Survival and Developmental Outcomes of Neonates Treated with Extracorporeal Membrane Oxygenation: A 10-Year Single-Center Experience.

OBJECTIVE: To evaluate the associations between the primary indication for extracorporeal membrane oxygenation (ECMO) in neonates and neurodevelopmental outcomes at 12 and 24 months of age. STUDY DESIGN: This is a retrospective cohort study of neonates treated with ECMO between January 2006 and January 2016 in the Children's Hospital of Philadelphia newborn/infant intensive care unit. Primary indication for ECMO was classified as medical (eg, meconium aspiration syndrome) or surgical (eg, congenital diaphragmatic hernia). Primary study endpoints were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Groups were compared with standard bivariate testing and multivariable regression. RESULTS: A total of 191 neonates met the study's inclusion criteria, including 96 with a medical indication and 95 with a surgical indication. Survival to discharge was 71%, with significantly higher survival in the medical group (82% vs 60%; P = .001). Survivors had high rates of developmental therapies and neurosensory abnormalities. Developmental outcomes were available for 66% at 12 months and 70% at 24 months. Average performance on the Bayley-III was significantly below expected population normative values. Surgical patients had modestly lower the Bayley-III scores over time; most notably, 15% of medical infants and 49% of surgical infants had motor delay at 24 months (P = .03). CONCLUSIONS: In this single-center cohort, surgical patients had lower survival rates and higher incidence of motor delays. Strategies to reduce barriers to follow-up and improve rates of postdischarge developmental surveillance and intervention in this high-risk population are needed.

Surfactant lavage for neonatal meconium aspiration syndrome-An updated meta-analysis.

BACKGROUND: Surfactant lavage seems to have a good application prospect both in experimental models and patients with meconium aspiration syndrome (MAS). Data regarding the effect of surfactant lavage on pulmonary complications of MAS are conflicting. In view of these uncertainties, an updated meta-analysis including the latest literatures is performed. METHODS: A search was conducted by two investigators involved in this research in PubMed, Embase, and Cochrane databases for studies in English and other languages, in Wanfang, VIP, and Cnki databases for Chinese studies (all last launched on December 18, 2018). Ultimately, we identified 11 original studies, including the surfactant lavage group (n = 189) and the control group (n = 204). Odds ratio and weighted mean difference were calculated using a random effects or fixed effects model, depending on the data type and heterogeneity of the included studies. RESULTS: The comparison of effectiveness on MAS: (1) With respect to oxygen index at 48 hours stage and 72 hours stage, data showed significant difference between surfactant lavage/control groups (we/ighted mean difference [WMD] = -3.37, 95% confidence interval [CI], -5.68 ~ -1.06; p = 0.004 and 95% CI, -5.03 ~ -2.37; p < 0.00001). (2) With respect to days on mechanical ventilation, the analysis showed that there was significant difference between surfactant lavage group and control group (WMD = -1.12, 95% CI, -1.40 ~ -0.84; p < 0.00001). (3) Regarding the need for extracorporeal membrane oxygenation, days of oxygen therapy, and hospital stay, no significant differences were found. The comparison of possible complications of MAS: (1) Regarding pneumothorax, the analysis showed there was significant difference between surfactant lavage and control groups (odds ratio [OR] = 0.46, 95% CI, 0.24 ~ 0.85; p = 0.01). (2) With respect to mortality, persist pulmonary hypertension and pulmonary hemorrhage, the results showed no difference between the two groups. CONCLUSION: With respect to oxygen index and days on mechanical ventilation, surfactant lavage is significantly effective compared with control group, though didn't eventually shorten days of oxygen therapy and hospital stay. In addition, our meta-analysis showed that surfactant lavage does not increase the risk of complications.

Cause and predictors of neonatal mortality among neonates admitted to neonatal intensive care units of public hospitals in eastern Ethiopia: a facility-based prospective follow-up study.

