital Affiliated of Zhengzhou University, Zhengzhou, China
| | - Hui Wu
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
| | - Qiong Ji
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
| | - Jianwei Sun
- Department of Neonatology, Henang Provincial People's Hospital, Zhengzhou, China
| | - Donglinag Cheng
- Department of Neonatology, Henang Provincial People's Hospital, Zhengzhou, China
| | - Zhichun Feng
- Pediatric Intensive Care Unit, Affiliated Bayi Children's Hospital, The Seventh Medical Center, PLA General Hospital, Beijing, China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
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16
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Kovler ML, Garcia AV, Beckman RM, Salazar JH, Vacek J, Many BT, Rizeq Y, Abdullah F, Goldstein SD. Conversion From Venovenous to Venoarterial Extracorporeal Membrane Oxygenation Is Associated With Increased Mortality in Children. J Surg Res 2019; 244:389-394. [DOI: 10.1016/j.jss.2019.06.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/25/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
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Sewell EK, Piazza AJ, Davis J, Heard ML, Figueroa J, Keene SD. Inotrope Needs in Neonates Requiring Extracorporeal Membrane Oxygenation for Respiratory Failure. J Pediatr 2019; 214:128-133. [PMID: 31443896 DOI: 10.1016/j.jpeds.2019.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/03/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate how inotropic requirements in neonates with respiratory failure are affected by extracorporeal membrane oxygenation (ECMO) mode and whether high requirements predict mortality. STUDY DESIGN This retrospective chart review included all neonates undergoing ECMO for primary respiratory failure from 2010 to 2016 at a single institution. The vasoactive inotropy score (VIS) was calculated as described in the literature. Data were analyzed with descriptive statistics and univariate analyses. RESULTS Of the 110 identified neonates, 96 underwent venovenous (VV) (87%), 11 (10%) venoarterial, and 3 (3%) converted from VV to venoarterial. The median precannulation VIS score was 33.02 for patients who underwent VV compared with 28.93 for venoarterial (P = .25) and 15 for infants converted. VIS decreased dramatically by 4 hours of ECMO in both groups. The VIS before cannulation was similar in survivors and nonsurvivors, but was significantly higher in nonsurvivors after 24 hours of ECMO (median VIS, 12 [IQR, 8-25] vs 8 [IQR, 3.0-14.5]; P = .035) and at decannulation (10 [IQR, 7-19] vs 3 [IQR, 0-7]; P < .001). CONCLUSIONS Neonates with respiratory failure can be successfully managed on VV ECMO even with considerable vasoactive requirements. Vasoactive requirement after 24 hours of ECMO was predictive of mortality.
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Affiliation(s)
- Elizabeth K Sewell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Division of Neonatology Children's Healthcare of Atlanta, Atlanta, GA; Emory + Children's Pediatric Institute, Atlanta, GA
| | - Anthony J Piazza
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Division of Neonatology Children's Healthcare of Atlanta, Atlanta, GA; Emory + Children's Pediatric Institute, Atlanta, GA
| | - Joel Davis
- ECMO and Advanced Technologies, Children's Healthcare of Atlanta, Atlanta, GA
| | - Micheal L Heard
- ECMO and Advanced Technologies, Children's Healthcare of Atlanta, Atlanta, GA
| | - Janet Figueroa
- Biostatistic Core, Emory + Children's Research Alliance, Atlanta, GA
| | - Sarah D Keene
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Division of Neonatology Children's Healthcare of Atlanta, Atlanta, GA; Emory + Children's Pediatric Institute, Atlanta, GA
