Intracranial hemorrhage in premature neonates treated with extracorporeal membrane oxygenation correlates with conceptional age

OBJECTIVE: To determine the effect of patient age on the risk of intracranial hemorrhage (ICH) in premature neonates treated with extracorporeal membrane oxygenation (ECMO). STUDY DESIGN: This was a retrospective cohort study of neonates of <37 weeks' gestation treated with ECMO in the years 1992 through 2000 and reported to the Extracorporeal Life Support Organization Registry (n=1524). The relation between ICH and patient age, defined as gestational age, postnatal age (PNA), and postconceptional age (PCA), was determined with the use of multiple logistic regression analysis. RESULTS: PNA was inversely correlated with ICH in the univariate analysis (P=.01) but not in the multivariate analysis (P=.36). PCA showed a strong univariate correlation with decreasing ICH: 26% of patients 相似文献   

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??Extracorporeal membrane oxygenation??ECMO?? is a kind of extra life support technique that can support cardiac and pulmonary function of critical neonates for a relatively long time. The principle and application of ECMO in foreign medical institutes and domestic medical institutes were summarized in order to improve the clinical application of ECMO in critically ill newborns to further improve the rescue success rate and reduce the neonatal mortality.     

Left ventricular performance in neonates on extracorporeal membrane oxygenation

Summary The evaluation of left ventricular systolic performance in infants undergoing extracorporeal membrane oxygenation (ECMO) using traditional ejection-phase indices is hampered by significant alterations in preload and afterload. Therefore, a load-independent index, which relates heart-rate-corrected mean velocity of circumferential fiber shortening (VCFc) to afterload, measured as end-systolic wall stress (ESS), was used to assess left ventricular function in 18 term neonates undergoing ECMO. The mean age at the onset of ECMO was 75.5 h and the duration of therapy was 171±106 h. Left ventricular performance was highest before the onset of ECMO (VCFc=1.65±0.49 circ/s) and decreased toward normal during (1.38±0.33 circ/s) and following ECMO (1.29±0.16 circ/s). Initially, nine of 17 (53%) patients had enhanced performance for the degree of afterload but in only 16 of 48 (33%) studies during ECMO and none following ECMO was VCFc elevated beyond the normal range predicted for ESS. These changes in left ventricular performance may be the result of variations in exogenous, as well as endogenous, catecholamines rather than intrinsic alterations in myocardial contractility. It is concluded that the VCFc/ESS relation permits a meaningful assessment of ventricular performance in critically ill neonates undergoing ECMO.     

Dexamethasone therapy in neonates treated with extracorporeal membrane oxygenation

OBJECTIVE: To test the hypothesis that infants who received dexamethasone would have a shorter length of time on extracorporeal membrane oxygenation (ECMO).Study design Infants placed on ECMO for respiratory failure were randomly assigned to receive either dexamethasone for 3 days or placebo. Chest radiographs were scored through the use of a validated standard scoring system to assess lung injury. RESULTS: Thirty infants received dexamethasone and 29 received placebo. The median (25th%, 75th%) duration of time on ECMO was 143.5 (100, 313) hours in the dexamethasone group and 160 (111, 303) hours in the placebo group (not significant). Survival was 80% in the dexamethasone group and 83% in the placebo group. Radiographic lung injury scores (mean+/-SEM) were significantly improved in the dexamethasone group (10.5+/-0.6) versus placebo (12.3+/-0.5) on day 3 of ECMO (P=.013). Hypertension developed in 27 of the 30 infants receiving dexamethasone and 13 of the 29 infants in the placebo group during ECMO (P<.01). CONCLUSIONS: Dexamethasone given during the first 3 days of ECMO results in significant improvement in lung injury scores by day 3 of ECMO but does not significantly decrease the duration of ECMO or improve survival. The preponderance of evidence would not support the use of dexamethasone in this setting.     

