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Olutoye OO, Lee T, Todd HF, King A, Keswani SG. Extracorporeal Membrane Oxygenation Before 34 Wks' Gestation: A Single-Center Experience. J Surg Res 2024; 301:302-307. [PMID: 38996721 DOI: 10.1016/j.jss.2024.06.012] [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: 03/01/2023] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION Traditionally, gestational age <34 wk and weight <2 kg are considered relative contraindications to extracorporeal membrane oxygenation (ECMO). There is a paucity of information that explains the outcomes in this unique population of premature neonates. The purpose of this study is to examine outcomes of patients who undergo ECMO at <34 wk at a single institution. METHODS A single-center retrospective review was performed for neonates managed with ECMO in the neonatal intensive care unit from January 2012 to April 2022. Characteristics and outcome data were collected. The primary outcome studied was survival at discharge. Secondary outcomes were intraventricular hemorrhage, ischemic brain injury, and thrombosis. Data were analyzed with descriptive statistics. RESULTS Following exclusion, 107 patients were included with eight having initiating ECMO at <34 wk. Three (38%) patients, who received ECMO at <34 wk, incurred intraventricular hemorrhages compared to 14 (14%) in the ≥34-wk cohort. Two (25%), who underwent ECMO at <34 wk, exhibited signs of brain ischemia on imaging compared to 9 (9%) in those ≥34 wk, and 3 (38%) patients <34 wk experienced thrombosis compared to 31 (31%) in the ≥34-wk cohort. Five (63%) of those in the <34-wk cohort survived to discharge, similar to 61 (61%) in the ≥34 wk cohort. CONCLUSIONS Our data suggest that EGA <34 wk may not be a contraindication for ECMO, with appropriate counseling of potential risks.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Taylor Lee
- Lab for Regenerative Tissue Repair, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Hannah F Todd
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alice King
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor, College of Medicine, Houston, Texas.
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Puligandla P, Skarsgard E, Baird R, Guadagno E, Dimmer A, Ganescu O, Abbasi N, Altit G, Brindle M, Fernandes S, Dakshinamurti S, Flageole H, Hebert A, Keijzer R, Offringa M, Patel D, Ryan G, Traynor M, Zani A, Chiu P. Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative. Arch Dis Child Fetal Neonatal Ed 2024; 109:239-252. [PMID: 37879884 DOI: 10.1136/archdischild-2023-325865] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'. DESIGN AND MAIN OUTCOME MEASURES Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field. RESULTS Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH. CONCLUSIONS The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.
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Affiliation(s)
- Pramod Puligandla
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Baird
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elena Guadagno
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexandra Dimmer
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nimrah Abbasi
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Altit
- Neonatology, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mary Brindle
- Department of Surgery, Section of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Sairvan Fernandes
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shyamala Dakshinamurti
- Department of Pediatrics and Child Health, Section of Neonatology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helene Flageole
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Audrey Hebert
- Department of Pediatrics, Division of Neonatology, Laval University, Quebec City, Quebec, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery and Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dylan Patel
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Greg Ryan
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Michael Traynor
- Department of Anesthesia, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Augusto Zani
- Department of Surgery, Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Priscilla Chiu
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Renik-Jankowska W, Buczyńska A, Sidorkiewicz I, Kosiński P, Zbucka-Krętowska M. Exploring new perspectives on congenital diaphragmatic hernia: A comprehensive review. Biochim Biophys Acta Mol Basis Dis 2024; 1870:167105. [PMID: 38428682 DOI: 10.1016/j.bbadis.2024.167105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
Congenital diaphragmatic hernia (CDH) represents a developmental anomaly that profoundly impacts the embryonic development of both the respiratory and cardiovascular systems. Understanding the influences of developmental defects, their origins, and clinical consequences is of paramount importance for further research and the advancement of therapeutic strategies for this condition. In recent years, groundbreaking studies in the fields of metabolomics and genomics have significantly expanded our knowledge regarding the pathogenic mechanisms of CDH. These investigations introduce novel diagnostic and therapeutic avenues. CDH implies a scarcity of available information within this domain. Consequently, a comprehensive literature review has been undertaken to synthesize existing data, providing invaluable insights into this rare disease. Improved comprehension of the molecular underpinnings of CDH has the potential to refine diagnostic precision and therapeutic interventions, thus potentially enhancing clinical outcomes for CDH patients. The identification of potential biomarkers assumes paramount significance for early disease detection and risk assessment in CDH, facilitating prompt recognition and the implementation of appropriate interventions. The process of translating research findings into clinical practice is significantly facilitated by an exhaustive literature review. It serves as a pivotal step, enabling the integration of novel, more effective diagnostic and therapeutic modalities into the management of CDH patients.
