Neonatal Respiratory Extracorporeal Membrane Oxygenation Research Articles

Risk factors, incidence, and outcomes of neonatal respiratory extracorporeal membrane oxygenation including association with therapeutic hypothermia in California during 2013-2020.

To evaluate the incidence, indications and outcomes with neonatal extracorporeal membrane oxygenation (ECMO) and its association with therapeutic hypothermia (TH) among infants undergoing invasive mechanical ventilation (IMV) in California during 2013-2020. We analyzed data on neonates ≥34 weeks gestation with ≥4 h of IMV over an 8-year period (2013-2020) from the California Perinatal Quality Care Collaborative (CPQCC) database. Between 2013 and 2020, the ranges for utilization of iNO (13.9 to 17.2%), ECMO (2.1 to 2.5%), TH (10.2 to 15.7%) and TH + ECMO (0.4 to 0.8%) were observed. The most common association with neonatal ECMO was TH (148 cases, OR 3.2, 95% CI 2.6-4.3, p < 0.01). The combination of meconium aspiration syndrome (MAS) and hypoxic ischemic encephalopathy (HIE) increased risk of iNO and ECMO use (OR 11.3, 1.5-86.9), p = 0.02). Ventilated infants ≥34 weeks gestational age undergoing TH are at risk for iNO/ECMO use and need close monitoring.

Use of point-of-care ultrasound (POCUS) to monitor neonatal and pediatric extracorporeal life support.

Extracorporeal membrane oxygenation (ECMO) is an invasive life support technique that requires a blood pump, an artificial membrane lung, and vascular cannulae to drain de-oxygenated blood, remove carbon dioxide, oxygenate, and return it to the patient. ECMO is generally used to provide advanced and prolonged cardiopulmonary support in patients with refractory acute cardiac and/or respiratory failure. After its first use in 1975 to manage a severe form of meconium aspiration syndrome with resultant pulmonary hypertension, the following years were dominated by the use of ECMO to manage neonatal respiratory failure and limited to a few centers across the world. In the 1990s, evidence for neonatal respiratory ECMO support increased; however, the number of cases began to decline with the use of newer pharmacologic therapies (e.g., inhaled nitric oxide, exogenous surfactant, and high-frequency oscillatory ventilation). On the contrary, pediatric ECMO sustained steady growth. Combined advances in ECMO technology and bedside medical management have improved general outcomes, although ECMO-related complications remain challenging. Point-of-care ultrasound (POCUS) is an essential tool to monitor all phases of neonatal and pediatric ECMO: evaluation of ECMO candidacy, ultrasound-guided ECMO cannulation, daily evaluation of heart and lung function and brain perfusion, detection and management of major complications, and weaning from ECMO support. Conclusion: Based on these considerations and on the lack of specific guidelines for the use of POCUS in the neonatal and pediatric ECMO setting, the aim of this paper is to provide a systematic overview for the application of POCUS during ECMO support in these populations. What is Known: • Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary support for patients with refractory acute cardiac and/or respiratory failure and requires appropriate monitoring. • Point-of-care ultrasound (POCUS) is an accessible and adaptable tool to assess neonatal and pediatric cardiac and/or respiratory failure at bedside. What is New: • In this review, we discussed the use of POCUS to monitor and manage at bedside neonatal and pediatric patients supported with ECMO. • We explored the potential use of POCUS during all phases of ECMO support: pre-ECMO assessment, ECMO candidacy evaluation, daily evaluation of heart, lung and brain function, detection and troubleshooting of major complications, and weaning from ECMO support.

