Consideration Of Extracorporeal Membrane Oxygenation Research Articles

Veno-Venous Extracorporeal Membrane Oxygenation for Myositis-Associated Rapidly Progressive Interstitial Lung Disease

Myositis-associated rapidly progressive interstitial lung disease (RP-ILD) is a rare, often fatal, condition in patients with myositis involving hypoxemic respiratory failure progressing over weeks to months.1 Patients without known myositis may be indistinguishable from those with ARDS, requiring a high index of clinical suspicion to diagnose and treat.2 Limited available evidence and expert opinion support early, aggressive, multi-drug immunosuppressive treatment.1,3-5 Consensus recommendations include consideration of extracorporeal membrane oxygenation (ECMO) as a bridge to recovery or transplantation.

Role of extracorporeal membrane oxygenation in children with sepsis: a systematic review and meta-analysis

BackgroundThe benefits of extracorporeal membrane oxygenation (ECMO) in children with sepsis remain controversial. Current guidelines on management of septic shock in children recommend consideration of ECMO as salvage therapy. We sought to review peer-reviewed publications on effectiveness of ECMO in children with sepsis.MethodsStudies reporting on mortality in children with sepsis supported with ECMO, published in PubMed, Scopus and Embase from 1972 till February 2020, were included in the review. This study was done in adherence to Preferred Reporting Items for Systematic Review and Meta-Analysis statement after registering the review protocol with PROSPERO. Study eligibility was independently assessed by two authors and disagreements resolved by a third author. Publications were reviewed for quality using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Random-effects meta-analyses (DerSimonian and Laird) were conducted, and 95% confidence intervals were computed using the Clopper-Pearson method. Outliers were identified by the Baujat plot and leave-one-out analysis if there was considerable heterogeneity. The primary outcome measure was survival to discharge. Secondary outcome measures included hospital length of stay, subgroup analysis of neonatal and paediatric groups, types and duration of ECMO and complications.ResultsOf the 2054 articles screened, we identified 23 original articles for systematic review and meta-analysis. Cumulative estimate of survival (13 studies, 2559 patients) in the cohort was 59% (95%CI: 51–67%). Patients had a median length of hospital stay of 28.8 days, median intensive care unit stay of 13.5 days, and median ECMO duration of 129 h. Children needing venoarterial ECMO (9 studies, 208 patients) showed overall pooled survival of 65% (95%CI: 50–80%). Neonates (< 4 weeks of age) with sepsis needing ECMO (7 studies, 85 neonates) had pooled survival of 73% (95%CI: 56- 87%). Gram positive organisms were the most common pathogens (47%) in septic children supported with ECMO.ConclusionSurvival rates of children with sepsis needing ECMO was 59%. Neonates had higher survival rates (73%); gram positive organisms accounted for most common infections in children needing ECMO. Despite limitations, pooled survival data from this review indicates consideration of ECMO in refractory septic shock for all pediatric age groups.

A Term Neonate with a Malpositioned Umbilical Artery Catheter Tip

A term neonate with respiratory distress receiving endotracheal mechanical ventilation undergoes placement of umbilical venous and arterial catheters. ### Prenatal and Birth Histories ### Presentation The infant was admitted to the community hospital NICU. Endotracheal intubation was performed at 2 hours of age for increasing oxygen requirements and respiratory failure. Conventional mechanical ventilation was initiated with a fraction of inspired oxygen of 1.0. Chest radiography suggested meconium aspiration syndrome. Exogenous surfactant was administered and umbilical vein catheter (UVC) was placed. On radiography, the UVC tip was visualized in the liver and the catheter readjusted to a low-lying position and secured at 5 cm. The umbilical artery catheter (UAC) placement was unsuccessful. Blood culture specimen was obtained and treatment with ampicillin and gentamicin initiated. Persistent pulmonary hypertension of the newborn was suspected based on a 10% difference in pre- and postductal oxygen saturation; at 3 hours of age, inhaled nitric oxide (iNO) of 20 parts per million (ppm) was initiated for an oxygen index of 18 determined on a radial arterial blood gas. The infant was transferred to a level IV NICU for further evaluation and consideration of extracorporeal membrane oxygenation. Upon arrival at the level IV NICU, the neonate was placed on high-frequency oscillatory ventilation …

