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   

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.     

The efficacy of extracorporeal membrane oxygenation (ECMO) in newborns with septic shock

The efficacy of extracorporeal membrane oxygenation (ECMO) for patients with septic shock has not yet been documented with certainty. Seven septic newborns who were resistant to conventional therapy were managed by ECMO in our hospital, and five (71.4%) survived. Veno-arterial ECMO thus was very beneficial in supporting cardiorespiratory insufficiency due to septic shock. Ultrafiltration or hemodialysis carried out on a bypass route in the ECMO circuit was also beneficial in controlling the fluid and electrolytic imbalance often encountered in septic newborns. On the other hand, despite activated clotting times being maintained at relatively low levels compared to non-septic cases, major hemorrhagic complications occurred in more than one-half of the cases and became the main cause of death in two. Some modifications will therefore be necessary in ECMO practice for septic newborns. Correspondence to: M. Nagaya     

体外膜肺氧合术后并发颅内出血的治疗总结

目的探讨儿童体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)术后颅内出血的诊断、治疗及预后。方法回顾性分析2011年1月至2018年6月复旦大学附属儿科医院ECMO病例,7年来共行ECMO治疗89例,ECMO治疗期间出现颅内出血6例(6.7%)。6例颅内出血病例中,男4例、女2例,年龄1 d至11岁;爆发型心肌炎1例,重症肺炎5例;院外ECMO置管转运2例;平均ECMO时长为126.8 h,范围为28.0~229.5 h。收集ECMO治疗过程中颅内出血患儿的临床资料,总结诊疗经过,分析婴幼儿ECMO并发颅内出血的危险因素、早期诊断、治疗。结果爆发型心肌炎2例瞳孔不等大后行CT检查、1例偏瘫后行MRI检查、2例例行B型超声检查、1例例行MRI检查后诊断颅内出血。硬膜下1例、深部脑组织1例、脑叶4例。2例经手术治疗(硬膜外1例、脑叶1例),2例保守治疗,2例家属放弃治疗后死亡。手术患儿GOS评分:硬膜外出血5分,脑叶内出血4分(偏瘫)。结论颅内出血是ECMO术后严重的出血性并发症,早期明确诊断及手术治疗可改善预后。     

Expanding neonatal ECMO criteria: When is the premature neonate too premature

Extracorporeal membrane oxygenation (ECMO) is a universally accepted and life-saving therapy for neonates with respiratory or cardiac failure that is refractory to maximal medical management. Early studies found unacceptable risks of mortality and morbidities such as intracranial hemorrhage among premature and low birthweight neonates, leading to widely accepted ECMO inclusion criteria of gestational age ≥34 weeks and birthweight >2 kg. Although contemporary data is lacking, the most recent literature demonstrates increased survival and decreased rates of intracranial hemorrhage in premature neonates who are supported with ECMO. As such, it seems like the right time to push the boundaries of ECMO on a case-by-case basis beginning with neonates 32–34 weeks GA in large volume centers with careful neurodevelopmental follow-up to better inform practices changes on this select population.     

Pertussis with severe pulmonary hypertension and leukocytosis treated with extracorporeal membrane oxygenation

Pertussis, or “whooping cough,” is a highly communicable disease caused by the coccobacillus Bordetella pertussis. Pertussis remains one of the most common causes of death from infectious diseases worldwide. We describe a 5-week-old infant girl who presented with severe pertussis infection associated with extreme leukocytosis and required prolonged extracorporeal membrane oxygenation (ECMO). Nitric oxide therapy resolved the pulmonary hypertension, and she was successfully weaned from ECMO and discharged home after 3 months. We report successful application of ECMO for severe pertussis-induced respiratory failure despite multiple grave prognostic indicators (<1 year age, leukocytosis, pulmonary hypertension) and discuss the role of extracorporeal life support in treating pertussis.     

Changes in amplitude-integrated electroencephalography in neonates treated with extracorporeal membrane oxygenation: a pilot study

Neonates (n = 20) treated with extracorporeal membrane oxygenation were evaluated with serial amplitude-integrated electroencephalography (aEEG). There was no acute change in aEEG during extracorporeal membrane oxygenation cannulation, nor were there lateralizing effects. An abnormal aEEG predicted death or moderate to severe intracranial neuropathology with sensitivity = 1.0, specificity = 0.75, positive predictive value = 0.86, and negative predictive value = 1.0.     