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Burgos CM, Frenckner B, Fletcher-Sandersjöö A, Broman LM. Transport on extracorporeal membrane oxygenation for congenital diaphragmatic hernia: A unique center experience. J Pediatr Surg 2019; 54:2048-2052. [PMID: 30824238 DOI: 10.1016/j.jpedsurg.2018.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/21/2018] [Accepted: 11/25/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Support on Extracorporeal oxygenation membrane (ECMO) represents the last therapeutic option in the management of respiratory failure and pulmonary hypertension refractory to treatment in patients with congenital diaphragmatic hernia (CDH). AIM The objective of this work was to present our experience of all the cases of CDH that we have transported on ECMO. MATERIAL AND METHODS Medical records of patients, national and international, with CDH transported by our service on ECMO from 1997 to 2018 were reviewed. RESULTS During 22 years, we performed 40 ECMO transports of newborns with CDH, 39 primary and one secondary. In 10% (4/40) we transferred patients from their primary hospital after the implantation of cannulae and commencement of ECMO to another center abroad owing to the lack of beds in our unit. Twenty (50%) of the transports were from a foreign country. Median transport distance was 560 (428-1381) km and the median transport time was 4.5 (4.2-6.3) h. The mode of transport was ground ambulance in 20%, helicopter in 10%, fixed wing aircraft in 62.5% and ground ambulance in Freight aircraft in 7.5%. In 40% of the transports, 20 complications occurred. In one of every four transports with complications, more than one event occurred. Most frequent complication was loss of tidal volumes (35%) and in 30% of the complications another patient related event was recorded. Equipment failure occurred in 20%, and climate problems and transport vehicle problems in 15%. No deaths occurred during transport. Venoarterial ECMO was used in 39 of the 40 cases. Survival to discharge was 87% for the entire period and long-term survival was 77%. CONCLUSIONS Long and short distance interhospital transports of CDH patients on ECMO can be performed safely. Despite occurrence of adverse events, the risk of mortality is very low. The personnel involved must be highly competent in intensive care, physiology and physics of ECMO, cannulation, intensive care transport and air transport medicine. They must also be trained to recognize risk factors in these patients. LEVEL OF EVIDENCE III Retrospective cohort study.
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Affiliation(s)
- Carmen Mesas Burgos
- Department of Pediatric Surgery, Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden; ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Björn Frenckner
- Department of Pediatric Surgery, Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden; ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Center Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Li G, Zhang L, Sun Y, Chen J, Zhou C. Co-initiation of continuous renal replacement therapy, peritoneal dialysis, and extracorporeal membrane oxygenation in neonatal life-threatening hyaline membrane disease: A case report. Medicine (Baltimore) 2019; 98:e14194. [PMID: 30681590 PMCID: PMC6358340 DOI: 10.1097/md.0000000000014194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) is a well-known technique to provide cardio-pulmonary support. Although continuous renal replacement therapy (CRRT) is frequently indicated, the need for faster fluid removal as the primary indication for ECMO is uncommon. Experiences on concomitant applications of ECMO, peritoneal dialysis (PD) and CRRT in neonates are relatively limited. PATIENT CONCERNS We report a 2-day-old male neonate with life-threatening hyaline membrane disease (HMD), accompained by severe systemic fluid retention, sepsis and abdominal compartment syndrome. DIAGNOSIS Hyaline membrane disease (HMD), neonatal respiratory distress syndrome, sepsis, capillary leakage syndrome, and abdominal compartment syndrome. INTERVENTION Veno-arterial ECMO, CRRT, and PD were synchronously initiated for the sake of faster fluid removal possible. OUTCOMES The infant was successfully weaned from ECMO circuit and fluid overload was greatly improved four days after extracorporeal life support (ECLS), without major complications. LESSONS Initiation of CRRT and PD during ECMO therapy is effective and safe to release fluid overload in neonates, and severe complications are absent. When a neonate requires dialysis of urgency, ECMO offers assured vascular access to hemodialysis, allowing faster fluid removal.