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Affiliation(s)
- Weronika Renik-Jankowska
- Department of Gynecological Endocrinology and Adolescent Gynecology, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland.
| | - Angelika Buczyńska
- Clinical Research Centre, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland.
| | - Iwona Sidorkiewicz
- Clinical Research Support Centre, Medical University of Bialystok, ul. M. Skłodowskiej-Curie 24a, 15-276 Bialystok, Poland.
| | - Przemysław Kosiński
- Department of Obstetrics, Perinatology, and Gynecology, Medical University of Warsaw, Żwirki i Wigury 63A, 02-091 Warszawa, Poland.
| | - Monika Zbucka-Krętowska
- Department of Gynecological Endocrinology and Adolescent Gynecology, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland
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Moynihan KM, Taylor LS, Siegel B, Nassar N, Lelkes E, Morrison W. "Death as the One Great Certainty": ethical implications of children with irreversible cardiorespiratory failure and dependence on extracorporeal membrane oxygenation. Front Pediatr 2024; 11:1325207. [PMID: 38274466 PMCID: PMC10808631 DOI: 10.3389/fped.2023.1325207] [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: 10/20/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Advances in medical technology have led to both clinical and philosophical challenges in defining death. Highly publicized cases have occurred when families or communities challenge a determination of death by the irreversible cessation of neurologic function (brain death). Parallels can be drawn in cases where an irreversible cessation of cardiopulmonary function exists, in which cases patients are supported by extracorporeal cardiopulmonary support, such as extracorporeal membrane oxygenation (ECMO). Analysis Two cases and an ethical analysis are presented which compare and contrast contested neurologic determinations of death and refusal to accept the irreversibility of an imminent death by cardiopulmonary standards. Ambiguities in the Uniform Determination of Death Act are highlighted, as it can be clear, when supported by ECMO, that a patient could have suffered the irreversible cessation of cardiopulmonary function yet still be alive (e.g., responsive and interactive). Parallel challenges with communication with families around the limits of medical technology are discussed. Discussion Cases that lead to conflict around the removal of technology considered not clinically beneficial are likely to increase. Reframing our goals when death is inevitable is important for both families and the medical team. Building relationships and trust between all parties will help families and teams navigate these situations. All parties may require support for moral distress. Suggested approaches are discussed.
