A.C. de Mol

Cerebral Aspects of Neonatal Extracorporeal Membrane Oxygenation: A Review

Background: Neonatal extracorporeal membrane oxygenation (ECMO) is a lifesaving therapeutic approach in newborns suffering from severe, but potentially reversible, respiratory insufficiency, mostly complicated by neonatal persistent pulmonary hypertension. However, cerebral damage, intracerebral hemorrhage as well as ischemia belong to the most devastating complications of ECMO. Objectives: The objectives are to give insights into what is known from the literature concerning cerebral damage related to neonatal ECMO treatment for pulmonary reasons. Methods: A short introduction to ECMO indications and technical aspects of ECMO are provided for a better understanding of the process. The remainder of this review focuses on outcome and especially on (potential) risk factors for cerebral hemorrhage and ischemia during ECMO treatment. Results: Although neonatal ECMO treatment shows improved outcome compared to conservative treatment in cases of severe respiratory insufficiency, it is related to disturbances in various aspects of neurodevelopmental outcome. Risk factors for cerebral damage are either related to the patients disease, EMCO treatment itself, or a combination of both. Conclusion: It is of ongoing importance to further understand pathophysiological mechanisms resulting in cerebral hemorrhage and ischemia due to ECMO and to develop neuroprotective strategies and approaches.

Major Sacrococcygeal Teratoma in an Extreme Premature Infant: A Multidisciplinary Approach

Antenatally diagnosed, large sacrococcygeal teratomas in very premature infants are associated with a very poor outcome. We present an extreme premature infant with cardiac decompensation, diagnosed at 27 weeks and 1 day of gestational age. A positive outcome could be achieved with intensive multidisciplinary planning of the delivery, postnatal stabilization and surgical resection, as demonstrated in this case report.

Intravascular volume administration: a contributing risk factor for intracranial hemorrhage during extracorporeal membrane oxygenation?

OBJECTIVE. The objective of this study was to determine the relationship between the frequency and total volume of intravascular volume administration and the development of intracranial hemorrhage during venoarterial extracorporeal membrane oxygenation. METHODS. In a retrospective, matched, case-control study, 24 newborns who developed an intracranial hemorrhage during venoarterial extracorporeal membrane oxygenation treatment were compared with 40 control subjects. Both groups were analyzed for gestational age, gender, race, Apgar scores at 1 and 5 minutes, birth weight, cardiopulmonary resuscitation before venoarterial extracorporeal membrane oxygenation, age at the start of treatment, duration of treatment, worst arterial blood gas sample preceding treatment, activated clotting time values, need for platelet transfusions, mean blood pressure, and the use of inotropics and steroids before the treatment. For both groups, total number and volume of intravascular infusions of normal saline, pasteurized plasma protein solution, erythrocytes, and platelets during the first 24 hours of treatment were determined. Variables were analyzed in their relationship to intracranial hemorrhage by using univariate and multivariate conditional logistic regression. RESULTS. The only statistically significant difference in patient characteristics between the case patients and control subjects was arterial blood gas values. Newborns who developed intracranial hemorrhage during the treatment received both a statistically significantly higher number and a statistically significantly higher total volume of intravascular volume administrations compared with control patients. After adjustment for pH, Paco2, and Pao2 in the multivariate analysis, we found a significant relation between the development of intracranial hemorrhage and >8 infusions or >300 mL of volume infusion in the first 8 hours and >10 infusions in the first 24 hours of treatment. CONCLUSIONS. The number and total volume of intravascular volume administration in the first 8 and 24 hours of venoarterial extracorporeal membrane oxygenation treatment are statistically significantly related to the development of intracranial hemorrhage.

Abnormalities of coagulation related to the use of inhaled nitric oxide before extracorporeal membrane oxygenation.