BACKGROUND: The first month is the most crucial period for child survival. Neonatal mortality continues to remain high with little improvement over the years in Sub-Saharan Africa, including Ethiopia. This region shows the least progress in reducing neonatal mortality and continues to be a significant public health issue. In this study setting, the causes and predictors of neonatal death in the neonatal intensive care units are not well documented. Hence, this study aimed to determine the causes and predictors of neonatal mortality among infants admitted to neonatal intensive care units in eastern Ethiopia. METHODS: A facility-based in prospective follow-up study was conducted among neonates admitted to neonatal intensive care units of public hospitals of eastern Ethiopia from November 1 to December 30, 2018. Data were collected using a pre-tested structured questionnaire and a follow-up checklist. The main outcomes and causes of death were set by pediatricians and medical residents. EpiData 3.1 and Statistical Package for Social Sciences Version 25 software were used for data entry and analysis, respectively. Multivariable logistic regression was used to identify the predictors of facility-based neonatal mortality. RESULTS: The proportion of facility-based neonatal mortality was 20% (95% CI:16.7-23.8%). The causes of death were complications of preterm birth (28.58%), birth asphyxia (22.45%), neonatal infection (18.36%), meconium aspiration syndrome (9.18%), respiratory distress syndrome (7.14%), and congenital malformation (4.08%). Low birth weight, preterm births, length of stay of the neonatal intensive care unit, low 5 min APGAR score, hyperthermia, and initiation of feeding were predictors of neonatal death among infants admitted to the neonatal intensive care units of public hospitals in eastern Ethiopia. CONCLUSIONS: The proportion of facility-based neonatal deaths was unacceptably high. The main causes of death were preventable and treatable. Hence, improving the timing and quality of antenatal care is essential for early detection, anticipating high-risk newborns, and timely interventions. Furthermore, early initiation of feeding and better referral linkage to tertiary health facilities could lead to a reduction in neonatal death in this setting.

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.

Retrospective review of neonatal morbidity and mortality at public referral hospitals in Greater Accra Region of Ghana:2013-2014.

BACKGROUND: Reliable local data for evaluating and planning neonatal interventions in low-resource countries are scarce. To provide data for evaluating neonatal interventions in an administrative region of Ghana, the study examined baseline data for inpatient neonatal services prior to the implementation of a 5-years national action plan to reduce newborn deaths. METHODS: This is a retrospective review of admissions and deaths registry for the years 2013 and 2014 at 3 referral neonatal units representing district, regional and tertiary referral centres in Greater Accra Region of Ghana. Perinatal, and neonatal hospitalisation data were extracted. Chi-squared test was used to compare outcomes. RESULTS: Of the 8228 newborn infants hospitalised for special care, over 99% had antenatal care and were delivered at a health facility, 96.7% and 91.7% had birth weight and outcome data, respectively. Low birth weight infants accounted for 48.5% of total admissions and 67% of deaths. Using birth weight criteria, survival to discharge was 25.6% for infants less than 1000grams, 67.9% for 1000-1499grams, 88% for 1500-2499grams and 88.7% for infants 2500grams and higher. Among infants with birth weight of 1000grams and higher, perinatal asphyxia (70.6%) and respiratory distress (16.4%) accounted for most deaths. CONCLUSION: There was significant burden of neonatal morbidity and mortality in hospitalized newborns prior to the implementation of the national action plan. The report provides a yardstick for assessing the impact of the national action plan and comparative analysis of future interventions on neonatal outcome in the region.

Endotracheal suctioning for prevention of meconium aspiration syndrome: a randomized controlled trial.

The current version of Neonatal Resuscitation Program no longer favors routine endotracheal suctioning (ETS) in non-vigorous newborns with meconium-stained amniotic fluid (MSAF) due to possibility of procedure-related harms and questionable benefits. However, it calls for additional research on this procedure to provide a definitive answer. The present study was conducted to evaluate the role of ETS in non-vigorous neonates of ≥ 34 weeks' gestation born through MSAF on the incidence of meconium aspiration syndrome (MAS). In this open-label randomized controlled trial, 132 non-vigorous neonates with MSAF were randomized to receive ETS (n = 66) or no-ETS (n = 66) during delivery room resuscitation (DRR). Primary outcome variable was incidence of MAS. Secondary outcome variables were requirement of DRR, need of respiratory support, development of complications, duration of hospitalization, and mortality. Both the groups were comparable with respect to maternal and neonatal characteristics. Incidence of MAS was 21 (31.8%) and 15 (22.7%) cases in ETS and no-ETS groups, respectively (relative risk (RR), 1.400, 95% confidence interval (CI), 0.793-2.470). The two groups did not differ with regard to DRR, need for respiratory support, and development of complications. Nine (13.6%) neonates in ETS group, and 5 (7.5%) in no-ETS group died (p > 0.05). Median (interquartile range) duration of hospital stay was 54 (31-141) h and 44 (26-102) h in ETS and no-ETS groups, respectively (p > 0.05).Conclusions: Routine ETS at birth is not useful in preventing MAS in non-vigorous neonates of ≥ 34 weeks' gestation born through MSAF.Trial registration: Clinical Trials Registry of India (CTRI/2015/04/008819).What is Known:• Routine endotracheal suctioning is of questionable benefit in non-vigorous newborns with meconium stained amniotic fluid and may have a possibility of procedure-related harms.What is New:• Routine endotracheal suctioning at birth is not useful in preventing meconium aspiration syndrome in non-vigorous newborns of ≥ 34 weeks' gestation born through meconium stained amniotic fluid.