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Affiliation(s)
| | - Li Zhang
- Department of Perfusion, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong
| | - Yunxia Sun
- Department of Neonatology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
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20
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Wen Z, Jin Y, Jiang X, Sun M, Arman N, Wen T, Lv X. Extracellular histones indicate the prognosis in patients undergoing extracorporeal membrane oxygenation therapy. Perfusion 2018; 34:211-216. [PMID: 30370815 DOI: 10.1177/0267659118809557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Extracellular histones have been recently identified as damage-associated molecular-pattern (DAMP) molecules involved with the pathogenesis of various inflammatory diseases. This study intended to investigate whether extracellular histones can indicate the prognosis in critically ill patients supported by extracorporeal membrane oxygenation (ECMO) therapy. Methods: A total of 56 patients undergoing ECMO were analysed retrospectively. Median concentrations of extracellular histones in patients before ECMO were assessed and used to divide the patients into two groups (Group 1 <48 µg/ml and Group 2 ⩾48 µg/ml). Mortality rate, Sequential Organ Failure Assessment (SOFA) scores and systemic inflammation were compared between the groups. Results: There were relatively higher concentrations of extracellular histones in Group 2 patients (57.78 µg/ml [48.4, 71.3]) than in Group 1 patients (36.76 µg/ml [28.5, 39.3], p<0.0001). The hospital mortality rate was 55.4% for the entire study subjects, with significantly worsened mortality in Group 2 in contrast to Group 1 (58.8% vs. 50%, p=0.031). Moreover, Group 2 patients had significantly higher SOFA scores and more pronounced systemic inflammation than Group 1 patients prior to ECMO initialization. Conclusions: Extracellular histones are known contributors to cell damage and organ injury. Our study showed that extracellular histones have a predictive value in the assessment of outcome of patients undergoing ECMO therapy and may be helpful for risk stratification in clinical settings.
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Affiliation(s)
- Zongmei Wen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Yang Jin
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Xuemei Jiang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Meng Sun
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | | | - Tao Wen
- Medical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin Lv
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
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Use of venovenous ECMO for neonatal and pediatric ECMO: a decade of experience at a tertiary children's hospital. Pediatr Surg Int 2018; 34:263-268. [PMID: 29349617 DOI: 10.1007/s00383-018-4225-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Advances in extracorporeal membrane oxygenation (ECMO) have led to increased use of venovenous (VV) ECMO in the pediatric population. We present the evolution and experience of pediatric VV ECMO at a tertiary care institution. METHODS A retrospective cohort study from 01/2005 to 07/2016 was performed, comparing by cannulation mode. Survival to discharge, complications, and decannulation analyses were performed. RESULTS In total, 160 patients (105 NICU, 55 PICU) required 13 ± 11 days of ECMO. VV cannulation was used primarily in 83 patients with 64% survival, while venoarterial (VA) ECMO was used in 77 patients with 54% survival. Overall, 74% of patients (n = 118) were successfully decannulated; 57% survived to discharge. VA ECMO had a higher rate of intra-cranial hemorrhage than VV (22 vs 9%, p = 0.003). Sixteen VA patients (21%) had radiographic evidence of a cerebral ischemic insult. No cardiac complications occurred with the use of dual-lumen VV cannulas. There were no differences in complications (p = 0.40) or re-operations (p = 0.85) between the VV and VA groups. CONCLUSION Dual-lumen VV ECMO can be safely performed with appropriate image guidance, is associated with a lower rate of intra-cranial hemorrhage, and may be the preferred first-line mode of ECMO support in appropriately selected NICU and PICU patients. LEVEL OF EVIDENCE II.
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Abstract
Extracorporeal membrane oxygenation (ECMO), a life-saving therapy for respiratory and cardiac failure, was first used in neonates in the 1970s. The indications and criteria for ECMO have changed over the years, but it continues to be an important option for those who have failed other medical therapies. Since the Extracorporeal Life Support Organization (ELSO) Registry was established in 1989, more than 29,900 neonates have been placed on ECMO for respiratory failure, with 84% surviving their ECMO course, and 73% surviving to discharge or transfer. In this chapter, we will review the basics of ECMO, patient characteristics and criteria, patient management, ECMO complications, special uses of neonatal ECMO, and patient outcomes.
