Neonatal ECMO Research Articles

92: Large Single Center Experience with Extubation During Neonatal and Pediatric ECMO

92: Large Single Center Experience with Extubation During Neonatal and Pediatric ECMO

76: ECMO Specialist Driven Hospital Acquired Prevention Injury Strategies for Neonatal and Pediatric ECMO Patients

76: ECMO Specialist Driven Hospital Acquired Prevention Injury Strategies for Neonatal and Pediatric ECMO Patients

50: Neonatal and pediatric mobile ECMO: Colombian single-center experience.

50: Neonatal and pediatric mobile ECMO: Colombian single-center experience.

138: Difficult Cannulations in Neonatal and Pediatric ECMO: Illuminating an Obstruction to Timely Therapy

138: Difficult Cannulations in Neonatal and Pediatric ECMO: Illuminating an Obstruction to Timely Therapy

233: Anticoagulation practices for neonatal respiratory ECMO therapy within the Children’s Hospitals Neonatal Consortium

233: Anticoagulation practices for neonatal respiratory ECMO therapy within the Children’s Hospitals Neonatal Consortium

Scar Perception in School-aged Children After Major Surgery in Infancy

BackgroundThe long-term effects of childhood surgery scars on health status, quality of life (QoL), self-esteem, and body image remain uncertain. This study explores these effects in school-aged children. MethodsWe conducted a retrospective cohort study involving 454 children (58% boys; 8–17 years) who had undergone surgical correction of anatomical anomalies or neonatal ECMO. Data included patient-reported scar perception and scar-related embarrassment, along with psychological assessment via questionnaires. ResultsAbout 34% of children rated their scars as 'nice-looking', 49% as 'indifferent', and 12% as 'rather ugly'. Most children (91%) never experienced scar-related embarrassment, while frequent embarrassment was reported by 3%. Surgical scar correction was desired by 6% of the 8-year-olds and 19% of the 17-year-olds. Scar perception did not significantly affect health status or QoL. However, negative scar perception was associated with lower self-esteem in girls and a more negative body image in boys. Girls were more likely to report negative scar perception (OR: 1.54, 95%-CI: 1.06–2.24) and scar-related embarrassment (OR: 4.29, 95%-CI: 1.77–10.44). ConclusionChildren who underwent surgery in the neonatal period and subsequently grew up with scars resulting thereof, mostly perceive them either indifferently or positively, with minimal effect on health status and QoL. Nonetheless, some children, particularly girls, experienced negative perceptions of their scars, although scar-related embarrassment was rare. We recommend integrating scar assessment into routine follow-up at ages 12 and 17, and offering appropriate and timely guidance and support to children at risk for negative effects of scars. Level of EvidenceIII.

Quantifying potential fluid transfused through pressure monitoring and circuit flushes in pediatric ECMO patients.

Pressure monitoring on pediatric Extracorporeal Membrane Oxygenation (ECMO) circuits is used to aid in the evaluation of patient hemodynamics and circuit health. Extracorporeal Life Support Organization (ELSO) recommends monitoring pressures on the venous line, pre-, and post-oxygenator. In order to keep pressure ports patent, crystalloid can be used as a flush. The fluid transfused to the patient through these lines can be challenging to quantify accurately due to variance in clinician practice. Currently, there is no published data or practice suggestions on this topic. In Vitro experiments using Edwards True Wave transducers and pressure bags were constructed, allowing for common negative and positive pressures to be simulated. Passive volume infused through the transducer as well as intermittent active flushing by pulling the snap tab were measured and the volumes were recorded. When the pressure transducer and associated tubing are kept patent by using a pressurized IV bag, per the instructions for use, the daily volume transfused was found to be 319.6mL or close to a typical neonate's total blood volume. Rather than using passive or active flushing, the use of automated syringe pumps can reduce the transfused volume to 24 mL per day. Further study is recommended to develop and publish best practices.

