Multi-factorial analysis of cerebral injury in children with a ligation of right carotid artery after extracorporeal membrane oxygenation

Abstract

Objective To explore the high-risk factors of cerebral injury with a ligation of right carotid artery after extracorporeal membrane oxygenation (ECMO). Methods A total of 19 patients with severe cardiopulmonary failure were selected for ECMO from July 2009 to November 2015. Right common carotid artery and right internal jugular vein were performed with a ligation of distal blood vessels. Results There were low perfusion (13/19), high lactic acid (10/19), oliguria (10/19), E-CPR (extracorporeal membrane oxygenation-cardiopulmonary resuscitation)(7/19) and hypoxia (16/19) prior to ECMO. VA-ECMO (n=18) and VV-ECMO (n=1) were employed. And 17 cases showed obvious tissue perfusion improvement after effective circulation within 1 hour. The duration of support time was 65-572 (172.0±141.0) h for 14 cases of successful weaning. The outcomes were survival (n=13) and death (n=6). The rates of weaning, survival and mortality were 73.7%, 68.4% and 31.6% respectively. Cerebral injury occurred in 4 cases and the mortality of brain injury was 50% (2/4). Among 3 cases of cardiac arrest, there were out-of-hospital (n=1) and E-CPR (n=2). Two cases of difficult intubation failed to achieve tissue perfusion improvement after 24 h ECMO. Sustained severe hypoxia existed in one case before ECMO. The rates of mortality and cerebral injury was the same 28.6%(2/7) as those of E-CPR cases. Two neonate cases had no cerebral injury. One case of diaphragmatic hernia survived while another one with meconium aspiration syndrome died of severe hemolytic failure. And 13 survivors were followed up from 1 month to 6 years. There was only 1 case of obvious cerebral injury. Neck vascular ultrasound showed that blood flow was normal in distal right carotid artery and carotid internal jugular vein of 9 surviors. For 6 survivors, magnetic resonance angiography (MRA) examination showed no abnormalities in bilateral anterior, middle and posterior cerebral arteries. Two cases of intracranial hemorrhage were detected by magnetic resonance imaging (MRI) and computed tomography (CT). Electroencephalogram showed no obvious abnormalities in 9 survivors and brainstem auditory evoked potential was normal. Conclusions ECMO can significantly improve the survival of children with severe heart and lung failure. The key of preventing cerebral injury after ECMO is monitoring the risk factors before and during ECMO. Neck vascular accessing is excellent and vascular ligation does not increase the incidence of cerebral injury. Key words: Extracorporeal circulation; Craniocerebral trauma; Carotid artery, common