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Affiliation(s)
- Kathryn Fletcher
- Department of Pediatrics, Division of Neonatology, LAC + USC Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, CA; Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Rachel Chapman
- Department of Pediatrics, Division of Neonatology, LAC + USC Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, CA; Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Sarah Keene
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
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Venoarterial Extracorporeal Life Support for Neonatal Respiratory Failure: Indications and Impact on Mortality. ASAIO J 2018; 63:490-495. [PMID: 27984316 DOI: 10.1097/mat.0000000000000495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Venoarterial (VA) extracorporeal life support (ECLS) for neonatal respiratory failure is associated with increased mortality compared with venovenous (VV) ECLS. It is unclear whether this is a causal relationship or reflects differences in baseline disease severity between infants managed with these two strategies. Our objective was to identify clinical variables associated with the preferential selection of VA over VV ECLS, as these may confound the association between VA ECLS and increased mortality. We identified documented indications for preferential VA selection through chart review. We then assessed how the presence of common indications impacted mortality. Thirty-nine cases met eligibility. Severity of hypotension/degree of inotropic support and ventricular dysfunction on echocardiogram before cannulation were the most common specific indications for preferential VA ECLS. Mortality was 12.5% when neither high inotropic support nor ventricular dysfunction was present. Mortality rose to 20% with high inotropic support and 25% with ventricular dysfunction present alone and to 50% when both were present. We conclude that severe hypotension and ventricular dysfunction before ECLS cannulation are common indications for VA ECLS that likely influence survival. Research assessing the impact of ECLS cannulation mode on survival should adjust for baseline differences between groups for these important variables.
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Maul TM, Nelson JS, Wearden PD. Paracorporeal Lung Devices: Thinking Outside the Box. Front Pediatr 2018; 6:243. [PMID: 30234079 PMCID: PMC6134049 DOI: 10.3389/fped.2018.00243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 08/13/2018] [Indexed: 11/18/2022] Open
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is a resource intensive, life-preserving support system that has seen ever-expanding clinical indications as technology and collective experience has matured. Clinicians caring for patients who develop pulmonary failure secondary to cardiac failure can find themselves in unique situations where traditional ECMO may not be the ideal clinical solution. Existing paracorporeal ventricular assist device (VAD) technology or unique patient physiologies offer the opportunity for thinking "outside the box." Hybrid ECMO approaches include splicing oxygenators into paracorporeal VAD systems and alternative cannulation strategies to provide a staged approach to transition a patient from ECMO to a VAD. Alternative technologies include the adaptation of ECMO and extracorporeal CO2 removal systems for specific physiologies and pediatric aged patients. This chapter will focus on: (1) hybrid and alternative approaches to extracorporeal support for pulmonary failure, (2) patient selection and, (3) technical considerations of these therapies. By examining the successes and challenges of the relatively select patients treated with these approaches, we hope to spur appropriate research and development to expand the clinical armamentarium of extracorporeal technology.
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Affiliation(s)
- Timothy M Maul
- Department of Cardiac Surgery, Nemours Children's Hospital, Orlando, FL, United States.,Department of Biomedical Engineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jennifer S Nelson
- Department of Cardiac Surgery, Nemours Children's Hospital, Orlando, FL, United States
| | - Peter D Wearden
- Department of Cardiac Surgery, Nemours Children's Hospital, Orlando, FL, United States.,Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
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Yang XF, Li BF, Miao JH, Zheng KJ, Cheng Z, Liao XZ, Wang LQ, Chen J. [Application of extracorporeal membrane oxygenation in 4 critically in neonates]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1114-1117. [PMID: 29046211 PMCID: PMC7389276 DOI: 10.7499/j.issn.1008-8830.2017.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/09/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Xiu-Fang Yang
- Department of NICU, Zhongshan People's Hospital of Guangdong Province, Zhongshan, Guangdong 528403, China
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Kuok CM, Tsao PN, Chen CY, Chou HC, Hsieh WS, Huang SC, Chen YS, Wu ET. Extracorporeal Membrane Oxygenation Support in Neonates: A Single Medical Center Experience in Taiwan. Pediatr Neonatol 2017; 58:355-361. [PMID: 28223011 DOI: 10.1016/j.pedneo.2016.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/26/2016] [Accepted: 08/02/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) was used in neonates with severe cardiopulmonary failure who failed to respond to conventional therapy. We started to apply neck venoarterial ECMO (VA-ECMO) in neonatal patients from 2000. In this study, we have focused on neonates who received ECMO support and described the current status of ECMO in neonates for both cardiac and pulmonary support and the risk factors associated with their outcomes. METHODS Data were retrieved from our ECMO database for the neonates (age < 28 days) who received neck VA-ECMO support from January 2005 to June 2015. RESULTS In total, 27 neonates, including 21 with respiratory support and six with cardiac support, were enrolled in this study. Sixteen (59.2%) patients survived to hospital discharge, and only one patient had a poor neurological outcome. The survival rate for respiratory support was 61.9% in which meconium aspiration syndrome with persistent pulmonary hypertension of a newborn had a superior outcome (11/13, 84.6%) and congenital diaphragmatic hernia had the worst outcome (4/7, 57.1%). The survival rate in the cardiac support group was only 50%. The median ECMO duration and hospital stay were 6 (1∼35.8) days and 37 (23∼232) days, respectively, for survivors. Furthermore, 11 (52.3%) neonates of 21 outborn patients were put on ECMO in other hospitals by our mobile ECMO team for respiratory support, and their survival (81.8%) was significantly better than those from in-house ECMO institution (40%). CONCLUSION This is the first report for ECMO in neonatal disease in Taiwan. We achieved an overall survival rate of 59.2% with good neurological outcomes in this 10-year experience. ECMO could be a useful transportation tool for critical neonates who have a poor response to ventilator support.
