Inflammatory Markers During Extracorporeal Membrane Oxygenation in Neonates With Congenital Diaphragmatic Hernia.

Predictability model of the need for extracorporeal membrane oxygenation in neonates with meconium aspiration syndrome treated with inhaled nitric oxide

BackgroundCongenital diaphragmatic hernia (CDH) is a rare disease often requiring mechanical ventilation after birth. In severe cases, extracorporeal membrane oxygenation (ECMO) may be needed. This study analyzed the outcomes of patients with CDH treated with ECMO and investigated factors related to in-hospital mortality.MethodsAmong 254 newborns diagnosed with CDH between 2008 and 2020, 51 patients needed ECMO support. At Asan Medical Center, a multidisciplinary team approach has been applied for managing newborns with CDH since 2018. Outcomes were compared between hospital survivors and nonsurvivors.ResultsECMO was established at a median of 17 hours after birth. The mean birth weight was 3.1±0.5 kg. Twenty-three patients (23/51, 45.1%) were weaned from ECMO, and 16 patients (16/51, 31.4%) survived to discharge. The ECMO mode was veno-venous in 24 patients (47.1%) and veno-arterial in 27 patients (52.9%). Most cannulations (50/51, 98%) were accomplished through a transverse cervical incision. No significant between-group differences in baseline characteristics and prenatal indices were observed. The oxygenation index (1 hour before 90.0 vs. 51.0, p=0.005) and blood lactate level (peak 7.9 vs. 5.2 mmol/L, p=0.023) before ECMO were higher in nonsurvivors. Major bleeding during ECMO more frequently occurred in nonsurvivors (57.1% vs. 12.5%, p=0.007). In the multivariate analysis, the oxygenation index measured at 1 hour before ECMO initiation was identified as a significant risk factor for in-hospital mortality (odds ratio, 1.02; 95% confidence interval, 1.01–1.04; p=0.05).ConclusionThe survival of neonates after ECMO for CDH is suboptimal. Timely application of ECMO is crucial for better survival outcomes.

Cannulation for repeat extracorporeal membrane oxygenation (ECMO) in neonates with respiratory failure may be associated with technical difficulties, especially after the ligation of both the carotid artery and internal jugular vein. In a newborn who required repeat ECMO, the previously reconstructed right carotid artery was used for arterial access. The right atrium was cannulated through a small submammary thoracotomy incision after the internal jugular vein was found to be thrombosed. This approach is relatively simple, provides excellent bypass flow, and is not associated with significant bleeding.

Introduction: Neonates with congenital diaphragmatic hernia (CDH) who undergo repair while on extracorporeal membrane oxygenation (ECMO) are at risk of developing post-operative bleeding complications. Balanced anticoagulation is critical to maintain ECMO flow and avoid bleeding. Heparin has historically been our first-line anticoagulant; however, recently, we transitioned to bivalirudin, a direct thrombin inhibitor. The objective of this pilot study was to compare post-operative surgical bleeding complications between the two groups. Methods: We performed a single center retrospective cohort study of patients who underwent CDH repair while on ECMO between 2008 and 2023. Neonates were stratified based on the type of anticoagulant initiated after CDH repair. Outcomes included bleeding requiring surgical re-operation, intracranial hemorrhage, volume of blood products transfused, number of circuit changes, days on ECMO, and overall survival. Results: Among 62 neonates with CDH who underwent repair on ECMO, 44 (71%) were managed post-CDH repair with heparin and 18 (29%) with bivalirudin. One (5.6%) neonate managed with bivalirudin underwent re-operation following CDH repair for a bleeding complication compared to 17 (38.6%) managed with heparin (p = 0.022). In addition, the bivalirudin cohort utilized half of the total blood product volume compared to the heparin cohort (p = 0.020). Despite these benefits, there were no significant differences between groups for incidence of intracranial hemorrhage, number of circuit changes, days on ECMO, and overall survival. Conclusion: Anticoagulation with bivalirudin in neonates who underwent CDH repair while on ECMO was associated with decreased surgical bleeding complications and less total blood product transfused. This pilot analysis is the first to compare heparin to bivalirudin and stresses the importance of a multicenter study.