ECMO in Poisoning

AbstractSevere poisoning may lead to life-threatening situation or death due to cardiovascular dysfunction, arrhythmia, or cardiogenic shock. The poisoning substance varies in different parts of world; in the Western world, the drugs with cardiotoxic potential are more common, while pesticides and other household toxins are common in the rest of the world. However, most of these patients are relatively young and otherwise healthy irrespective of poisoning substances. Extracorporeal membrane oxygenation (ECMO) has regained interest in recent past and now its use is being explored for newer indications. The use of ECMO in poisoning has shown promising results as salvage therapy and can be used as bridge to recovery, antidote, and toxin removal with renal replacement therapy or transplant. The ECMO has been used in those poisoned patients who have persistent cardiogenic shock or refractory hypoxemia despite adequate supportive therapy. ECMO may be useful in providing adequate cardiac output and maintain tissue perfusion which helps in the redistribution of toxins from central circulation and facilitate the metabolism and excretion. However, the available literature is not sufficient and is based on case reports, case series, and retrospective cohort study. In spite of high mortality with severe poisoning and encouraging outcome with use of ECMO, it is an underutilized modality across the world. Though evidences suggest that early consideration of ECMO in severely poisoned patients with refractory cardiac arrest or hemodynamic compromise refractory to standard therapies may be beneficial, the right time to start ECMO in poisoned patients, criteria to start ECMO, and prognostication prior to initiation of ECMO is yet to be answered. Future studies and publications may address these issues, whereas the ELSO (Extracorporeal Life Support Organization) data registry may help in collecting global data on poisoning more effectively.

Persistent Pulmonary Hypertension of the Newborn.

Persistent pulmonary hypertension of the newborn (PPHN) is often secondary to parenchymal lung disease (such as meconium aspiration syndrome) or lung hypoplasia (with congenital diaphragmatic hernia) but can also be idiopathic. PPHN is characterized by elevated pulmonary vascular resistance, resulting in right-to-left shunting of blood and hypoxemia. The diagnosis of PPHN is based on clinical evidence of labile hypoxemia often associated with differential cyanosis and confirmed by echocardiography. Lung volume recruitment with optimal use of positive end-expiratory pressure or mean airway pressure and/or surfactant is very important in secondary PPHN due to parenchymal lung disease. Other management strategies include optimal oxygenation, avoiding respiratory and metabolic acidosis, blood pressure stabilization, sedation, and pulmonary vasodilator therapy. Failure of these measures leads to consideration of extracorporeal membrane oxygenation, although this rescue therapy is needed less frequently with advances in medical management. Randomized clinical trials with long-term follow-up are required to evaluate various therapeutic strategies in PPHN.

Primary care - The unrecognized member of the intensive care team.

I have been working at National University Hospital Singapore for a year now on a busy intensive care unit (ICU), much like others in the UK in which I’ve worked. This week there is someone pre-liver transplant, someone for consideration of ECMO (extracorporeal membrane oxygenation) and the usual gamut of critical care staples – severe pneumonias, pancreatitis and acute renal failure. My senior resident is stuck in the emergency department intubating a sick patient, while 80-odd patients wait for a hospital bed to appear for their admission. I’m considering sending someone home from ICU, as there hasn’t and won’t be an in-patient bed for her in the near future. The department has diverse interests in teaching, research and clinical service, and camaraderie is evident among the consultant body. In patient mix and system pressures, this could be the UK. Other aspects are very different – the physiotherapists have mobilized a ventilated patient outside (32 and sunny, as opposed to a British January), there is no sign of a desultory sandwich for lunch (instead a buffet meal prior to the medical grand round) and my juniors have been through an aspirational trans-thoracic echocardiogram program, ensuring that I have regular excellent bedside assessments for my sick patients. All in all, it’s a great place to be an intensive care physician. Singapore has been consistently cited as a model of healthcare economics, with 4% of gross domestic product invested in healthcare. Secondary care is recognized to be world class, and there is a voracious interest in continued advancement, tying in international experience with local research addressing certain aspects of disease unique to their racial mix. However, I am acutely aware of the absence of organized general practice in this system. Primary care remains fractured. There are 18 polyclinics (subsidized) and 1400 private primary healthcare clinics in Singapore. As a result of shared financial responsibility (fees can be subsidized up to 80% depending on means testing), patients shop around for what they perceive to be the best primary care doctors, with long-term plans difficult to develop. Costs of drugs interfere with compliance. Defaulting to follow-up seems to be the norm, either due to costs or as a result of difficulties with integrating personal health needs into everyday life. Leading causes of morbidity are the major non-communicable diseases: cancer, coronary heart disease, diabetes and hypertension. Long-term management of such chronic diseases is taxing even for the best systems. The lack of continuum of healthcare provision leads to a high level of preventable end organ damage. Ischaemic heart disease and chronic renal failure are common secondary to hypertension or diabetes. My remark regarding the relative youth of long-term dialysis patients with triple-vessel disease was met with the international medical language of one-upmanship – ‘‘40? Do you know how many 30 year-olds I see?’’ Teaching on the airway management of severe asthma had to be modified – near fatal asthma with community arrests is common. Sadly the majority that make it to our unit recover with beta agonists and steroids – there is no need for high-level care, merely compliance and access to healthcare. This preponderance of established chronic disease impacts on critical care both directly and indirectly. In the acutely unstable patient, hypertensive heart disease contributes to mortality, acute renal failure (pre-disposed to by chronic organ failure) has a high mortality rate, and chronic lung disease may lead to prolonged ventilator weaning. ICU survival is only the first stage: chronic disease states are associated with a decline in functional capacity and a higher level of institutionalization. Many in critical care focus on survival and subsequent functional disability. Yet, it seems increasingly clear that without good long-term chronic disease management – for which the general practice team is essential – critical care will see an increasing number of patients with preventable chronic organ failure, at a younger age. Not only will they be younger but also from areas of social deprivation – those who already