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Affiliation(s)
- Chi-Man Kuok
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Pediatrics, National Taiwan University Children Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Children Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Children Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Children Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, National Taiwan University Children Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Cardiothoracic Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Cardiothoracic Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - En-Ting Wu
- Department of Pediatrics, National Taiwan University Children Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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Abstract
Despite wide use and decades of experience, survival of congenital diaphragmatic hernia (CDH) patients treated with extra-corporeal membrane oxygenation (ECMO), as reported by the extra-corporeal life support organization (ELSO), remains unchanged at 50%. High-survival rates both with and without utilizing ECMO have been reported, fueling questions about the utility of ECMO support in this difficult population. This review looks at data from the Congenital Diaphragmatic Hernia Study Group and individual center reports, to evaluate the role of ECMO in CDH, focusing on defining the patients most likely to benefit, and discussing how those benefits can best be achieved. These data show that ECMO improves survival in those CDH patients who are most severely affected, but potential complications of ECMO delivery outweigh benefit in patients with less severely affected. Improved results can be expected by minimizing ECMO complications, and by improving rates of CDH repair in patients that require ECMO.
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Affiliation(s)
- David W Kays
- Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, Division of Pediatric Surgery, 601 5th St South, Suite 306, St. Petersburg, Florida 33701.
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Abstract
Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a form of heart lung bypass that is used to support neonates, pediatrics, and adult patients with cardiorespiratory failure for days or weeks till organ recovery or transplantation. Venoarterial (VA) and venovenous (VV) ECLS are the most common modes of support. ECLS circuit components and monitoring have been evolving over the last 40 years. The technology is safer, simpler, and more durable with fewer complications. The use of neonatal respiratory ECLS use has been declining over the last two decades, while adult respiratory ECLS is growing especially since the H1N1 influenza pandemic in 2009. This review provides an overview of ECLS evolution over the last four decades, its use in neonatal, pediatric and adults, description of basic principles, circuit components, complications, and outcomes as well as a quick look into the future.
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The Impact of Venoarterial and Venovenous Extracorporeal Membrane Oxygenation on Cerebral Metabolism in the Newborn Brain. PLoS One 2016; 11:e0168578. [PMID: 28033354 PMCID: PMC5199081 DOI: 10.1371/journal.pone.0168578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 12/02/2016] [Indexed: 12/13/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an effective therapy for supporting infants with reversible cardiopulmonary failure. Still, survivors are at risk for long-term neurodevelopmental impairments, the cause of which is not fully understood. Objective To elucidate the effects of ECMO on the newborn brain. We hypothesized that the cerebral metabolic profile of neonates who received ECMO would differ from neonates who did not receive ECMO. To address this, we used magnetic resonance spectroscopy (1H-MRS) to investigate the effects of venoarterial and venovenous ECMO on cerebral metabolism. Methods 41 neonates treated with ECMO were contrasted to 38 age-matched neonates. Results All 1H-MRS data were acquired from standardized grey matter and white matter regions of interest using a short-echo (TE = 35 milliseconds), point-resolved spectroscopy sequence (PRESS) and quantitated using LCModel. Metabolite concentrations (mmol/kg) were compared across groups using multivariate analysis of covariance. Elevated creatine (p = 0.002) and choline (p = 0.005) concentrations were observed in the grey matter among neonates treated with ECMO relative to the reference group. Likewise, choline concentrations were elevated in the white matter (p = 0.003) while glutamate was reduced (p = 0.03). Contrasts between ECMO groups revealed lower osmolite concentrations (e.g. myoinositol) among the venovenous ECMO group. Conclusion Neonates who underwent ECMO were found to have an abnormal cerebral metabolic profile, with the pattern of abnormalities suggestive of an underlying inflammatory process. Additionally, neonates who underwent venovenous ECMO had low cerebral osmolite concentrations as seen in vasogenic edema.
