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Osman A, Halling C, Crume M, Al Tabosh H, Odackal N, Ball MK. Meconium aspiration syndrome: a comprehensive review. J Perinatol 2023; 43:1211-1221. [PMID: 37543651 DOI: 10.1038/s41372-023-01708-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/02/2023] [Accepted: 06/19/2023] [Indexed: 08/07/2023]
Abstract
Meconium aspiration syndrome (MAS) is a complex respiratory disease that continues to be associated with significant morbidities and mortality. The pathophysiological mechanisms of MAS include airway obstruction, local and systemic inflammation, surfactant inactivation and persistent pulmonary hypertension of the newborn (PPHN). Supplemental oxygen and non-invasive respiratory support are the main therapies for many patients. The management of the patients requiring invasive mechanical ventilation could be challenging because of the combination of atelectasis and air trapping. While studies have explored various ventilatory modalities, evidence to date does not clearly support any singular modality as superior. Patient's pathophysiology, symptom severity, and clinician/unit expertise should guide the respiratory management. Early identification and concomitant management of PPHN is critically important as it contributes significantly to mortality and morbidities.
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Affiliation(s)
- Ahmed Osman
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA.
| | - Cecilie Halling
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Mary Crume
- Neonatal-Perinatal Fellowship Program, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Hayat Al Tabosh
- Pediatrics Residency Program, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Namrita Odackal
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
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Al Kharusi AA, Al Maawali A, Traynor M, Adreak N, Ting J, Skarsgard ED. High frequency jet ventilation for congenital diaphragmatic hernia. J Pediatr Surg 2023; 58:799-802. [PMID: 36788056 DOI: 10.1016/j.jpedsurg.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND The optimal role of high frequency jet ventilation (HFJV) in lung protective stabilization of congenital diaphragmatic hernia (CDH) remains uncertain. We aimed to describe our center's experience with HFJV as both a rescue (following failed stabilization with CMV) and primary ventilation mode in the management of CDH. METHODS Liveborn CDH patients treated from 2013 to 2021 in a single institution were reviewed. We compared 3 groups based on their primary and last ventilation mode prior to surgery: CMV (Group 1); HFJV (Group 2); and CMV/HFJV (Group 3). Outcomes included a composite primary outcome (≥1 of mortality, need for ECMO or need for supplemental O2 at discharge), total invasive ventilation days and development of pneumothorax. A descriptive analysis including univariate group comparisons was performed. Multivariate logistic regression models investigating the relationship between mode of ventilation and the primary outcome adjusted by potentially confounding covariates were constructed. RESULTS 56 patients (32 Group 1, 18 Group 2, 6 Group 3) were analyzed. Group 2 and 3 patients had more severe disease based on liver position, SNAP-II score, pulmonary hypertension severity, need for inotropic support, CDHSG defect size and need for patch repair. There were no group differences in survival, need for ECMO, or pneumothorax occurrence, although infants receiving HFJV required longer invasive ventilation and had a greater need for O2 at discharge. Multivariate logistic regression revealed no associations between mode of ventilation and outcome. CONCLUSIONS HFJV appears effective, both for CMV rescue and as a primary ventilation strategy in high risk CDH. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Al Anoud Al Kharusi
- Departments of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Alghalya Al Maawali
- Departments of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Traynor
- Departments of Anesthesiology, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Najah Adreak
- Departments of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph Ting
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Erik D Skarsgard
- Departments of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.
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Das S, Gupta S, Das D, Dutta N. Basics of extra corporeal membrane oxygenation: a pediatric intensivist's perspective. Perfusion 2021; 37:439-455. [PMID: 33765881 DOI: 10.1177/02676591211005260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Extra Corporeal membrane oxygenation (ECMO) is one of the most advanced forms of life support therapy in the Intensive Care Unit. It relies on the principle where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) within which blood becomes enriched with oxygen and has carbon dioxide removed. The blood is then returned to the patient via a central vein or an artery. The goal of ECMO is to provide a physiologic milieu for recovery in refractory cardiac/respiratory failure. The technology is not a definitive treatment for a disease, but provides valuable time for the body to recover. In that way it can be compared to a bridge, where patients are initiated on ECMO as a bridge to recovery, bridge to decision making, bridge to transplant or bridge to diagnosis. The use of this modality in children is not backed by a lot of randomized controlled trials, but the use has increased dramatically in our country in last 10 years. This article is not intended to provide an in-depth overview of ECMO, but outlines the basic principles that a pediatric intensive care physician should know in order to manage a kid on ECMO support.
