Neonatal myocardial infarction and the role of extracorporeal membrane oxygenation

Acute myocardial infarction is a cause of neonatal collapse. The diagnosis is suggested by ischaemic electrocardiography, raised cardiac enzymes and deteriorating cardiac function and should be considered in severe neonatal cardiac dysfunction without other identifiable causes. This paper presents four cases of neonatal myocardial infarction treated with veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiorespiratory support. The paper illustrates that left ventricular function may recover after neonatal myocardial infarction if it can be supported for long enough, and that early ECMO referral may be of benefit.

Developmental outcome in newborn infants treated for acute respiratory failure with extracorporeal membrane oxygenation: present experience

OBJECTIVE

To describe the later health status of newborn infants who received extracorporeal membrane oxygenation (ECMO) for acute respiratory failure in the era after the UK ECMO trial.

DESIGN

Prospective follow up study of newborn infants who received ECMO at a single centre between January 1997 and January 2001.

SETTING

Departments of ECMO and Paediatric Intensive Care, University Hospitals of Leicester.

PATIENTS

All babies who received ECMO within 14 days of birth.

INTERVENTIONS

Neurodevelopment screening using the schedule for growing skills-II (SGS-II) assessment tool.

MAIN OUTCOME MEASURES

Survival at 12 months of age by disease and functional development at follow up.

RESULTS

A total of 145 neonates received ECMO for treatment of respiratory failure. Of these, 108 (75%) were alive at 1 year of age. There were no deaths in children treated for respiratory failure secondary to meconium aspiration syndrome (73/145). Ninety three (86% of survivors) infants attended a follow up visit at 11-19 months postnatal age. Eighty two were classed as normal, seven as having "impairment", and four as having "severe disability".

CONCLUSIONS

Most newborn infants with acute respiratory failure treated with ECMO will have a normal neurodevelopment screening assessment at 11-19 months of postnatal age. There is no evidence to suggest that changes in neonatal practice since the UK ECMO trial have led to changes in outcome of infants undergoing ECMO therapy.

Extracorporeal life support for children with meningococcal septicaemia

OBJECTIVE

To describe the short-term outcome of children with meningococcal sepsis treated with extracorporeal membrane oxygenation (ECMO) in a single centre.

DESIGN

Retrospective analysis of case notes.

SETTING

The Heartlink ECMO Centre, Glenfield Hospital, Leicester.

PATIENTS

Eleven children (8 boys) out of a total caseload of 800 patients were treated for meningococcal sepsis with ECMO.

INTERVENTIONS

Extracorporeal membrane oxygenation.

RESULTS

All children with meningococcal sepsis treated with ECMO had a Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS) > or = 12 (positive predictive risk of death of approximately 90%). Five children had adult respiratory distress syndrome (ARDS) and six had refractory shock with multi-organ dysfunction syndrome (MODS) at presentation for ECMO. All five children in the ARDS group survived, four of five receiving veno-venous (VV-) ECMO therapy. In contrast, only one of six children with refractory shock with MODS survived, all of whom required veno-arterial (VA-) ECMO therapy.

CONCLUSIONS

Most children with meningococcal sepsis and severe ARDS can be successfully treated with VV-ECMO. In contrast, children with refractory shock and MODS die despite treatment with VA-ECMO. This report does not resolve whether ECMO therapy offers any advantage over conventional therapy in treating severe meningococcal sepsis.

Plasma aluminum levels during sucralfate prophylaxis for stress ulceration in critically ill patients on continuous venovenous hemofiltration: a randomized, controlled trial

OBJECTIVE

To investigate plasma aluminum levels in critically ill patients requiring continuous venovenous hemofiltration (CVVH), while receiving sucralfate for stress ulcer prophylaxis.

DESIGN

Randomized, controlled study.

SETTING

Cardiothoracic intensive care unit.

PATIENTS

Twenty postoperative cardiac surgical patients

INTERVENTIONS

Twenty patients requiring CVVH support for acute renal failure were randomized into two groups for concurrent stress ulcer prophylaxis. Group 1 (n = 10) received nasogastric sucralfate, and group 2 patients received intravenous ranitidine. Plasma aluminum samples were analyzed at baseline and on days 1, 4, 8, and 14.

MEASUREMENTS AND MAIN RESULTS

In both the sucralfate and ranitidine groups, clinical characteristics, number of days the patients were on CVVH support (median, 5.5 [range, 2-32] days, and median, 3 [range, 2-18] days, respectively) and duration of prophylaxis (median, 12 [range, 4-42] days, and median, 16 [range, 3-62] days, respectively) were similar. There were no significant differences in the baseline aluminum concentrations (median, 0.37 [range, 0.15-1.63] micromol/L, vs. median, 0.32 [range, 0.11-1.0] micromol/L; p =.79). On initiation of therapy, aluminum levels in the sucralfate group increased dramatically on day 1 (median, 0.87 [range, 0.26-4.4] micromol/L) and peaked on day 4 (median, 2.84 [range, 1.52-4.44] micromol/L) with seven of the ten patients exhibiting levels of >2 micromol/L. In the ranitidine group, there were no significant elevations in aluminum levels above baseline. Analysis of the two groups at the four time points revealed that aluminum levels in the sucralfate group were up to 14 times higher, with the confidence intervals suggesting that the true value may be 2-27 times higher (p <.0001). On cessation of CVVH, a rapid decline in aluminum levels was observed. No clinical manifestations of these potentially toxic levels were observed.

CONCLUSIONS

The use of sucralfate for stress ulcer prophylaxis in patients requiring CVVH results in toxic elevations in plasma aluminum levels. Alternative agents should be considered for prophylaxis in these patients.

Extracorporeal membrane oxygenation in the treatment of inhalation injuries

Smoke inhalation is a leading cause of death in burns patients. Conventional ventilation cannot always maintain adequate tissue oxygenation. Extracorporeal membrane oxygenation (ECMO) has rarely been used in the treatment of smoke inhalation injuries. ECMO is a proven therapy in severe neonatal respiratory failure and has also been used to good effect in the treatment of children and adults. We report the cases of two children who developed severe respiratory failure refractory to maximal ventilation, one case followed smoke inhalation alone, the other followed smoke inhalation and burns. Pre-ECMO PaO2/FIO2 ratios were 6.5 and 8 kPa, respectively. The patients were treated with veno venous ECMO for 72 and 144 h, respectively. The use of ECMO for respiratory failure due to smoke inhalation and thermal injury is discussed.

The 'topping-up' effect: differences between low- and non-alcoholic lager on blood ethanol

The peak blood alcohol levels attained in male and female subjects after consumption of 3 pints of regular lager (4.2%) over a 30 min period was 73.5 +/- 6.9 mg% in males and 113 +/- 17 mg% in females. Peak values occurred at 60 and 90 min post-ingestion in males and females, respectively. Consumption of 3 pints of low-alcohol lager gave a maximum blood alcohol level of 13 mg% while there was no measurable blood alcohol content after three pints of non-alcohol lager. 'Topping-up' with a non-alcohol lager after 2 pints of regular lager leads to significantly lower blood alcohol levels when compared with 'topping-up' with low-alcohol lager over a comparable time in males but not in females.