体外膜肺氧合技术在4例危重新生儿中的应用

<正>体外膜肺氧合技术(extracorporeal membrane oxygenation,ECMO)是一种体外生命支持技术,能为急性严重心肺衰竭患者提供心肺支持。1971年,Hill等~([1])首次应用心肺转流术设备成功救治1例24岁患多脏器损伤合并急性呼吸窘迫综合征(ARDS)的患者,标志着ECMO技术开始应用在临床。Bartlett等~([2])在1975年为1例婴儿成功进行床边心肺支持后,ECMO技术逐渐应用到儿科领域,     

Auditory brain-stem responses in neonates receiving extracorporeal membrane oxygenation.

Auditory brain-stem responses from 25 neonates treated with extracorporeal membrane oxygenation were compared with those of 11 control subjects. Results revealed no statistically significant differences for recorded responses, either between ears or between groups. We conclude that infants who receive extracorporeal membrane oxygenation, with or without carotid artery repair, are not at greater risk for auditory brain-stem dysfunction than similar infants who do not receive extracorporeal membrane oxygenation.     

Routine enteral nutrition in neonates on extracorporeal membrane oxygenation.

OBJECTIVES: To evaluate over a 5-yr period the feasibility and tolerance of a protocol of routine enteral nutrition in neonates requiring extracorporeal membrane oxygenation (ECMO). DESIGN: Retrospective medical chart review. SETTING: Level III children's hospital, pediatric surgical intensive care unit. PATIENTS: Neonates treated with venoarterial ECMO (VA-ECMO) between January 1997 and January 2002. Patients with congenital diaphragmatic hernia were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Charts of all neonates treated with VA-ECMO were reviewed. Feasibility was evaluated by recording the time period needed for enteral nutrition to reach 40% of total fluid intake; tolerance was evaluated by reviewing data on enteral nutrition related morbidity. Sixty-seven of the 77 eligible patients received enteral feeding during ECMO. Thirty-six of these patients (54%) received 40% of total fluid intake as enteral nutrition within a median of 3 (range, 2-4) days. Over the years there was a trend toward an increasing usage of enteral nutrition from 71% to 94% (p = .07). Enteral nutrition was temporarily discontinued in 16 patients, with 14 showing gastric retentions, one showing discomfort, and one showing aspiration. Symptoms of bilious vomiting, blood-stained stool, or abdominal distention were not present. CONCLUSION: Neonates on ECMO in this series tolerated enteral feeding well and did not show serious adverse effects. Overall, it is our experience that routine use of enteral feeding in critically ill neonates on VA-ECMO is feasible.     

Dense pulmonary opacification in neonates treated with extracorporeal membrane oxygenation

Chest radiographic findings in three neonates with respiratory failure secondary to meconium aspiration treated with extracorporeal membrane oxygenation (ECMO) are described. The degree of pulmonary opacification on the chest radiographs failed to correlate with the patients' clinical status as measured by the arterial oxygen levels but correlated well with the peak airway pressure (PAP) and continuous positive airway pressure (CPAP) settings on the mechanical ventilator. Because a variable portion of the arterial blood oxygenation is performed by the extracorporeal membrane oxygenator and unusually large fluctuations in airway pressure settings can occur in these patients while on ECMO, it is important to realize that the chest radiograph may not be an accurate predictor of the patients' clinical status. The opinions expressed herein are those of the authors and do not necessarily reflect official USAF policy.     

Pilot investigation of hypothermia in neonates receiving extracorporeal membrane oxygenation