Neonatal Carotid Artery and Internal Jugular Vein Management Practices at Extracorporeal Membrane Oxygenation Decannulation: No Standard Approach

BackgroundThere are currently no commonly accepted standardized guidelines for management of cervical vessels at neonatal extracorporeal membrane oxygenation (ECMO) decannulation. This study investigates neonatal ECMO decannulation practices regarding management of the carotid artery and internal jugular vein, use of post-repair anticoagulation, and follow-up imaging. MethodsA survey was distributed to the 37 institutions in the Children's Hospitals Neonatal Consortium. Respondents reported their standard approach to carotid artery and internal jugular vein management (ligation or repair) at ECMO decannulation by their pediatric surgery and cardiothoracic (CT) surgery teams as well as post-repair anticoagulation practices and follow-up imaging protocols. ResultsThe response rate was 95%. Pediatric surgeons performed most neonatal respiratory ECMO cannulations (88%) and decannulations (85%), while all neonatal cardiac ECMO cannulations and decannulations were performed by CT surgeons. Pediatric surgeons overwhelmingly ligate both vessels (90%) while CT surgeons typically repair both vessels at decannulation (83%). Of the responding centers that repair, 28% (7) have a standard anticoagulation protocol after neck vessel repair. While 52% (13) of centers routinely image cervical vessel patency at least once post repair, most do not subsequently repeat neck vessel imaging. ConclusionsSignificant practice differences exist between pediatric and CT surgeons regarding the approach to cervical vessels at neonatal ECMO decannulation. For those centers that do repair the vessels there is little uniformity in post-repair anticoagulation or imaging protocols. There is a need to develop standardized cervical vessel management guidelines for neonatal ECMO patients and to study their impact on both short- and long-term outcomes. Level of EvidenceIV.

Hemostasis in neonatal ECMO.

Extracorporeal membrane oxygenation (ECMO) is a life-saving support for cardio-respiratory function. Over the last 50 years, the extracorporeal field has faced huge technological progress. However, despite the improvements in technique and materials, coagulation problems are still the main contributor to morbidity and mortality of ECMO patients. Indeed, the incidence and survival rates of the main hemorrhagic and thrombotic complications in neonatal respiratory ECMO are relevant. The main culprit is related to the intrinsic nature of ECMO: the contact phase activation. The exposure of the human blood to the non-endothelial surface triggers a systemic inflammatory response syndrome, which chronically activates the thrombin generation and ultimately leads to coagulative derangements. Pre-existing illness-related hemostatic dysfunction and the peculiarity of the neonatal clotting balance further complicate the picture. Systemic anticoagulation is the management's mainstay, aiming to prevent thrombosis within the circuit and bleeding complications in the patient. Although other agents (i.e., direct thrombin inhibitors) have been recently introduced, unfractionated heparin (UFH) is the standard of care worldwide. Currently, there are multiple tests exploring ECMO-induced coagulopathy. A combination of the parameters mentioned above and the evaluation of the patient's underlying clinical context should be used to provide a goal-directed antithrombotic strategy. However, the ideal algorithm for monitoring anticoagulation is currently unknown, resulting in a large inter-institutional diagnostic variability. In this review, we face the features of the available monitoring tests and approaches, mainly focusing on the role of point-of-care (POC) viscoelastic assays in neonatal ECMO. Current gaps in knowledge and areas that warrant further study will also be addressed.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Successful Establishment of the First Neonatal Respiratory Extracorporeal Membrane Oxygenation (ECMO) Program in the Middle East, in Collaboration With Pediatric Services.

Background: Extracorporeal membrane oxygenation (ECMO) is a complex life-saving support for acute cardio-respiratory failure, unresponsive to medical treatment. Starting a new ECMO program requires synergizing different aspects of organizational infrastructures and appropriate extensive training of core team members to deliver the care successfully and safely.Objectives: To describe the process of establishing a new neonatal ECMO program and to evaluate the program by benchmarking the ECMO respiratory outcomes and mechanical complications to the well-established Extracorporeal Life Support Organization (ELSO) registry data.Materials and Methods: We reviewed the processes and steps involved in planning and setting up the new ECMO program. To assess the success of the ECMO implementation program, we retrospectively reviewed data of clinical outcomes and technical complications for the first 11 patients who have received ECMO therapy for respiratory indications since program activation (July 2018–May 2020). We analyzed mechanical complications as a tool to measure infrastructures and our effective training for the core team of ECMO specialists. We also looked at all clinical complications and benchmarked these numbers with the last 10 years of ELSO registry data (2009–2019) in the corresponding categories for comparison. Chi-square test was used to compare, and outcomes are presented in percentage; a p-value of <0.05 is considered significant.Results: A total of 27 patients underwent ECMO in the hospital, out of which 11 (six neonatal and five pediatric) patients had acute respiratory failure treated with venovenous (VV) ECMO or veno-arterial (VA) ECMO over a 22-month period. We had a total of 3,360 h of ECMO run with a range from 1 day to 7 weeks on ECMO. Clinical outcomes and mechanical complications are comparable to ELSO registry data (no significant difference); there were no pump failure, oxygenator failure, or pump clots.Conclusions: Establishing the ECMO program involved a multisystem approach with particular attention to the training of ECMO team members. The unified protocols, equipment, and multistep ECMO team training increased staff knowledge, technical skills, and teamwork, allowing the successful development of a neonatal respiratory ECMO program with minimal mechanical complications during ECMO runs, showing a comparable patient flow and mechanical complications.

