Etiology, Diagnosis and Management of Persistent Pulmonary Hypertension of the Newborn in Resource-limited Settings.

Persistent Pulmonary Hypertension of the Newborn (PPHN) is more common in Low and middle income countries (LMICs) due to high incidence of sepsis, perinatal asphyxia and meconium aspiration syndrome. Presence of hypoxic respiratory faillure and greater than 5% difference in preductal and post ductal saturation increases clinical sucipision for PPHN. The availability of Inhaled nitric oxide and extracorporaeal membrane oxygenation is limited but pulmonary vasodilators such as sildenafil are readily available in most LMICs.

Síndrome de aspiración meconial: revisión de la fisiopatología y estrategias de manejo / Meconium aspiration syndrome: review of the pathophysiology and management strategies

El síndrome de aspiración meconial, es una condición clínica caracterizada por insuficiencia respiratoria que ocurre en neonatos nacidos a través de líquido amniótico teñido de meconio, y que puede presentarse como una enfermedad grave con riesgo vital. Su incidencia ha disminuido gracias a mejores prácticas obstétricas y atención perinatal y se ha observado una mejoría en la sobrevida, gracias a mejores prácticas en la UCI neonatal. Sin embargo, el abordaje más adecuado sigue siendo un tema de debate, dado que hasta el momento se basa sólo en medidas de soporte, sin que existan medidas que actúen sobre los mecanismos de daño. Por otro lado, la morbilidad a largo plazo entre los sobrevivientes sigue siendo una preocupación importante. Esta revisión ofrece una visión general actualizada de la epidemiología, la fisiopatología, el diagnóstico, el manejo terapéutico, la prevención y el pronóstico de los pacientes que presentan este cuadro.

Meconium aspiration syndrome is a clinical condition characterized by respiratory failure that occurs in neonates born through meconium-stained amniotic fluid and can present as a serious life-threatening disease. Its incidence has decreased thanks to better obstetric practices and perinatal care, and an improvement in survival has been observed, thanks to better practices in the neonatal ICU. However, the most appropriate approach is still a matter of debate, given that so far it is based only on support measures, without any measures that act on the damage mechanisms. On the other hand, long-term morbidity among survivors remains a major concern. This review offers an updated overview of the epidemiology, pathophysiology, diagnosis, therapeutic management, prevention, and prognosis of patients with this condition.

A randomized single-center controlled trial of synchronized intermittent mandatory ventilation with heliox in newborn infants with meconium aspiration syndrome.

OBJECTIVE: This study aimed to investigate the beneficial effects of synchronized intermittent mandatory ventilation (SIMV) with heliox in newborn infants with meconium aspiration syndrome (MAS). METHODS: Seventy-one newborn infants with MAS in the neonatal intensive care unit (NICU) of Daping Hospital of Army Medical University were enrolled in the trial. Infants treated with SIMV were randomized and divided into the heliox group (n = 35) and control group (n = 36). The heliox group received heliox for 6 h followed by air-oxygen mixed gas, and the control group received air-oxygen mixed gas. The primary outcome measures were PaO2 /FiO2 (P/F) and the extubation time. The secondary outcome measures were the incidence of mechanical ventilation complications, hospital length of stay in the NICU, blood gas analysis, and inflammation markers. RESULTS: The P/F in the heliox group was significantly better than that in the control group (p < .001). The extubation time and hospital length of stay in the NICU in the heliox group were shorter than those in the control group (p < .001). The inflammation markers at 6 h and myocardial injury markers at 24 h were decreased compared with those at 0 h, and those in the heliox group were more significantly decreased than those in the control group ([interleukin {IL}-6/IL-8/tumor necrosis factor α] p < .001, [C-reaction protein] p = .012; [creatine kinase] p < .001, [CK-MB] p = .041). CONCLUSION: Heliox appears to be more effective in reducing the length of ventilation and increasing carbon dioxide eliminations than an air-oxygen mixture in infants with MAS under the support of SIMV.

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

BACKGROUND: Outcomes 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. METHODS: We 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. RESULTS: 3831 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. CONCLUSION: Conversion 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 EVIDENCE: Level of evidence 3 Retrospective comparative study.

Haematoma complicating subcutaneous fat necrosis of the newborn: a rare complication following therapeutic hypothermia.

