Use Of ECMO Research Articles

Extracorporeal support of oxygenation and ventilation.

The management of the patient with respiratory failure is instituted in step-wise fashion. Each successive step requires higher levels of intervention. The final level of support when all conventional means fail is the use of ECMO. The specific method of extracorporeal support may or may not be important in determining ultimate outcome. However, the means of ventilator support during extracorporeal support is controversial. No study has shown a beneficial effect of one method over another. The avoidance of further barotrauma and high oxygen concentration is the keystone to individual ventilator management. The method of introducing extracorporeal devices on to a patient's cardiovascular circuit varies. The technical aspects differ from institution to institution and may reflect surgeon preference. However, all methods are relatively quick and efficient. The amount of personnel needed to manage an extracorporeal circuit varies from institution to institution but nonetheless requires extra people and equipment. The cost of instituting this type of therapy is high. And, although the cost efficiency of ECMO has not been closely analyzed, it is hoped that the judicious use of this technology will produce a favorable result.

IMPROVED OXYGENATION IN A RANDOMIZED TRIAL OF INHALED NITRIC OXIDE FOR PPHN.• 1498

The effect of inhaled nitric oxide(NO) on clinical outcome in infants with PPHN is uncertain. We randomized 49 newborns, transferred to our center with clinical and echocardiographic evidence of severe PPHN (PaO2<100, FiO2=1), to treatment with or without NO. Patients with gestational age< 34 weeks or with congenital heart disease or diaphragmatic hernia were excluded. High frequency ventilation(HFOV) was used but not allowed concomitantly with NO. Median baseline oxygenation index(OI) was similar in 23 control (OI=26) and 26 NO(OI=31) patients. Mortality (8%), use of ECMO (32%), median days on mechanical ventilation (9d) or supplemental oxygen (13d) were not different between treatment groups. PaO2/FiO2, oxygen saturation and OI improved in the NO group compared to baseline and to control patients at 15 minutes and later times during the first 12hrs. Percent change in OI in the NO group was different(p<.05) from baseline(*) and from the control group(†)(see figure). Prior to ECMO, oxygenation was better in the NO group compared to control (p<.02). A trend toward fewer adverse neurologic events (seizure and intracranial hemorrhage) was seen in the NO group (4/26 vs. 8/23, p=0.10). Whether better oxygenation with NO improves neurologic outcome awaits further study. Additional advantages of NO therapy may be identified in larger trials designed to include NO with HFOV.

The Effect of On-Site Extracorporeal Membrane Oxygenation on the Therapy Choice and Outcomes of Neonates With Persistent Pulmonary Hypertension

The effect of on-site extracorporeal membrane oxygenation (OS-ECMO) and selection criteria on the utilization rate of this technology is unknown. We retrospectively studied 55 neonates who were admitted to Arkansas Children's Hospital from 1985 to 1993. We compared the ECMO utilization, mortality, and morbidity rates for outborn neonates with moderate and severe persistent pulmonary hypertension (PPHN) before and after the establishment of an ECMO program with guidelines for its use at our institution. The rate of ECMO use was three times higher and the mortality rate was 13 times lower in the period after OS-ECMO compared with the period when ECMO was available only at other institutions. No differences were observed in the morbidity rates between the two periods. Physician decisions to initiate ECMO involved more than guidelines, since 37% of the increased ECMO use was not associated with use of the guidelines. Possible reasons for noncompliance with the guidelines are discussed. Neonates who had received medical therapy only and who had an oxygenation index > or = 30 and < 40 had no mortality. Our findings suggest that the need for ECMO in this group of neonates is low.

A CASE OF THYROID ADENOMA WITH SEVERE DYSPNEA

A case of thyroid adenoma with severe dyspnea, who underwent emergency operation with the use of ECMO, is reported. A 58-year-old woman complained of rapid enlargement of goiter, cough and severe dyspnea with orthopnea, and was admitted as an emergency. X-ray of the neck revealed shift and stenosis of the trachea. Anaplastic carcinoma of the thyroid was suspected, but no definitive diagnosis was made. As intratracheal intubation was thought to be dangerous, ECMO was applied by percutaneous cannulation into the bilateral femoral veins in the sitting position under local anesthesia. Right hemithyroidectomy was performed in the supine position. The resected tumor was 7.2×6.0×5.1cm (140g) with a hematomatous appearance. The historgical diagnosis was microfollicular adenoma of the thyroid associated with massive hematoma. Dyspnea disappeared completely in the immediate postoperative period. ECMO support might be feasible for thyroid surgery in which of intratracheal intubation is impossible.

Transport of Critically Ill Patients in need of Extracorporeal Life Support

In the past 10 years, we have seen tremendous growth in the use of ECMO for neonatal cardiopulmonary failure, and new indications are being recognized for the use of ECMO and other forms of ECLS in older children and adults. The number of medical centers providing ECLS is and will always be limited, so services are needed to transport critically ill patients to ECLS centers. Transport teams should be thoroughly familiar with the pathophysiology of cardiac and respiratory failure. They should be equipped to continue the monitoring and treatment initiated at the referring center, to maintain that level of care during transfer, and to treat complications of the diseases or of the therapy itself. The responsibilities of the referring centers are to acquaint themselves with ECLS programs in their geographic areas and with transport services available. Early communication with complete and accurate information is essential. Developing a program for ECLS during transport is a huge undertaking that should be considered seriously. Not every ECLS center has the resources to embark on such a program. Timely referral should make such complex transfers unnecessary for most patients.

Combined use of ECMO with IABP for cardiogenic shock following open heart surgery

Combined use of ECMO with IABP for cardiogenic shock following open heart surgery