A novel approach to delivery of extracorporeal support using a modified continuous flow ventricular assist device in a mid‐volume congenital heart program

Extracorporeal life support (ECLS) is an essential component of a modern congenital cardiac surgery program. The circuit components and bedside management team may, however, vary among institutions. Here, we evaluate our initial experience with a modified ventricular assist device—based ECLS circuit primarily managed by the bedside nurse. We hypothesize that our outcomes are comparable to Extracorporeal Life Support Organization (ELSO) registry data. All patients who received ECLS from January 1, 2016 to December 31, 2019 at a single institution were included. Primary outcomes were survival to ECLS decannulation and discharge or transfer. Secondary outcomes included complications from ECLS. Data were compared to available ELSO registry data. Thirty‐seven patients underwent 44 ECLS runs during the study period. Forty percent of patients had single ventricle physiology. Nearly 46% of patients received ECLS as part of extracorporeal cardiopulmonary resuscitation (eCPR). Survival to ECLS decannulation (68.2%) and survival to discharge or transfer (61.4%) did not differ from overall ELSO outcomes (69.7%, P = .870 and 50.7%, P = .136), as well as survival to discharge or transfer in a comparable cohort of ELSO centers (53.1%, P = .081). Patients with complications had a lower rate of survival to discharge or transfer but this did not reach statistical significance (47.7% vs. 75.0%, P = .455). Neurologic (50.0%), hemorrhagic (45.5%), and renal complications (31.8%) were most common in this cohort. A modified ventricular assist device‐based ECLS circuit with primary management by the bedside nurse can provide comparable support in a neonatal and pediatric cardiac surgery population. Cost analyses and further delineation of the complication profile are necessary for a complete characterization of this system.     

HandS ECMO: Preliminary Experience With “Hub and Spoke” Model in Neonates With Meconium Aspiration Syndrome

We aim to evaluate clinical outcomes of emergent extracorporeal membrane oxygenation (ECMO) implantation in newborns with life‐threatening meconium aspiration syndrome (MAS) in peripheral hospitals with Hub and Spoke (HandS) setting. We retrospectively reviewed all neonates presenting with MAS, with no other comorbidities, treated with HandS ECMO, in peripheral hospitals. Team activation time (TAT) was described as the time from first alerting call to ECMO support initiation. From May 2014 to December 2016, 4 patients met our inclusion criteria. In addition, 2 cases occurred on the same day, requiring a second simultaneous HandS ECMO team activation. All patients were younger than 8 days of life (1, 1, 4, and 7), with a mean BSA 0.21 ± 0.03m², and TAT of 203, 265, 320, and 340 min. One patient presented ventricular fibrillation after priming administration. Veno‐arterial ECMO was established in all patients after uneventful surgical neck vessels cannulation (right carotid artery and jugular vein). Mean time from skin incision to ECMO initiation was 19 ± 1.4 min. Mean length of ECMO support was 2.75 ± 1.3 days. All patients were weaned off support without complications. At a mean follow up of 20.5 ± 7.8 months, all patients are alive, with no medications, normal somatic growth, and neuropsychological development. MAS is a life‐threatening condition that can be successfully managed with ECMO support. A highly trained multidisciplinary HandS ECMO team is crucial for the successful management of these severely ill newborns in peripheral hospitals.     

Out-of-center extracorporeal membrane oxygenation for adult cardiogenic shock patients

Patients with cardiogenic shock refractory to conventional management require advanced mechanical circulatory support such as extracorporeal membrane oxygenation (ECMO). In hospitals lacking ECMO facilities, interhospital transportation is necessary for further patient management. Thirty-one adult cardiac patients, who were transported to our hospital by our ECMO transport team between January 1998 and July 2004, were enrolled in this study. The median transportation distance was 200 km (range: 3-300 km). During transportation, the ECMO circuit per se and the patients did not have complications. Of the 31 patients, 20 (64.2%) were weaned off ECMO or bridged to ventricular assist devices and 10 patients (32.1%) survived to discharge. Delayed transfer (>2 days) and high organ dysfunction score were associated with poor outcomes. The survival rate was similar to that of our in-hospital group (survival rate: 32.8%, n = 64). In conclusion, adult cardiogenic shock patients requiring interhospital ECMO transport had a reasonable chance of survival.     