A term, large for gestational age male newborn, was admitted to the neonatal intensive care unit with meconium aspiration syndrome and severe hypoxic-ischaemic encephalopathy. The baby was treated with therapeutic hypothermia using a total body cooling blanket. After 48 hours, the baby developed tender, indurated subcutaneous nodules consistent with subcutaneous fat necrosis (SCFN). The lesions started initially over the back but gradually spread to cover both shoulders, upper arms, chest area and both thighs. On day 19 of life, multiple small nodules on the back softened and coalesced to form one sizeable fluctuant swelling over the thoracolumbar area. Over a few hours, the swelling rapidly progressed to a large, tense mass with sloughing of the gangrenous overlying skin. This unusual complication of SCFN required surgical intervention for evacuation and debridement of the haematoma followed by graft repair of the skin defect.

Extra-Corporeal Membrane Oxygenation for Neonatal Respiratory Support.

To review our experience with Extra-Corporeal Membrane Oxygenation (ECMO) for respiratory support in neonates. From 1989 to 2018 2114 patients underwent respiratory ECMO support, with 764 (36%) neonates. Veno-Venous (V-V) cannulation was used in 428 (56%) neonates and Veno-Arterial (V-A) in 336 (44%). Historically V-V ECMO was our preferred modality, but due to lack of suitable cannula in the last 7 years V-A was used in 209/228 (92%) neonates. Mean and inter-quartile range of ECMO duration was 117 hours (inter-quartile range 90 to 164 hours). Overall 724 (95%) neonates survived to ECMO decannulation, with 640 (84%) hospital discharge. Survival varied with underlying diagnosis: meconium aspiration 98% (354/362), persistent pulmonary hypertension 80% (120/151), congenital diaphragmatic hernia 66% (82/124), sepsis 59% (35/59), pneumonia 86% (6/7), other 71% (43/61). Survival was 86% with V-V and 80% with V-A cannulation, better than ELSO Registry with 77% V-V and 63% V-A. Major complications: cerebral infarction/hemorrhage in 4.7% (31.1% survival to discharge), renal replacement therapy in 17.6% (58.1% survival to discharge), new infection in 2.9%, with negative impact on survival (30%). Following a circuit design modification and subsequent reduction in heparin requirement, intracerebral hemorrhage decreased to 9/299 (3.0%) radiologically proven cerebral infarction/hemorrhage. We concluded (1) outcomes from neonatal ECMO in our large case series were excellent, with better survival and lower complication rate than reported in ELSO registry. (2) These results highlight the benefits of ECMO service in high volume units. (3) The similar survival rate seen in neonates with V-A and V-V cannulation differs from the ELSO register; this may reflect the change in cannulation enforced by lack of suitable V-V cannula and all neonates undergoing V-A cannulation.

Meconium aspiration syndrome requiring ECMO in newborns with gastroschisis: incidence and surgical outcomes.

AIM OF THE STUDY: To evaluate the incidence of respiratory failure requiring ECMO in newborns with gastroschisis (GC), compare it to the incidence in the general population, review the surgical outcomes of newborns with GC requiring ECMO and compare them to newborns with GC not requiring ECMO. METHODS: This is a retrospective review of all neonatal admissions for GC from December 2010 to September 2015. MAIN RESULTS: 110 newborns with GC were admitted to our NICU between 12/2010 and 9/2015; 36 were term. Four cases, all term, all prenatally diagnosed, all outborn, developed respiratory failure requiring ECMO secondary to meconium aspiration syndrome (MAS). This 11% (4/36 term GC) represents a 300-fold increase in the incidence of MAS-associated respiratory failure requiring ECMO compared to the general population of term newborns (0.037%). Median time on ECMO was 12 (9-20) days. The time to achieve full enteral feedings in the GC/ECMO group was twice the time of the 106 newborns in the GC/non-ECMO group [median: 70 (48-77) vs. 35 (16-270) days, respectively]. Time to hospital discharge was three times longer in the GC/ECMO group compared to the GC/non-ECMO group (median: 42 [20-282] versus 125 [69-223] days, respectively). All patients survived. CONCLUSION: The incidence of respiratory failure requiring ECMO is remarkably higher in patients with GC than in the general population and much higher in the subgroup of term GC. While infrequent, the possibility of this event supports the concept that fetuses with GC benefit from being delivered at tertiary centers with immediate pediatric surgery and ECMO capabilities.