Neonates with severe congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation (ECMO) have a high rate of mortality. There is controversy regarding optimal time of surgical intervention. We present our data over a 26-year period. We analysed data from our Extracorporeal Life Support Organization registry forms between 1989 and 2015, in order to determine the factors affecting survival outcome for repair of congenital diaphragmatic hernia with ECMO as a bridge to surgery and/or recovery. Ninety-eight neonates with congenital diaphragmatic hernia requiring ECMO were identified. In-hospital mortality was 32%. The overall mortality (47.9%) in our study was seen up to 7 months, after this point there was no mortality. There was no difference in survival in patients repaired using pre-, intra- or postoperative ECMO (P = 0.65). Requiring haemofiltration at any point was significantly associated with reduced survival [hazard ratio 2.7 (95% confidence interval 1.5-4.9); P = 0.01] as was the presence of neurological complications [hazard ratio 3.7 (95% confidence interval 1.6-8.5); P = 0.003]. Age, Apgar score, mode of delivery, side, associated cardiac comorbidities, pH, partial pressure of carbon dioxide, partial pressure of oxygen, oxygen saturations, bicarbonate, high-frequency oscillatory ventilation, mode of ECMO, inhaled nitric oxide, pulmonary complications and bleeding were not associated with any survival difference. We believe that all neonates with severe diaphragmatic hernia should be given the option of ECMO if clinically indicated. Provided these patients survive the initial postoperative period, they go on to have a sustained survival benefit. Long-term cost analysis and morbidity need to be taken into account to determine the true effect of ECMO on congenital diaphragmatic hernia.

Hemolysis during Venovenous Extracorporeal Membrane Oxygenation in Neonates with Congenital Diaphragmatic Hernia: A Prospective Observational Study

Role of therapeutic plasma exchange in management of hemolysis associated with extracorporeal membrane oxygenation in neonates with congenital diaphragmatic hernia: A case series

Although respiratory management with high-frequency oscillatory ventilation (HFOV) has generally been used for neonates with congenital diaphragmatic hernia (CDH), entry criteria for extracorporeal membrane oxygenation (ECMO) based on data from patients who underwent HFOV have not yet been reported. To establish entry criteria for ECMO in such patients, we retrospectively studied 36 neonates with CDH treated by HFOV in our institutions between 1986 and 1994. From the admission records, preductal and postductal arterial blood gas data and HFOV ventilation conditions for 72 h after admission were extracted. Oxygenation index (01) and alveolar-arterial oxygen gradient (A-aD02) time interval combinations were calculated. Patients were divided into two groups: candidates for ECMO (n = 22) who underwent ECMO (n = 18) or died without ECMO (n = 4); and non-candidates (n = 14), who survived without ECMO. Blood gas data in patients placed on ECMO were comparable to those in patients who died without ECMO: mean pre- and postductal OI for 4 h > 30, postductal A-aD02 ≥620 mmHg for 4 h, postductal A-aD02 ≥580 mmHg for 8 h, and postductal A-aD02 ?550 mmHg for 12 h showed better sensitivity with a specificity of more than 90% compared to entry criteria that had previously been used in our institutions: a postductal OI >40 for 4 h and postductal A-aDO2 ≥610 mmHg for 8 h. In addition, a combination of preand postductal OI >30 for 4 h indicated a sensitivity of 95.5% and a specificity of 92.9%.