Fetal, neonatal, and infant death in central China (Hubei): A 16-year retrospective study of forensic autopsy cases.

Data based on forensic autopsy in neonates and infants in China are rare in the literature. The purpose of this study is to evaluate the characteristics of fetal, neonatal, and infant death and to determine the main cause of death among them.A retrospective analysis of fetal and infant forensic autopsies referred to the Tongji Forensic Medical Center (TFMC) in Hubei, central China, during a 16-year period between January 1999 and December 2014, was performed.In this period, there were 1111 males and 543 females; the total male-to-female ratio (MFR) was 2.05:1. There were 173 fetal and infant autopsies conducted, comprised of 43 fetal, 84 neonatal (<28 days) and 46 infant (4 weeks to 1 year) cases. The annual case number ranged from 5 in 2004 to 18 in 2014 (annual mean of 10.8). MFR was 1.75:1. About 94% of these deaths (163/173) resulted from natural causes, 6 cases (3.5%) were accidental deaths, and 4 (2.3%) resulted from homicide (4 abandoned babies). Among fetuses, the most common causes of death were placental and umbilical cord pathologies (28%, 12/43), followed by intrapartum asphyxia resulting from amniotic fluid aspiration (AFA) or meconium aspiration syndrome (MAS) (18.6%, 8/43), congenital malformation (14%, 6/43), and intrapartum infection (9.3%, 4/43). A majority of neonatal deaths (66.7%, 56/84) died within 24 hours of birth. The main causes of neonatal death were asphyxia resulting from AFA, MAS, or hyaline membrane disease, and congenital malformation. The main causes of infant (1-12 months) death were infectious diseases, including pneumonia, meningitis, and viral brainstem encephalitis.This study was the 1st retrospective analysis of autopsies of fetal, neonatal, and infant death in TFMC and central China. We delineate the common causes of early demise among cases referred for autopsy, and report a male preponderance in this population. Our data observed that placental and/or umbilical cord pathology, asphyxia due to AFA, and/or MAS, and pneumonia were the leading causes of fetal, neonatal, and infant death, respectively. And it can inform clinical practitioners about the underlying causes of some of the most distressing cases in their practices.

HandS ECMO: Preliminary Experience With "Hub and Spoke" Model in Neonates With Meconium Aspiration Syndrome.

We aim to evaluate clinical outcomes of emergent extracorporeal membrane oxygenation (ECMO) implantation in newborns with life-threatening meconium aspiration syndrome (MAS) in peripheral hospitals with Hub and Spoke (HandS) setting. We retrospectively reviewed all neonates presenting with MAS, with no other comorbidities, treated with HandS ECMO, in peripheral hospitals. Team activation time (TAT) was described as the time from first alerting call to ECMO support initiation. From May 2014 to December 2016, 4 patients met our inclusion criteria. In addition, 2 cases occurred on the same day, requiring a second simultaneous HandS ECMO team activation. All patients were younger than 8 days of life (1, 1, 4, and 7), with a mean BSA 0.21 ± 0.03m2 , and TAT of 203, 265, 320, and 340 min. One patient presented ventricular fibrillation after priming administration. Veno-arterial ECMO was established in all patients after uneventful surgical neck vessels cannulation (right carotid artery and jugular vein). Mean time from skin incision to ECMO initiation was 19 ± 1.4 min. Mean length of ECMO support was 2.75 ± 1.3 days. All patients were weaned off support without complications. At a mean follow up of 20.5 ± 7.8 months, all patients are alive, with no medications, normal somatic growth, and neuropsychological development. MAS is a life-threatening condition that can be successfully managed with ECMO support. A highly trained multidisciplinary HandS ECMO team is crucial for the successful management of these severely ill newborns in peripheral hospitals.