BACKGROUND: Infants requiring extracorporeal membrane oxygenation (ECMO) support represent a high risk group in terms of cerebral injury. Mild hypothermia both during and after cerebral hypoxic ischaemia appears to be a promising strategy for offering neuroprotection. OBJECTIVE: To investigate whether mild hypothermia was both feasible and safe in infants receiving ECMO as a prelude to any formal assessment of this approach in a randomised trial. METHODS: Twenty infants (body weight less than 5 kg) with severe cardiopulmonary insufficiency, referred for ECMO support at Glenfield Hospital, Leicester, were enrolled in this study. Twenty consecutive infants (compromising four groups of five) were studied. Baseline data were obtained from a control group who were run throughout their course at 37 degrees C. The patients in the next group were managed with a core temperature of 36 degrees C for the first 12 hours of their ECMO run, before being warmed up to 37 degrees C. After successful completion, the next group of five were cared for at 35 degrees C for the first 12 hours, and, there having been no previous complications, the final group were cared for at 34 degrees C for the first 12 hours. Patients were assessed clinically and biologically. In addition to routine laboratory tests, cytokines (interleukin 6, interleukin 8, tumour necrosis factor alpha, and C reactive protein) were measured and coagulation tests (D-dimer, thrombin-antithrombin III complex, plasmin-alpha(2)-antiplasmin complex) were performed serially for five days. RESULTS: There were no significant differences among the four groups in gestational age, birth weight, age at the time of ECMO, Apgar scores at one and five minutes, pH before cannulation, oxygenation index, duration of ECMO, and survival rate to discharge from hospital. No adverse effects of mild hypothermia were found on patient management during ECMO. Laboratory data for up to five days of ECMO also showed no difference among the four groups. CONCLUSION: Mild hypothermia (34 degrees C) for the initial 12 hours of an ECMO run is feasible.     

Nitrogen balance during extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) has been used as a support system for neonates with pulmonary failure since 1975. During ECMO, thermal regulation, pulmonary gas exchange, and cardiac output can be partially or nearly completely provided by the circuit. The presumed resultant decrease in energy requirement has prompted the question of whether infants are in a catabolic or anabolic state of metabolism while on ECMO. Directly measuring the metabolic rate in babies on ECMO is difficult. However, studying the nitrogen balance in these infants may suggest an answer. Nitrogen balance was studied in 21 neonates spanning a single ECMO team's experience at two institutions. Children were studied at the Ochsner Clinic from 1986 to 1990 and at the University of Chicago Wyler Children's Hospital from 1990 to the present. The infants received total parenteral nutrition (TPN) as their only nutritional source during the entire ECMO course. During this time, 24-h urine collections were analyzed for urea nitrogen (UUN). The daily nitrogen balance was calculated by subtracting nitrogen output (estimated as the UUN) from nitrogen input (the measured amino acid content of the intravenous feeding). Fecal losses were not included in the nitrogen output since the infants were not enterally fed and rarely had stools while on ECMO. The kilojoules (1 kilocalorie = 4.2 kilojoules) and protein provided by the parenteral nutrition varied. Nitrogen intake exceeded nitrogen output by ECMO day 2 (the initial nitrogen balance determination). Infants receiving as little as 0.4 g/kg protein and 168 kJ/kg daily remained in positive nitrogen balance. Correspondence to: R. Arensmann     

Hemolysis during long-term extracorporeal membrane oxygenation

We studied the cause of hemolysis during extracorporeal membrane oxygenation (ECMO) by monitoring hematologic and coagulation profiles in seven consecutive infants treated with this procedure. A constrained vortex pump was used in all patients, and the average duration of ECMO was 224 +/- 111 (SD) hours. In all patients, plasma free hemoglobin was low during the first 48 hours after the initiation of ECMO. Later, when visible clots appeared in the ECMO circuit, plasma hemoglobin progressively rose. A rise in the level of fibrin degradation products and a fall in the fibrinogen level were observed concurrently with a rise in the plasma hemoglobin level. After complete circuit changes in six patients, plasma free hemoglobin, fibrin split products, and fibrinogen all returned to baseline values. Neither circuit component changes nor exchange transfusion was effective in normalizing the levels of plasma free hemoglobin, fibrin split products, and fibrinogen. We conclude that when ECMO is administered for prolonged periods, circuit thrombosis occurs and hemolysis ensues. Additional studies are needed to assess the contribution of the constrained vortex pump to this process.     

Use of recombinant factor VIIa for refractory hemorrhage during extracorporeal membrane oxygenation.