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Affiliation(s)
- Shubhadeep Das
- Department of Pediatric Cardiac Intensive Care, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Sandip Gupta
- Department of Pediatric Intensive Care, Aster CMI Hospital, Bangalore, Karnataka, India
| | - Debasis Das
- Department of Cardiac Surgery, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Nilanjan Dutta
- Department of Cardiac Surgery, NH Narayana Superspeciality Hospital, Howrah, West Bengal, India
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Alvarado-Socarrás JL, Gómez C, Gómez A, Cruz M, Díaz-Silva GA, Niño MA. [Current state of neonatal extracorporeal membrane oxygenation in Colombia: description of the first cases]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2014; 84:121-7. [PMID: 24794914 DOI: 10.1016/j.acmx.2013.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 07/11/2013] [Accepted: 07/19/2013] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal membrane oxygenation is considered a rescue therapy and complex vital support with benefits in cardiorespiratory diseases during neonatal period that fulfil the characteristics of being reversible in neonates older than 34 weeks. The criteria for patient selection and its prompt use are critical for the final result. Even though new alternatives for management of hypoxemic respiratory failure in full term and almost full term neonates have decreased its use, congenital diaphragmatic hernia continues being a complex disease where it can have some applicability. Even though our experience is beginning, constant training will make of extracorporeal membrane oxygenation an option for complex patients in whom maximum therapy fails. This is a report of the first neonatal cases of hypoxemic respiratory failure managed at Fundación Cardiovascular de Colombia.
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Affiliation(s)
- Jorge Luis Alvarado-Socarrás
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.
| | - Carolina Gómez
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Andrea Gómez
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Mónica Cruz
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Gustavo Adolfo Díaz-Silva
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - María Azucena Niño
- Área de Investigación en Pediatría, Unidad Neonatal, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
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Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012). Pediatr Crit Care Med 2013; 14:851-61. [PMID: 24108118 DOI: 10.1097/pcc.0b013e3182a5540d] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure. DATA SOURCE A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations. STUDY SELECTION Clinical trials published between January 1, 2002, and October 1, 2012, including "extracorporeal membrane oxygenation" or "ECMO" and limited to studies involving humans aged 0-18 years. Trials focused on extracorporeal membrane oxygenation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation. DATA EXTRACTION Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygenation utilization, and ancillary therapies. DATA SYNTHESIS Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained. CONCLUSIONS Despite a large number of published extracorporeal membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients.
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Schaible T, Hermle D, Loersch F, Demirakca S, Reinshagen K, Varnholt V. A 20-year experience on neonatal extracorporeal membrane oxygenation in a referral center. Intensive Care Med 2010; 36:1229-34. [PMID: 20425105 DOI: 10.1007/s00134-010-1886-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Accepted: 03/29/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Advances in treatment of neonatal respiratory failure are responsible for a decline in the number of newborns treated with extracorporeal membrane oxygenation (ECMO). The aim of this study are to determine demographic changes, focusing on time of referral, diagnosis, and respiratory parameters in neonates put on ECMO. DESIGN Retrospective review. SETTING Tertiary ECMO center. PATIENTS A total of 321 neonates were treated with ECMO from January 1987 to December 2006. RESULTS Overall number of patients increased with every 5-year period, whereby congenital diaphragmatic hernia (CDH) was the most common diagnosis (53%), followed by meconium aspiration syndrome (MAS) (21%), sepsis and/or pneumonia (13%), and others such as persistent pulmonary hypertension of the newborn (PPHN), respiratory distress syndrome (RDS), or hypoplasia of the lung (13%). Worsening severity of illness as measured by ECMO duration and days on ventilator has to be stated for all diagnoses. Nevertheless, survival rate remained stable; both overall and diagnosis-specific mortality rates did not change significantly. Of all children, 67% survived to discharge or transfer, while best rates were seen for MAS (94%), followed by sepsis and/or pneumonia (69%), CDH (62%), and other diagnoses (43%). Concerning survival rate, no difference between inborn and outborn children occurred. However, between early- and late-referred children, a referral to the ECMO center during the first 24 h of life was associated with a significantly higher rate of survival (77% versus 54%, p = 0.0004), predominantly seen for CDH (67% versus 35%, p = 0.02). CONCLUSION We strongly recommend timely transfer to an ECMO center in patients with CDH who are at risk of circulatory failure.