Persistent pulmonary hypertension of the newborn.

Persistent pulmonary hypertension of the newborn (PPHN) is characterized by elevated pulmonary vascular resistance resulting in right-to-left shunting of blood and hypoxemia. PPHN is often secondary to parenchymal lung disease (such as meconium aspiration syndrome, pneumonia or respiratory distress syndrome) or lung hypoplasia (with congenital diaphragmatic hernia or oligohydramnios) but can also be idiopathic. The diagnosis of PPHN is based on clinical evidence of labile hypoxemia often associated with differential cyanosis. The diagnosis is confirmed by the echocardiographic demonstration of – (a) right-to-left or bidirectional shunt at the ductus or foramen ovale and/or, (b) flattening or leftward deviation of the interventricular septum and/or, (c) tricuspid regurgitation, and finally (d) absence of structural heart disease. Management strategies include optimal oxygenation, avoiding respiratory and metabolic acidosis, blood pressure stabilization, sedation and pulmonary vasodilator therapy. Failure of these measures would lead to consideration of extracorporeal membrane oxygenation (ECMO); however decreased need for this rescue therapy has been documented with advances in medical management. While trends also note improved survival, long-term neurodevelopmental disabilities such as deafness and learning disabilities remain a concern in many infants with severe PPHN.Funded by: 1R01HD072929-0 (SL)

Venovenous Extracorporeal Membrane Oxygenation in Adults: Practical Aspects of Circuits, Cannulae, and Procedures

INTEREST IN extracorporeal membrane oxygenation (ECMO) for treating severe respiratory failure in adults has increased substantially in the last 5 years. There are several reasons for this increase. The first reason is the publication of the CESAR study in 2009, which showed improved survival in adults with severe acute respiratory distress syndrome (ARDS) randomized to consideration of ECMO compared with patients treated conventionally.1 Second is the H1N1 influenza pandemic of 2009 and 2010, which resulted in a substantial increase in the use of ECMO for treating severe respiratory failure.

Ambulatory veno-venous extracorporeal membrane oxygenation: Innovation and pitfalls