High Hemoglobin Is an Independent Risk Factor for the Development of Hemolysis During Pediatric Extracorporeal Life Support.

OBJECTIVE: To evaluate risk factors for hemolysis in pediatric extracorporeal life support. DESIGN: Retrospective, single-center study. SETTING: Pediatric intensive care unit. PATIENTS: Two hundred thirty-six children who received extracorporeal membrane oxygenation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Risk factors for hemolysis were retrospectively analyzed from a single center in a total of 236 neonatal and pediatric patients who received extracorporeal membrane oxygenation support (ECMO). There was no difference in the incidence of hemolysis between centrifugal (127 patients) and roller head (109 patients) pump type or between venoarterial and venovenous ECMO. High hemoglobin (Hb) was found to be an independent risk factor for hemolysis in both pump types. The Hb level >12 g/dL was significant in the roller group and the Hb level >13 g/dL was significant in the centrifugal group for the development of hemolysis for the cumulative ECMO run. The presence of high Hb levels on any given day increased the risk of hemolysis for that day of the ECMO run regardless of ECMO pump type. Higher revolutions per minute (RPMs) and higher inlet pressures on any given day increased the risk for the development of hemolysis in the centrifugal pump. Lower inlet venous pressures and RPMs were not associated with hemolysis in the roller group. CONCLUSIONS: An Hb level greater than 13 g/dL was associated with an increased risk of hemolysis, and a high Hb on a given day was associated with a significantly higher risk of hemolysis on the same day. Higher RPMs and lower inlet venous pressures were associated with an increased risk of hemolysis in the centrifugal pump only.

[Multicenter investigation of extracorporeal membrane oxygenation application in pediatric intensive care unit in China].

Objective: To survey the conduction and evaluate the effectiveness of extracorporeal membrane oxygenation (ECMO) therapy in pediatric intensive care unit (PICU) in China mainland. Methods: In a questionnaire-based survey, we retrospectively reviewed the application of ECMO in children's hospital and general hospital in China mainland to summarize and analyze the categories of diseases and prognosis of children treated with ECMO therapy. Results: By December 31, 2017, a total of 23 hospitals using ECMO, including 22 tertiary referral hospitals and 1 secondary hospital, among which 16 were children's hospitals and 7 were general hospitals. Thirty-seven ECMO equipment was available. A total of 518 patients treated with ECMO, within whom 323 (62.4%) successfully weaned from ECMO and 262 (50.6%) survived to discharge. Among 375 pediatric patients, 233 (62.1%) were successfully weaned from ECMO and 186 (49.6%) survived to discharge. Among 143 newborn patients, 90 (62.9%) successfully weaned from ECMO, 76 (53.1%) survived to discharge. ECMO was applied in veno-arterial (VA) mode to 501 (96.7%) patients, veno-venous (VV) mode to 14 (2.7%) patients, and VV-VA conversion mode to 3 (0.6%) patients. Sixty-nine patients required extracorporeal cardiopulmonary resuscitation (ECPR), including 20 newborn patients (29.0%) and 38 pediatric patients (71.0%), who were all with cardiovascular disease. Neonatal respiratory distress syndrome (26/61), persistent pulmonary hypertension of the newborn (PPHN) (12/61), and meconium aspiration syndrome (MAS) (11/61) are the most common pulmonary diseases in newborn patients; among whom, infants with PPHN had highest survival rate (10/12), followed by MAS (9/11). Among newborn patients with cardiovascular diseases, those who admitted were after surgery for congenital cardiac disease were the most common (54/82), while those with septic shock had the highest survival rate (2/3). In pediatric pulmonary diseases, acute respiratory distress syndrome was the most common (42/93), while plastic bronchitis was with the highest survival rate (4/4), followed by viral pneumonia (13/16). Among pediatric cardiovascular diseases, congenital cardiac defect was the most common (124/282), while fulminant myocarditis had the highest survival rate (54/77). Conclusion: The application of ECMO as a rescue therapy for children with severe cardiopulmonary failure has dramatically developed in China mainland.

Hypertrophic pyloric stenosis following persistent pulmonary hypertension of the newborn: a case report and literature review.