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Affiliation(s)
- Katie M. Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lisa S. Taylor
- Office of Ethics, Boston Children’s Hospital, Boston, MA, United States
| | - Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Natasha Nassar
- Clinical and Population Translational Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Efrat Lelkes
- Department of Pediatrics, MaineGeneral Medical Center, Augusta, ME, United States
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Divisions of Critical Care and Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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5
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Fallon BP, Lautner-Csorba O, Major TC, Lautner G, Harvey SL, Langley MW, Johnson MD, Saveski C, Matusko N, Rabah R, Rojas-Pena A, Meyerhoff ME, Bartlett RH, Mychaliska GB. Extracorporeal life support without systemic anticoagulation: a nitric oxide-based non-thrombogenic circuit for the artificial placenta in an ovine model. Pediatr Res 2024; 95:93-101. [PMID: 37087539 PMCID: PMC10600655 DOI: 10.1038/s41390-023-02605-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/26/2023] [Accepted: 03/20/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Clinical translation of the extracorporeal artificial placenta (AP) is impeded by the high risk for intracranial hemorrhage in extremely premature newborns. The Nitric Oxide Surface Anticoagulation (NOSA) system is a novel non-thrombogenic extracorporeal circuit. This study aims to test the NOSA system in the AP without systemic anticoagulation. METHODS Ten extremely premature lambs were delivered and connected to the AP. For the NOSA group, the circuit was coated with DBHD-N2O2/argatroban, 100 ppm nitric oxide was blended into the sweep gas, and no systemic anticoagulation was given. For the Heparin control group, a non-coated circuit was used and systemic anticoagulation was administered. RESULTS Animals survived 6.8 ± 0.6 days with normal hemodynamics and gas exchange. Neither group had any hemorrhagic or thrombotic complications. ACT (194 ± 53 vs. 261 ± 86 s; p < 0.001) and aPTT (39 ± 7 vs. 69 ± 23 s; p < 0.001) were significantly lower in the NOSA group than the Heparin group. Platelet and leukocyte activation did not differ significantly from baseline in the NOSA group. Methemoglobin was 3.2 ± 1.1% in the NOSA group compared to 1.6 ± 0.6% in the Heparin group (p < 0.001). CONCLUSIONS The AP with the NOSA system successfully supported extremely premature lambs for 7 days without significant bleeding or thrombosis. IMPACT The Nitric Oxide Surface Anticoagulation (NOSA) system provides effective circuit-based anticoagulation in a fetal sheep model of the extracorporeal artificial placenta (AP) for 7 days. The NOSA system is the first non-thrombogenic circuit to consistently obviate the need for systemic anticoagulation in an extracorporeal circuit for up to 7 days. The NOSA system may allow the AP to be implemented clinically without systemic anticoagulation, thus greatly reducing the intracranial hemorrhage risk for extremely low gestational age newborns. The NOSA system could potentially be applied to any form of extracorporeal life support to reduce or avoid systemic anticoagulation.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Orsolya Lautner-Csorba
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Terry C Major
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gergely Lautner
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephen L Harvey
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark W Langley
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matthew D Johnson
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Claudia Saveski
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Niki Matusko
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Raja Rabah
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alvaro Rojas-Pena
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Surgery, Section of Transplantation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark E Meyerhoff
- Department of Chemistry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert H Bartlett
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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6
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Wood S, Iacobelli R, Kopfer S, Lindblad C, Thelin EP, Fletcher-Sandersjöö A, Broman LM. Predictors of intracranial hemorrhage in neonatal patients on extracorporeal membrane oxygenation. Sci Rep 2023; 13:19249. [PMID: 37935800 PMCID: PMC10630488 DOI: 10.1038/s41598-023-46243-4] [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: 05/07/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-supportive treatment in neonatal patients with refractory lung and/or heart failure. Intracranial hemorrhage (ICH) is a severe complication and reliable predictors are warranted. The aims of this study were to explore the incidence and possible predictors of ICH in ECMO-treated neonatal patients. We performed a single-center retrospective observational cohort study. Patients aged ≤ 28 days treated with ECMO between 2010 and 2018 were included. Exclusion criteria were ICH, ischemic stroke, cerebrovascular malformation before ECMO initiation or detected within 12 h of admission, ECMO treatment < 12 h, or prior treatment with ECMO at another facility > 12 h. The primary outcome was a CT-verified ICH. Logistic regression models were employed to identify possible predictors of the primary outcome. Of the 223 patients included, 29 (13%) developed an ICH during ECMO treatment. Thirty-day mortality was 59% in the ICH group and 16% in the non-ICH group (p < 0.0001). Lower gestational age (p < 0.01, odds ratio (OR) 0.96; 95%CI 0.94-0.98), and higher pre-ECMO lactate levels (p = 0.017, OR 1.1; 95%CI 1.01-1.18) were independently associated with increased risk of ICH-development. In the clinical setting, identification of risk factors and multimodal neuromonitoring could help initiate steps that lower the risk of ICH in these patients.