Ten years of the neonatal respiratory extracorporeal membrane oxygenation program in an Argentinian public hospital.

Extracorporeal membrane oxygenation (ECMO) is a highly invasive rescue treatment for critically-ill patients. The objective of the study was to show the outcomes of patients treated with ECMO in the neonatal intensive care unit of Hospital de Pediatria Juan P. Garrahan in the first 10 years of the program, and to analyze the risk factors associated with mortality on ECMO. Descriptive, retrospective study with risk factor analysis. All patients treated with ECMO between April 2008 and February 2019 were included. A total of 77 patients were included: 72 neonates and 5 infants younger than 1 year. Patients' median age at admission was 2 days (1-150); weight: 3200 g ± 730 g; gestational age: 37.5 weeks ± 4.2; 53 % were males; and 50 % had been born by C-section. The most common diagnoses included congenital diaphragmatic hernia and meconium aspiration syndrome. Fifty-six patients (73 %) survived ECmO; of them, 17 (30 %) died before discharge. The outcome measures associated with mortality on ECMO were central nervous system hemorrhage (p < 0.01), hémodiafiltration requirement (p < 0.01), inotrope requirement during ECMO (p < 0.01), and presence of hemorrhage not affecting the central nervous system (p < 0.01). This study describes the outcomes of the first 10 years of the neonatal respiratory ECMO program. The onset of complications increased mortality during ECMO.

Optimizing knowledge and skills through protocol-based ECMO management and simulation-based training: A novice clinician's perspectives of a successful ECMO program

Background: Starting a new extracorporeal membrane oxygenation (ECMO) program requires synergizing different organizational aspects and extensive training of a core team to deliver care safely.1,2 Sidra Medicine, a newly opened facility in Qatar, started accepting acute inpatients and activated its ECMO program in 2018. The aim of this quality review is to evaluate the training of ECMO Specialists through benchmarking our ECMO program mechanical complications to the Extracorporeal Life Support Organization (ELSO) data. Methods: The hospital trained ECMO Specialists (experts and novices) come from different parts of the world with varying degrees of knowledge and experience and use a comprehensive training program based on the ELSO guidelines for ECMO training and continuous education.3 This program was delivered over a two-year period to all ECMO team members and included: multiple conferences on key ECMO topics; basic wet labs and emergency drills including the change of different components, and; immersive simulation-based training (SBT) on a modified neonatal manikin (Figures 1 and 2). These face to face interactions, in small groups, with different critical scenarios were followed by debriefing.4,5 SBT sessions started before the opening of the acute unit and continued after the acceptance of the first ECMO patient. Immersive SBT sessions occur monthly and include minor and major troubleshooting, de-airing, priming, circuit change, oxygen failure, pump failure, and other problems that can be encountered during ECMO runs.All ECMO Specialists, both experts and novices, completed a full ECMO training program and had gone through the Sidra ECMO certification examination before handling ECMO patients. They were evaluated and certified using a checklist assessment tool and with skills having to be demonstrated competently by the candidates. Novice clinicians were initially ECMO bedside nurses and as they became familiar with the ECMO daily routine and learned the protocols and policies, they started caring for patients as ECMO Specialists.We retrospectively reviewed collected data of technical complications for the 13 patients who have received ECMO therapy since program activation. We analyzed ECMO mechanical complications and benchmarked them with ELSO registry data in corresponding categories to evaluate the training of ECMO specialists and our ECMO program infrastructure. Result: The Sidra ECMO program has now trained a total of 20 ECMO Specialists (experts and novices). Out of the 13 novice clinicians who volunteered to be trained, 8 successfully became ECMO Specialists.There has been a total of 13 patients on ECMO (Table 1). One of these was the first successful neonatal respiratory ECMO patient in Qatar. Over the 13 cases, minor mechanical complications and usual circuit clots were experienced. There was no pump failure or oxygenator failure encountered. Conclusion: SBT is a valuable ECMO educational approach. It offers the opportunity to practice technical skills repeatedly and to become proficient in high-risk/low frequency events while avoiding harm to patients. Using consistent and continuous training is the key for the success of the ECMO Specialist's model. This is a limited study due to the low number of patients, but as ECMO is a low-volume/high-risk procedure, it still highlights the benefits of simulation in establishing new ECMO programs.