Exploratory factor analysis yields grouping of brain injury biomarkers significantly associated with outcomes in neonatal and pediatric ECMO

In this two-center prospective cohort study of children on ECMO, we assessed a panel of plasma brain injury biomarkers using exploratory factor analysis (EFA) to evaluate their interplay and association with outcomes. Biomarker concentrations were measured daily for the first 3 days of ECMO support in 95 participants. Unfavorable composite outcome was defined as in-hospital mortality or discharge Pediatric Cerebral Performance Category > 2 with decline ≥ 1 point from baseline. EFA grouped 11 biomarkers into three factors. Factor 1 comprised markers of cellular brain injury (NSE, BDNF, GFAP, S100β, MCP1, VILIP-1, neurogranin); Factor 2 comprised markers related to vascular processes (vWF, PDGFRβ, NPTX1); and Factor 3 comprised the BDNF/MMP-9 cellular pathway. Multivariable logistic models demonstrated that higher Factor 1 and 2 scores were associated with higher odds of unfavorable outcome (adjusted OR 2.88 [1.61, 5.66] and 1.89 [1.12, 3.43], respectively). Conversely, higher Factor 3 scores were associated with lower odds of unfavorable outcome (adjusted OR 0.54 [0.31, 0.88]), which is biologically plausible given the role of BDNF in neuroplasticity. Application of EFA on plasma brain injury biomarkers in children on ECMO yielded grouping of biomarkers into three factors that were significantly associated with unfavorable outcome, suggesting future potential as prognostic instruments.

Neonatal seizures during extra corporeal membrane oxygenation support.

To evaluate EEG monitoring during neonatal ECMO and to identify any correlations between seizure detection to abnormal neuroimaging.Eight-year, service evaluation of neonates who received at least one continuous EEG (cEEG) whilst on ECMO at Great Ormond Street Hospital. Pearson's chi-square test and multivariate logistic regression analysis were used to assess clinical and EEG variables association with seizures and neuroimaging findings.Fifty-seven neonates were studied; 57 cEEG recordings were reviewed. The incidence of seizures was 33% (19/57); of these 74% (14/19) were electrographic-only. The incidence of status epilepticus was 42%, (8/19 with 6 neonates having electrographic-only status and 2 electro-clinical status. Seizures were detected within an hour of recording in 84%, (16/19). The overall mortality rate was 39% (22/57). Seizure detection was strongly associated with female gender (OR 4.8, 95% CI: 1.1-20.4, p = 0.03), abnormal EEG background activity (OR 2.8, 95% CI: 1.1-7.4, p = 0.03) and abnormal EEG focal features (OR 23.6, 95% CI: 5.4-103.9, p = 0.001). There was a strong association between the presence of seizures and abnormal neuroimaging findings (OR 10.9, 95% CI: 2.8-41.9, p = 0.001). Neonates were highly likely to have abnormal neuroimaging findings in the presence of severely abnormal background EEG (OR 9.5, 95% CI 1.7-52.02, p = 0.01) and focal EEG abnormalities (OR 6.35, 95% CI 1.97-20.5, p = 0.002)Conclusion: The study highlights the importance of cEEG in neonates undergoing ECMO. An association between seizure detection and abnormal neuroimaging findings was described. What is Known: • Patients on ECMO are at a higher risk of seiures. • Continuous EEG monitoring is recommended by the ACNS for high risk and ECMO patients. What is New: • In this cohort, neonates with sezirues were 11 times more likely of having abnromal neuroimaging findings. • Neonates with burst suppressed or suppressed EEG background were 9.5 times more likely to have abnormal neuroimaging findings. What does this study add? • This study reports a 33% incidence of neonatal seizures during ECMO. • Neonates with seizures were 11 times more likely to have an abnormal brain scan. • The study captures the real-time approach of EEG monitoring. • Recommended cEEG monitoring should last at least 24h for ECMO patients. • This is the first study to assess this in neonates only.