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Zhou J, Chen C, Lu G, Cao Y. Neonatal extracorporeal membrane oxygenation: A case report and current state in Mainland China. Indian J Crit Care Med 2016; 20:735-738. [PMID: 28149033 PMCID: PMC5225776 DOI: 10.4103/0972-5229.195715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Predicting death or extended length of stay in infants with congenital diaphragmatic hernia. J Perinatol 2016; 36:654-9. [PMID: 26963428 DOI: 10.1038/jp.2016.26] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/11/2015] [Accepted: 12/18/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To predict mortality or length of stay (LOS) >109 days (90th percentile) among infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN We conducted a retrospective analysis using the Children's Hospital Neonatal Database during 2010 to 2014. Infants born >34 weeks gestation with CDH admitted at 22 participating regional neonatal intensive care units were included; patients who were repaired or were at home before admission were excluded. The primary outcome was death before discharge or LOS >109 days. Factors associated with this outcome were used to develop a multivariable equation using 80% of the cohort. Validation was performed in the remaining 20% of infants. RESULTS The median gestation and age at referral in this cohort (n=677) were 38 weeks and 6 h, respectively. The primary outcome occurred in 242 (35.7%) infants, and was distributed between mortality (n=180, 27%) and LOS >109 days (n=66, 10%). Regression analyses showed that small for gestational age (odds ratio (OR) 2.5, P=0.008), presence of major birth anomalies (OR 5.9, P<0.0001), 5- min Apgar score ⩽3 (OR 7.0, P=0.0002), gradient of acidosis at the time of referral (P<0.001), the receipt of extracorporeal support (OR 8.4, P<0.0001) and bloodstream infections (OR 2.2, P=0.004) were independently associated with death or LOS >109 days. This model performed well in the validation cohort (area under curve (AUC)=0.856, goodness-of-fit (GF) χ(2), P=0.16) and acted similarly even after omitting extracorporeal support (AUC=0.82, GF χ(2), P=0.05). CONCLUSIONS Six variables predicted death or LOS ⩾109 days in this large, contemporary cohort with CDH. These results can assist in risk adjustment for comparative benchmarking and for counseling affected families.
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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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Neonatal Extracorporeal Membrane Oxygenation: Update on Management Strategies and Long-Term Outcomes. Adv Neonatal Care 2016; 16:26-36. [PMID: 26808515 DOI: 10.1097/anc.0000000000000244] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) can be deployed to support patients with severe cardiorespiratory failure unresponsive to conventional medical interventions. Neonatal trials have demonstrated that ECMO is an effective treatment of severe respiratory failure, with acceptable cognitive and functional outcomes. Technological advances in ECMO have resulted in improved safety and accessibility, contributing to decreased morbidity and improved survival of increasingly complex patients requiring ECMO support. PURPOSE This review aims to describe the innovations in ECMO technology and management in the neonatal population in the last decade. The long-term outcomes of neonatal patients requiring ECMO support will be discussed. SEARCH STRATEGY Relevant clinical trials from MEDLINE and the Cochrane Library were identified. The following key words were used: ECMO, infant, neonate, and outcomes. FINDINGS Challenges still remain in supporting the premature and/or low-birth-weight infant with severe respiratory failure, as well as infants with congenital diaphragmatic hernia. Neonatal ECMO survivors can present with neurodevelopmental and respiratory problems, which become more prominent with time. IMPLICATIONS FOR PRACTICE While newer technologies have led to fewer neonates with respiratory failure progressing to ECMO, it remains an important tool to in those who have failed conventional therapies. Given the presence of neurodevelopmental problems in neonatal ECMO survivors, multidisciplinary follow-up targeting motor performance, exercise capacity, behavior, and subtle learning deficits is warranted. IMPLICATIONS FOR RESEARCH With the overall decreasing use of neonatal ECMO, ECMO centers must find ways to maintain their expertise in the light of lower patient volumes amidst complex patient physiology.