Surgical Expertise in Neonatal Extracorporeal Membrane Oxygenation (ECMO): A Single Center Experience.

Introduction: The surgical technique for peripheral cannulation aimed at providing extracorporeal membrane oxygenation (ECMO) is well described. Training methods for surgeons still need proper standardization, especially in newborn patients. This study aims to evaluate the surgical training outcomes of a neonatal ECMO team.Materials and Methods: A 4 year training program (2014–2018) was developed to achieve the skills in the surgical technique for neonatal veno-arterial ECMO. Surgeons with experience in neonatal and vascular surgery were selected for the training. The training consisted of educational sessions, high-fidelity simulations, in vivo swine model procedures, international fellowship, and periodical simulations. The preliminary clinical experience in surgical neonatal ECMO management (2016-present) was analyzed by recording the following data: indications for ECMO and patients' data; effectiveness of cannulations (number; perioperative complications of cannulation; major surgical events during ECMO); efficacy of decannulation (number and perioperative complications).Results: 12 neonates (5 females) fitted the ELSO criteria for ECMO. Nine newborns were affected by CDH; 1 by H1N1 flu-related pneumonia; 1 by meconium aspiration syndrome and one by Respiratory Syncytial Virus related bronchiolitis. Mean weight at cannulation was 3,281 g (range 2,330–3,840 g); mean gestational age was 36 weeks. No procedure was aborted, and no intra-operatory mortality was recorded. Mean operative time was 86 ± 30 min. The caliber of the carotideal cannulas ranged from 8F (8 patients) to 10F (2 patients); the caliber of the jugular cannulas were: 8F cannula (2 patients), 10F (6 patients), and 12F (2 patients). Four complications occurred: a case of air in the circuit, two cases of azygous vein cannulation and a partial dislocation of the venous cannula during the daily care maneuvers. All of them were promptly recognized and successfully treated. The mean ECMO duration was 7.1 ± 4.2 days (range 2–16 days). Seven patients (78%) were decannulated effectively. Mean decannulation time was 53 min (range 45–80 min). No complications occurred during the decannulation process. No ECMO–related deaths were recorded.Conclusions: Neonatal respiratory ECMO still represents a challenge. Experienced neonatal surgeons can manage the neck vascular cannulation. The codified procedure must be adhered to after appropriate training and following a proper learning curve.

Start a Neonatal Extracorporeal Membrane Oxygenation Program: A Multistep Team Training.

