Neonatal herpes virus infection and extracorporeal life support

Mechanical Circulatory Support for Septic Shock in Children and Adults: Different But Similar

Although extracorporeal membrane oxygenation (ECMO) for circulatory support in patients with severe septic shock commenced in newborn infants and children in the late 1980s, ECMO has remained a controversial treatment for adults with refractory septic shock (RSS). This is fundamentally because of differences in the predominant hemodynamic response to sepsis. In newborn infants and very young children ventricular failure, low cardiac output syndrome (LCOS) is the major hemodynamic response whereas adolescents and adults mainly have vasoplegic shock. ECMO is a very effective treatment for cardiogenic shock even shock caused by sepsis, with a survival that has varied from 40% to 70%; vasoplegic shock, however, requires vasopressors rather than ECMO, and hence survival of these patients with ECMO was poor (< 20%). However, since the early 2000s, sepsis- induced cardiomyopathy (SCM) with ventricular failure (identical to LCOS in children) has been increasingly described in adults, and the occurrence of cardiogenic shock caused by septic shock is treatable with ECMO. In the last 6 years, increasing publications of series of adults with RSS and cardiogenic shock receiving ECMO and ∼70+% surviving has led to increased use of VA ECMO for RSS.

International treatment outcomes of neonates on extracorporeal membrane oxygenation (ECMO) with persistent pulmonary hypertension of the newborn (PPHN): a systematic review

BACKGROUND

PPHN is a common cause of neonatal respiratory failure and is still a serious condition and associated with high mortality.

OBJECTIVES

To compare the demographic variables, clinical characteristics, and treatment outcomes in neonates with PHHN who underwent ECMO and survived compared to neonates with PHHN who underwent ECMO and died.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and searched ProQuest, Medline, Embase, PubMed, CINAHL, Wiley online library, Scopus and Nature for studies on the development of PPHN in neonates who underwent ECMO, published from January 1, 2010 to May 31, 2023, with English language restriction.

RESULTS

Of the 5689 papers that were identified, 134 articles were included in the systematic review. Studies involving 1814 neonates with PPHN who were placed on ECMO were analyzed (1218 survived and 594 died). Neonates in the PPHN group who died had lower proportion of normal spontaneous vaginal delivery (6.4% vs 1.8%; p value > 0.05) and lower Apgar scores at 1 min and 5 min [i.e., low Apgar score: 1.5% vs 0.5%, moderately abnormal Apgar score: 10.3% vs 1.2% and reassuring Apgar score: 4% vs 2.3%; p value = 0.039] compared to those who survived. Neonates who had PPHN and died had higher proportion of medical comorbidities such as omphalocele (0.7% vs 4.7%), systemic hypotension (1% vs 2.5%), infection with Herpes simplex virus (0.4% vs 2.2%) or Bordetella pertussis (0.7% vs 2%); p = 0.042. Neonates with PPHN in the death group were more likely to present due to congenital diaphragmatic hernia (25.5% vs 47.3%), neonatal respiratory distress syndrome (4.2% vs 13.5%), meconium aspiration syndrome (8% vs 12.1%), pneumonia (1.6% vs 8.4%), sepsis (1.5% vs 8.2%) and alveolar capillary dysplasia with misalignment of pulmonary veins (0.1% vs 4.4%); p = 0.019. Neonates with PPHN who died needed a longer median time of mechanical ventilation (15 days, IQR 10 to 27 vs. 10 days, IQR 7 to 28; p = 0.024) and ECMO use (9.2 days, IQR 3.9 to 13.5 vs. 6 days, IQR 3 to 12.5; p = 0.033), and a shorter median duration of hospital stay (23 days, IQR 12.5 to 46 vs. 58.5 days, IQR 28.2 to 60.7; p = 0.000) compared to the neonates with PPHN who survived. ECMO-related complications such as chylothorax (1% vs 2.7%), intracranial bleeding (1.2% vs 1.7%) and catheter-related infections (0% vs 0.3%) were more frequent in the group of neonates with PPHN who died (p = 0.031).

CONCLUSION

ECMO in the neonates with PPHN who failed supportive cardiorespiratory care and conventional therapies has been successfully utilized with a neonatal survival rate of 67.1%. Mortality in neonates with PPHN who underwent ECMO was highest in cases born via the caesarean delivery mode or neonates who had lower Apgar scores at birth. Fatality rate in neonates with PPHN who underwent ECMO was the highest in patients with higher rate of specific medical comorbidities (omphalocele, systemic hypotension and infection with Herpes simplex virus or Bordetella pertussis) or cases who had PPHN due to higher rate of specific etiologies (congenital diaphragmatic hernia, neonatal respiratory distress syndrome and meconium aspiration syndrome). Neonates with PPHN who died may need a longer time of mechanical ventilation and ECMO use and a shorter duration of hospital stay; and may experience higher frequency of ECMO-related complications (chylothorax, intracranial bleeding and catheter-related infections) in comparison with the neonates with PPHN who survived.