BACKGROUND: Although persistent pulmonary hypertension of the newborn (PPHN) and infantile hypertrophic pyloric stenosis (HPS) are both well-known diseases that occur in early infancy, PPHN complicated by HPS is rare. As nitric oxide (NO) is an important mediator of biological functions, on both the vascular endothelium and smooth muscle cells, the decreased production of NO might play a role in the pathogenesis of both PPHN and HPS. We present the case of a neonate who developed HPS following PPHN, including a detailed review on research published to date, and we discuss the pathogenesis of PPHN and HPS. CASE PRESENTATION: A female neonate born at 38 weeks of gestation, weighing 3140 g, developed PPHN due to meconium aspiration syndrome. Intensive treatment with high frequency oscillations and inhaled NO were initiated, and sildenafil and bosentan were added. She gradually recovered. At 15 days of age, the patient developed recurrent vomiting after feeding and the diagnosis of HPS was made. Intravenous atropine therapy was started at 20 days of age, but the efficacy was clinically unsatisfactory. The coadministration with transdermal nitroglycerin improved the symptoms, and oral feeding was successfully re-introduced. CONCLUSIONS: Our patient recovered from both PPHN and HPS using NO-related medications. A decrease in NO synthesis is likely to be a common pathway for PPHN and HPS.

Effects of hypothermia on lung inflammation in a rat model of meconium aspiration syndrome.

PURPOSE: To evaluate the effects of hypothermia treatment on meconium-induced inflammation. METHODS: Fifteen rats were instilled with human meconium (MEC, 1.5 mL/kg, 65 mg/mL) intratracheally and ventilated for 3 hours. Eight rats that were ventilated and not instilled with meconium served as a sham group. In MEC-hypothermia group, the body temperature was lowered to 33±0.5°C. Analysis of the blood gases, interleukin (IL)-1ß, IL-6, IL-8, and tumor necrosis factor (TNF)-α in bronchoalveolar lavage (BAL) fluid samples, and histological analyses of the lungs were performed. RESULTS: The BAL fluid TNF-α, IL-1ß, IL-6 and IL-8 concentrations were significantly higher in the MEC-hypothermia group than in the MEC-normothermia (p < 0.001, p < 0.001, p = 0.001, p < 0.001, respectively) and sham-controlled groups (p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). CONCLUSION: Meconium-induced inflammatory cytokine production is affected by the body temperature control.

Effects of hypothermia on lung inflammation in a rat model of meconium aspiration syndrome

Abstract Purpose: To evaluate the effects of hypothermia treatment on meconium-induced inflammation. Methods: Fifteen rats were instilled with human meconium (MEC, 1.5 mL/kg, 65 mg/mL) intratracheally and ventilated for 3 hours. Eight rats that were ventilated and not instilled with meconium served as a sham group. In MEC-hypothermia group, the body temperature was lowered to 33±0.5°C. Analysis of the blood gases, interleukin (IL)-1β, IL-6, IL-8, and tumor necrosis factor (TNF)-α in bronchoalveolar lavage (BAL) fluid samples, and histological analyses of the lungs were performed. Results: The BAL fluid TNF-α, IL-1β, IL-6 and IL-8 concentrations were significantly higher in the MEC-hypothermia group than in the MEC-normothermia (p < 0.001, p < 0.001, p = 0.001, p < 0.001, respectively) and sham-controlled groups (p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). Conclusion: Meconium-induced inflammatory cytokine production is affected by the body temperature control.

Trainees success rates with intubation to suction meconium at birth.

OBJECTIVES: To assess the success rate and main reasons for failure of intubation performed by medical trainees to suction meconium below the vocal cords in non-vigorous infants delivered at ≥36 week gestation. DESIGN: We conducted a prospective cohort study involving 54 residents and nine neonatology fellows in a Canadian level 3 neonatal intensive care unit. Endotracheal intubation to suction meconium was performed using a videolaryngoscope, the video screen being covered during the procedure. All videos were reviewed by two experts blinded to the procedure and to the identity of the trainee. RESULTS: Sixteen videos were available to review between July 2014 and March 2016. Intubation success rate assessed by the reviewers was 6%, compared with 21% as assessed by the trainees. The most common reasons for intubation failure were an improper view of the glottis (87%) and meconium or secretions obscuring the view (67%). 36 % of the time, the trainees identified different reasons for intubation failure than the reviewers. CONCLUSION: Success rate of neonatal intubation to suction meconium was much lower than the success rate reported on infants without meconium. Teaching should be geared towards the most common reasons for intubation failure, possibly using video-based teaching.

