Single-Center Experience Using the Cardiohelp System for Neonatal and Pediatric Extracorporeal Membrane Oxygenation.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) systems have continued to evolve and improve with the development of smaller and portable systems. The Cardiohelp (Maquet Getinge Cardiopulmonary AG, Rastatt, Germany) portable life support device is a compact ECMO system used widely in adults and for ECMO transport. Reports of its use in neonatal and pediatric centers remain limited. In this single-center retrospective review, we describe our institutional experience with the Cardiohelp. DESIGN: Single-center retrospective review. SETTING: Neonatal ICUs and PICUs in a tertiary-care children's hospital. PATIENTS: Seventeen pediatric patients on ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Median (interquartile range, IQR) of patient age was 0.5 years (0-7 yr). Eleven of 17 patients were on veno-arterial ECMO, five on veno-venous ECMO, and one on veno-venoarterial ECMO. All veno-venous and veno-venoarterial runs ( n = 6) were accomplished with bicaval, dual-lumen cannulae. Median duration on Cardiohelp was 113 hours (IQR 50-140 hr). Median anti-Xa level for patients was 0.43 IU/mL (IQR 0.35-0.47 IU/mL), with median heparin dose of 23.6 U/kg/hr (IQR 17.6-28.1 U/kg/hr). Median plasma-free hemoglobin was 41.4 mg/dL (IQR 30-60 mg/dL). Circuit change was required in three cases. Fourteen patients survived ECMO, with 13 patients surviving to discharge. CONCLUSIONS: We have used the Cardiohelp system to support 17 neonatal and pediatric ECMO patients, without complications. Further studies are warranted to compare complications, outcomes, and overall cost with other institutions and other existing ECMO systems.

Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs.

To describe ventilation strategies used during extracorporeal membrane oxygenation (ECMO) for neonatal respiratory failure among level IV neonatal ICUs (NICUs). DESIGN: Cross-sectional electronic survey. SETTING: Email-based Research Electronic Data Capture survey. PATIENTS: Neonates undergoing ECMO for respiratory failure at level IV NICUs. INTERVENTIONS: A 40-question survey was sent to site sponsors of regional referral neonatal ECMO centers participating in the Children's Hospitals Neonatal Consortium. Reminder emails were sent at 2- and 4-week intervals. MEASUREMENTS AND MAIN RESULTS: Twenty ECMO centers responded to the survey. Most primarily use venoarterial ECMO (65%); this percentage is higher (90%) for congenital diaphragmatic hernia. Sixty-five percent reported following protocol-based guidelines, with neonatologists primarily responsible for ventilator management (80%). The primary mode of ventilation was pressure control (90%), with synchronized intermittent mechanical ventilation (SIMV) comprising 80%. Common settings included peak inspiratory pressure (PIP) of 16-20 cm H2O (55%), positive end-expiratory pressure (PEEP) of 9-10 cm H2O (40%), I-time 0.5 seconds (55%), rate of 10-15 (60%), and Fio2 22-30% (65%). A minority of sites use high-frequency ventilation (HFV) as the primary mode (5%). During ECMO, 55% of sites target some degree of lung aeration to avoid complete atelectasis. Fifty-five percent discontinue inhaled nitric oxide (iNO) during ECMO, while 60% use iNO when trialing off ECMO. Nonventilator practices to facilitate decannulation include bronchoscopy (50%), exogenous surfactant (25%), and noninhaled pulmonary vasodilators (50%). Common ventilator thresholds for decannulation include PEEP of 6-7 (45%), PIP of 21-25 (55%), and tidal volume 5-5.9 mL/kg (50%). CONCLUSIONS: The majority of level IV NICUs follow internal protocols for ventilator management during neonatal respiratory ECMO, and neonatologists primarily direct management in the NICU. While most centers use pressure-controlled SIMV, there is considerable variability in the range of settings used, with few centers using HFV primarily. Future studies should focus on identifying respiratory management practices that improve outcomes for neonatal ECMO patients.

Comprehensive pain management strategy for infants with moderate to severe osteogenesis imperfecta in the perinatal period.

Osteogenesis imperfecta (OI) is a rare genetic heterogeneous disorder that causes increased bone fragility and recurrent fractures. For infants with OI and diffuse fractures, pain management, which is nuanced and specific for this population, is of the utmost importance to their neonatal care. Through experience at our center, we have developed a standard approach that has been successful in optimizing survival for these infants during this tenuous period. In this paper, we outline our multidisciplinary approach to pain management for infants with moderate to severe OI during the neonatal period, with emphasis on promotion of fracture healing and adequate pain control.

Preoperative Blood Transfusions and Morbidity in Neonates Undergoing Surgery.