肺移植研究现状及移植期的规范化管理

肺移植是终末期肺疾病患者唯一的治疗手段,该领域也是目前国际范围内的研究热点。相关研究既促进了肺移植的进步与发展,也改善了移植后患者的生活质量。随着肺移植技术的发展,适应人群相关指南不断修订,供体肺来源也一直是所有移植中心亟待解决的问题。移植期的规范化管理涉及麻醉诱导、术中液体管理、气道管理、重要步骤的处理及术后疼痛管理等方面。体外生命支持(ECLS)包括体外循环(CPB)及体外膜肺氧合(ECMO)。随着ECLS技术的发展,ECMO作为肺移植桥梁在术中及术后循环支持中的优更加突出,帮助受体患者顺利度过肺移植窗口期。虽然肺移植在基础科学和临床研究方面都有许多进展,但要提高移植后的生存率,还须克服包括如何成功完成肺移植、扩大肺供体库、诱导耐受、预防移植后并发症、原发性移植物功能障碍(PGD)、细胞和抗体介导的排斥反应以及感染等在内的诸多问题。     

Extracorporeal Life Support After Cardiac Surgery in Children: Outcomes From a Single Institution

Extracorporeal life support (ECLS) is used after congenital heart surgery for several indications, including failure to separate from cardiopulmonary bypass, postoperative low cardiac output syndrome, and extracorporeal cardiopulmonary resuscitation. Here, we assessed the outcomes of ECLS in children after cardiac surgery at our institution. Medical records of all children who required postoperative ECLS at our institution were reviewed. Between 2003 and 2011, 36 (1.4%) of 2541 pediatric cardiac surgical cases required postoperative ECLS. Median age of patients was 64 days (range: 0 days–4.1 years). ECLS was in the form of either extracorporeal membrane oxygenation (ECMO; n = 24) or ventricular assist system (VAS; n = 12). Mean duration of ECLS was 4.9 ± 4.2 days. Overall, 21 patients (58%) were weaned off ECLS, and 17 patients (47%) were successfully discharged from the hospital. Patients with biventricular heart (BVH) had higher survival‐to‐hospital discharge rates compared with those with univentricular heart (UVH) (P = 0.019). Regarding ECLS type, UVH patients who received VAS showed higher rates of device discontinuation than UVH patients who received ECMO (P = 0.012). However, rates of hospital discharge were not significantly different between UVH patients who received VAS or ECMO. Surgical interventions, such as banding of Blalock–Taussig shunt to reduce pulmonary blood flow or placing bidirectional cavopulmonary shunt to minimize ventricular volume overload, were effective for weaning off ECLS in patients with UVH. ECLS is beneficial to children with low cardiac output after cardiac surgery. Rates of survival‐to‐hospital discharge were higher in BVH patients than UVH patients. Additional interventions to reduce ventricular volume load may be effective for discontinuing ECLS in patients with UVH.     

Pediatric Single‐Lumen Cannula Venovenous Extracorporeal Membrane Oxygenation: A French Center Experience

Single‐lumen cannula venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a special extracorporeal life support (ECLS) technique used for neonatal and pediatric refractory hypoxemia. This is an alternative flow rate ECLS that consists of successive clamping on the drainage and the injection lines. Currently, the Armand‐Trousseau's pediatric intensive care unit remains the only pediatric ECMO center proposing this partial assistance. This article details a technical note and a retrospective analysis of our experience in refractory hypoxemia. The retrospective study, from 2007 to 2011, included all pediatric and neonatal patients treated by single‐lumen cannula VV ECMO. The study was focused on pre‐ECMO patient characteristics and complications during ECMO course. During the last 5 years, 67 pediatric patients were assisted by this single‐lumen cannula VV ECMO. Sixty‐one patients (91%) were newborns. Thirty‐nine patients presented with meconium aspiration syndrome (58%), which was the most frequent etiology. Before cannulation, mean oxygenation index (OI) was 32 ± 11, alveolar‐arterial oxygen difference was 604 ± 47 mm Hg, and partial pressure arterial oxygen/fraction inspired oxygen ratio was 59.2 ± 35.8. Forty‐eight patients (72%) presented pulmonary hypertension, and 66 patients were treated by nitric oxide (98%). Fifty patients (75%) were treated by vasopressors or inotropic drugs. Average duration of ECMO was 13.2 ± 7.8 days. There were forty‐six survivors (69%). The worst prognosis was for respiratory syncytial virus pneumonia. Complications like acute renal injury and hematologic and transfusion acts were not so different than those observed in classical ECMO techniques. Nevertheless, 19 patients presented a stroke (28% of the overall population), but this high rate did not seem to be due to the ECLS technique used. Single‐lumen cannula VV ECMO is a partial and efficient ECMO support. Our experience shows that this technique is as efficient and less invasive than two cannulas ECMO. The single‐lumen cannula VV ECMO is a simple and safe ECLS support used for neonatal or pediatric refractory hypoxemia. Because this is a partial assistance, it is a promising ECLS support.     