Histopathological features of open lung biopsies in children treated with extracorporeal membrane oxygenation (ECMO)

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has become an established treatment for severe respiratory distress in a range of pediatric conditions. This study describes the histopathological features in a series of 22 children receiving ECMO therapy in whom open lung biopsy was carried out. AIMS: To describe the histopathological features of open lung biopsies in children receiving ECMO therapy. STUDY DESIGN: Retrospective review of clinical material. SUBJECTS: Children receiving ECMO therapy in whom open lung biopsy was carried out. RESULTS: In those investigated in infancy, open lung biopsy allowed a definite diagnosis to be made of the underlying condition in more than 90% of cases. In older children, the histopathological changes were more non-specific and, although providing useful clinical information, a definitive diagnosis could often not be made. In about a quarter of cases, there are additional pathological features, which may be related to ECMO treatment, such as significant intra-alveolar haemorrhage, but ECMO does not in itself impair the diagnostic usefulness of open lung biopsy in these selected patients. CONCLUSION: Open lung biopsy provides clinically useful information in infants receiving ECMO therapy. The histopathological changes may be complex and represent both the effects of ECMO and progression of the underlying disease.     

Significance of seizures associated with extracorporeal membrane oxygenation

We previously reported a predominance of left focal motor seizures in infants receiving extracorporeal membrane oxygenation (ECMO), raising concerns about possible ischemia resulting from the right common carotid artery ligation. We therefore evaluated the neurologic and psychologic outcome at 2 years of age of all infants with ECMO-related seizures. Although 8 of 12 infants had left focal seizures in infancy, there was no lateralization of motor findings at 2 years of age; left hemiparesis was present in three of the infants and right hemiparesis in three. The developmental quotient was normal in 6 of 12 infants, low-average in three, borderline in two, and in the mentally handicapped range in one. We conclude that any ischemia resulting from carotid ligation is not great enough to produce long-term lateralizing findings but that seizures during ECMO are a risk factor for later cerebral palsy or developmental delay.     

Perioperative extracorporeal membrane oxygenation for tracheal reconstruction in congenital tracheal stenosis

The management of a critical airway in infants and toddlers with congenital tracheal stenosis (CTS) continues to be an enormous challenge to the surgeon. Until recently, this condition often proved fatal. Improvements in surgical techniques, anesthetic management, and postoperative critical care have resulted in successful outcomes in children not long ago considered untreatable. However, issues such as the best operative approach and the optimal perioperative management are still unresolved. The diagnosis of CTS, often delayed, must be considered in any infant with stridor, wheezing, cyanosis, or recurrent episodes of pneumonia. Associated anomalies are the rule, including frequently vascular rings and rarely pulmonary agenesis. These defects can be repaired with conventional ventilatory support under cardiopulmonary bypass, or using extracorporeal membrane oxygenation (ECMO). We report our experience in which ECMO was used to support two patients with CTS during the perioperative period. ECMO proved to be both safe and practical, allowing unrushed, precise repair of the tracheal stenosis and providing brief postoperative support. Perioperative outcomes were excellent, although one of our patients died months after the repair. A review of the literature and our experience in which ECMO was used to provide cardiopulmonary support during repair of CTS showed uniformly successful perioperative outcomes. Accepted: 3 November 1998     

Repeat extracorporeal membrane oxygenation in a neonate: An alternative method for cannulation

Cannulation for repeat extracorporeal membrane oxygenation (ECMO) in neonates with respiratory failure may be associated with technical difficulties, especially after the ligation of both the carotid artery and internal jugular vein. In a newborn who required repeat ECMO, the previously reconstructed right carotid artery was used for arterial access. The right atrium was cannulated through a small submammary thoracotomy incision after the internal jugular vein was found to be thrombosed. This approach is relatively simple, provides excellent bypass flow, and is not associated with significant bleeding.     

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.     