Background: Extracorporeal membrane oxygenation (ECMO) is a complex life-saving support for acute cardio-respiratory failure, unresponsive to medical treatment. Emergency events on ECMO are rare but require immediate and proficient management. Multidisciplinary ECMO team members need to acquire and maintain over time cognitive, technical and behavioral skills, to safely face life-threatening clinical scenarios.Methods: A multistep educational program was delivered in a 4-year period to 32 ECMO team members, based on guidelines from the Extracorporeal Life Support Organization. A first traditional module was provided through didactic lectures, hands-on water drills, and laboratory animal training. The second phase consisted of a multi-edition high-fidelity simulation-based training on a modified neonatal mannequin (SimNewB®). In each session, participants were called to face, in small groups, ten critical scenarios, followed by debriefing time. Trainees underwent a pre-test for baseline competency assessment. Once completed the full training program, a post-test was administered. Pre- and post-test scores were compared. Trainees rated the educational program through survey questionnaires.Results: 28 trainees (87.5%) completed the full educational program. ECMO staff skills improved from a median pre-test score of 7.5/18 (IQR = 6–11) to 14/18 (IQR = 14–16) at post-test (P < 0.001, Wilcoxon rank test). All trainees highly rated the educational program and its impact on their practice. They reported high-fidelity simulations to be beneficial to novice learners as it increased self-confidence in ECMO-emergencies (according to 100% of surveyed), theoretical knowledge (61.5%) and team-work/communicative skills (58%).Conclusions: The multistep ECMO team training increased staff' knowledge, technical skills, teamwork, and self-confidence, allowing the successful development of a neonatal respiratory ECMO program. Conventional training was perceived as relevant in the early phase of the program development, while the active learning emerged to be more beneficial to master ECMO knowledge, specific skills, and team performance.

Lung Rest During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure-Practice Variations and Outcomes.

Describe practice variations in ventilator strategies used for lung rest during extracorporeal membrane oxygenation for respiratory failure in neonates, and assess the potential impact of various lung rest strategies on the duration of extracorporeal membrane oxygenation and the duration of mechanical ventilation after decannulation. Retrospective cohort analysis from the Extracorporeal Life Support Organization registry database during the years 2008-2013. All extracorporeal membrane oxygenation runs for infants less than or equal to 30 days of life for pulmonary reasons were included. Ventilator type and ventilator settings used for lung rest at 24 hours after extracorporeal membrane oxygenation initiation were obtained. A total of 3,040 cases met inclusion criteria. Conventional mechanical ventilation was used for lung rest in 88% of cases and high frequency ventilation was used in 12%. In the conventional mechanical ventilation group, 32% used positive end-expiratory pressure strategy of 4-6 cm H2O (low), 22% used 7-9 cm H2O (mid), and 43% used 10-12 cm H2O (high). High frequency ventilation was associated with an increased mean (SEM) hours of extracorporeal membrane oxygenation (150.2 [0.05] vs 125 [0.02]; p < 0.001) and an increased mean (SEM) hours of mechanical ventilation after decannulation (135 [0.09] vs 100.2 [0.03]; p = 0.002), compared with conventional mechanical ventilation among survivors. Within the conventional mechanical ventilation group, use of higher positive end-expiratory pressure was associated with a decreased mean (SEM) hours of extracorporeal membrane oxygenation (high vs low: 136 [1.06] vs 156 [1.06], p = 0.001; mid vs low: 141 [1.06] vs 156 [1.06]; p = 0.04) but increased duration of mechanical ventilation after decannulation in the high positive end-expiratory pressure group compared with low positive end-expiratory pressure (p = 0.04) among survivors. Wide practice variation exists with regard to ventilator settings used for lung rest during neonatal respiratory extracorporeal membrane oxygenation. Use of high frequency ventilation when compared with conventional mechanical ventilation and use of low positive end-expiratory pressure strategy when compared with mid positive end-expiratory pressure and high positive end-expiratory pressure strategy is associated with longer duration of extracorporeal membrane oxygenation. Further research to provide evidence to drive optimization of pulmonary management during neonatal respiratory extracorporeal membrane oxygenation is warranted.