End-stage lung disease and severe acute lung injury are complex entities that remain challenges to manage. Therapies include early institution of mechanical ventilation with positive end-expiratory pressure, permissive hypercapnia, pulmonary vasodilators, and complex fluid regimens. Veno-venous extracorporeal membrane oxygenation is an available treatment option for these patients but, in its conventional form, can be associated with significant complications. We present our early experience with an attempt to optimize extracorporeal membrane oxygenation, emphasizing reduced adjunctive mechanical ventilatory support and aggressive rehabilitation, with a goal of ambulation. This strategy has been enabled by the introduction of a dual-lumen draw and return cannula placed via the internal jugular vein. The first 10 patients (mean age of 45.3 years, 8 male) treated with this strategy between January 1, 2009, and October 1, 2009, were retrospectively reviewed. The ambulatory extracorporeal membrane oxygenation strategy was initiated with an aim of minimal mechanical ventilation and aggressive rehabilitation. The patients were intended to be weaned from all respiratory support or bridged to transplantation. The mean duration of extracorporeal membrane oxygenation was 20 (9-59) days, with average mean blood flows of 3.5 (1.6-4.9) L/min, and levels of CO(2) removal and O(2) transfer of 228 (54-570) mL/min and 127 (36-529) mL/min, respectively. Six of 10 patients were weaned from respiratory support (N = 4) or underwent transplantation (N = 2) and survived to discharge from the hospital. The remaining 4 patients died of sepsis (N = 3) and withdrawal of care after renal failure (N = 1). Four of the 6 surviving patients were extubated and ambulatory while still on extracorporeal membrane oxygenation. During that time, 3 of the 4 patients exercised at the bedside, with the remaining patient able to undergo full cardiopulmonary rehabilitation, including treadmill walking. Improvements in the durability of membrane blood oxygenators and pumps have prompted renewed consideration of extracorporeal membrane oxygenation in patients with severe lung disease. This report describes an attempt to augment extracorporeal membrane oxygenation with the goal of ambulation by minimizing mechanical ventilatory support and using aggressive in-and-out-of-bed rehabilitation.

Étude CESAR : justification de l’assistance respiratoire extra corporelle pour les graves syndromes de détresse respiratoire de l’adulte

Background Severe acute respiratory failure in adults still has a high mortality in adults despite improvements in ventilation techniques and other treatments. The evidence about the effectiveness of extracorporeal membrane oxygenation (ECMO) was equivocal. Method National multi-center pragmatic randomized controlled trial. 180 adults (18-65 years) with severe (Murray score > 3.0 or pH < 7.2) but potentially reversible respiratory failure were randomized to receive either continued conventional management (CM) or to be transferred to Glenfield Hospital, Leicester, UK for consideration of ECMO. Patients were excluded if they had been on high pressure (> 30 cm H 2O of peak inspiratory pressure) and/or high FiO 2 (> 0.8) ventilation for > 7 days; had signs of intra-cranial bleeding ; had any other contra-indication to limited heparinisation ; or had any contra-indication to continuation of active treatment. The primary outcome measure was death or severe disability at six months. Analysis was by intention to treat. Results 766 patients were screened. 180 were randomised; 90 to the ECMO arm of whom 68 received ECMO. No cm patients received ECMO. Fewer patients in the ECMO arm than the cm arm had died or were severely disabled 6 months after randomisation, (33/90 (36.7%) vs 46/87 (52.9%) ; RR=0.69 (95%CI 0.50 to 0.97) ; p=0.030). Only one patient (in the cm arm) was known to be severely disabled at 6 months. Randomised controlled trial and economic evaluationControlled Trial of Conventional Ventilatory Support vs Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure (CESAR) [ISRCTN47279827].

Randomised controlled trial and parallel economic evaluation of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR)

To determine the comparative effectiveness and cost-effectiveness of conventional ventilatory support versus extracorporeal membrane oxygenation (ECMO) for severe adult respiratory failure. A multicentre, randomised controlled trial with two arms. The ECMO centre at Glenfield Hospital, Leicester, and approved conventional treatment centres and referring hospitals throughout the UK. Patients aged 18-65 years with severe, but potentially reversible, respiratory failure, defined as a Murray lung injury score > or = 3.0, or uncompensated hypercapnoea with a pH < 7.20 despite optimal conventional treatment. Participants were randomised to conventional management (CM) or to consideration of ECMO. The primary outcome measure was death or severe disability at 6 months. Secondary outcomes included a range of hospital indices: duration of ventilation, use of high frequency/oscillation/jet ventilation, use of nitric oxide, prone positioning, use of steroids, length of intensive care unit stay, and length of hospital stay - and (for ECMO patients only) mode (venovenous/veno-arterial), duration of ECMO, blood flow and sweep flow. A total of 180 patients (90 in each arm) were randomised from 68 centres. Three patients in the conventional arm did not give permission to be followed up. Of the 90 patients randomised to the ECMO arm, 68 received that treatment. ECMO was not given to three patients who died prior to transfer, two who died in transit, 16 who improved with conventional treatment given by the ECMO team and one who required amputation and could not therefore be heparinised. Ninety patients entered the CM (control) arm, three patients later withdrew and refused follow-up (meaning that they were alive), leaving 87 patients for whom primary outcome measures were available. CM consisted of any treatment deemed appropriate by the patient's intensivist with the exception of extracorporeal gas exchange. No CM patients received ECMO, although one received a form of experimental extracorporeal arteriovenous carbon dioxide removal support (a clear protocol violation). Fewer patients in the ECMO arm than in the CM arm had died or were severely disabled 6 months after randomisation, [33/90 (36.7%) versus 46/87 (52.9%) respectively]. This equated to one extra survivor for every six patients treated. Only one patient (in the CM arm) was known to be severely disabled at 6 months. Patients allocated to ECMO incurred average total costs of 73,979 pounds compared with 33,435 pounds for those undergoing CM (UK prices, 2005). A lifetime model predicted the cost per quality-adjusted life-year (QALY) of ECMO to be 19,252 pounds (95% confidence interval 7622 pounds to 59,200 pounds) at a discount rate of 3.5%. Lifetime QALYs gained were 10.75 for the ECMO group compared with 7.31 for the conventional group. Costs to patients and their relatives, including out of pocket and time costs, were higher for patients allocated to ECMO. Compared with CM, transferring adult patients with severe but potentially reversible respiratory failure to a single centre specialising in the treatment of severe respiratory failure for consideration of ECMO significantly increased survival without severe disability. Use of ECMO in this way is likely to be cost-effective when compared with other technologies currently competing for health resources. Current Controlled Trials ISRCTN47279827.

CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure

BackgroundAn estimated 350 adults develop severe, but potentially reversible respiratory failure in the UK annually. Current management uses intermittent positive pressure ventilation, but barotrauma, volutrauma and oxygen toxicity can prevent lung recovery. An alternative treatment, extracorporeal membrane oxygenation, uses cardio-pulmonary bypass technology to temporarily provide gas exchange, allowing ventilator settings to be reduced. While extracorporeal membrane oxygenation is proven to result in improved outcome when compared to conventional ventilation in neonates with severe respiratory failure, there is currently no good evidence from randomised controlled trials to compare these managements for important clinical outcomes in adults, although evidence from case series is promising.Methods/DesignThe aim of the randomised controlled trial of Conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR) is to assess whether, for patients with severe, but potentially reversible, respiratory failure, extracorporeal membrane oxygenation will increase the rate of survival without severe disability ('confined to bed' and 'unable to wash or dress') by six months post-randomisation, and be cost effective from the viewpoints of the NHS and society, compared to conventional ventilatory support. Following assent from a relative, adults (18–65 years) with severe, but potentially reversible, respiratory failure (Murray score ≥ 3.0 or hypercapnea with pH < 7.2) will be randomised for consideration of extracorporeal membrane oxygenation at Glenfield Hospital, Leicester or continuing conventional care in a centre providing a high standard of conventional treatment. The central randomisation service will minimise by type of conventional treatment centre, age, duration of high pressure ventilation, hypoxia/hypercapnea, diagnosis and number of organs failed, to ensure balance in key prognostic variables. Extracorporeal membrane oxygenation will not be available for patients meeting entry criteria outside the trial. 180 patients will be recruited to have 80% power to be able to detect a one third reduction in the primary outcome from 65% at 5% level of statistical significance (2-sided test). Secondary outcomes include patient morbidity and health status at 6 months.DiscussionAnalysis will be based on intention to treat. A concurrent economic evaluation will also be performed to compare the costs and outcomes of both treatments.

Experience with mobile inhaled nitric oxide during transport of neonates and children with respiratory insufficiency to an extracorporeal membrane oxygenation center

To share our experience with the use of inhaled nitric oxide (iNO) during the transport of ventilated neonates and children to an extracorporeal membrane oxygenation (ECMO) center and to discuss the efficacy and safety of iNO use in this situation. Case note review of 55 consecutive patients transported while receiving iNO to Glenfield Hospital, Leicester, UK, for consideration of ECMO. Retrospective case note review. The clinical condition of each patient recorded at arrival of the transport team at the referring hospital, during transport, and at arrival at Glenfield Hospital. Preclinical and postclinical conditions were compared using the paired Student's t-test. Overall data showed a significant improvement in transcutaneous oximetry measurements (Spo(2): 84.8% preclinical, 90.6% postclinical; p = .006) and Pao(2) (59 torr [7.87 kPa] preclinical, 84 torr [11.23 kPa] postclinical; p = .001) during transport in our patient group. Based on limited safety data, no untoward events or toxic metabolites were observed with iNO therapy during transport. iNO does appear to improve oxygenation during transfer of patients for ECMO in our series. Based on limited safety data, iNO appears safe to use in transport.