PaO2/FiO2 Ratio as Predictor of Mortality in Neonates with Meconium Aspiration Syndrome.

OBJECTIVES: Partial arterial pressure of oxygen/fraction of oxygen in inspired air (PaO2/FiO2) ratio has been used as a predictor of outcome in some neonatal conditions, but has not been used in meconium aspiration syndrome (MAS). This study was conducted with the objective to study if the PaO2/FiO2 ratio of < 200 at 6, 12, and 24 hours of life can predict mortality in neonates with MAS. STUDY DESIGN: Two hundred neonates with MAS were included in the study. PaO2/FiO2 ratio was calculated at 6, 12, and 24 hours of life. Sensitivity, specificity, predictive values, and likelihood ratio at cut-off < 200 to predict mortality was calculated. RESULTS: PaO2/FiO2 ratio at cut-off of < 200 was found to predict mortality in neonates with MAS with 94.1% sensitivity and 96.6% specificity. It was also able to predict development of severe MAS. CONCLUSION: PaO2/FiO2 at < 200 can predict all-cause mortality in neonates with MAS. It can be used as vital tool in identifying newborns at high risk, thus helping in focused care.

Approach to Infants Born Through Meconium Stained Amniotic Fluid: Evolution Based on Evidence?

Meconium-stained amniotic fluid (MSAF) during delivery is a marker of fetal stress. Neonates born through MSAF often need resuscitation and are at risk of meconium aspiration syndrome (MAS), air leaks, hypoxic-ischemic encephalopathy, extracorporeal membrane oxygenation (ECMO), and death. The neonatal resuscitation approach to MSAF has evolved over the last three decades. Previously, nonvigorous neonates soon after delivery were suctioned under the vocal cords with direct visualization technique using a meconium aspirator. The recent neonatal resuscitation program (NRP) recommends against suctioning but favors resuscitation with positive pressure ventilation of nonvigorous neonates with MSAF. This recommendation is aimed to prevent delay in resuscitation and minimize hypoxia-ischemia often associated with MSAF. In this review, we discuss the pathophysiology, evolution and the evidence, randomized control trials, observational studies, and translational research to support these recommendations. The frequency of ECMO use for neonatal respiratory indication of MAS has declined over the years probably secondary to improvements in neonatal intensive care and reduction of postmaturity. Changes in resuscitation practices may have contributed to reduced incidence and severity of MAS. Larger randomized controlled studies are needed among nonvigorous infants with MSAF. However, ethical dilemmas and loss of equipoise pose a challenge to conduct such studies.

An overview of medical ECMO for neonates.

Extracorporeal membrane oxygenation (ECMO), a life-saving therapy for respiratory and cardiac failure, was first used in neonates in the 1970s. The indications and criteria for ECMO have changed over the years, but it continues to be an important option for those who have failed other medical therapies. Since the Extracorporeal Life Support Organization (ELSO) Registry was established in 1989, more than 29,900 neonates have been placed on ECMO for respiratory failure, with 84% surviving their ECMO course, and 73% surviving to discharge or transfer. In this chapter, we will review the basics of ECMO, patient characteristics and criteria, patient management, ECMO complications, special uses of neonatal ECMO, and patient outcomes.

Current trends in neonatal ECMO.

Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with respiratory and cardiac failure refractory to maximal medical management. The extracorporeal life support organization registry is the largest available resource for describing the population and outcomes of patients treated with this therapy. The use of ECMO for neonatal patients is decreasing in proportion to the total annual ECMO runs most likely due to advancements in medical management. Although the overall survival for neonatal ECMO has decreased, this is likely a reflection of the increasingly complex neonatal patients treated with this therapy. Although many patient and mechanical complications are decreasing over time, there remains a high percentage of morbidities and risks associated with ECMO. Continued refinements in management strategies are important to improving overall patient outcomes.

Respiratory distress in term neonates in low-resource settings.