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Affiliation(s)
- T Schaible
- Department of Pediatrics, University Medicine Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim, 68167, Germany.
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Maeda Y, Nomura S, Kurokawa T, Ishihara H, Harada K, Yoneda H, Kato S, Fujisawa H, Suzuki M. Cerebrovascular moyamoya disease in a 5-year-old girl who underwent interruption of the right common carotid artery in the neonatal period. J Neurosurg Pediatr 2009; 3:316-9. [PMID: 19338411 DOI: 10.3171/2008.12.peds08221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report on the case of a girl with cerebrovascular moyamoya disease born with severe respiratory failure caused by a congenital diaphragmatic hernia. Cardiopulmonary management included extracorporeal membrane oxygenation until the diaphragm defect was repaired. The right common carotid artery (CA) was interrupted and cannulated for extracorporeal membrane oxygenation. When she was 5 years of age, the patient experienced ischemic symptoms in her right extremities. Angiography revealed stenosis of the terminal portion of the internal CA (ICA) with the development of moyamoya vessels on the left side of the brain; the right ICA was supplied by extracranial anastomotic arteries. Indirect extracranial-intracranial bypass surgery was performed in the left hemisphere, and the hypoperfusion improved. The same change in the intracranial ICA with the development of moyamoya vessels occurred on her right side when she was 7 years old. Decreased cerebral blood flow occurred twice, and the moyamoya vessels developed to compensate for the cerebral ischemia. However, the occlusion of the extracranial common CA in infancy induced extracranial anastomosis rather than moyamoya vessel proliferation, and collateral circulation was formed at the lesion site. This finding indicates that neoangiogenesis requires both cerebral ischemia and growth factors derived from the lesion.
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Affiliation(s)
- Yoshihiko Maeda
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
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Pawlik TD, Porta NFM, Steinhorn RH, Ogata E, deRegnier RAO. Medical and financial impact of a neonatal extracorporeal membrane oxygenation referral center in the nitric oxide era. Pediatrics 2009; 123:e17-24. [PMID: 19064612 DOI: 10.1542/peds.2007-3566] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The primary objective of this study was to determine whether widespread use of nitric oxide after Food and Drug Administration approval decreased admissions to a neonatal referral center for extracorporeal membrane oxygenation evaluation. We also sought to determine whether antecedent treatment delayed eventual transfer, resulting in sicker patients, increased mortality, increased extracorporeal membrane oxygenation application, and higher direct costs of care. METHODS This was a retrospective cohort study of all of the patients transferred to a neonatal referral center for extracorporeal membrane oxygenation evaluation before (1995-1999) and after (2000-2005) Food and Drug Administration approval of nitric oxide. Patients were divided into "congenital diaphragmatic hernia" and "persistent pulmonary hypertension" (all other diagnoses) for additional analysis. RESULTS Admission rates for extracorporeal membrane oxygenation evaluation decreased in the nitric oxide era, and eventual transfer was not delayed. Persistent pulmonary hypertension patients had improved oxygen indexes, a trend toward decreased mortality, decreased extracorporeal membrane oxygenation use, and decreased direct costs. Congenital diaphragmatic hernia patients had unchanged physiologic measurements, mortality, and extracorporeal membrane oxygenation use with increased direct costs of care. As a whole, outcomes for patients transferred for extracorporeal membrane oxygenation evaluation improved, whereas direct costs were unchanged. CONCLUSIONS Persistent pulmonary hypertension patients had improved outcomes with decreased costs, whereas congenital diaphragmatic hernia patients had unchanged outcomes with increased costs. Overall, patients admitted to this NICU because of the presence of extracorporeal membrane oxygenation services had improved outcomes without increased costs in the nitric oxide era.