Extracorporeal membrane oxygenation as a bridge vs. non‐bridging for lung transplantation: A systematic review and meta‐analysis

Whether extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) can achieve a similar survival to non‐BTT remains controversial. We conducted this meta‐analysis to compare the outcomes between ECMO BTT and non‐BTT to facilitate better clinical decision‐making. Seven databases were searched for eligible studies comparing ECMO BTT and non‐BTT. The primary endpoints included survival, intraoperative indicators, postoperative hospitalization indicators, and postoperative complications. Nineteen studies (involving 7061 participants) were included in the final analysis. The outcomes of overall survival, overall survival rate, graft survival rate, in‐hospital mortality, postoperative hospital days, postoperative intensive care unit days, postoperative ventilation time, blood transfusion volume, and postoperative complications were all better in the non‐BTT group. The total mortality in ECMO bridging was 23.03%, in which the top five causes of death were right heart failure (8.03%), multiple organ failure (7.03%), bleeding (not cranial) (4.67%), cranial bleeding (3.15%), and sepsis (2.90%). In summary, Non‐BTT is associated with better survival and fewer complications compared to BTT. When ECMO may be the only option, the patient and medical team need to realize the increased risk of ECMO by complications and survival.     

Erstellung einer S3-Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“

In Germany, the ever-increasing use of mechanical extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed over the last few years. In 2015, more than 2,800 ECLS/ECMO implantations were carried out in Germany. Despite this widespread use of the systems, the only national and international guidelines that are available are those in which the use of ECMO/ECLS is described as just one aspect of complex treatment cascades for various illnesses. Against this background it appears necessary to draft evidence-based recommendations on the complex management of patients who need and receive ECMO/ECLS treatment, in which staff-related, procedural and infrastructural requirements are defined.Therefore, in July 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered an S3 guideline with the Association of Scientific Medical Societies in Germany (AWMF).The aim of this interdisciplinary and multiprofessional guideline is to provide substantiated recommendations on the use of extracorporeal procedures (extracorporeal life support/extracorporeal membrane oxygenation) in cases of cardiac, circulatory, and cardiopulmonary failure.With the aim of drawing up a methodically high-quality guideline, the project management was designed according to the internationally accepted quality criteria for guidelines, “The Appraisal of Guidelines for Research and Evaluation” (AGREE) and the Germany Guideline Evaluation Instrument (DELBI).     

Clinical outcomes of neonatal and pediatric extracorporeal life support: A seventeen‐year,single institution experience

The objective of this study was to describe a single‐center experience with neonatal and pediatric extracorporeal life support (ECLS) and compare patient‐related outcomes with those of the Extracorporeal Life Support Organization (ELSO) Registry. A retrospective review of subject characteristics, outcomes, and complications of patients who received the ECLS at Penn State Health Children’s Hospital (PSHCH) from 2000 to 2016 was performed. Fisher’s exact test was used to compare the PSHCH outcomes and complications to the ELSO Registry report. Data from 118 patients were included. Survival to discontinuation of the ECLS was 70.3% and 65.2% to discharge/transfer. Following circuitry equipment changes, the survival to discharge/transfer improved for both neonatal (<29 days) and pediatric (29 days to <18 years) patients. The most common complications associated with ECLS were clinical seizures, intracranial hemorrhage, and culture‐proven infection. ECLS for pulmonary support appeared to be associated with a higher risk of circuit thrombus and cannula problems. When compared to the ELSO Registry, low volume ECLS centers, like our institution, can have outcomes that are no different or statistically better as noted with neonatal and pediatric cardiac patients. Pediatric patients requiring pulmonary support appeared to experience more mechanical complications during ECLS suggesting the need for ongoing technological improvement.     

