Extracorporeal Membrane Oxygenation In Infants Research Articles

Extracorporeal Membrane Oxygenation in Infants with Congenital Diaphragmatic Hernia: Follow-Up MRI Evaluating Carotid Artery Reocclusion and Neurologic Outcome

Extracorporeal Membrane Oxygenation in Infants with Congenital Diaphragmatic Hernia: Follow-Up MRI Evaluating Carotid Artery Reocclusion and Neurologic Outcome

Bronchioalveolar lavage with perfluorochemical liquid during conventional ventilation

Therapeutic approaches with bronchioalveolar lavage are currently used in infants with severe alveolar space-occupying material. In many circumstances, bronchioalveolar lavage has been performed in conjunction with extracorporeal membrane oxygenation. A 2-month-old boy with severe respiratory failure requiring assisted ventilation did not respond to any conventional treatments, including surfactant. An open-lung biopsy showed intra-alveolar accumulation of proteinaceous material and foamy macrophages but was not diagnostically conclusive. Therapeutic trials with bronchioalveolar lavage using normal saline were unsuccessful, causing episodes of severe hypoxemia. Then, bronchioalveolar lavage during conventional mechanical ventilation was performed with the use of a medical-grade perfluorochemical liquid (perfluordecalin). After instillation of liquid (10 mL/kg), the lungs were refilled three times during the first 24 hrs and repeated 48 hrs later. During perfluorochemical liquid treatment, the infant's condition remained stable, with small improvements in pulmonary mechanics. Suction from the endotracheal cannula yielded only small amounts of gelatinous material. Considering the progression of the disease and just minimal pulmonary improvements by this intervention, further treatment was considered futile. Support was, thus, minimized, and the infant died a few days later. An autopsy revealed the diagnosis to be consistent with Niemann-Pick C2 disease. This study demonstrated that bronchioalveolar lavage with perfluorochemical liquid could be performed safely during conventional mechanical ventilation without the additional support of extracorporeal membrane oxygenation in infants with severe alveolar space-occupying material.

Extracorporeal Membrane Oxygenation in Infants with Congenital Diaphragmatic Hernia: Follow-Up MRI Evaluating Carotid Artery Reocclusion and Neurologic Outcome

The purpose of our study was to prospectively assess, using MRI and MR angiography, the cerebral and vascular status of 2-year-old children with congenital diaphragmatic hernia (CDH) in whom carotid artery reconstruction was performed after neonatal extra-corporeal membrane oxygenation (ECMO) therapy and to compare the neurologic development of children with vascular reocclusion with that of CDH children with successful repair and with non-ECMO controls. A total of 30 infants (17 boys, 13 girls; 2 +/- 0.26 years) were included. Of these, 18 (60%) infants received arteriovenous ECMO therapy with subsequent reconstruction of the right common carotid artery (RCCA). Two years postoperatively, the children were examined with cerebral MRI, including 3D time-of-flight and contrast-enhanced 3D MR angiography of the intra- and extracranial brain-supplying arteries. The pathologic findings were analyzed for the ability to predict impaired neurologic development. The RCCA was occluded or highly stenotic in 13 (72%) of 18 children. All infants showed intra- and extracranial collaterals and a patent internal carotid artery. The average duration of ECMO was not longer than in cases of successful reconstruction (p = 1). The ECMO group showed a significantly greater incidence of cerebral injuries (p = 0.007) but no relevant impairment in neurologic development compared with controls (p = 0.26). Unsuccessful RCCA repair had no predictive value for a poor neurologic outcome (p = 1). The outcome of RCCA repair after ECMO is possibly poorer than expected, with vascular occlusion or high-grade stenosis occurring in almost three quarters of patients. Although reocclusion of the RCCA does not increase the risk for cerebral lesions or an impaired neurologic development during the first 2 years postoperatively, the overall benefit of RCCA repair remains doubtful, and the potential long-term risk arising from these plaques has yet to be assessed.