Most neonatal deaths worldwide occur in low- and middle-income countries (LMICs). Respiratory distress is an important cause of neonatal morbidity and mortality. The epidemiology of respiratory distress among term neonates who constitute the vast majority of births is under reported. The scarcely available data from LMICs suggest an incidence of 1.2% to 7.2% among term live births and greater morbidity compared to that in high-income countries. Pneumonia and meconium aspiration syndrome are the predominant causes among outborn neonates, but next only to transient tachypnea among inborn neonates. Community management of neonatal sepsis/pneumonia using simplified antibiotic regimens when referral is not feasible, implementation of non-invasive ventilation, and innovative low-cost technologies to deliver respiratory therapy are important advances that have taken place in these settings. There is an urgent need to generate data on respiratory morbidities among term neonates so that the limited resources in these settings can be allocated judiciously.

Surfactant reduced the mortality of neonates with birth weight ⩾1500 g and hypoxemic respiratory failure: a survey from an emerging NICU network.

OBJECTIVE: We evaluated the efficacy of surfactant therapy and assisted ventilation on morbidity and mortality of neonates with birth weight (BW) ⩾1500 g and hypoxemic respiratory failure (HRF). STUDY DESIGN: We retrospectively analyzed 5650 patients with BW ⩾1500 g for incidence, management and outcome of HRF, defined as acute hypoxemia requiring mechanical ventilation and/or nasal continuous positive airway pressure ⩾24 h. The patients were allocated into groups of moderate preterm (1735, 30.7%), late preterm (1431, 25.4%), early term (ETM, 986, 17.5%), full term (1390, 24.6%) and post term (79, 1.4%), with gestational age ⩽33, 34 to 36, 37 to 38, 39 to 41 and ⩾42 weeks, respectively. RESULTS: In the five groups, 66.9, 42, 21.6, 12.8 and 5.1% had respiratory distress syndrome (RDS). For pneumonia/sepsis and meconium aspiration syndrome (MAS), the proportion was 13.8%, 25.4%, 38.0%, 52.5% and 76.0%, respectively. Surfactant was given to 21.9% (n=1238) of HRF and 51.2% (n=1108) of RDS. Survival rates of RDS were 82.2%, 87.8%, 84.5%, 77.1% and 75.0%, respectively (numbers needed to treat was 8 to 11 for surfactant benefit). Overall mortality rate of HRF was 21%, or 17.9%, 14.7%, 25.6%, 28.9% and 39.2%, respectively. Mortalities of MAS and pneumonia/sepsis were 29.4 and 27.6%. Relative risk of death was associated with initial disease severity, female gender, mechanical ventilation and congenital anomalies by multivariate logistic regression analysis. CONCLUSION: Surfactant was effective for infants with RDS and BW ⩾1500 g, and different incidences and outcome of HRF among GA groups reflected standard of perinatal and respiratory care in emerging neonatal intensive care unit network.

Endotracheal suction in term non vigorous meconium stained neonates-A pilot study.

AIM: To evaluate the effect of 'No endotracheal suction' on occurrence of meconium aspiration syndrome (MAS) and/or all-cause mortality in non-vigorous neonates born through meconium stained amniotic fluid (MSAF). METHODS: This pilot randomized controlled trial enrolled term non-vigorous neonates (≥37 weeks) born through MSAF. Neonates randomized to 'No Endotracheal suction group' ('No ET' Group; n=88) did not undergo endotracheal suction before the definitive steps of resuscitation. Neonates randomized to 'Endotracheal suction group' ('ET' Group; n=87) underwent tracheal suction as part of the initial steps as per the current NRP recommendations. The primary outcome was occurrence of MAS and/or death. Secondary outcome variables were duration and severity of respiratory distress, need for respiratory support, development of hypoxic ischemic encephalopathy (HIE) and duration of oxygen therapy and hospitalization. RESULTS: Baseline characters including birth weight and gestational age were similar between the two groups. MAS was present in 23 (26.1%) vs. 28 (32.2%) neonates in 'No ET' and 'ET' groups respectively (OR 0.4 (0.12-1.4); p=0.14) with 4 (4.6%) and 9 (10.34%) deaths amongst these neonates with MAS in respective groups (OR 0.75 (0.62-1.2); p=0.38). Other parameters like severity and duration of respiratory distress, need for respiratory support, incidence of HIE, duration of oxygen therapy and duration of hospitalization were comparable. CONCLUSION: This study demonstrates that it is feasible to randomize non-vigorous infants born through meconium stained liquor to receive on not receive endotracheal suction. There is a need for a multi-center trial to address whether the current practices and guidelines can be justified.