Outcomes of congenital heart surgery patients after extracorporeal life support at Texas Children's Hospital

The objective of this study was to investigate the outcomes of children with heart failure of various etiologies requiring temporary use of currently available technology in the U.S.A. after extracorporeal life support (ECLS) [left ventricular assist device (LVAD) or extracorporeal membrane oxygenation (ECMO)] at Texas Children's Hospital. Between July of 1995 and October of 2002, 2847 patients underwent congenital heart surgical repairs with the aid of cardiopulmonary bypass at Texas Children's Hospital. During this period, 17 patients required chronic mechanical circulatory assistance with Biomedicus centrifugal pump (n=8) or Thoratec LVAD (n=4), and ECMO (n=5). Six out of 17 patients required ECLS for postcardiotomy heart failure. Seven of the 17 patients had congenital heart disease, six had cardiomyopathy, three had late acute rejection following heart transplantation, and one had myocardial infarction. Twelve patients survived and five patients expired. Six of 12 survivors recovered sufficient cardiac function to allow device removal; and the remaining six patients underwent heart transplantation. Three out of five deaths were ECMO patients. The need for ECLS following repair of congenital heart disease is extremely rare in our institution. The requirement for the use of ECMO confers a significantly higher mortality presumably because of associated combined cardiopulmonary failure. Congenital heart disease appears to be associated with significantly higher mortality.     

Extrakorporale Membranoxygenierung

Altough the concept of extracorporeal membrane oxygenation (ECMO) therapy has been established and used for over 30 years, in recent years the number of implanted ECMO systems has increased and it has developed into an integral component of the clinical routine. All forms of ECMO therapy can be summarized under the term extracorporeal life support (ECLS). The latest developments are surface-coated and miniaturized ECMO systems which allow the long-term support of critically ill patients. Severe lung failure with a normal cardiac index is treated by venovenous ECMO (vv-ECMO). The interventional lung assist/pumpless extracorporeal lung assist (iLA/PECLA) systems are mostly indicated for hypercapnic respiratory acidosis as is frequent with acute respiratory distress syndrome (ARDS). The support of ARDS patients with ECMO seems to improve outcome by allowing further protective lung ventilation. Cardiopulmonary failure is treated by venoarterial ECMO (va-ECMO) and is often used in an interdisciplinary setting in emergency rooms where survival of these patients is increased by up to 40%. Although clear indications are defined only a few risk analyses have been carried to show which patients benefit most from va-ECMO. The decision whether to implant a va-ECMO or not is still based on center and physician experience. To guarantee safe and high quality treatment for patients interdisciplinary ECMO therapy has to be regulated in the near future. New concepts for ECMO therapy, e.g. the total artificial lung concept or the long-term treatment of patients with pulmonary hypertension with ECMO need further clinical observation and testing.     

Neonatal extra corporeal membrane oxygenation

Extracorporeal life support (ECLS) has been proven to be very useful in the neonatal period. For reversible respiratory and cardiac disorders, when maximal conventional measures have failed to provide life support, extracorporeal membrane oxygenation (ECMO) becomes the treatment of choice. The indications, contra-indications for ECMO, optimization of the care prior to embracing ECMO, cannulation techniques, daily management of ECMO from the practical standpoint, weaning and decannulation, complications, and special circumstances in neonatal period have been described. The follow-up of neonatal ECMO and various system manifestations necessitating careful review will be highlighted.     

Transfert interhospitalier sous assistance circulatoire extracorporelle (ECMO) : l’expérience martiniquaise

Objective

The transportation of critically ill patients in the French West Indies represents a real challenge; in order to ensure territorial continuity of health care provision, the cardiac surgical department of the Fort-de-France Hospital created a mobile ECMO/ECLS unit. The aim of our work is to describe the logistical, technical and financial aspects of the interhospital transfer of ECMO/ECLS-assisted patients in the French Caribbean.