(J Extra-Corpor. Technol. 20[1] pp. 19–23, 32 references, Spring 1988) Complement activation is known to occur in procedures where blood comes into contact with non-biological surfaces. We followed complement activation in 5 infants undergoing long term extracorporeal membrane oxygenation (ECMO). Duration of ECMO varied from 121 hours to 309 hours. Changes in plasma C3a, C4a, C5a, and serum CH50 levels where measured before, during, and after ECMO. Upon initiation of ECMO, plasma C3a levels increased significantly during the first 2 hours. This was followed by a steady decline to pre-ECMO levels within 24 hours. Serum whole complement, measured by CH50 units, dropped markedly by 10 minutes after initiation of ECMO, returning to pre-ECMO levels in 24 hours. Plasma levels of C5a (a factor with high affinity for neutrophils) did not change significantly; nor did plasma C4a (a factor produced via activation of the classical pathway) show significant changes. Chest X-ray images uniformly demonstrated the onset of dense pulmonary opacification during the first 24 hours of ECMO treatment. This condition slowly cleared and appeared normal at termination of ECMO. We conclude that current ECMO circuitry mediates complement activation in neonates, probably via the alternate pathway. Activation is primarily limited to the first hours of ECMO and is no longer evident after 24 hours.

This study aimed to investigate the impact of the patent ductus arteriosus (DA) on pulmonary conditions and to evaluate the outcomes during neonatal extracorporeal membrane oxygenation (ECMO). Thirteen neonates who received ECMO support at Kaohsiung Chang Gung Memorial Hospital from June 2009 to June 2021 were retrospectively reviewed. Clinical data including diagnosis, duration of ECMO support, serial chest X-rays, echocardiography findings, and outcomes were recorded. The study population underwent peripheral ECMO placement, and echocardiography was performed to assess the DA condition. Chest X-rays were evaluated using the Radiographic Assessment of Lung Edema (RALE) score to assess pulmonary edema. Statistical analyses were conducted to compare pre- and post-ECMO pulmonary conditions and outcomes. The study population consisted of neonates diagnosed with congenital diaphragmatic hernia (CDH), acute respiratory distress syndrome (ARDS), or meconium aspiration syndrome (MAS). All neonates presented with pulmonary hypertension and patent DA before ECMO initiation, which DA spontaneously closed in surviving neonates after ECMO. The RALE score showed no significant differences in pulmonary edema between pre-ECMO and post-ECMO setup. The overall survival rate of neonates undergoing ECMO support with DA was 53.8%. The ECMO weaning success rates and survival-to-discharge rates were 62.5% and 50.0% in the CDH group, compared to 80% and 60% in the non-CDH group, respectively. The presence of DA during neonatal ECMO may not deteriorate the condition of pulmonary hypertension and pulmonary edema. Additionally, all surviving neonates showed spontaneous closure of the DA during follow-up. These findings suggest that peripheral ECMO without routine PDA ligation may be feasible in newborns.

Extracorporeal membrane oxygenation is a modern therapeutic strategy aimed to stabilize vital function in a patient suffering from severe circulatory failure and refractory hypoxia.Purpose. To describe two clinical cases of venoarterial extracorporeal membrane oxygenation in neonates with mеconium aspiration syndrome, complicated by persistent pulmonary hypertension and refractory hypoxia during medical evacuation.Material and methods. The authors performed a comprehensive analysis of the condition specifics based on clinical and instrumental work up.Results. We demonstrated that early application of venoarterial extracorporeal membrane oxygenation in neonates with meconium aspiration syndrome promotes the quickest possible stabilization and reverse of hypoxia and low cardiac output.Conclusion. Venoarterial extracorporeal membrane oxygenation in neonates with meconium aspiration syndrome and refractory hypoxemia is a life-saving procedure, that can be applied during medical evacuation by qualified medical staff.

BackgroundSurvival of neonates with intrauterine renal insufficiency and oligo- or anhydramnios correlates with the severity of secondary pulmonary hypoplasia. Early prenatal diagnosis together with repetitive amnioinfusions and modern intensive care treatment have improved the prognosis of these neonates. Extracorporeal membrane oxygenation is an established treatment option, mainly applied to neonates with pulmonary hypoplasia caused by congenital diaphragmatic hernia. However, a few case reports of extracorporeal membrane oxygenation in neonates with lower urinary tract obstruction have been published.Case presentationWe describe a case of a Caucasian male infant with prenatally diagnosed lower urinary tract obstruction and secondary pulmonary hypoplasia who was delivered spontaneously at 36 + 2 weeks of gestation. Venovenous extracorporeal membrane oxygenation was initiated on the first day of life for severe respiratory failure and consecutive hypoxemia despite treatment with inhaled nitric oxide and high-frequency oscillation. The patient was supported by extracorporeal membrane oxygenation for 10 days and extubated 6 weeks later. Hemofiltration was required on the second day of life because of renal insufficiency and was later replaced by peritoneal dialysis. The child was discharged after 4 months with nasal high-flow mild oxygen therapy and peritoneal dialysis.ConclusionNeonatal extracorporeal membrane oxygenation support is a possible treatment option for neonates with lower urinary tract obstruction and pulmonary hypoplasia.