Management strategy during neonatal/paediatric VV ECMO run

Introduction: Strategy during extracorporeal membrane oxygenation (ECMO) support is guided by available outcome data. Boundaries limiting selection of cases are shifting with advances in ECMO technology, conventional support, and destination therapies. Evolution: Neonatal respiratory ECMO numbers continue to decline due to improved conventional therapies, whereas infants historically excluded from ECMO (for example, ex-premature infants with O2-dependent chronic lung disease and severe RSV) are now successfully supported. ECMO for bridging of children to lung transplant is now established.1 Advances are also being made in mobile ECMO,2 long duration of ECMO support, and ECMO while wide awake. Initiation: Flow requirements and patient or vessel size govern cannula choice. Percutaneous cannulation of vessels with ultrasound guidance is described in all sizes of children, including small infants.3 Serial imaging and ECHO control are needed for optimisation of cannula position and orientation. Transoesophageal ECHO is preferable to transthoracic where available. Reconfiguration of the circuit may prove necessary in some cases and is better done early in the run.4Troubleshooting: Protocol and bundle adherence are the keys to preventing complications. Detection requires vigilance and rigorous checks along with comprehensive handover and tight teamwork. Management is about appropriate escalation and pathway utilisation. Simulation is an essential component of staff training and a powerful tool for reinforcing these points.5Lung recovery: ECMO can be considered the ultimate in “lung rest” techniques. Enhancing lung recovery during the rest provided by ECMO is mainly achieved by attention to fluid balance, pulmonary toilet, and adoption of ventilator rest settings. Bronchoscopy is also particularly useful in this context.6 Other therapies such as prone position, steroid use, surfactant, perfluorocarbon,7 and even individual lung ventilation2 have a role in selected cases. De-cannulation: Patience can be needed when timing the end to VV ECMO support. Removing the sweep gas from the oxygenator can be done simply without having to wean ECMO flow. In more difficult situations, 12–24 h trial off can be used. Radiological lung clearance, improving lung compliance, reduction of sweep gas requirements, and oxygen challenges are all informative in the run up to a decision to trial off. Lung biopsy8 or genetic test results are useful when recovery is absent to help establish futility. Earlier de-cannulation can be indicated in the setting of an intractable or severe complication. Summary: Strategy for management of VV ECMO support is evolving with improvements in ECMO techniques and advances in supporting therapies. A proactive, rigorous but flexible approach to individual cases can deliver excellence.

Patient selection for neonatal extracorporeal membrane oxygenation: beyond severity of illness

Objective:To explore how neonates with respiratory failure are selected for extracorporeal membrane oxygenation (ECMO) once severity of illness criteria are met, and to determine how conflicts between ECMO providers and parents over the initiation of ECMO are addressed.Study Design:A cross-sectional study was conducted using a data collection survey, which was sent to the directors of neonatal respiratory ECMO centers.Result:The lowest birth weight and gestational age at which respondents would consider placing a neonate on ECMO were frequently below recommended thresholds. There was wide variability in respondents' willingness to place neonates on ECMO in the presence of conditions such as intraventricular hemorrhage and hypoxic ischemic encephalopathy. The number of respondents who would never seek to override parental refusal of ECMO was equal to the number who would always do so.Conclusion:Significant variability exists in the selection criteria for neonatal ECMO and in how conflicts with parents over the provision of ECMO are resolved.

Neonatal ECMO: Current Controversies and Trends

Extracorporeal membrane oxygenation (ECMO), a technique for providing life support to patients with cardiac and/or respiratory dysfunction, allows the heart and lungs to "rest." The neonatal respiratory population has been a major benefactor of ECMO since 1982. Its use for neonatal respiratory disease increased dramatically until the past few years, when the number of neonatal respiratory ECMO cases began a downward trend. Fewer patients with persistent pulmonary hypertension of the newborn (PPHN), meconium aspiration syndrome, respiratory distress syndrome, or sepsis are requiring ECMO support as frequently as in the past. Many attribute this decline to the newer respiratory therapies-mainly, surfactant, high-frequency oscillatory ventilation, and inhaled nitric oxide. Neonates who continue to require ECMO today are sicker than the historic norm and have more complicated and lengthy ECMO runs. Patients with congenital diaphragmatic hernia, PPHN, and sepsis remain the most consistent in their representation among ECMO recipients within this author's institution, suggesting that the newer respiratory therapies have not had the same impact on these patients' needs for ECMO support. Better guidelines for determining which patients would benefit from earlier inititation of ECMO are needed.