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Affiliation(s)
- Sara Wood
- ECMO Centre Karolinska, Intensive Care and Transport, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Stråket 14, 171 76, Stockholm, Sweden
| | - Riccardo Iacobelli
- ECMO Centre Karolinska, Intensive Care and Transport, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Stråket 14, 171 76, Stockholm, Sweden.
| | - Sarah Kopfer
- ECMO Centre Karolinska, Intensive Care and Transport, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Stråket 14, 171 76, Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Alexander Fletcher-Sandersjöö
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Intensive Care and Transport, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Stråket 14, 171 76, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Spencer BL, Mychaliska GB. Updates in Neonatal Extracorporeal Membrane Oxygenation and the Artificial Placenta. Clin Perinatol 2022; 49:873-891. [PMID: 36328605 DOI: 10.1016/j.clp.2022.07.002] [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: 01/27/2023]
Abstract
Extracorporeal life support, initially performed in neonates, is now commonly used for both pediatric and adult patients requiring pulmonary and/or cardiac support. Data suggests the clinical feasibility of Extracorporeal Membrane Oxygenation for premature infants (29-33 weeks estimated gestational age [EGA]). For extremely premature infants less than 28 weeks EGA, an artificial placenta has been developed to recreate the fetal environment. This approach is investigational but clinical translation is promising. In this article, we discuss the current state and advances in neonatal and "preemie Extracorporeal Membrane Oxygenation" and the development of an artificial placenta and its potential use in extremely premature infants.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Fetal Diagnosis and Treatment Center, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA.
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Wild KT, Burgos CM, Rintoul NE. Expanding neonatal ECMO criteria: When is the premature neonate too premature. Semin Fetal Neonatal Med 2022; 27:101403. [PMID: 36435713 DOI: 10.1016/j.siny.2022.101403] [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: 11/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a universally accepted and life-saving therapy for neonates with respiratory or cardiac failure that is refractory to maximal medical management. Early studies found unacceptable risks of mortality and morbidities such as intracranial hemorrhage among premature and low birthweight neonates, leading to widely accepted ECMO inclusion criteria of gestational age ≥34 weeks and birthweight >2 kg. Although contemporary data is lacking, the most recent literature demonstrates increased survival and decreased rates of intracranial hemorrhage in premature neonates who are supported with ECMO. As such, it seems like the right time to push the boundaries of ECMO on a case-by-case basis beginning with neonates 32-34 weeks GA in large volume centers with careful neurodevelopmental follow-up to better inform practices changes on this select population.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Carmen Mesas Burgos
- Department of Pediatric Surgery, Karolinska University Hospital, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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9
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Incidence and predictors of brain infarction in neonatal patients on extracorporeal membrane oxygenation: an observational cohort study. Sci Rep 2022; 12:17932. [PMID: 36289242 PMCID: PMC9605965 DOI: 10.1038/s41598-022-21749-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/30/2022] [Indexed: 01/20/2023] Open
Abstract
To determine the incidence and identify predictors of brain infarctions (BI) in neonatal patients treated with extracorporeal membrane oxygenation (ECMO). We performed a retrospective cohort study at ECMO Centre Karolinska, Stockholm, Sweden. Logistic regression models were used to identify BI predictors. Neonates (age 0-28 days) treated with veno-arterial (VA) or veno-venous (VV) ECMO between 2010 and 2018. The primary outcome was a computed tomography (CT) verified BI diagnosed during ECMO treatment. In total, 223 patients were included, 102 patients (46%) underwent at least one brain CT and 27 patients (12%) were diagnosed with a BI. BI diagnosis was associated with increased 30-day mortality (48% vs. 18%). High pre-ECMO Pediatric Index of Mortality score, sepsis as the indication for ECMO treatment, VA ECMO, conversion between ECMO modes, use of continuous renal replacement therapy, and extracranial thrombosis were identified as independent predictors of BI development. The incidence of BI in neonatal ECMO patients may be higher than previously understood. Risk factor identification may help initiate steps to lower the risk or facilitate earlier diagnosis of BI in neonates undergoing ECMO treatment.
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