Dietrich W. Roloff

Extracorporeal membrane oxygenation in term newborns : a prospective cost-benefit analysis

Clinicians reserve ECMO for neonates at >80% predicted mortality risk. The authors hypothesized that ECMO instituted at lower (50%) mortality risk would result in fewer intensive care unit days and a lower hospital cost compared with conventional therapy (including ECMO at high mortality risk). This was a randomized control trial, cost-benefit analysis in an academic newborn intensive care unit. The patients were a prospectively studied, consecutive sample of 41 term neonates with 1) age 24-72 hours, 2) “maximal medical management” for > 6 hours, 3) oxygenation index (OI) values > 25 but < 40. (Severity of illness measured by OI=((mean airway pressure X FiO2 X 100) PaO2)). All eligible patients entered. Thirty-two of 37 survivors were evaluated at 1 year. Intervention occurred when OI = 25. Patients were randomized to ECMO or continued medical management (ECMO possible at OI = 40). Planned primary outcome measures were ICU days and hospital charges. Secondary measures were pulmonary and neurologic outcomes at discharge and 1 year. Twenty-two early ECMO patients, 19 controls, 14/19 met late ECMO criteria. Four patients died (two each group). No statistically significant difference was seen in hospital charges (early ECMO =

Venovenous perfusion in ECMO for newborn respiratory insufficiency. A clinical comparison with venoarterial perfusion

49,500 versus control=

Continuous negative pressure in themanagement of severe respiratory distress syndrome

53,7000), (95% confidence intervals= -

TRACHEAL ASPIRATE (TA) LECITHIN SPHINGOMYELIN RATIO (L/S) AND RECOVERY FROM RDS

3200 to +

Combined Positive and Negative Pressure Ventilation in the Management of Severe Respiratory Distress Syndrome in Newborn Infants

5100 more for controls) or ICU days (early =14 + 5 days versus control=19 + 12 days) (95% CI=- 0.8 to +10 more for controls). At 1 year the early group had a higher mental developmental index score (115 + 11) versus (103 + 18), (p = 0.07). Secondary analyses comparing early, late, and no ECMO showed trends toward decreased use of hospital resources and lower morbidity in the early group. The early use of ECMO does not increase hospital cost or utilization and suggests a lower morbidity rate for patients so treated.

1177 VENTILATOR MANAGEMENT AND PNEUMOTHORAX IN NEONATES WITH RDS

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) has been successful in the treatment of newborns less than 1 week of age and greater than 2000 gm birthweight with respiratory failure resistant to current medical and surgical management. While VA ECMO supports the heart as well as the lungs, it has the disadvantage of requiring carotid artery ligation and the possibility of perfusing air bubbles or particles into the arterial tree. We have treated 11 newborns with respiratory failure with venovenous (VV) ECMO returning the oxygenated blood to a cannula in the distal iliac vein. We compared these patients with 16 patients treated during the same period of time with VA ECMO. Three of the 11 VV patients required conversion to VA ECMO because of inadequate oxygenation and unstable hemodynamic situations. Ten of the 11 VV patients survived. Eleven of the 16 VA patients survived. The better survival in these patients treated with VV ECMO is attributed to their more favorable initial condition compared to patients treated with VA ECMO. The disadvantages of VV ECMO include a longer operative time to place the cannulas, groin wound problems, and persistent leg swelling along with the necessity to convert some patients to VA ECMO. Although this experience demonstrates that newborns with severe respiratory failure can be supported with VV ECMO, the complications and lack of practical advantages over VA lead us to recommend VA ECMO for routine clinical use at present.

Radionuclide cisternography in the preterm neonate

Fourteen infants with severe idiopathic respiratory distress syndrome were treated with a continuous negative pressure of −4 to −8 cm. H 2 O about the chest. Arterial oxygen tension rose significantly by a mean of 23.3±4.2 mm. Hg (p

BILIRUBIN ALBUMIN BINDING (BAB) ASSAY IN NEWBORN INFANTS BEFORE, DURING AND AFTER EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Previously we have demonstrated that changing TA L/S were associated with survival from RDS. In this current report L/S of serial TA obtained during the first 120 hrs. of life were examined in 30 infants with severe RDS requiring endotracheal intubation. The infants were divided into two groups by survival: survivors (S), n=19; non-survivors (NS), n=ll. The means of all L/S values per day in infants with at least three samples per 24 hr. period were calculated. In S 10/14 (71%), 10/12 (83%) and 9/9 (100%) infants had mean L/S > 2.5 on days 3, 4 and 5 respectively. In NS 1/5 (20%), 1/6 (17%) and 1/7 (14%) infants had mean L/S > 2.5 on days 3, 4 and 5 respectively. This difference was significant by day 4 (p < 0.05). Both S and NS were similar in their requirement for ventilatory support at 48 and 72 hrs. of life. At 96 and 120 hrs. there were significantly fewer S requiring mechanical ventilation. Thus, the attainment of a TA L/S > 2.5 by day 4 appears to be a chemical predictor of survival in infants with severe RDS.A significant observation in this study was that the attainment of a TA L/S > 2.5 on day 4 was independent of gestational age. This observation suggests that TA L/S is related to postnatal factors.

Use of phenobarbital for the prevention of neonatal intracranial hemorrhage: A controlled trial

Eleven newborn infants with severe respiratory distress syndrome (RDS) were artificially ventilated with an intermittent positive pressure respirator while a continuous negative pressure of ––4 to ––8

HYPEROXEMIA AND INCREASED MORTALITY IN PREMATURES

An apparent doubling of the incidence of pneumothorax in premature neonates mechanically ventilated for RDS prompted a comparison of ventilator therapy in these patients, past and present. In 1973-75, 16 of 16 infants treated for RDS developed pneumothorax/pneumomediastinum/pneumopericardium (PN) after intermittent mandatory ventilation using a Baby Bird respirator, while in 1976-77 the frequency of PN increased to 28 of 54 patients ventilated (p < 0.03). Record review demonstrated no differences in birth weight, severity of disease, age at intubation, interval from intubation to PN or mortality. Ventilator settings immediately prior to clinical evidence of PN showed similar peak pressures, PEEP, and FiO2. However, there were significant differences (p <0.01) in ventilator rates and flow rates:Between these periods a change in ventilator policy to using longer inspiratory times occurred. The association between lower flow and ventilatory rates and a higher incidence of PN suggests that either variable alone or in combination with longer inspiratory times may increase the risk for alveolar rupture and development of pneumothorax.