Patients and methods

All ECMO/ECLS-assisted patients in the French Antilles-Guyane area subsequently repatriated towards the Fort-de-France Hospital were included from December 29th, 2009 to September 30th, 2011. Indication and type of the extracorporeal assistance used, location of departure, type of transport vehicle, complications during transfer, survival after hospital discharge and direct costs were collected.

Results

Nineteen patients were supported by our mobile unit far away from our centre (sex-ratio 0.63, median age 34 years old [16–64]). Twelve were assisted by ECMO for a refractory ARDS, and seven were assisted by ECLS for a refractory cardiogenic shock. Four patients were transferred by ambulance (7–29 km), seven by helicopter (190–440 km), and eight by plane (440–1430 km). No patient died during transfer. No major adverse event occurred during these transfers. Fifteen patients survived. An economic assessment was conducted.

Conclusion

Interhospital transfer of ECMO/ECLS-assisted patients by land or air is technically feasible under perfectly secure conditions in our area. Prior coordination of this activity has helped to make it affordable.     

Mechanical Ventilation and Extracorporeal Membrane Oxygenation as a Bridging Strategy to Lung Transplantation: Significant Gains in Survival

Mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO) are increasingly used to bridge patients to lung transplantation. We investigated the impact of using MV, with or without ECMO, before lung transplantation on survival after transplantation by performing a retrospective analysis of 826 patients who underwent transplantation at our high‐volume center. Recipient characteristics and posttransplant outcomes were analyzed. Most lung transplant recipients (729 patients) did not require bridging; 194 of these patients were propensity matched with patients who were bridged using MV alone (48 patients) or MV and ECMO (49 patients). There was no difference in overall survival between the MV and MV+ECMO groups (p = 0.07). The MV+ECMO group had significantly higher survival conditioned on surviving to 1 year (median 1,811 days ([MV] vs. not reached ([MV+ECMO], p = 0.01). Recipients in the MV+ECMO group, however, were more likely to require ECMO after lung transplantation (16.7% MV vs. 57.1% MV+ECMO, p < 0.001). There were no differences in duration of postoperative MV, hospital stay, graft survival, or the incidence of acute rejection, renal failure, bleeding requiring reoperation, or airway complications. In this contemporary series, the combination of MV and ECMO was a viable bridging strategy to lung transplantation that led to acceptable patient outcomes.     

Morbidity of conversion from venovenous to venoarterial ECMO in neonates with meconium aspiration or persistent pulmonary hypertension

BackgroundOutcomes in neonates receiving extracorporeal membrane oxygenation (ECMO) for meconium aspiration syndrome (MAS) and/or persistent pulmonary hypertension (PPHN) are favorable. Infants with preserved perfusion are often offered venovenous (VV) support to spare morbidities of venoarterial (VA) ECMO. Worsening perfusion or circuit complications can prompt conversion from VV-to-VA support. We examined whether outcomes in infants requiring VA ECMO for MAS/PPHN differed if they underwent VA support initially versus converting to VA after a VV trial, and what factors predicted conversion.MethodsWe reviewed the Extracorporeal Life Support Organization registry from 2007 to 2017 for neonates with primary diagnoses of MAS/PPHN. Propensity score analysis matched VA single-runs (controls) 4:1 against VV-to-VA conversions based on age, pre-ECMO pH, and precannulation arrests. Primary outcomes were complications and survival. Data were analyzed using Mann–Whitney U and Fisher's exact testing. Multivariate regression identified independent predictors of conversion for VV patients.Results3831 neonates underwent ECMO for MAS/PPHN, including 2129 (55%) initially requiring VA support. Of 1702 patients placed on VV ECMO, 98 (5.8%) required VV-to-VA conversion. Compared with 364 propensity-matched isolated VA controls, conversion runs were longer (190 vs. 127 h, P < 0.001), were associated with more complications, and decreased survival to discharge (70% vs. 83%, P = 0.01). On multivariate regression, conversion was more likely if neonates on VV ECMO did not receive surfactant (OR = 1.7;95%CI = 1.1–2.7;P = 0.03) or required high-frequency ventilation (OR = 1.9;95%CI = 1.2–3.3;P = 0.01) before ECMO.ConclusionConversion from VV-to-VA ECMO in infants with MAS/PPHN conveys increased morbidity and mortality compared to similar patients placed initially onto VA ECMO. VV patients not receiving surfactant or requiring high-frequency ventilation before cannulation may have increased risk of conversion. While conversions remain rare, decisions to offer VV ECMO for MAS/PPHN must be informed by inferior outcomes observed should conversion be required.Level of evidenceLevel of evidence 3Retrospective comparative study.     