Extracorporeal Membrane Oxygenation in Infants with Congenital Diaphragmatic Hernia: A Systematic Review of the Evidence

The aim of this study was to evaluate the evidence supporting the use of extracorporeal membrane oxygenation (ECMO) in infants with congenital diaphragmatic hernia (CDH) and severe respiratory failure. Medline, Embase, ISI Current Contents and Biosis databases were searched using a defined strategy. Case reports and opinion articles were excluded. We performed: 1) a systematic review of non randomised studies comparing mortality when ECMO was not available with a period when ECMO was available. Mortality was classified as "early" (before hospital discharge) and "late" (after discharge). Patients were classified as "ECMO" and "non-ECMO" candidates according to criteria reported by the authors; 2) a meta-analysis of randomised controlled trials (RCTs) comparing ECMO and conventional mechanical ventilation (CMV). Differences in mortality are reported as relative risk (RR) and 95 % confidence intervals. A) SYSTEMATIC REVIEW: 658 studies and 21 (2043 patients) fulfilled the entry criteria. Both early (RR 0.60 [0.51-0.70]; p < 0.001) and late mortality (RR 0.63 [0.53-0.73]; p < 0.001) were significantly lower when ECMO was available than when ECMO was unavailable. This difference in mortality was observed in "ECMO candidates" (RR 0.46 [0.32-0.68]; p < 0.001) but not in "non-ECMO candidates" (RR 0.80 [0.58-1.10]; p = 0.17). B) META-ANALYSIS: 3 trials comparing ECMO and conventional ventilation were identified which included 39 infants with CDH. The early mortality was significantly lower with ECMO compared to CMV (RR 0.73 [95 % CI 0.55-0.99]; p < 0.04), however, late mortality was similar in the two groups (RR 0.83 [0.66-1.05]; p = 0.12). Non randomised studies suggest a reduction in mortality with ECMO. However, differences in the indications for ECMO and improvements in other treatment modalities may contribute to this reduction. The meta-analysis of RCTs indicates a reduction in early mortality with ECMO but no long-term benefit. A large RCT in infants with CDH and severe respiratory failure is warranted.

Extracorporeal membrane oxygenation in infants with meconium aspiration syndrome: a decade of experience with venovenous ECMO

Background Despite the emergence of new therapies for respiratory failure of the newborn with meconium aspiration syndrome (MAS), extracorporeal membrane oxygenation (ECMO) has a significant role as a rescue modality in these infants. Our objective was to compare the use of venovenous (VV) vs venoarterial (VA) ECMO in newborns with MAS who need ECMO and to ascertain the impact of new therapies in these infants during the last decade. We also evaluated how disease severity or time of ECMO initiation affected mortality and morbidity. Methods A report of 12 years experience (1990-2002) of a single center, comparing VV and VA ECMO, is given. Venovenous ECMO was the preferred rescue modality for respiratory failure unresponsive to maximal medical therapy. Venoarterial ECMO was used only when the placement of a VV ECMO 14-F catheter was not possible; 128 patients met ECMO criteria, 114 were treated with VV ECMO, and 12 with VA ECMO. Two patients were converted from VV to VA ECMO. Results Venovenous and VA ECMO patients had comparable birth weight (mean ± SEM, 3.48 ± 0.05 vs 3.35 ± 0.15 kg) and gestational age (40.3 ± 0.1 vs 40.7 ± 0.3 weeks). Before ECMO, there was no difference between VV and VA ECMO patients in oxygenation index (60 ± 3 vs 63 ± 8), mean airway pressure (19.5 ± 0.4 vs 20.8 ± 1.5 cm H 2O), alveolar-arterial O 2 gradient (630 ± 2 vs 632 ± 4 torr), ECMO cannulation age (median [25th-75th percentiles], 23 [14-47] vs 26 [14-123] hours), or in the % of patients who needed vasopressors/inotropes (98% vs 100%). From November 1994, inhaled nitric oxide (NO) was available. Before VV ECMO, 67% of the patients received NO, 24% received surfactant, and 48% were treated with high-frequency ventilation (HFV). There was no significant difference between VV and VA ECMO patients in survival rate (94% vs 92%), ECMO duration (88 [64-116] vs 94 [55-130] hours), time of extubation (9 [7-11] vs 14 [9-15] days), age at discharge (23 [18-30] vs 27 [15-41] days), or incidence of short-term intracranial complications (5.3% vs 16.7%). For the total cohort of 126 infants, indices of disease severity (oxygenation index, alveolar-arterial O 2 gradient, mean airway pressure) did not correlate with outcome measures. Delay in ECMO initiation (>96 hours) was associated with prolonged mechanical ventilation and hospitalization ( P < .01). New therapies (NO, HFV, surfactant) in the second part of the decade were associated with a longer ECMO duration (98 [80-131] vs 87 [60-116] hours; P < .05), no delay in ECMO initiation time (23 [10-40] vs 24 [14-52] hours), and no significant change in survival (97% vs 92.5%). No patient was treated with VA ECMO after 1994. Conclusions Venovenous ECMO is as reliable as VA ECMO in newborns with MAS in severe respiratory failure who need ECMO. Delay in ECMO initiation may result in prolonged mechanical ventilation and increased length of hospital stay. The emergence of new conventional therapies (NO, HFV, surfactant) and particularly increased experience enable sole use of VV ECMO with no significant change in survival in infants with MAS.