Veno-arterial extracorporeal membrane oxygenation for respiratory and cardiac support in neonates: a single center experience.

Extracorporeal membrane oxygenation (ECMO) is an advanced life support that has been utilized in the neonate for refractory respiratory and circulatory failure. Striving for the best outcomes and understanding optimal surgical techniques continue to be at the forefront of discussion and research. This study presents a single-center experience of cervically cannulated neonatal patients on V-A ECMO, a description of our cannulation/decannulation techniques and our patient outcomes. Single center retrospective review of neonates who received neck V-A ECMO support from January 2012 to December 2022. The data and outcomes of the patients were retrospectively analyzed. A total of 78 neonates received V-A ECMO support. There were 66 patients that received ECMO for respiratory support, the other 12 patients that received ECMO for cardiac support. The median duration of ECMO support was 109 (32-293) hours for all patients. During ECMO support, 20 patients died and 5 patients discontinued treatment due to poor outcome or the cost. A total of 53 (68%) patients were successfully weaned from ECMO, but 3 of them died in the subsequent treatment. Overall 50 (64%) patients survived to hospital discharge. In this study, 48 patients were cannulated using the vessel sparing technique, the other 30 patients were cannulated using the ligation technique. We found no significant difference in the rates of normal cranial MRI at discharge between survivors with and without common carotid artery ligation. We achieved satisfactory outcomes of neonatal ECMO in 11-year experience. This study found no significant difference in early neuroimaging between survivors with and without common carotid artery ligation. The long-term neurological function of ECMO survivors warranted further follow-up and study.

Extracorporeal membrane oxygenation in paediatric cardiac surgery: 5-year single centre experience

BackgroundExtracorporeal membrane oxygenation (ECMO) has become an integral part of paediatric cardiac surgery. We report the experience of a well-established ECMO service over 5 years.MethodsThis retrospective study analysed all paediatric patients who required ECMO support following cardiac surgery from April 2015 to March 2020. Inclusion criteria were age less than 18 years and post-operative ECMO support. Patients were analysed dividing into groups according to the urgency for ECMO support (extracorporeal cardiopulmonary resuscitation (ECPR) and cardiac ECMO) and according to age (neonatal and paediatric ECMO groups). They were followed for 30-day, 6-month mortality, long-term survival, postoperative morbidity and the need for reintervention.ResultsForty-six patients were included who had a total of venoarterial (VA) 8 ECMO runs. The 5-year incidence of the need for VA ECMO after cardiac surgery was 3.3% (48 of the overall 1441 cases recorded). The median follow-up period was 3.5 (interquartile ranges, 0.8–4.7) years. Thirty-day, 6-month and follow-up survival rate was 85%, 65% and 52% respectively. At the 6-month follow-up, the ECPR group showed a trend towards worse survival compared with the cardiac ECMO group (47% vs. 55%) but with no statistical significance (p = 0.35). Furthermore, the survival rates between paediatric (60%) and neonatal (46%) ECMO groups were similar, with no statistical significance (p = 0.45). The rate of acute neurological events was 27% (13/48).ConclusionECPR and neonatal ECMO groups had higher mortality. VA ECMO 30-day and 6-month survival rates were 85% and 65% respectively. Major neurological injury resulting in ECMO termination occurred in 3 patients. Accumulated experiences and protocols in ECMO management can improve mortality and morbidity.