Mechanical Ventilation of Neonates at the University Hospital of the West Indies 1987-2015 / Ventilación Mecánica de Neonatos en el Hospital Universitario de West Indies 1987-2015

ABSTRACT Aim: To compare present trends in utilization of the neonatal intensive care unit (NICU) with trends seen during the period when neonates were ventilated in the main intensive care unit of the University Hospital of the West Indies. Methods: Data from previously published studies on outcome of neonates ventilated at the main intensive care unit 1987-2001, the neonatal intensive care unit 2002-2004 and the annual perinatal statistics (2006-2010, 2015) were reviewed to detect trends in mechanical ventilation, utilization and outcome. Descriptive analyses were performed. Results: The number of neonates mechanically ventilated per thousand admissions increased from 10/1000 in the 1990s to 73/1000 in 2015. Percentage mortality for ventilated neonates increased from 51% between 1987-1991 to 62 % in 2015. The proportion of extremely low birthweight infants (< 1000 g) mechanically ventilated increased from 29% in 1987-1991 to 50% in 2015. The percentage mortality for extremely low birthweight infants increased from 17.5% in 1987-1991 to 40.6% in 2015. The percentage mortality for all other birthweight categories decreased over time. Respiratory distress syndrome remains the major reason for neonates requiring mechanical ventilation. Fifty per cent of neonates < 1500 g ventilated for respiratory distress syndrome received surfactant replacement therapy. Conclusion: Access to mechanical ventilation by neonates has increased tremendously at the University Hospital of the West Indies. The present challenge, however, is decreasing mortality in these neonates who access this technology.

RESUMEN Objetivo: Comparar las tendencias actuales en la utilización de la Unidad de Cuidados Intensivos Neonatales (UCIN) con las tendencias observadas durante el período en que los neonatos eran ventilados en la Unidad Principal de Cuidados Intensivos del Hospital Universitario de West Indies. Métodos: Se revisaron los datos de estudios publicados anteriormente sobre el resultado clínico de los neonatos ventilados en la Unidad Principal de Cuidados Intensivos en 1987-2001, La Unidad de Cuidados Intensivos Neonatales en 2002-2004 y las y las Esta-dísticas Perinatales Anuales (2006-2010, 2015) con el propósito de detectar las tendencias en la utilización y los resultados de la ventilación mecánica. Se realizaron análisis descriptivos. Resultados: El número de neonatos ventilados mecánicamente por cada mil ingresos aumentó de 10/1000 en la década de 1990 a 73/1000 en 2015. El porcentaje de mortalidad de neonatos ventilados aumentó de 51% entre 1987-1991 a 62% en 2015. La proporción de neonatos de peso extremadamente bajo al nacer (< 1000 g) ventilados mecánicamente aumentó de 29% en 1987-1991 a 50% en 2015. El porcentaje de mortalidad de recién nacidos de peso extremadamente bajo al nacer aumentó de 17.5% en 1987-1991 a 40.6% en 2015. La mortalidad porcentual para todas las otras categorías de peso al nacer disminuyó con el tiempo. El síndrome de dificultad respiratoria sigue siendo la razón principal por la que los neonatos requieren ventilación mecánica. El cincuenta por ciento de los neonatos < 1500 g ventilados por el síndrome de dificultad respiratoria recibió terapia de reemplazo de surfactantes. Conclusión: El acceso a la ventilación mecánica por los neonatos ha aumentado enormemente en el Hospital Universitario de West Indies. No obstante, el reto actual es disminuir la mortalidad de los neonatos que acceden a esta tecnología.

Frequency of intrahepatic cholestasis of pregnancy in Punjab Pakistan: A single centre study.

OBJECTIVE: To find out the frequency of intrahepatic cholestasis of pregnancy and its identification parameters. METHODS: The cross-sectional observational study was conducted in the Department of Medicine and the Department of Obstetrics, Combined Military Hospital, Kharian, from October 2013 to March 2014, and comprised all pregnant patients having symptoms suggestive of intrahepatic cholestasis which was confirmed after systemic inquiry, examination and biochemical analysis. Patients with cholestasis due to another reason, coagulopathies, thrombocytopenia and tumours were excluded. The patients were followed up till delivery to see the effects of cholestasis on mother and child. RESULTS: Out of 1001 obstetric patients, 31(3.1%) had intrahepatic cholestasis of pregnancy. Pruritus was the main symptom in 25 (85%) patients followed by rash in 20 (65%). In 20 (64%) patients, labour was induced. Mode of delivery was Caesarean Section in 18 (58%) patients and 9 (29%) had postpartum haemorrhage. Regarding neonatal complications, 22 (70%) required admission to neonatal intensive care and 15 (48%) had meconium aspiration. CONCLUSIONS: A high frequency of intrahepatic cholestasis of pregnancy was observed. It had significant impact on maternal and foetal health.