Extracorporeal membrane oxygenation (ECMO) can act as a bridge to recovery in both pre- and postoperative patients with transposition of the great arteries (TGA). However, literature on its use in these patients is scarce. Retrospective single-centre cohort study encompassing all TGA patients who received ECMO between January 2009 and March 2024. Twenty-two neonates received ECMO during the study period, with an overall median age and weight at time of ECMO cannulation of 6.5 (1.8-10) days and 3.7 (3.3-4.0) kg, respectively. Twelve neonates received ECMO prior to the arterial switch operation because of severe persistent pulmonary hypertension (83%), respiratory failure due to severe pulmonary atelectasis (8%) or hypoxia after pulmonary arterial banding procedure (8%). Postoperative ECMO was used in 11 patients; of these, 1 (9%) had also received ECMO preoperatively. Postoperative indications for the remaining patients included failure to wean from cardiopulmonary bypass (50%), low cardiac output in Intensive Care Unit (20%), or after cardiopulmonary arrest (30%). Overall, median ECMO duration for all TGA patients was 75 (45-171) h, with a survival rate of 59% to hospital discharge. Among the preoperative ECMO patients, 5 patients (42%) died (4 preoperatively, 1 postoperatively performed while on ECMO). In the postoperative ECMO group, survival rate was 60%. In this single-centre retrospective study, TGA neonates received ECMO preoperatively primarily for severe pulmonary hypertension and postoperatively for failure to wean from cardiopulmonary bypass. This study showed a 58% and 60% survival to hospital discharge in ECMO patients supported preoperatively and those supported postoperatively, respectively.

BackgroundBronchiolitis is the most common lower respiratory tract infection in infants under 1 year of age. Although outcomes are generally good in neonates, preterm infants may experience rapid clinical deterioration and require extracorporeal membrane oxygenation (ECMO) as a rescue therapy.ObjectiveTo describe the characteristics and clinical outcomes of neonates requiring ECMO for acute bronchiolitis over the past decade.MethodsAn observational, retrospective, single-center study conducted in a level IIIC neonatal unit. All neonates admitted between 2013 and 2022 who required ECMO for bronchiolitis-related respiratory failure were included. Demographic, clinical, and outcome variables were analyzed.ResultsSix patients were included: five (83%) were preterm, with a median gestational age of 28.6 weeks (IQR 27.1-29.6). Respiratory syncytial virus was isolated in four patients, rhinovirus in one and influenza A in one. At ECMO initiation, median age was 48.5 days (IQR 34-120), median postmenstrual age was 38 weeks (IQR 35-41.8), and median weight was 2490g (IQR 1800-2900). The median duration of ECMO was 14 days (IQR 9-24). Two patients (33%) died, both preterm with RSV infection. All survivors were followed up by pediatric pulmonologists and neurologists. Two required home oxygen, and three showed neurodevelopmental disorders.ConclusionIn our cohort, the two non-survivors were preterm, RSV positive, and required prolonged ECMO support. Among survivors, respiratory and neurodevelopmental complications were common, underscoring the need for structured long-term follow-up. Neurodevelopmental impairment was the most frequent sequela observed.

Some critically ill neonates with congenital diaphragmatic hernia (CDH) require extracorporeal membrane oxygenation (ECMO) during the perioperative period. Neonates on ECMO face a significantly increased risk of thrombotic events. Thrombosis management varies across centers and may include anticoagulation, thrombolysis, or thrombectomy. We present our experience using low molecular weight heparin (LMWH) to treat a right atrial thrombus (RAT) following ECMO in a neonate with CDH.