Usefulness of implementation of a protective mechanical ventilation bundle during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome.

OBJECTIVE: Defining the best ventilatory settings under ECMO remains a challenging question. Despite a well-defined ARDS treatment before ECMO initiation, there is no recommendation on how to ventilate a patient under ECMO for P-ARDS. Only a few descriptive studies are available on ventilatory settings during respiratory ECMO. We aim at evaluating the usefulness of a protective ventilation bundle under ECMO and its capacity to reduce the ventilatory pressure in our ECMO center. METHODS: We performed a monocentric retrospective study from January 2007 to December 2018. All children aged from 1 month to 18 years old and requiring an extracorporeal membrane oxygenation for a refractory acute respiratory distress syndrome were included. A protective mechanical ventilation under ECMO bundle has been developed in 2014. We compare the period 1 (before 2014) to the period 2 (after 2014). RESULTS: Eighty-three patient had been included during the study. We reported a significant increase of PEEP and mean pressure respectively at day 3, day 7 and day 14 of ECMO during the period 2. Conversely, the driving pressure were significantly lower in the period 2 at day 3 (p: 0.009), day 7 (p:0.001) and day 14 (p: 0.001). We also shown a strong increase in the use of prone positioning during ECMO in the period 2 (p: 0.01). There was no significant effect of our bundle on the length of mechanical ventilation, of hospitalization and on the survival rate. CONCLUSIONS: The implementation of a protective mechanical ventilation bundle during ECMO is usefulness to apply for lower ventilatory pressure and higher use of prone positioning. Nonetheless, the lack of power of our study prevents us from showing its efficacy on outcome criteria.

Incidence and risk factors of ventilator-associated pneumonia in neonatal intensive care unit: a first French study.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a severe intensive complication and remains under estimated in neonatal intensive care unit (NICU). Center for Disease Control defined criteria for adults and pediatrics without neonatal criteria. The objective of this article was to evaluate the rate, the risks factors and the outcome of neonates suffering from ventilator-associated pneumonia in a French NICU. METHODS: We conducted a prospective observational study within a one-year period in our NICU. Three hundred and eighty-one neonates under 28 days of age were included. Data analyses were performed using Fischer exact-test, Kolgomorov analysis, Mann-Whitney test and logistic regression. RESULTS: Seventeen patients were diagnosed with ventilator-associated pneumonia. Incidence rate of VAP was 8.8 per 1000 invasive mechanical ventilator days. The median age at diagnosis was 20 days (range: 4-45). Extremely low birth weight (under than 1000 grams) were significantly associated with VAP (OR=4.31 [95% CI: 1.38-13.39]). Newborns suffering from VAP had a significantly longer duration of invasive ventilation (median: 16 days [range 4-75] versus 3 days [range 1-28], P<0.001) and hospital length of stay (median: 34 days [range 7-91] versus 7 days [range 1-56], P<0.001). Mortality rate was significantly higher in patient with VAP (P=0.028). CONCLUSIONS: We describe the first French study on VAP in a neonatal population. Amongst nosocomial infections, VAP is a complication with severe consequences for NICU patients. Larger studies are needed to better define a diagnosis strategy and prevention bundle.