Changing populations being treated with ECMO in the neonatal period - who are the others?

Extracorporeal life support via extracorporeal membrane oxygenation (ECMO) has served the sickest of neonates for almost 50 years. Naturally, the characteristics of neonates receiving ECMO have changed. Advances in care have averted the need for ECMO for some, while complex cases with uncertain outcomes, previously not eligible for ECMO, are now considered. Characterizing the disease states and outcomes for neonates on ECMO is challenging as many infants do not fall into classic categories, i.e. meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or congenital diaphragmatic hernia (CDH). Since 2017, over one third of neonatal respiratory ECMO runs reported to the Extracorporeal Life Support Organization Registry are grouped as Other, a catch-all that encompasses those with a diagnosis not included in the classic categories. This review summarizes the historical neonatal ECMO population, reviews advances in therapy and technology impacting neonatal care, and addresses the unknowns in the ever-growing category of Other.

Precision in Cardiovascular Care Using Targeted Neonatal Echocardiography in Lethal Neonatal Disseminated Herpes Infection: A Case Series

Neonates with disseminated neonatal herpes simplex virus infection often present with cardiorespiratory failure. The pathophysiological contributors to the disease phenotype, biologic mechanisms underlying the hemodynamic instability and optimal approach to cardiovascular treatment have not been well described. We describe clinical and echocardiography features of cardiovascular dysfunction, in a case series of neonates with disseminated herpes simplex virus, and response to physiology-based hemodynamic management. The biologic phenotype includes low systemic vascular resistance state, hypovolemia secondary to third space losses, myocardial dysfunction and pulmonary hypertension. Early targeted neonatal echocardiography provided hemodynamic insights on blood flow, shunt characterization, vascular resistance and cardiac function, that were difficult to gauge clinically (eg, differentiating parenchymal from pulmonary vascular disease) thereby positively impacted clinical care. All patients were stabilized hemodynamically without utilizing extracorporeal membrane oxygenation, although all patients died of multiorgan failure.

ECMO for Neonatal Sepsis in 2019

Sepsis and septic shock in newborns causes mortality and morbidity depending on the organism and primary site. ECMO provides cardiorespiratory support to allow adequate organ perfusion during the time for antibiotics and source control surgery (if needed) to occur. ECMO mode and cannulation site vary depending on support required and local preference. Earlier and more aggressive use of ECMO can improve survival.

Extracorporeal Membrane Oxygenation for Severe Adenoviral Pneumonia in Neonatal, Pediatric, and Adult Patients

OBJECTIVES

We examined data on patients with severe adenoviral pneumonia from the international registry of the Extracorporeal Life Support Organization to identify risk factors for mortality in patients receiving extracorporeal membrane oxygenation.

DESIGN

Retrospective analysis.

SETTING

International Registry of Extracorporeal Life Support Organization.

PATIENTS

We collected de-identified data on all patients with adenoviral pneumonia who needed extracorporeal membrane oxygenation from 1992 to 2016 using International Classification of Diseases, 9th Edition, criteria.

INTERVENTIONS

Our primary outcome measure was in-hospital mortality. We also collected data on demographics, preextracorporeal membrane oxygenation ventilator settings, biochemical variables, extracorporeal membrane oxygenation mode, duration, and complications. Initial bivariate analysis assessed potential associations between mortality and various preextracorporeal membrane oxygenation variables as well as extracorporeal membrane oxygenation factors. Variables with p values of less than 0.1 were considered for logistic regression analysis that identified predictors of mortality.

MEASUREMENTS AND RESULTS

There were 542 patients with adenoviral pneumonia who were supported with extracorporeal membrane oxygenation. Overall mortality was 58% (307/529 patients) (neonates 86.4% [108/125 patients], children 49% [158/327 patients], and adults 49% [41/83 patients]). Multivariate regression identified hypercapnia (PCO2 > 45.7; odds ratio > 3.2; p < 0.001), immunosuppression (odds ratio, 4.44; 95% CI, 1.69-11.61; p = 0.002] and lack of pharmacologic paralysis (odds ratio, 0.30; 95% CI, 0.16-0.57; p < 0.001] as significant preextracorporeal membrane oxygenation factors for mortality. Neonatal patients had significantly higher mortality than pediatric or adult patients (odds ratio, 10.9; 95% CI, 3.2-37.3; p < 0.001). The presence of renal (odds ratio, 4.4; 95% CI, 2.5-7.7; p < 0.001), neurologic (odds ratio, 2.5; 95% CI, 1.2-5.1; p = 0.014), hemorrhagic (odds ratio, 2.2; 95% CI, 1.2-4.0; p = 0.014), or cardiovascular complications (odds ratio, 2.4; 95% CI, 1.3-4.6; p = 0.006) was associated with higher mortality on extracorporeal membrane oxygenation.