The use of extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia

The use of extracorporeal membrane oxygenation (ECMO) has revolutionized the care of the critical infant born with a congenital diaphragmatic hernia (CDH). In some respects, this is surprising given our current lack of understanding regarding optimal preoperative ventilation strategy, identification of patients most likely to benefit from ECMO, and the correct timing of hernia repair for the infant treated with ECMO. Historically, repair of CDH was considered one of the few true pediatric surgical emergencies. Mortality, however, was high. In the 1970s, ECMO was first utilized as a rescue therapy following repair of CDH when conventional methods failed. In the 1980s, advancements in neonatal intensive care and an understanding of the pathophysiology of pulmonary hypertension associated with CDH led to a strategy involving preoperative stabilization and delayed surgical intervention. Historical reviews demonstrate an improvement of survival in infants treated with ECMO from 56% to 71%. This paper will outline the advances in the care of the CDH patient and the approach used for treatment with ECMO.

Neonatal and pediatric extracorporeal membrane oxygenation using nonocclusive blood pumps: the Vienna experience.

Neonatal and pediatric extracorporeal membrane oxygenation (ECMO) is carried out commonly using occlusive blood pumps. Centrifugal pumps provide simple and safe technology for transportation on ECMO. The assistence respiratoire extra corporelle (AREC) system enables single needle venovenous ECMO for infants. We report on our experience with neonatal and pediatric ECMO treatments using nonocclusive blood pumps. One-hundred forty-six ECMO treatments were performed for cardiac, neonatal, and pediatric indications in 54, 19, and 27% of cases. Centrifugal pumps were used in 99, and the AREC system in 42 cases. Hospital mortality was estimated retrospectively and influence of type of pump, type of ECMO belonging to indication group, and lactate at ECMO installation were estimated. Irreversible organ failure leading to ECMO termination was investigated within groups of indications. Survival (recent 50 ECMO treatments) was 80, 70, 43, and 30% after meconium aspiration syndrome, acute respiratory distress syndrome, cardiac surgery, and prolonged resuscitation. Lactate exceeding 100 mg/dl at ECMO installation predicted significantly worse outcome. Cerebral damage was the main reason for ECMO termination in all but persistent circulatory failure in the cardiac group. Myocardial recovery resulted in all except 2 cardiac cases. Nonocclusive blood pumps can be used safely in neonatal and pediatric ECMO. Early installation may improve outcome markedly. In cardiac cases results of surgery should be thoroughly investigated on the table before ECMO installation to prevent hopeless ECMO treatments.