Surgical experience in repairing the right common carotid artery and the right internal jugular vein after ECMO in neonates: early clinical results

BackgroundThe purpose of this study was to summarize the early clinical results and surgical experience of repairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates.MethodsWe retrospectively collected the clinical data of 16 neonates with circulatory and respiratory failure who were treated with ECMO via the right common carotid artery and the right internal jugular vein in our hospital from June 2021 to December 2022. The effects of repairing the common carotid artery and internal jugular vein were evaluated.ResultsAll 16 patients successfully underwent right cervical vascular cannulation, and the ECMO cycle was successfully established. Twelve patients were successfully removed from ECMO. The right common carotid artery and the right internal jugular vein were successfully repaired in these 12 patients. There was unobstructed arterial blood flow in 9 patients, mild stenosis in 1 patient, moderate stenosis in 1 patient and obstruction in 1 patient. There was unobstructed venous blood flow in 10 patients, mild stenosis in 1 patient, and moderate stenosis in 1 patient. No thrombosis was found in the right internal jugular vein. Thrombosis was found in the right common carotid artery of one patient.ConclusionRepairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates was feasible, and careful surgical anastomosis techniques and standardized postoperative anticoagulation management can ensure early vascular patency. However, long-term vascular patency is still being assessed in follow-up.

149: Risk of intracranial hemorrhage or death during ECMO in neonates with hypoxic ischemic encephalopathy

149: Risk of intracranial hemorrhage or death during ECMO in neonates with hypoxic ischemic encephalopathy

223: Long Term Functional Outcomes and Important Need for Follow-Up in Neonatal And Pediatric ECMO

223: Long Term Functional Outcomes and Important Need for Follow-Up in Neonatal And Pediatric ECMO

Use of bi-caval cannulae for veno-venous ECMO in neonates and children

PurposeVeno-arterial ECMO remains the most common mode of extracorporeal support in infants and children, and despite increases in overall ECMO numbers the utilisation of veno-venous ECMO in neonates appears to be decreasing. We report here outcomes of neonatal and paediatric patients managed with veno-venous ECMO via bi-caval cannulae over a 10-year period in a tertiary referral ICU.MethodsRetrospective single-centre case series of veno-venous ECMO cases using dual lumen cannulae over a 10-year period at a tertiary referral paediatric hospital with a low volume ECMO program.ResultsIn the 10-year period 2013–2022, 33 patients required ECMO with 23 receiving veno-arterial ECMO and 10 managed with veno-venous cannulation - 8 with bi-caval cannulae and 2 with multi-site cannulation. Overall survival was 23/33 (69.6%) and in the veno-venous group survival was 7/10 (70%). Median oxygenation index prior to veno-venous cannulation in the 8 patients undergoing bi-caval cannulation was 48 (range 34–54) and median PaO2 was 42 mmHg (range 34–59 mmHg). Duration of ECMO ranged from 7 to 14 days (median 9 days). Complications included migration of the cannula into the hepatic vein, minor and major bleeding, and compromised blood flow secondary to pneumomediastinum.ConclusionsVeno-venous ECMO can be reliably established via a single bi-caval cannula in the majority of patients. Outcomes in this small series from a low volume centre are broadly comparable to those reported from the ELSO database.

Neonatal venoarterial and venovenous ECMO

ECMO remains an important support tool in the treatment of neonates with reversible congenital cardiopulmonary diseases. There are specific circumstances that call for either venoarterial (VA) or venovenous (VV) ECMO in neonates. While limited by the infant's the size and gestational age, ECMO can confer exceptional survival rates to a number of neonates who can often develop without devastating complications. However, it remains a labor and time intensive endeavor, which may be impractical or unattainable in resource-limited environments. While adult and pediatric ECMO indications and equipment options have expanded in recent years, neonatal ECMO continues to be a niche subspecialty requiring specific expertise and technical skill, especially considering the ever-changing neonatal physiology in the setting of cardiopulmonary support.It is critical to recognize the unique approaches to cannulation options, imaging, vessel management, anticoagulation, and monitoring protocols to achieve optimal outcomes. Thus, it becomes nearly impossible to separate the role of pediatric surgeons from the continuous involvement with and management of neonatal ECMO patients. This necessitates that pediatric surgeons in ECMO centers continue to hone their expertise and remain heavily involved in neonatal ECMO. This section reviews the most critical current approaches and unresolved controversies in neonatal ECMO with special attention to the practical aspects and decisions a surgeon faces in initiation and termination of neonatal ECMO.