Pediatric arteriovenous extracorporeal membrane oxygenation (ECMO) as a bridge to cardiac transplantation.

BACKGROUND: Since 1990, extracorporeal membrane oxygenation (ECMO) has been used as a bridge to cardiac transplantation in 47 patients. METHODS: A review of the ECMO database, approved by the Arkansas Children's Hospital institutional review board, forms the basis of this report. We made statistical comparison using Fisher's exact probability testing. The ECMO circuitry was a roller occlusion pump with computer-assisted perfusion system technology. RESULTS: Thirty-two (68%) patients underwent transcatheter septostomy for cardiac decompression. Diagnosis at presentation was either congenital heart disease (CHD, n = 15) or cardiomyopathy (n = 32). Ages ranged from 1 day to 22 years old (median, 18 months old), and weight ranged from 2.9 to 100 kg (median, 10 kg). The average duration of support was 242 hours (range, 22-1078 hours). Overall long-term survival was 47%, with 16 (34%) patients successfully bridged to cardiac transplantation (of which 9 [56%] survived) and 13 (28%) successfully weaned from ECMO. Patients undergoing ECMO after cardiotomy had 31% survival. Survival was improved significantly (p < 0.02) in patients with cardiomyopathy (59%) vs those with CHD (20%). Patients with cardiomyopathy underwent 8 transplantations with 7 survivors (88%), whereas in the CHD group, there were 8 transplantations with only 2 survivors (25%), p < 0.05. Sub-analysis of the cardiomyopathy group revealed that patients with acute cardiomyopathy in association with documented viral illness had a 75% chance of being weaned from ECMO without undergoing transplantation. Complications during ECMO occurred in 45% of survivors and were more frequent in non-survivors. Infectious complications were most frequent, followed by neurologic complications, technical ECMO problems, and renal insufficiency. CONCLUSIONS: Patients with cardiomyopathy has a better prognosis than did those with CHD when using ECMO as a bridge to transplantation or survival. Complications are significant and increase with the duration of support. Extracorporeal membrane oxygenation for salvage and subsequent transplantation in this high-risk group of patients requires critical review. Alternative support options must be developed in the pediatric population that will allow improved outcomes, comparable with outcomes achieved in the adult population.     

Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A (H1N1) 2009 infection in Canada

Background

From March to July 2009, influenza A (H1N1) 2009 (H1N1-2009) virus emerged as a major cause of respiratory failure that required mechanical ventilation. A small proportion of patients who had this condition developed severe respiratory failure that was unresponsive to conventional therapeutic interventions. In this report, we describe characteristics, treatment, and outcomes of critically ill patients in Canada who had H1N1-2009 infection and were treated with extracorporeal lung support (ECLS).

Methods

We report the findings of a case series of six patients supported with ECLS who were included in a cohort study of critically ill patients with confirmed H1N1-2009 infection. The patients were treated in Canadian adult and pediatric intensive care units (ICUs) from April 16, 2009 to August 12, 2009. We describe the nested sample treated with ECLS and compare it with the larger sample.

Results

During the study period, 168 patients in Canada were admitted to ICUs for severe respiratory failure due to confirmed H1N1-2009 infection. Due to profound hypoxemia unresponsive to conventional therapeutic interventions, six (3.6%) of these patients were treated with ECLS in four ICUs. Four patients were treated with veno-venous pump-driven extracorporeal membrane oxygenation (vv-ECMO), and two patients were treated with pumpless lung assist (NovaLung iLA). The mean duration of support was 15 days. Four of the six patients survived (66.6%), one of the surviving patients was supported with iLA and the other three surviving patients were supported with ECMO. The two deaths were due to multiorgan failure, which occurred while the patients were on ECLS.

Interpretation

Extracorporeal lung support may be an effective treatment for patients who have H1N1-2009 infection and refractory hypoxemia. Survival of these patients treated with ECLS is similar to that reported for patients who have acute respiratory distress syndrome of other etiologies and are treated with ECMO.     