CONCLUSIONS

Patients with adenoviral pneumonia supported on extracorporeal membrane oxygenation had mortality of 58% over a 25-year-old period. We identified risk factors both before and during extracorporeal membrane oxygenation which were associated with higher mortality. Mortality in neonatal patients was particularly high.

Extracorporeal Life Support: Four Decades and Counting

Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a form of heart lung bypass that is used to support neonates, pediatrics, and adult patients with cardiorespiratory failure for days or weeks till organ recovery or transplantation. Venoarterial (VA) and venovenous (VV) ECLS are the most common modes of support. ECLS circuit components and monitoring have been evolving over the last 40 years. The technology is safer, simpler, and more durable with fewer complications. The use of neonatal respiratory ECLS use has been declining over the last two decades, while adult respiratory ECLS is growing especially since the H1N1 influenza pandemic in 2009. This review provides an overview of ECLS evolution over the last four decades, its use in neonatal, pediatric and adults, description of basic principles, circuit components, complications, and outcomes as well as a quick look into the future.

The mortality of neonatal herpes simplex virus infection

This retrospective study characterized the clinical course of 13 neonates who died with herpes simplex virus infection from 2001 to 2011, representing a 26% case-fatality rate. Fatal disease developed at ≤ 48 hours of age in one-third of infants, was mostly disseminated disease, and occurred despite early administration of high-dose acyclovir therapy.

Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012)

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.

Extracorporeal membrane oxygenation for refractory, life-threatening, and herpes simplex virus 1-induced acute respiratory distress syndrome. Our experience and literature review

We report our first experience of treating an immunocompetent adult patient with acute respiratory distress syndrome (ARDS) due to type 1 herpes simplex (HSV1) pneumonitis, using extracorporeal membrane oxygenation (ECMO). Similar cases reported in literature are reviewed as well. The therapeutic options for this particular complication are discussed. Pneumonia caused by HSV1 is a rare finding in immunocompetent individuals; it occurs more often in immunosuppressed and ventilated patients. It is a severe illness; therefore, early diagnosis and initiation of treatment are imperative. Diagnosis is based on cytologic and histologic findings, viral cultures, or serologic methods. This condition can be reversible; however, often, it can progress into refractory ARDS with limited therapeutic options available. We demonstrate the causative role of HSV1 in refractory ARDS of a previously healthy 18-year-old man who presented to the intensive care unit with acute respiratory distress after a week of flulike syndrome. Due to severe hypoxemia and hypercarbia, the patient required mechanical ventilation and later emergent blood oxygenation with extracorporeal support. For the first time in this condition, we used venovenous ECMO management, to rest the lung, sustain blood oxygenation and end-organ oxygen delivery, and promote potential lung recovery. During ECMO and after our etiologic diagnosis, specific therapy was introduced. After viral negativization, corticosteroid therapy (Meduri protocol) was initiated. Extracorporeal membrane oxygenation allowed us to initiate therapy while maintaining end-organ oxygenation and support the patient until lung recovery. After 18 days of ECMO, our patient recovered completely. Near-normal lung structures and functions were documented on a chest x-ray/computed tomography, thoracic ultrasonography, and pulmonary functional tests at hospital discharge and at a 1-year follow-up. Data suggest that severe pulmonary involvement in HVS1 infection associated with septicemia/shock is a rare but often fatal in immunocompetent adult as well. We suggest that ECMO might be the selected treatment for severe refractory ARDS in this clinical scenario. It seems to be an effective and useful ultimate therapeutic strategy for preventing death and furthermore permitting near-full pulmonary function recovery.

Current status of pediatric/neonatal extracorporeal life support: clinical outcomes, circuit evolution, and translational research

Extracorporeal life support (ECLS) offers lifesaving mechanical circulatory support for patients afflicted with respiratory and/or cardiac failure. Neonatal respiratory patients have higher survival rates compared to pediatric patients, while, for cardiac cases, pediatric patients are more likely to survive. The indications for ECLS have been expanded due to the improved technology and favorable outcomes. However, the rate of mortality and morbidity for ECLS patients remains significant. Mechanical complications still comprise a large percentage of ECLS complications, leaving definite room for improvement in ECLS circuit technology in the future. As a pre-clinical evaluating tool, translational research will provide more useful information for the selection of ECLS devices, encourage further development of ECLS technology, and, ultimately, benefit the patients.