ECMO for premature neonates- Are we there yet?

Despite ECMO being a well-accepted and established life-saving support for newborns, prematurity (<34 weeks of gestation) and low birth weight <2.0 kg are still considered relative contraindications due to the fear of intracranial bleeding complications.In the last decades, outcome in extracorporeal life support for pre-term babies has improved, and morbidity dominated by intracranial bleedings has decreased.With the introduction of new methodologies and technological development, the current ELSO guideline for ECMO (GA >34 w, BW > 2.0 kg) deserves to be challenge.The authors suggest that Prem-ECMO (GA 32-33) could be considered when restricted to experienced high-volume neonatal ECMO centers, with closed monitoring and rigorous reporting to the ELSO registry, providing close targeting of oxygen delivery for prevention of retinopathy and being active participants in continuous development of technology and devices for improved biocompatibility for use in the neonate.

23: ANTICOAGULATION DURING PEDIATRIC ECMO: EVALUATION OF EFFICACY AND COST

Introduction: ECMO typically requires systemic anticoagulation to prevent thrombosis. While unfractionated heparin (UFH) has been traditionally used, direct thrombin inhibitor (DTI) use in pediatric ECMO has increased. However, drug cost for bivalirudin has been reported as potentially prohibitive for some centers. We aimed to evaluate efficacy and cost-effectiveness of these 2 anticoagulants at a single institution. Methods: Retrospective review of pediatric patients requiring ECMO at a tertiary center was conducted from June 2020-June 2022, with initiation of ECMO anticoagulation consultation (EAC). Results: Forty-four patients required ECMO for 47 runs (45 VA, 2 VV), with 40% (19.47) being neonatal ECMO. Median weight was 4 kg (2.4-131 kg). DTIs were used in 34% (16/47) as primary anticoagulant and an additional 21% (10/47) transitioned from UFH to DTI due to inadequate anticoagulation or development of circuit thrombosis. Most common DTI was bivalirudin (23/26). UFH was used in 49% (23/47) with 43% conversion to DTI on mean ECMO day 5. Mean duration of ECMO was 262 hours (48-1200 hours) on DTI and 133 hours (31-412) on UFH. For bivalirudin, mean time to therapeutic range PTT was 5 hours. Mean peak dose of bivalirudin was 1.39 mg/kg/hr. For UFH, mean time to therapeutic range anti-Xa was 9 hours. Mean UFH therapeutic dose was 27 units/kg/hr. Mean daily cost for 5 kg and 25 kg patient on UFH and antithrombin (AT) per institutional practice (to maintain normal AT activity) was $1262, with 64% drug costs (almost all due to AT) and 36% lab cost. Mean daily cost for 5 kg and 25 kg patient on bivalirudin was $235 and $382, respectively with majority of cost related to labs. 13% (6/47) of runs required circuit component changes or thrombectomy, 83% of clots occurring on therapeutic UFH. Survival to ECMO decannulation was 72%. Conclusions: DTI use in pediatric ECMO was efficacious for prolonged runs, directed by EAC, with rapid time to therapeutic range and decreased thrombotic complications, as well as being cost-effective While drug cost for UFH alone is inexpensive, laboratory cost for anti-Xa was more expensive than PTT and if antithrombin is administered the cost significantly increases, for drug and monitoring of activity.

Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs.