Ventilator management of infants before extracorporeal membrane oxygenation.

The aim of this project was to review the course of infants referred for consideration of extracorporeal membrane oxygenation (ECMO) to identify maximal ventilator settings that, when exceeded, did not provide clinical benefit to the patient. These settings might then be used in defining failure of conventional mechanical ventilation. We reviewed referral records and hospital charts of all infants treated for severe respiratory failure due to meconium aspiration syndrome during the 52.5 month period from March 15, 1985, to August 1, 1989. At an inspiratory pressure > 35 cm H2O, 75% (43/57) of patients eventually required ECMO, and 28% (4/14) of the infants who did not receive ECMO died. When the inspiratory pressure was > or = 40 cm H2O, 39/49 patients required ECMO, and 30% (3/10) of those not treated with ECMO died. Once the inspiratory pressure was > 45 cm H2O, 91% (29/32) of patients required ECMO, and only one third of those not treated with ECMO survived. Although the limitations for conventional therapy suggested in this paper may be helpful to clinicians, each center needs to establish guidelines for maximal conventional ventilator support. If these guidelines are clearly defined, alternative methods of therapy can be used once these criteria are achieved.

Severe pulmonary hypertension as a cause of reverse aortic arch flow in the neonate: Report of two cases

We describe two newborn infants with severe pulmonary hypertension and circulatory collapse. In both cases, pulsed and color flow Doppler studies showed systolic and diastolic reversal of flow in the transverse aortic arch to the level of the innominate artery. No associated cardiac or noncardiac anomalies could explain the reverse flow in the aortic arch. Severe pulmonary hypertension and low left ventricular output were thought to be responsible for the Doppler findings. Reversal of the aortic arch flow in the newborn with pulmonary hypertension may be associated with a poor prognosis, and early consideration of extracorporeal membrane oxygenation in such patients may be indicated.

UK collaborative randomised trial of neonatal extracorporeal membrane oxygenation

<h2>Summary</h2><h3>Background</h3> Extracorporeal membrane oxygenation (ECMO) is a complex and expensive technology that can be used to provide temporary support during respiratory failure. Its value for mature newborn infants is controversial because of varying interpretation of the available evidence. We undertook a collaborative trial throughout the UK to assess whether a policy of referral for ECMO has a beneficial effect on survival to 1 year without severe disability in comparison with conventional management. <h3>Methods</h3> Between 1993 and 1995, 185 mature (gestational age at birth ⩾35 weeks, birthweight ⩾2 kg) newborn infants with severe respiratory failure (oxygenation index ⩾40) were enrolled from 55 hospitals in a randomised comparison of either referral to one of five specialist centres for consideration of ECMO or continued intensive conventional management at the original hospital. The most common diagnoses were persistent pulmonary hypertension due to meconium aspiration, congenital diaphragmatic hernia, isolated persistent fetal circulation, sepsis, and idiopathic respiratory distress syndrome. Of the infants allocated ECMO, 84% received this support. Recruitment to the trial was stopped early (November, 1995) by the trial steering committee on the advice of the independent data-monitoring committee, because the data accumulated showed a clear advantage with ECMO. 124 children were enrolled before December, 1994; those who survived to 1 year of age have undergone neurological assessment at that age (by one of three developmental paediatricians unaware of treatment allocation). <h3>Findings</h3> Overall, 81 (44%) infants died before leaving hospital, and two are known to have died later. Death rates differed between the two trial groups; 30 of 93 infants allocated ECMO died compared with 54 of 92 allocated conventional care. The relative risk was 0·55 (95% CI 0·39–0·77; p=0·0005), which is equivalent to one extra survivor for every three to four infants allocated ECMO. The difference in survival applied irrespective of the primary diagnosis, disease severity, and type of referral centre. The benefit of ECMO was also found for the primary outcome measure of death or disability at 1 year (among 124 children enrolled before December, 1994). One child in each group has severe disability (overall Griffiths' developmental quotient <50, or untestable), and 16 (ten ECMO, six conventional management) have impairments with a lesser degree of disability. <h3>Interpretation</h3> These preliminary results demonstrate the clinical effectiveness of a well-staffed and organised neonatal ECMO service. ECMO support should be actively considered for neonates with severe but potentially reversible respiratory failure.