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Nasr DM, Rabinstein AA. Neurologic Complications of Extracorporeal Membrane Oxygenation. J Clin Neurol 2015; 11:383-9. [PMID: 26320848 PMCID: PMC4596114 DOI: 10.3988/jcn.2015.11.4.383] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/05/2015] [Accepted: 06/08/2015] [Indexed: 11/20/2022] Open
Abstract
Background and Purpose The rate and outcomes of neurologic complications of patients receiving extracorporeal
membrane oxygenation (ECMO) are poorly understood. The purpose of this study was to
identify these parameters in ECMO patients. Methods All patients receiving ECMO were selected from the Nationwide Inpatient Sample between
2001-2011. The rate and outcomes of neurologic complications [acute ischemic stroke,
intracranial hemorrhage (ICH), and seizures] among these patients was determined.
Discharge status, mortality, length of stay, and hospitalization costs were compared
between patients with and without neurologic complications using chi-squared tests for
categorical variables and Student's t-test for continuous
variables. Results In total, 23,951 patients were included in this study, of which 2,604 (10.9%)
suffered neurologic complications of seizure (4.1%), stroke (4.1%), or ICH
(3.6%). When compared to patients without neurologic complications, acute
ischemic stroke patients had significantly higher rates of discharge to a long-term
facility (12.2% vs. 6.8%, p<0.0001) and a
significantly longer mean length of stay (41.6 days vs. 31.9 days,
p<0.0001). ICH patients had significantly higher rates of
discharge to a long-term facility (9.5% vs. 6.8%,
p=0.007), significantly higher mortality rates (59.7% vs.
50.0%, p<0.0001), and a significantly longer mean length
of stay (41.8 days vs. 31.9 days) compared to patients without neurologic complications.
These outcomes did not differ significantly between seizure patients and patients
without neurologic complications. Conclusions Given the increasing utilization of ECMO and the high costs and poor outcomes
associated with neurologic complications, more research is needed to help determine the
best way to prevent these sequelae in this patient population.
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Affiliation(s)
- Deena M Nasr
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Neonatal carotid repair at ECMO decannulation: patency rates and early neurologic outcomes. J Pediatr Surg 2015; 50:64-8. [PMID: 25598095 PMCID: PMC5285515 DOI: 10.1016/j.jpedsurg.2014.10.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/06/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE Neonates placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) undergo either carotid repair or ligation at decannulation. Study aims were to evaluate carotid patency rates after repair and to compare early neurologic outcomes between repaired and ligated patients. METHODS A retrospective study of all neonates without congenital heart disease (CHD) who had VA-ECMO between 1989 and 2012 was completed using our institutional ECMO Registry. Carotid patency after repair, neuroimaging studies, and auditory brainstem response (ABR) testing at time of discharge were examined. RESULTS 140 neonates were placed on VA-ECMO during the study period. Among survivors, 84% of carotids repaired and imaged remained patent at last study. No significant differences were observed between infants in the repaired and ligated groups regarding diagnosis, ECMO duration, or length of stay. A large proportion (43%) developed a severe brain lesion after VA-ECMO, but few failed their ABR testing. Differences in early neurologic outcomes between the two groups of survivors were not significant. CONCLUSIONS At this single institution, carotid patency is excellent following repair at ECMO decannulation. No increased incidence of severe brain lesions or greater neurosensory impairment in the repair group was observed. Further studies are needed to investigate the effects of ligation on longer-term neurocognitive outcomes.
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