12例心脏病术后患儿体外膜肺的临床结果及经验

目的回顾性总结分析阜外心血管病医院12例儿童体外膜肺氧合(ECMO)支持治疗的临床结果和经验。方法2004年12月~2005年12月共实施儿童ECMO病例12例,所有患儿均使用Medtronic ECMO系统,管道、氧合器及离心泵内膜采用全肝素涂抹技术,行静脉-动脉ECMO辅助,激活凝血时间维持146~258 s,肝素用量5~20 U/(kg.h)。辅助期间平均流量在40~220 ml/(kg.min)。结果ECMO支持时间55~266 h,平均120 h;9例(75%)顺利撤离ECMO,其中6例康复出院(67%),3例术后死亡,3例不能撤离ECMO而放弃治疗;总出院率为50%(6/12)。存活出院患儿EC-MO前的动脉血乳酸水平明显低于死亡患儿(P=0.022),两组患儿体重也存在统计学差异(P=0.019)。结论ECMO支持在儿童复杂先天性心脏病术后循环呼吸衰竭的治疗中是一种有效的机械辅助方法,同时可以作为心脏移植患儿等待供体期间的过渡桥梁。手术畸形纠治满意、尽早对心肺衰竭的患儿使用ECMO支持、避免重要脏器的不可逆损伤依然是ECMO成功的关键。     

Elevated S100B protein as an early indicator of intracranial haemorrhage in infants subjected to extracorporeal membrane oxygenation

The aim of this investigation was to verify whether plasma S100B could be a useful tool in identifying which infants subjected to extracorporeal membrane oxygenation (ECMO) might develop intracranial haemorrhage (ICH). A case-control study of eight infants who developed ICH during ECMO was conducted. Plasma samples collected daily after ECMO insertion were assessed for S100B and compared with those obtained from eight infants supported by ECMO who did not develop ICH. Cerebral ultrasound and Doppler velocimetry waveform patterns in the middle cerebral artery (MCA PI) were also recorded at the same time as blood sampling. S100B blood concentrations were significantly higher in the group of infants with ICH 72 h before any signs of haemorrhage could be detected by ultrasound (ICH: 2.91 +/- 0.91 microg/L vs. control: 0.53 +/- 0.15 microg/L), reaching their peak at day 6, when cerebral ultrasound scan patterns were suggestive of intracranial haemorrhage (ICH: 3.50 +/- 1.03 microg/L vs. control: 0.66 +/- 0.27 microg/L) (p < 0.05, for both). The highest S100B levels were observed in the three ICH infants who expired during the ECMO procedure (3.43 microg/L, 4.0 microg/L, 4.12 microg/L, respectively). MCA PI values in the ICH group were also significantly higher, but only 24 h before any ultrasound pattern of bleeding was detected (ICH: 2.31 +/- 0.22 vs control: 1.81 +/- 0.24) (p < 0.05). CONCLUSION: This study suggests that blood S100B measurement could be a promising tool for the identification of infants at risk of ICH when imaging assessment and clinical symptoms of haemorrhage might still be silent.     

儿童重症监护病房急性颅内出血病因和预后分析

目的调查儿童重症监护病区(PICU)急性颅内出血的病因和预后。方法对2000年1月~2004年12月我院PICU危重病患儿中,急性颅内出血患儿临床资料进行回顾性病因和预后分析。结果近5年来共收治急性颅内出血患儿58例,病因是迟发性维生素K(VitK)缺乏症28例,颅脑外伤16例,脑血管畸形6例,病毒性脑炎2例,血友病、血小板减少症、脑肿瘤破裂各1例,不明原因3例。其中15例放弃治疗,9例并发继发性脑梗塞。8例死亡(病死率13.8%)。结论迟发性VitK缺乏症和颅脑外伤是PICU小儿颅内出血的主要原因,预防性应用VitK或改变喂养方式可能降低婴儿早期颅内出血发病率。颅内出血预后较差,重在预防。     

The value of EEG and cerebral evoked potentials in the assessment of neonatal intracranial hemorrhage

The EEG, visual and auditory evoked potentials (VEP, AEP) were evaluated in 16 full-term newborn infants who had intracranial hemorrhage documented by computerized tomography (CT). Three of them had supratentorial, three, supra- and infratentorial hemorrhage, while the other ten had infra- or peri-tentorial bleeding. Three died during the neonatal period. Eight of the 13 surviving infants were neurologically normal and five were abnormal at the time of the follow-up. Those who had normal or mildly abnormal background EEGs all developed normally, while those whose neonatal EEG was severely abnormal subsequently developed neurological sequelae irrespective of the extent of intracranial hemorrhage. The EEG, VEP or AEP is of little value in the diagnosis of intracranial bleeding but the EEG is valuable in assessing the degree of associated parenchymatous damage and is of great prognostic significance.The authors are grateful to Professors Suzuki, Wada and Kageyama for their continued interest and encouragement