Utility of extracorporeal membrane oxygenation for early graft failure following heart transplantation in infancy

Background: Extracorporeal membrane oxygenation (ECMO) is widely used for postcardiotomy cardiogenic shock in children. However, the efficacy of ECMO for early post-heart transplant graft failure in infants has not been reported. Our aims were to determine: (1) the utility of ECMO in infants with severe donor-heart dysfunction, (2) predictors for requiring ECMO, and (3) the long-term outcome of surviving ECMO patients. Methods All infants (age < 6 months at listing) undergoing heart transplantation were reviewed. Diagnostic categories were hypoplastic left heart syndrome (HLHS) and non-HLHS (complex congenital heart disease and cardiomyopathies). Continuous and categorical comparisons were by Wilcoxon’s rank sum test and Fisher’s exact test respectively. Results 14 (12 HLHS, 2 non-HLHS) of 63 (46 HLHS, 17 non-HLHS) infants were placed on ECMO. Ten patients (71%) were successfully weaned from ECMO and 8 (57%) were discharged alive. All ECMO hospital survivors remain alive (mean follow-up 36.2 ± 21.4 months, range 13.1–77.6 months). Mean duration of ECMO support was 68 hours in weaned patients vs 144 hours ( p = 0.19) in nonweaned patients, and 64 hours in survivors vs 123 hours ( p = 0.35) in nonsurvivors. ECMO deaths were due to sepsis ( n = 3), intractable pulmonary hypertension ( n = 2), and intracranial bleed ( n = 1). Neurologic deficits occurred in 2 survivors. Median ICU and hospital stays for ECMO survivors were 29 and 33 days vs 7 ( p = 0.0003) and 9 ( p = 0.0004) days for non-ECMO patients. Age listed, age transplanted, wait time, body weight, donor/recipient weight ratio, total ischemia time, and diagnosis did not predict the need for ECMO. Conclusions (1) ECMO is useful for post-heart transplant circulatory support in infants with early graft failure. (2) All survivors were weaned in fewer than 4 days. (3) Three-year survival of ECMO hospital survivors has been high, but neurologic complications are prevalent.

Significantly Decreased Referrals to Extracorporeal Membrane Oxygenation for Infants with Severe Meconium Aspiration without Nitric Oxide Therapy and without Increased Mortality: A Report of 134 Cases

Significantly Decreased Referrals to Extracorporeal Membrane Oxygenation for Infants with Severe Meconium Aspiration without Nitric Oxide Therapy and without Increased Mortality: A Report of 134 Cases

Venovenous extracorporeal membrane oxygenation: The effects of proximal internal jugular cannulation

Venovenous (VV) extracorporeal membrane oxygenation (ECMO) using a double-lumen catheter has become an accepted method of providing ECMO support for critically ill newborn infants. In addition, use of the cephalic jugular catheter can provide augmented venous blood flow, potentially prevent increased cerebral venous pressure, maintain cerebral venous blood flow, and increase ECMO oxygen delivery. The authors compared their experience using VV double-lumen (VVDL) ECMO with a cephalic jugular catheter with their previous experience using venoarterial (VA) ECMO. They compared 15 infants who had meconium aspiration syndrome (MAS) and 12 who had congenital diaphragmatic hernia (CDH) treated with VVDL ECMO with a cephalic jugular catheter with the same number of infants with each condition treated with VA ECMO (historical controls). There were no significant differences between the groups with respect to birth weights, oxygen indexes before ECMO, or ECMO flows at 4 and 24 hours. For infants with MAS treated with VVDL ECMO, the overall duration of ECMO support was significantly shorter (63 hours VVLD v 118 hours VA; P = .001), and the average cephalic flow was 33 mL/kg for infants treated with VVDL support. For infants with CDH, there were no differences in any of the variables evaluated, including total duration (100 hours VVDL v 128 hours VA; P = .06 [NS]), and the average cephalic flow was 39 mL/kg for infants treated with VVDL support. The venous oxygen content was significantly lower in infants with MAS treated with VVDL ECMO than for historical controls treated with VA ECMO at 4 hours of ECMO support (15.8 v 16.7; P <- .05). No other significant differences were noted for any of the calculated oxygen transport variables comparing VVDL with VA ECMO. Infants with CDH treated with VVDL ECMO were extubated sooner than those treated with VA ECMO (10.3 days VVDL v 15.4 days VA; P = .048). In addition, there was no significant difference in the overall incidence of complications or death. This experience suggests that VVDL ECMO using a cephalic jugular catheter results in shorter ECMO runs and provides support that is comparable to VA ECMO for infants with CDH and MAS while avoiding carotid artery cannulation and ligation.