High-Frequency Ventilation in Acute Pediatric Respiratory Failure

High-Frequency Ventilation in Acute Pediatric Respiratory Failure

Diagnosis-Related Criteria in the Consideration of Extracorporeal Membrane Oxygenation in Neonates Previously Treated With High-Frequency Jet Ventilation

High-frequency jet ventilation (HFJV) is one of several high-frequency techniques that are particularly valuable for treating the neonate with lung disease refractory to conventional ventilation or with pulmonary air leak. Extracorporeal membrane oxygenation (ECMO) has also emerged as a valuable rescue therapy for neonates of more than 2000 g birth weight and 34 weeks' gestation with intractable respiratory failure. With the concurrent introduction of HFJV and ECMO, the authors sought to evaluate the role of HFJV prior to the institution of ECMO therapy. The data base for 2856 neonates receiving mechanical ventilation in one unit was used to identify 73 (of 298 total) neonates treated with HFJV, who were eligible by age and weight criteria for ECMO. Patients were grouped by diagnosis, and the oxygenation index (OI) was calculated during therapy. Outcome was evaluated for mortality, and the sensitivity of the OI for predicting mortality was calculated. Neonates who survived with HFJV alone presented with an OI of 0.30 +/- 0.03 (SEM), significantly less than nonsurvivors (0.42 +/- 0.04, P = .016). Survivors responded to HFJV with a rapid decrease in OI at 1 hour (0.19 +/- 0.02, P less than .001) and 6 hours (0.15 +/- 0.01, P less than .001). Nonsurvivors did not respond significantly at 1 hour (OI = 0.33 +/- 0.04, P = not significant [NS]) or at 6 hours (OI = 0.40 +/- 0.06, P = NS). By diagnosis, neonates with respiratory distress syndrome survived more often with HFJV (28/34, 82%) than neonates with meconium aspiration (10/26, 38%) or diaphragmatic hernia (3/9, 33%). Neonates with respiratory distress syndrome seldom presented with high OI values, but the majority of those who did survived (5/7 survived with initial OI greater than or equal to 0.40).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of extracorporeal membrane oxygenation on survival of infants with congenital diaphragmatic hernia

To determine the effect of extracorporeal membrane oxygenation (ECMO) on the survival of infants with congenital diaphragmatic hernia, we undertook a retrospective review of 31 infants with congenital diaphragmatic hernia treated at Children's National Medical Center. Infants were categorized by means of the Bohn quadrant analysis to determine the impact of ECMO on infants with congenital diaphragmatic hernia and a "poor prognosis." All infants assigned to the Bohn 100% mortality quadrant required ECMO. The survival rate in this group was 86% (6/7) when assessed preoperatively and 67% (6/9) when assessed postoperatively. Comparison of the change occurring in ventilation index and arterial carbon dioxide pressure demonstrated that after repair the clinical condition of 48% of infants deteriorated, 40% improved, and 12% remained unchanged. Of the 12 infants whose condition was worse after surgery, 11 eventually required ECMO. Our review demonstrates that ECMO improved survival significantly in infants with congenital diaphragmatic hernia who had a "poor prognosis" by the criteria of Bohn et al. We recommend consideration of ECMO for all infants with congenital diaphragmatic hernia for whom maximal medical therapy has failed.

Extracorporeal membrane oxygenation and congenital diaphragmatic hernia: Should any infant be excluded?

Mortality in infants with congenital diaphragmatic hernia (CDH) remains high despite improvements in neonatal and surgical care because many infants develop persistent pulmonary hypertension of the newborn (PPHN) following repair. Since 1984, extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy in all infants (n = 25) with PPHN following CDH repair when conventional management failed, with an overall survival of 60%. Repair was performed in this hospital on 12 infants and in other hospitals in 13 infants transferred for consideration of ECMO after repair. Mortality was the same in the group repaired here and those transferred for ECMO. Although complications were frequent in the surviving group, they were successfully managed with nonoperative or operative therapy. Selective use of ECMO has been advocated in CDH patients based on various predictors of high mortality such as “best” PO 2 postrepair <100 mm Hg, oxygenation index >40, and ventilation index >1,000 with PCO 2 >40. Seven surviving infants following ECMO would have been classified as unsalvageable by at least one parameter if selection criteria based on these parameters had been used. We conclude from this series that current predictors of high mortality in CDH patients are unreliable when ECMO is used. Surgeons caring for infants with CDH should consider the use of ECMO in all infants.