OBJECTIVE: To describe the outcome and treatment of two patients with recombinant factor VIIa (rFVIIa) for severe hemorrhage associated with extracorporeal membrane oxygenation (ECMO). DESIGN: Case report. SETTING: A 38-bed pediatric intensive care unit and 20-bed pediatric cardiac intensive care unit at a tertiary care children's hospital. Patient: Two patients with life-threatening hemorrhagic complications associated with ECMO requiring massive transfusion of blood products. INTERVENTIONS: Administration of repeated doses of rFVIIa at 90 microg/kg/dose. MEASUREMENT AND MAIN RESULTS: Patient 1 was an 11-yr-old male with a dilated cardiomyopathy who had undergone an orthotopic heart transplant treated with venoarterial ECMO postoperatively for right ventricular dysfunction. Patient 2 was a 13-yr-old male treated with venoarterial ECMO for cardiopulmonary failure from necrotizing staphylococcal pneumonia. Both patients had severe hemorrhage from the cannulation sites and thoracostomy tubes requiring massive transfusion to maintain intravascular blood volume and replace clotting factors. Both patients were treated with rFVIIa every 2-4 hrs and attained hemostasis. Patient 1 was administered three doses and Patient 2 was administered ten doses. No evidence of abnormal thrombus formation was noted in their respective ECMO circuits. CONCLUSIONS: The efficacy of rFVIIa in reducing intractable bleeding postcardiac surgery and in other coagulopathic states is being investigated. Despite theoretical concerns of thrombosis, these cases illustrate that there may be a role for the cautious use of rFVIIa in treating severe and intractable hemorrhage associated with ECMO.     

Gut hormone profiles in critically ill neonates on extracorporeal membrane oxygenation

OBJECTIVES: The objective of this study was to gain insight into the hormonal responses to enteral nutrition in critically ill newborns requiring venoarterial extracorporeal membrane oxygenation (ECMO) by analyzing plasma gut hormone levels of gastrin, cholecystokinin and peptide-YY in relation to enteral nutrition. METHODS: In 24 consecutive neonates treated with venoarterial ECMO intestinal hormone secretions were determined by radioimmunoassay at 2-day intervals. Twelve received parenteral nutrition only. In 12 enteral nutrition was introduced later. The findings in these patients were compared with those of 16 measurements in eight non-ECMO treated age-matched controls. Mixed model analysis of variance was used for statistical analysis. RESULTS: Concentrations of gastrin, cholecystokinin and peptide-YY were significantly higher in ECMO patients receiving enteral nutrition compared with ECMO patients who received parenteral nutrition (62, 3.8 and 59.4 pmol/L versus 46, 3.1 and 34.7 pmol/L, respectively). Overall, plasma hormone levels did not differ from those in age-matched controls. CONCLUSIONS: Intestinal hormone levels showed normal responses after introduction of enteral feeding, comparable with those in age-matched controls without ECMO. These results do not provide an argument for withholding enteral nutrition even in the most severely ill neonates on venoarterial ECMO.     

Bypass cannulas utilized in extracorporeal membrane oxygenation in neonates: Radiographic findings

ECMO, as applied to neonates with severe respiratory failure, involves either a single or dual cannula system for removal of desaturated blood from and return of oxygenated blood to the patient. ECMO cannulas have undergone considerable change and improvement since the early 1980s, and a variety of cannulas are now available commercially for neonatal ECMO. All ECMO cannulas have a characteristic appearance on the chest radiograph, which is important in the assessment of cannula position and some cannula complications. We report the physical characteristics, advantages, disadvantages, and radiographic appearance of the most widely utilized neonatal ECMO cannulas.     

Cerebral proton magnetic resonance spectroscopy of neonates after extracorporeal membrane oxygenation

During venoarterial extracorporeal membrane oxygenation the right carotid artery is ligated in a hypoxic neonate. The aim of the present study was to compare the morphology and metabolism of the left and right basal ganglia in 10 neonates after extracorporeal membrane oxygenation, using proton magnetic resonance imaging and spectroscopy. Data could be obtained in 9 neonates. No significant metabolic differences were found between either the left or right basal ganglia, despite a small right-sided thalamic infarct in one child. Metabolism was normal in all cases. All the infants showed symmetrical neurodevelopment.

Conclusion: Ligation of the right carotid artery for venoarterial extracorporeal membrane oxygenation did not produce persistent changes in brain metabolism in the basal ganglia in this small group of patients.