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Lowe CG, Trautwein JG. Inhaled nitric oxide therapy during the transport of neonates with persistent pulmonary hypertension or severe hypoxic respiratory failure. Eur J Pediatr 2007; 166:1025-31. [PMID: 17205243 DOI: 10.1007/s00431-006-0374-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2006] [Revised: 11/02/2006] [Accepted: 11/07/2006] [Indexed: 10/23/2022]
Abstract
Our aim was to determine whether starting inhaled nitric oxide (iNO) on critically ill neonates with severe hypoxemic respiratory failure and/or persistent pulmonary hypertension (PPH), at a referring hospital at the start of transport, decreases the need for extracorporeal membrane oxygenation (ECMO), lessens the number of hospital days and improves survival in comparison with those patients who were started on iNO only at the receiving facility. The study was a retrospective review of 94 charts of neonates that had iNO initiated by the transport team at a referring hospital or only at the tertiary neonatal intensive care unit (NICU) of the receiving hospital. Data collected included demographics, mode of transport, total number of hospital days, days on inhaled nitric oxide and ECMO use. Of the 94 patients, 88 were included. Of these, 60 were started on iNO at the referring facility (Field-iNO) and 28 were started at the receiving NICU (CHLA-iNO). All patients survived transport to the receiving NICU. Death rates and ECMO use were similar in both groups. Overall, patients who died were younger and had lower birth weights and Apgar scores. For all surviving patients who did not require ECMO, the length of total hospital stay (median days 22 versus 38, P = 0.018), and the length of the hospital stay at the receiving hospital (median days 18 versus 29, P = 0.006), were significantly shorter for the Field-iNO patients than for the CHLA-iNO patients, respectively. Earlier initiation of iNO may decrease length of hospital stay in surviving neonates with PPH not requiring ECMO.
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Affiliation(s)
- Calvin G Lowe
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Ostrea EM, Villanueva-Uy ET, Natarajan G, Uy HG. Persistent pulmonary hypertension of the newborn: pathogenesis, etiology, and management. Paediatr Drugs 2007; 8:179-88. [PMID: 16774297 DOI: 10.2165/00148581-200608030-00004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is characterized by severe hypoxemia shortly after birth, absence of cyanotic congenital heart disease, marked pulmonary hypertension, and vasoreactivity with extrapulmonary right-to-left shunting of blood across the ductus arteriosus and/or foramen ovale. In utero, a number of factors determine the normally high vascular resistance in the fetal pulmonary circulation, which results in a higher pulmonary compared with systemic vascular pressure. However, abnormal conditions may arise antenatally, during, or soon after birth resulting in the failure of the pulmonary vascular resistance to normally decrease as the circulation evolves from a fetal to a postnatal state. This results in cyanosis due to right-to-left shunting of blood across normally existing cardiovascular channels (foramen ovale or ductus arteriosus) secondary to high pulmonary versus systemic pressure. The diagnosis is made by characteristic lability in oxygenation of the infant, echocardiographic evidence of increased pulmonary pressure, with demonstrable shunts across the ductus arteriosus or foramen ovale, and the absence of cyanotic heart disease lesions. Management of the disease includes treatment of underlying causes, sedation and analgesia, maintenance of adequate systemic blood pressure, and ventilator and pharmacologic measures to increase pulmonary vasodilatation, decrease pulmonary vascular resistance, increase blood and tissue oxygenation, and normalize blood pH. Inhaled nitric oxide has been one of the latest measures to successfully treat PPHN and significantly reduce the need for extracorporeal membrane oxygenation.
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Abstract
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.
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Affiliation(s)
- Jesse W Ford
- Arkansas Children's Hospital, NICU, Little Rock 72202, USA.