Adenosine Infusion Improves Oxygenation in Term Infants With Respiratory Failure

Adenosine infusion causes selective pulmonary vasodilation in fetal and neonatal lambs with pulmonary hypertension. We investigated the effects of a continuous infusion of adenosine on oxygenation in term infants with persistent pulmonary hypertension of newborn (PPHN). A randomized, placebo-controlled, masked trial comparing the efficacy of intravenous infusion of adenosine to normal saline infusion over a 24-hour period. Inborn and outborn level III neonatal intensive care units at a university medical center. Eighteen term infants with PPHN and arterial postductal PO2 of 60 to 100 Torr on inspired O2 concentration of 100% and optimal hyperventilation (PaCO2 <30 Torr) were enrolled into the study. Study infants were randomly assigned to receive a placebo infusion of normal saline, or adenosine infusion in doses of 25 to 50 microg/kg/min over a 24-hour period. Eighteen term infants with PPHN and arterial postductal PO2 of 60 to 100 Torr on inspired O2 concentration of 100% and optimal hyperventilation (PaCO2 <30 Torr) were enrolled into the study. Study infants were randomly assigned to receive a placebo infusion of normal saline, or adenosine infusion in doses of 25 to 50 microg/kg/min over a 24-hour period. Nine infants each received adenosine or placebo. The two groups did not differ in birth weight, gestational age, or blood gases and ventilaator requirements at the time of entry into the study. Four of nine infants in the adenosine group and none of the placebo group had a significant improvement in oxygenation, defined as an increase in postductal PaO2 of > or =20 Torr from preinfusion baseline. The mean PaO2 in the adenosine group increased from 69 +/- 19 at baseline to 94 +/- 15 during 50 microg/kg/min infusion rate of adenossine and did not change significantly in the placebo group. Arterial blood pressure and heart rate did not change during the study in either group. The need for extracorporeal membrane oxygenation, incidence of bronchopulmonary dysplasia, and mortality were not different in the two groups. Data from this pilot study indicate that adenosine infusion at a dose of 50 microg/kg/min improves PaO2 in infants with PPHN without causing hypotension or tachycardia. Larger trials are needed to determine its effects on mortality and/or need for extracorporeal membrane oxygenation in infants with PPHN.

Successful use of transesophageal echocardiography during extracorporeal membrane oxygenation in infants after cardiac operations

We report the use of transesophageal echocardiography in infants after cardiac operations while supported on extracorporeal membrane oxygenation. In all patients transesophageal echocardiography provided valuable information when standard transthoracic echocardiographic evaluation was limited by poor acoustic windows. This report describes the application of transesophageal echocardiography during extracorporeal membrane oxygenation after cardiac operations. (J T HORAC C ARDIOVASC S URG 1995;109:846-8)

Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia and cardiac malformations

Since the introduction of neonatal extracorporeal membrane oxygenation (ECMO) in Canada, the authors have treated three infants with congenital diaphragmatic hernia (CDH) who had serious congenital cardiac anomalies (among 26 infants with CDH treated with ECMO). To determine the incidence of and outcome for infants with combined lesions who received ECMO, 19 years' data (April 1973 to October 1992) from the Extracorporeal Life Support Organization (ELSO) registry were reviewed. Seventeen infants with combined cardiac and diaphragmatic lesions were registered as receiving ECMO in the United States or Canada. Thus, the incidence of combined cardiac and diaphragmatic lesions was 2.5 per thousand neonates (17 of 6,295) receiving ECMO and 13 per thousand neonates (17 of 1,318) receiving ECMO for CDH. Five (29.4%) of the 17 infants survived. A congenital cardiac lesion may not be an absolute contraindication to ECMO in infants with CDH. Decisions to cannulate for ECMO should be based on the potential outcome of the underlying cardiac defect.