Surfactant therapy and antibiotics in neonates with meconium aspiration syndrome: a systematic review and meta-analysis.

Meconium aspiration syndrome (MAS), a common cause of respiratory failure in neonates, is associated with high mortality and morbidity. The objectives of this review were to evaluate the effects of administration of (a) surfactant-either as lung lavage (SLL) or bolus surfactant (BS) and (b) antibiotics on mortality and severe morbidities in neonates with MAS. We searched the following databases: MEDLINE via PubMed, Cochrane CENTRAL, WHOLIS and CABI using sensitive search strategies. We included eight studies on use of surfactant and three studies on use of antibiotics. Neither SLL nor BS reduced the risk of mortality in neonates with MAS (relative risk (RR) 0.38, 95% confidence interval (CI) 0.09 to 1.57; and RR 0.80, 95% CI 0.39 to 1.66, respectively). Both SLL and BS reduced the duration of hospital stay (mean difference -2.0, 95% CI -3.66 to -0.34; and RR -4.68, 95% CI -7.11 to -2.24 days, respectively) and duration of mechanical ventilation (mean difference -1.31, 95% CI -1.91 to -0.72; and mean difference 5.4, 95% CI -9.76 to -1.03 days). Neonates who received BS needed extracorporeal membrane oxygenation (ECMO) less often than the controls (RR 0.64, 95% CI 0.46 to 0.91). Use of antibiotics for MAS did not result in significant reduction in the risk of mortality, sepsis or duration of hospital stay. Surfactant administration either as SLL or BS for MAS was found to reduce the duration of mechanical ventilation and hospital stay; BS also reduced the need for ECMO. Administration of antibiotics did not show any significant clinical benefits in neonates with MAS and no evidence of sepsis. Given the limited number of studies and small number of neonates enrolled, there is an urgent need to generate more evidence on the efficacy and cost-effectiveness of these two treatment modalities before recommending them in routine clinical practice.

Detrimental Complications Of Meconium Aspiration Syndrome And Their Impact On Outcome.

BACKGROUND: Meconium aspiration syndrome (MAS) is respiratory distress in an infant born through meconium stained amniotic fluid (MSAF) whose signs cannot be otherwise explained. MAS is associated with different complications. Many studies have been conducted in developed world to find the outcome associated with MAS but data from developing countries is lacking. Present study was conducted to determine the impact of chemical pneumonitis, pulmonary hypertension (PHN) and air leak on outcome of new-borns with MAS. METHODS: This cross sectional descriptive study was conducted in a tertiary care Neonatology unit. The babies diagnosed with MAS were included in the study. All patients were monitored for development of complications. Outcome in terms of mortality was recorded. Outcome was compared by chisquare test and p-value <0.05 is considered significant. RESULTS: Seventy two babies were included in the study. Mean gestation was 37±0.56 weeks and birth weight was 2.87±0.49 kg. Male to female ratio was 1.57:1 and mean age of admission was 9.59±5.27 hours. Chemical pneumonitis, PHN and chemical pneumonitis with PHN were observed in 23.6%, 20.8% and 26.4% neonates respectively. Mortality rate was 19.44%. The mortality was highest in babies having chemical pneumonitis with PHN (p-value=0.013) followed by chemical pneumonitis group (p-value=0.02) and PHN group (p-value=0.032). CONCLUSIONS: About three fourth babies with MAS developed one or more complications. Mortality is significantly increases with the development of complications so as more the complications more is the mortality.

[Good long-term survival after ECMO treatment]. / God långtidsöverlevnad efter ECMO-behandling.

ECMO is used more and more globally, and to date more than 60,000 patients have undergone ECMO treatment. At the ECMO Center Karolinska in Stockholm, Sweden, more than 900 neonatal, pediatric and adult patients with primarily respiratory failure have been treated since 1987. This study investigated 217 consecutive patients of all ages who were treated 1995-2005 at our center, of which 76 % survived treatment. The mean follow-up time was 7.9 years. Of the patients who survived more than 90 days after treatment, 91 % were alive at follow-up 5 years later, similar in all age categories (89-93 %). The highest mortality risk was observed within the first months after ECMO. We conclude that both short and long-term survival is high in all age categories, especially considering the high mortality risk of the patients eligible for ECMO treatment. More studies are needed to evaluate long term prognostic markers, cognitive functions and quality of life, especially in the adult.

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.