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Fliman PJ, deRegnier RAO, Kinsella JP, Reynolds M, Rankin LL, Steinhorn RH. Neonatal extracorporeal life support: impact of new therapies on survival. J Pediatr 2006; 148:595-9. [PMID: 16737868 DOI: 10.1016/j.jpeds.2005.12.024] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2005] [Revised: 11/10/2005] [Accepted: 12/12/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the effects of pre-extracorporeal life support (ECLS) management with nitric oxide (NO), high frequency ventilation (HFV), and surfactant on mortality among neonates supported with ECLS. STUDY DESIGN Extracorporeal Life Support Organization (ELSO) data on 7017 neonates cannulated for respiratory reasons between 1996 and 2003 were analyzed using chi2, analysis of variance, and logistic regression. RESULTS The use of ECLS declined by 26.6% over the study period with no significant change in mortality. Unadjusted ECLS mortality for NO-treated patients was lower than for infants not treated with NO (25.1% vs 28.6%, P = .0012) and for infants treated with surfactant than for infants not treated with surfactant (18.7% vs 30.3%, p <.0001.) Unadjusted mortality for HFV-treated patients was no different than for non-HFV-treated patients (26.0% vs 26.6%, P = .56). After adjusting for confounders (primary diagnosis, age at cannulation, ECMO year 1996-1999 vs 2000-2003), surfactant use was associated with decreased mortality. NO-treated neonates were less likely to have a pre-ECLS cardiopulmonary arrest than infants not treated with NO. NO, HFV, and surfactant were not associated with prolongation of ECLS or mechanical ventilation. CONCLUSIONS NO, HFV, and surfactant were not associated with increased mortality in neonates who require ECLS for hypoxic respiratory failure.
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Affiliation(s)
- Paola J Fliman
- Division of Neonatology, Northwestern University, Chicago, Illinois, USA.
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13
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Abstract
Persistent pulmonary hypertension of the newborn is a disorder of transition to extrauterine life, in which the newly born baby cannot decrease the high pulmonary vascular resistance and low pulmonary blood flow, characteristic of the fetus, to that of a low pulmonary vascular resistance and high pulmonary blood flow necessary for postnatal survival. The syndrome primarily affects the neonate 34 weeks postmenstrual age and greater. The article will summarize the latest understanding of the pathophysiology and review innovations in management strategies that have greatly decreased mortality and morbidity since the advent of neonatal intensive care units.
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Affiliation(s)
- M Terese Verklan
- University of Texas Health Science Center at Houston School of Nursing. Houston, Tex, USA.
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Brown KL, Miles F, Sullivan ID, Hoskote A, Verhulst L, Ridout DA, Goldman AP. Outcome in neonates with congenital heart disease referred for respiratory extracorporeal membrane oxygenation. Acta Paediatr 2005; 94:1280-4. [PMID: 16278994 DOI: 10.1111/j.1651-2227.2005.tb02089.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the proportion of neonates referred for extracorporeal membrane oxygenation (ECMO) support in the modern era of advanced conventional treatments for respiratory failure who actually had congenital heart disease (CHD), and to assess the impact of this diagnostic route on patient condition and outcome. METHODS A retrospective case-note review of neonatal ECMO and cardiac admissions to a single, tertiary ECMO and cardiac intensive care unit (ICU) between March 1999 and February 2002. RESULTS 287 symptomatic neonates presented to the ICU with previously undiagnosed cardiac or respiratory disease. Eighty-two with presumed respiratory failure were referred for ECMO, and 205 with suspected CHD were referred for cardiac evaluation. Eight (10%) ECMO referrals, all with presumed persistent pulmonary hypertension of the newborn (PPHN), were found to have CHD (transposition: 3; total anomalous pulmonary venous connection: 3; left heart obstructive lesions: 2). Mortality in this group was 50%, compared with 11% for correctly identified CHD patients (odds ratio 8.2, 95% CI 1.92, 35.4, p<0.01). For all neonates with CHD, the risk of death was increased by the presence of cardiovascular collapse and end-organ dysfunction at presentation to the ICU (p<0.01 for both). CONCLUSION Neonates with CHD may present as severe "PPHN" via the ECMO service. Poor outcome in these patients relates to the high incidence of cardiovascular collapse and end-organ dysfunction. Early echocardiography is recommended for neonates with presumed PPHN. Neonatal ECMO support should be based in centres with cardiac surgical services.