Objective: Evaluation of the influence of previous inhaled nitric oxide (iNO) treatment on the occurrence of clotting complications and disseminated intravascular coagulation during extracorporeal membrane oxygenation (ECMO). Design: Retrospective study in newborns treated with venoarterial ECMO during a 5-yr period. Setting: Neonatal intensive care unit of a university medical center. Patients: A total of 59 newborns with severe respiratory insufficiency treated with venoarterial ECMO. Interventions: Patients received iNO before ECMO (iNO group) or not (control group). Measurements and Main Results: There were no differences between the groups for patient characteristics and medication use before ECMO, except for norepinephrine. After correction for diagnosis and duration of ECMO, significantly more clotting complications and disseminated intravascular coagulation as individual variables were seen in the iNO group. For the combination of clotting complications and disseminated intravascular coagulation, there was a significantly higher prevalence in the iNO group. Conclusions: In our population, we found a remarkable relationship between clotting complications or disseminated intravascular coagulation and iNO use before ECMO treatment, which needs further prospective research before conclusions can be drawn.

Disturbed cerebral circulation during opening of the venoarterial bypass bridge in extracorporeal membrane oxygenation.

Purpose To describe the effects on cerebral blood flow velocity (CBFV) of intermittent opening of the venoarterial bridge (VA bridge) during venoarterial extracorporeal membrane oxygenation (VA-ECMO). Study design Prospective study in 22 newborns during VA-ECMO. CBFV was measured in the perical-losal artery by Doppler ultrasound. Changes in peak systolic flow velocity (PSV), end diastolic flow velocity (EDV) and time-averaged mean flow velocity (TAM) on day 1, 2, 3, and 5 and at low ECMO flow (50–150 ml/min) were analyzed (mean percentage±standard deviation (t-tests, p<0.05)). Changes >25% were considered relevant. The relationship between changes in CBFV and ECMO flow rate (Pearson correlation, p<0.01) was studied. Results Opening of the VA bridge resulted in statistically significant and relevant decreases in PSV (35 ± 18%), EDV (93 ± 15%) and TAM (68 ± 13%), persisting during the consecutive days of treatment. Smaller changes in CBFV at low ECMO flow were statistically significant and mostly relevant: PSV (15 ± 7%), EDV (76 ± 21%) and TAM (40 ± 12%). Changes in CBFV were positively correlated to the ECMO flow. Conclusion: Use of the VA bridge results in significant and relevant ECMO flow-dependent changes in CBFV, persisting during the treatment. The VA bridge should be used in such a way as to allow regular unclamping to be omitted.

IS-042 Neonatal Extracorporeal Membrane Oxygenation, Neuroimaging And Outcome

ECMO in neonates: neuroimaging findings and outcome Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for newborns with severe but reversible respiratory failure. Although ECMO has significantly improved survival, it is associated with substantial complications of which intracranial injuries are the most important. These injuries consist of haemorrhagic and non-haemorrhagic, ischaemic lesions. Different from the classical presentation of haemorrhages in preterm infants, in ECMO treated newborns haemorrhages are mainly parenchymal and with a high percentage in the posterior fossa area. There are conflicting data on the predominant occurrence of cerebral lesions in the right hemisphere. The existence of intracerebral injuries and the classification of its severity are the major predictors of neurodevelopmental outcome. This section will discuss the known data on intracranial injury in the ECMO population and the effect of ECMO on the brain. Abstract IS-042 Table 1 Neuroimaging score Abnormal finding Score Ventricular Dilatation (rw = 1) Minimal 1.0 Moderate 2.0 Marked 3.0 Subarachnoid Space (rw = 1) Wide interhemsipheric fissure 0.5 Large subarchnoid space 1.0 Haemorrhage (rw = 2) Subependymal only 0.5 Single petechial 0.5 Scattered petechial 1.0 Intraventricular 1.0 Small parenchymal (<1 cm) 1.5 Large parenchymal 3.0 Extraaxial small 0.5 Extraaxial large 1.0 Parenchymal lesions (rw = 3) Focal PVL or hypodensity 0.5 Focal atrophy 0.5 Patchy PVOL of hypodensity 2.0 Diffuse PVL or hypodensity 3.0 Mild generalised atrophy 2.0 Moderate generalised atrophy 3.0 Mass lesion/infaction 3.0 rw = relative weight.