Cross-sectional electronic survey. Email-based Research Electronic Data Capture survey. Neonates undergoing ECMO for respiratory failure at level IV NICUs. A 40-question survey was sent to site sponsors of regional referral neonatal ECMO centers participating in the Children's Hospitals Neonatal Consortium. Reminder emails were sent at 2- and 4-week intervals. Twenty ECMO centers responded to the survey. Most primarily use venoarterial ECMO (65%); this percentage is higher (90%) for congenital diaphragmatic hernia. Sixty-five percent reported following protocol-based guidelines, with neonatologists primarily responsible for ventilator management (80%). The primary mode of ventilation was pressure control (90%), with synchronized intermittent mechanical ventilation (SIMV) comprising 80%. Common settings included peak inspiratory pressure (PIP) of 16-20 cm H2O (55%), positive end-expiratory pressure (PEEP) of 9-10 cm H2O (40%), I-time 0.5 seconds (55%), rate of 10-15 (60%), and Fio2 22-30% (65%). A minority of sites use high-frequency ventilation (HFV) as the primary mode (5%). During ECMO, 55% of sites target some degree of lung aeration to avoid complete atelectasis. Fifty-five percent discontinue inhaled nitric oxide (iNO) during ECMO, while 60% use iNO when trialing off ECMO. Nonventilator practices to facilitate decannulation include bronchoscopy (50%), exogenous surfactant (25%), and noninhaled pulmonary vasodilators (50%). Common ventilator thresholds for decannulation include PEEP of 6-7 (45%), PIP of 21-25 (55%), and tidal volume 5-5.9 mL/kg (50%). The majority of level IV NICUs follow internal protocols for ventilator management during neonatal respiratory ECMO, and neonatologists primarily direct management in the NICU. While most centers use pressure-controlled SIMV, there is considerable variability in the range of settings used, with few centers using HFV primarily. Future studies should focus on identifying respiratory management practices that improve outcomes for neonatal ECMO patients.

Associations of cephalad drainage in neonatal veno-venous ECMO – A mixed-effects, propensity score adjusted retrospective analysis of 20 years of ELSO data

BackgroundNeurologic complications can occur during neonatal Veno-Venous (VV) ECMO. The addition of a cephalad drainage cannula (i.e., VVDL+V) to dual lumen cannulation (i.e., VVDL) has been advocated to reduce such complications, but previous studies have presented mixed results. MethodsData from the ECMO Registry of the Extracorporeal Life Support Organization was used to extract all neonates (≤28 days old) who underwent VV ECMO for respiratory support between 2000 and 2019. Primary outcomes were mortality, conversion to Veno-Arterial (VA) ECMO, pump flows, and complications. A mixed-effects, propensity score adjusted analysis was performed. Results4,275 neonates underwent VV ECMO, 581 (13.6%) via VVDL+V cannulation, and 3,694 (86.4%) via VVDL. On unadjusted analyses, VVDL+V patients had higher rates of mortality (25.5% vs 19.0%, p<0.001), conversion to VA ECMO (14.5% vs 4.1%, p<0.001), and higher pump flows at 4 h from ECMO initiation (112.7 vs 105.5 mL/Kg/min, p<0.001), but lower at 24 h (100.3 vs 104.0 mL/Kg/min, p = 0.004), and a higher proportion of them experienced hemorrhagic (29.3% vs 18.3%, p<0.001), cardiovascular (60.8% vs 45.8%, p<0.001), and mechanical (42.5% vs 32.6%, p<0.001) complications compared to VVDL patients. After adjusting for propensity scores and the multi-level nature of ELSO data, there were no differences in neurologic outcomes, pump flows, or mortality. Rather, VVDL+V cannulation was associated with higher rates of conversion to VA ECMO (adjusted odds ratio [AOR] 43.3, 95% CI 24.3 – 77.4, p<0.001), and increased mechanical (AOR 2.2, 95% CI 1.6 – 3.0, p<0.001) and hemorrhagic (AOR 2.0, 95% CI 1.4 – 3.0, p<0.001) complications. ConclusionsIn this analysis, VVDL+V cannulation was not associated with any improvement in neurologic outcomes, pump flows, or mortality, but was rather associated with higher rates of conversion to Veno-Arterial ECMO, mechanical, and hemorrhagic complications.