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Affiliation(s)
- Kate L Brown
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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15
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Abstract
Neonatal extracorporeal support is most often required for neonatal hypoxemic respiratory failure, usually accompanied by persistent pulmonary hypertension of the newborn (PPHN). PPHN is a clinical syndrome that results from the failure of pulmonary vascular transition to extrauterine life. Infants typically present shortly after birth with respiratory distress and cyanosis, but a structurally normal heart. The incidence of PPHN is estimated at 0.2% of live-born term infants. Respiratory failure and hypoxemia in the term newborn result from a heterogeneous group of disorders, and the therapeutic approach and response often depend on the underlying disease. PPHN can largely be thought of as one of three types: (1) the abnormally constricted pulmonary vasculature which is the most common type and includes diagnoses such as meconium aspiration syndrome, respiratory distress syndrome, and sepsis; (2) the structurally abnormal vasculature, which is often termed idiopathic PPHN; or (3) the hypoplastic vasculature such as is seen in congenital diaphragmatic hernia, or alveolar capillary dysplasia, a rare malformation of lung development. The pathophysiology of each type is dependent on the point in gestation when the normal transition to extrauterine life fails. This article will discuss the known pathophysiology in PPHN and new treatment modalities.
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Affiliation(s)
- Kathryn N Farrow
- Division of Neonatology, Children's Memorial Hospital and Northwestern University, Chicago, IL, USA
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Brown KL, Walker G, Grant DJ, Tanner K, Ridout DA, Shekerdemian LS, Smith JH, Davis C, Firmin RK, Goldman AP. Predicting outcome in ex-premature infants supported with extracorporeal membrane oxygenation for acute hypoxic respiratory failure. Arch Dis Child Fetal Neonatal Ed 2004; 89:F423-7. [PMID: 15321962 PMCID: PMC1721757 DOI: 10.1136/adc.2003.033308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To identify predictors of outcome in ex-premature infants supported with extracorporeal membrane oxygenation (ECMO) for acute hypoxic respiratory failure. METHODS Retrospective review of ex-premature infants with acquired acute hypoxic respiratory failure requiring ECMO support in the United Kingdom from 1992 to 2001. Review of follow up questionnaires completed by general practitioners and local paediatricians. RESULTS Sixty four ex-premature infants (5-10 each year) received ECMO support, despite increased use of advanced conventional treatments over the decade. The most common infective agent was respiratory syncytial virus (85% of cases). Median birth gestation was 29 weeks and median corrected age at the time of ECMO support was 42 weeks. Median ECMO support duration was relatively long, at 229 hours. Survival to hospital discharge and to 6 months was 80%, remaining similar throughout the period of review. At follow up, 60% had long term neurodisability and 79% had chronic pulmonary problems. Of pre-ECMO factors, baseline oxygen dependence, younger age, and inpatient status were associated with non-survival (p < or = 0.05). Of ECMO related factors, patient complications were independently associated with adverse neurodevelopmental outcome and death (p < 0.01). CONCLUSIONS Survival rates for ex-premature infants after ECMO support are favourable, but patients suffer a high burden of morbidity during intensive care and over the long term. At the time of ECMO referral, baseline oxygen dependence is the most important predictor of death, but no combination of the factors considered was associated with a mortality that would preclude ECMO support.
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Affiliation(s)
- K L Brown
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Abstract
Extracorporeal membrane oxygenation (ECMO) is essentially a heart-lung bypass machine that can be used to support certain critically ill neonates. ECMO therapy reached a peak in usage in the mid to late 1980s. At that time, ECMO was most often used for severe complications of persistent pulmonary hypertension, meconium aspiration, congenital diaphragmatic hernia, and sepsis. Since that time, the use of ECMO has decreased, due largely to newer medical advances that have improved the course of these neonates. Whether a nurse works in a Level III ECMO center or a Level I, II, or III NICU, ECMO treatment has become less familiar than it once was. But even though ECMO is used less often, there are times when nothing can take its place. It is important to stay informed so that families of those critically ill newborns who do need ECMO can be educated and supported. This article defines ECMO, discusses when it should be incorporated into the plan of care, describes advances in the NICU that have resulted in the dramatic reduction in the use of ECMO, and provides information and communication strategies to better support the family of a very sick newborn.
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Affiliation(s)
- Dina R Tulenko
- Valley Hospital Medical Center, NICU, Pediatrix Medical Group, Las Vegas, NV 89106, USA.
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Colombani PM. What's new in pediatric surgery. J Am Coll Surg 2003; 197:278-84. [PMID: 12892812 DOI: 10.1016/s1072-7515(03)00542-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paul M Colombani
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Dalton HJ. Renal replacement therapy: not just for the kidneys anymore? Pediatr Crit Care Med 2003; 4:126-7. [PMID: 12656564 DOI: 10.1097/00130478-200301000-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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