Tracheal suctioning improves gas exchange but not hemodynamics in asphyxiated lambs with meconium aspiration.

BACKGROUND: Current neonatal resuscitation guidelines recommend tracheal suctioning of nonvigorous neonates born through meconium-stained amniotic fluid. METHODS: We evaluated the effect of tracheal suctioning at birth in 29 lambs with asphyxia induced by cord occlusion and meconium aspiration during gasping. RESULTS: Tracheal suctioning at birth (n = 15) decreased amount of meconium in distal airways (53 ± 29 particles/mm(2) lung area) compared to no suction (499 ± 109 particles/mm(2); n = 14; P < 0.001). Three lambs in the suction group had cardiac arrest during suctioning, requiring chest compressions and epinephrine. Onset of ventilation was delayed in the suction group (146 ± 11 vs. 47 ± 3 s in no-suction group; P = 0.005). There was no difference in pulmonary blood flow, carotid blood flow, and pulmonary or systemic blood pressure between the two groups. Left atrial pressure was significantly higher in the suction group. Tracheal suctioning resulted in higher Pao2/FiO2 levels (122 ± 21 vs. 78 ± 10 mm Hg) and ventilator efficiency index (0.3 ± 0.05 vs.0.16 ± 0.03). Two lambs in the no-suction group required inhaled nitric oxide. Lung 3-nitrotyrosine levels were higher in the suction group (0.65 ± 0.03 ng/µg protein) compared with the no-suction group (0.47 ± 0.06). CONCLUSION: Tracheal suctioning improves oxygenation and ventilation. Suctioning does not improve pulmonary/systemic hemodynamics or oxidative stress in an ovine model of acute meconium aspiration with asphyxia.

Experience with the Avalon® bicaval double-lumen veno-venous cannula for neonatal respiratory ECMO.

OBJECTIVE: We report a single centre experience of neonatal respiratory ECMO using the Avalon® double-lumen venous cannula and compare it with reports in the literature. RESULTS: Between 2008 and 2012, the Avalon® cannula was used in 72 neonates: median age at cannulation was 1.8 days (IQR 1.2-2.8 days) and bodyweight 3.4 Kg (3.0-3.7 Kg). Meconium aspiration syndrome (61.1%), persistent hypertension of the newborn (25%) and congenital diaphragmatic hernia (5.6%) were the most common diagnoses. Complications occurred in 19 patients (26.4%): cannula site bleeding in 6 (8.3%), the cannula perforating the right atrial wall and requiring emergency midline sternotomy in 5 (6.9%) and the cannula needing repositioning in 3 (4.2%). Overall survival at discharge or transfer to the referring hospital was 88.8%. Successful wean off ECMO occurred in 68 patients (94.4%) after a median of 90.5 hours (63.4-136.11). ECMO support was withdrawn in 4 patients (5.6%). CONCLUSIONS: The Avalon® dual-lumen veno-venous cannula can be used for respiratory ECMO in the neonatal population. However, as the incidence of right atrial perforation is not negligible, we suspended its used in this group of patients.

Pump controlled retrograde trial off from VA-ECMO.

We describe our novel technique of Pump Controlled Retrograde Trial Off that relies on the retrograde flow to maintain circuit integrity and allow a longer trial off from venoarterial extracorporeal membrane oxygenation support without circuit clot formation or significant patient hemodynamic compromise. This technique avoids the insertion of an arteriovenous bridge and the need to clamp the circuit. We present data on five neonatal patients who were trialled off using this method.

Colorectal considerations in pediatric patients.

Colorectal disease in pediatric patients includes a spectrum of diseases, many of which have a significant impact on quality of life and warrant long-term follow-up and treatment into adulthood. Although many diseases, such as inflammatory bowel disease and colon cancer, are managed similar to adults, other disease processes are more common to pediatric patients and are the focus of this article.