Need for and impact on neonatal mortality of extracorporeal membrane oxygenation in infants of greater than 2500-gram birth weight : W.M. Southgate, C.G. Howell, and W.P. Kanto, Jr. Pediatrics 86:71–74, (July), 1990

Need for and impact on neonatal mortality of extracorporeal membrane oxygenation in infants of greater than 2500-gram birth weight : W.M. Southgate, C.G. Howell, and W.P. Kanto, Jr. Pediatrics 86:71–74, (July), 1990

Cardiac stun in infants undergoing extracorporeal membrane oxygenation

Previous studies have shown that cardiac performance decreases in infants undergoing extracorporeal membrane oxygenation (ECMO). Some infants have an exaggerated decrease in cardiac performance during ECMO. This syndrome has been called cardiac stun. To better understand this phenomenon, we reviewed the records of infants with cardiac stun and compared them with infants who did not have the syndrome. Cardiac stun was detected in 12 of 240 infants (5.0%) undergoing ECMO. The diagnoses were congenital diaphragmatic hernia (7/12), meconium aspiration syndrome (3/12), respiratory distress syndrome (1/12), and persistent pulmonary hypertension of the newborn (1/12). The weight, gestational age, inotropic support, and time to start of ECMO were similar to infants without cardiac stun. Arterial oxygen tension was lower, carbon dioxide tension was higher, and pH was lower before ECMO in infants in whom cardiac stun developed (p less than or equal to 0.03). Cardiac arrests were more common, before ECMO, in infants in whom cardiac stun developed (6/12; p less than or equal to 0.01). Cardiac stun began at an average 2 1/2 hours after beginning ECMO (range 0.1 to 7 hours). Pulse pressure decreased from 20 mm Hg (range 10 to 45 mm Hg) before stun to 8 mm Hg (range 4 to 12 mm Hg) after stun. Heart rate did not change. Cardiac stun lasted for 33 hours (range 1 to 64 hours) on ECMO and recurred in three infants. Decreases in pump flow and increases in preload, afterload reduction, and inotropic agents did not improve cardiac performance. Survival was lower in the infants in whom cardiac stun developed (p less than or equal to 0.001). Only 5 of 12 infants (42%) survived ECMO when cardiac stun occurred. Our findings show that cardiac stun occurs infrequently during ECMO and is transient in most infants. Infants in whom cardiac stun develops appear to be more ill before ECMO and have a higher mortality after ECMO.

Extracorporeal membrane oxygenation in infants: angiographic and parenchymal evaluation of the brain with MR imaging.

The authors report their preliminary experience with intracranial three-dimensional Fourier transform magnetic resonance (MR) angiography and T2-weighted MR imaging of the brain parenchyma in 15 neonates less than 1 week old after extracorporeal membrane oxygenation (ECMO) with permanent ligation of the right common carotid artery and internal jugular vein, four 1-year-old infants after ECMO with carotid ligation, and four neonates less than 1 week old after ECMO with reanastomosis of the same artery. MR angiography was technically satisfactory in 20 of the 23 patients and documented patency of the right internal carotid artery proximal to the ophthalmic artery in nine of 16 patients with permanent carotid ligation and in all four patients with reanastomosis. This study suggests MR angiography is feasible in newborns and infants and that, in combination with parenchymal MR imaging, it provides a sensitive, noninvasive method to assess vessel patency and follow cerebrovascular and parenchymal changes in infants after ECMO.