Outcome after recannulation and a second course of extracorporeal membrane oxygenation

Background/Purpose: Controversy surrounds the justification of a second course of extracorporeal membrane oxygenation (ECMO) for patients that deteriorate after initial decannulation. The authors' experience with a small number of patients requiring recannulation led them to investigate the results of a second ECMO course from all institutions that report to the ELSO registry. Methods: The ELSO neonatal registry for patients that underwent multiple ECMO courses was reviewed and mortality and complication rates between first and second courses were compared. Complications were classified according to the following ELSO registry defined categories: hemorrhagic, mechanical, metabolic, infectious, renal, pulmonary, neurologic, and cardiac. Results: Of the 16,450 patients in the ELSO neonatal registry in January 2000, 205 patients (1.25%) have required multiple ECMO courses. There have been 201 patients (1.22%) who have needed 2 courses of ECMO and 4 patients (0.024%) have undergone 3 ECMO runs. A total of 557 complications occurred during the first ECMO course in these 205 patients, and 672 complications developed during the second course. This represents an increase in the complication rate by 20.6% during the second ECMO course. Although mechanical complications were the most common, there was no change in the incidence between first and second courses. However, the frequency of complications increased in all other classifications during the second course when compared with the first. The largest increases occurred with neurologic and infectious complications (134% and 79% increases, respectively). Renal and metabolic complications also were markedly elevated (35% and 24%, respectively). Seventy-six of 201 (38%) patients who required 2 courses of ECMO and 1 of 4 patients undergoing 3 runs survived. Survival was more likely for patients with meconium aspiration. Primary pulmonary hypertension and total anomalous pulmonary venous return had low survival rates. Conclusions: A small subset of patients may require recannulation and a second ECMO course. Although survival may be achieved in more than one third of these patients, complication rates are increased during the second course. Specifically, neurologic, infectious, renal, and metabolic complication rates are increased. Long-term consequences of recannulation are unknown. Selection criteria identifying patients that may benefit from recannulation have not been established. J Pediatr Surg 37:845-850.     

A prospective,randomized pilot trial of perfluorocarbon-induced lung growth in newborns with congenital diaphragmatic hernia

Background/Purpose: Initial laboratory and clinical data suggest that partial liquid ventilation (PLV) can enhance pulmonary function and that lung growth can be induced via distension of the newborn lung using perfluorocarbon in patients with congenital diaphragmatic hernia (CDH). The authors, therefore, performed a prospective, randomized pilot study evaluating PLV and perfluorocarbon-induced lung growth (PILG) in newborns with CDH on extracorporeal life support (ECLS) at 6 medical centers. Methods: Patients were selected randomly using a permuted block design to PLV/PILG (n = 8) or conventional mechanical ventilation (CMV/control, n = 5). Patients in the PILG group received daily doses which filled the lungs with perflubron for up to 7 days and were placed on continuous positive airway pressure of 5 to 8 cm H₂O. CMV patients were treated with standard mechanical ventilation while on extracorporeal membrane oxygenation (ECMO). Results: A total of 13 patients were evaluated in this study. All 3 patients enrolled without being on ECLS rapidly transitioned to ECLS. The study, therefore, effectively evaluated PILG (n = 8) versus standard ventilation (control, n = 5) on ECLS. Mean ([plusmn] SE) gestational age was 37 [plusmn] 1 weeks and weight was 3.1 [plusmn] 0.1 kg. Time on ECMO was 9.8 [plusmn] 2.3 days in the PILG and 14.5 [plusmn] 3.5 days (P = .58) in the control group. Survival rate in the PILG group was 6 of 8 (75%), whereas survival rate was 2 of 5 (40%) in the control group (P = .50). The number of days free from the ventilator in the first 28 days (VFD) was 6.3 [plusmn] 3.3 days with PILG and 4.6 [plusmn] 4.6 days with control (P = .9). Causes of death in the PILG group included sepsis and renal failure in one patient and pulmonary hypertension in the other. There were no safety issues, and the deaths in the PILG group did not appear to be related to the administration of perflubron. Conclusions: These data show that PILG can be performed safely. The survival rate, VFD, and time on ECMO data, although not conclusive, are encouraging and indicate the need for a definitive trial of this novel intervention in these neonates with high mortality. J Pediatr Surg 38:283-289.