Elisabetta Pasotti

Ultrasound-guided central venous cannulation in infants weighing less than 5 kilograms

Purpose Recent reports suggest that ultrasound-guided central venous cannulation may also be safe and effective in infants. This study aimed to evaluate the success and complications rate of this technique in infants weighing less than 5 kg. Methods We studied 45 infants, weighing less than 5 kg (mean weight: 2.9 ± 1.1 kg, median: 3.1) needing a central venous access for intensive care treatment. In all patients, venous access was obtained by ultrasound-guided cannulation of the internal jugular vein (IJV). Results Central venous cannulation was successful in all 45 infants. The right internal jugular vein (IJV) was used in most cases (92%). The IJV was antero-lateral to the carotid artery in 66% of patients, lateral in 28% and anterior in 6%. Although we recorded 10 complications (22.2%), only one was clinically relevant (one pneumothorax). The other complications were repeated venipunctures (n=4), kinking of the guidewire (n=3) and local venous hematomas (n=2). The time required for completing the procedure was 7 ± 4.3 min, while the mean time of central venous catheter permanence was 5.5 ± 8 days. There was a negative correlation between the patients weight and the time needed for cannulation (p<0.01). Complications occurred in infants with a lower body weight (p<0.01). Conclusions Our experience suggests that ultrasound-guided central vein cannulation can be performed by well-trained physicians in infants weighing less than 5 kg without relevant risks.

The first five years of neonatal and pediatric transports on extracorporeal membrane oxygenation in the center and south of Italy: The pediatric branch of the Italian “Rete Respira” network:

Introduction: Neonatal and pediatric ECMO is a high-risk procedure that should be performed only in expert centers. Children who are eligible for ECMO and are managed in hospitals without ECMO capabilities should be referred to the closest ECMO center before the severity of illness precludes safe conventional transport. When the clinical situation precludes safe conventional transport, ECMO should be provided on site with the patient transported on ECMO. Methods: We retrospectively reviewed our institutional database of all ECMO transports for neonatal and pediatric respiratory failure from February 2013 to February 2018. Results: Over the last 5 years, we provided 24 transports covering all requests from the center and south of Italy except for the islands. Of these transports, 20 were performed on ECMO and 4 without ECMO. No patient died during transportation. Five complications were reported only during the ECMO transports, and all of these were managed without compromising the patient’s safety. The preferred modes of transport were by ambulance (70%) and ambulance transported into the fixed wing aircraft (30%) for longer national distances. The survival to hospital discharge of the patients transported with ECMO was 75% among the neonatal transports and 83.3% among the pediatric transports. The survival to hospital discharge of the four patients transported without ECMO was 100% for both neonates and children. Conclusions: Neonatal and pediatric ECMO transports can be safely performed with a dedicated team that maintains stringent adherence to well-designed management protocols.

Progressive increase in D-dimer levels during extracorporeal membrane oxygenation can predict membrane oxygenator failure in children given hematopoietic stem cell transplantation?

We found very interesting the results reported by Lubnow et al [1] and by Panigada et al [2] regarding the evaluation of clinical indicators of membrane oxygenator (MO) failure in their population of adults with respiratory failure. They both reported an increase in D-dimer levels within days before MO exchange (MOE), whereas Panigada et al [2] also showed a significant increase of MO shunt and a decrease in platelet count from the start to the discontinuation of extracorporeal membrane oxygenation (ECMO). We report our single-center retrospective analysis about the use of ECMO to support cardiorespiratory failure in children receiving hematopoietic stem cell transplantation (HSCT) to evaluate if laboratory parameters predicting clot formation and parameters of MO performance could be useful to the early detection of MO failure in this special population of patients. Patients given HSCT receive many transfusions predisposing MO to clot formation. Therefore, early identification of MO failure may allow optimization of MOE, avoiding emergency procedures and life-threatening risks. Children givenHSCT are exposed to a prolonged period of immune deficiency predisposing to the development of severe complications, including respiratory failure and septic shock [3]. Aminority of themmay develop cardiorespiratory failure not responding to conventional treatment and requiring ECMO. Despite the use of systemic anticoagulation and heparin-coated polymer circuits, MO failure remains one of the most common and dangerous complications of ECMO [4,5]. We retrospectively surveyed our internal ECMO registry from 2010 to 2015 to evaluate if laboratory parameters (D-dimers, fibrinogen, platelets) predicting thrombotic tendency and functional MO parameters (transmembrane oxygenator pressure gradient and MO performance index [PaO2 at the exit port of the MO divided by the fraction of inspired oxygen]) could be used to detect MO failure. All patients included in the analysis were treated with the same tipto-tip–coated circuits. Phosphorylcoline-coated circuits (Eurosets, Medolla, MO, Italy) and oxygenators (Pediatric ECMO and Newborn ECMO Oxygenators, Eurosets, Medolla, MO, Italy) were used. Cannulas were coated with heparin (Carmeda BioActive Surface; Carmeda, Kanalvägen, Sweden or Bioline; Maquet Cardiopulmonary AG, Rastatt, Germany). Levitronix CentiMag and PediVas centrifugal pumps (Thoratec Corporation, Huntingdon, Cambridgeshire, United Kingdom) were used according to the pump flow requested for each patient.