BACKGROUND: Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs). METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Data Files from 2012 to 2015, we identified all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion. RESULTS: A total of 12 184 neonates were identified, of whom 1209 (9.9%) received a PBT. Neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with those who did not receive a transfusion (composite morbidity: 46.2% vs 16.2%; P < .01). On multivariable regression analysis, PBTs were independently associated with increased 30-day morbidity (odds ratio [OR] = 1.90; 95% confidence interval [CI]: 1.63-2.22; P < .01) and mortality (OR = 1.98; 95% CI: 1.55-2.55; P < .01). In a propensity score-matched analysis, PBTs continued to be associated with increased 30-day morbidity (OR = 1.53; 95% CI: 1.29-1.81; P < .01) and mortality (OR = 1.58; 95% CI: 1.24-2.01; P = .01). CONCLUSIONS: In a propensity score-matched model, PBTs are independently associated with increased morbidity and mortality in neonates who undergo surgery. Prospective data are needed to better understand the potential effects of a red blood cell transfusion in this patient population.

International Survey on Extracorporeal Membrane Oxygenation Transport.

Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for severe respiratory and circulatory failure. It is best performed in high-volume centers to optimize resource utilization and outcomes. Regionalization of ECMO might require the implementation of therapy before and during transfer to the high-volume center. The aim of this international survey was to describe the manner in which interhospital ECMO transport care is organized at experienced centers. Fifteen mobile ECMO centers from nine countries participated in this survey. Seven (47%) of them operated under the "Hub-and-Spoke" model. Transport team composition varies from three to nine members, with at least one ECMO specialist (i.e., nurse or perfusionist) participating in all centers, although intensivists and surgeons were present in 69% and 50% of the teams, respectively. All centers responded that the final decision to initiate ECMO is multidisciplinary and made bedside at the referring hospital. Most centers (75%) have a quality control system; all teams practice simulation and water drills. Considering the variability in ECMO transport teams among experienced centers, continuous education, training and quality control within each organization itself are necessary to avoid adverse events and maintain a low mortality rate. A specific international ECMO Transport platform to share data, benchmark outcomes, promote standardization, and provide quality control is required.

Awake Neonatal Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is used in patients with acute respiratory failure that is not responsive to conventional management. The practice of awake ECMO has become an area of interest but with limited data and experience. Most reported experience comes from adult and pediatric populations. Traditional management of these patients still includes mechanical ventilator support and often requires the use of sedatives for provision of safe care. We present a series of eight neonates who were electively extubated while on ECMO, with expanded discussion of two representative cases. We discuss the rationale for extubation and outcomes. The greatest benefit of this management was seen in patients with significant air leak, and in no reported case did we experience any adverse effects or complications as a direct result of extubation while on ECMO. In conclusion, in our experience, awake neonatal ECMO appears safe and effective and may offer significant advantages over traditional management in certain clinical scenarios. Prospective comparison trials are warranted to further investigate the clinical benefits and risks of awake neonatal ECMO.

Extracorporeal Membrane Oxygenation in a Pediatric Patient with Hepatopulmonary Syndrome and Interrupted Inferior Vena Cava After Living Related Liver Donation.

Extracorporeal membrane oxygenation (ECMO) is used for cardiopulmonary dysfunction. Hepatopulmonary syndrome (HPS) occurs in the setting of liver failure and may cause hypoxemia. Previous reports have described the use of ECMO for HPS after liver transplant. Our patient is a 19-month-old female with biliary atresia, an interrupted inferior vena cava, and HPS on 8 liters per minute of high-flow oxygen. Following liver transplantation, her postoperative course was complicated by severe hypoxemia requiring ECMO. Due to her interrupted inferior vena cava, our standard bi-caval cannula could not be used. Hence, a 16-French double lumen venovenous right internal jugular to right atrial cannula was used to provide extracorporeal life support. She was decannulated after 17 days, remained intubated for 2 days, and weaned to room air over the next 3 weeks. This is the third pediatric liver transplant patient supported with ECMO identified in the literature, and the youngest and smallest of those reported. This approach to cannulation is unique because of the use of a double lumen venovenous cannula for HPS in a child, selected due to complex anatomy. Posttransplant ECMO may provide pediatric patients with HPS and posttransplant hypoxemia a period of support for their pulmonary remodeling and recovery from HPS.

Lung Rest During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure-Practice Variations and Outcomes.

OBJECTIVE: Describe practice variations in ventilator strategies used for lung rest during extracorporeal membrane oxygenation for respiratory failure in neonates, and assess the potential impact of various lung rest strategies on the duration of extracorporeal membrane oxygenation and the duration of mechanical ventilation after decannulation. DATA SOURCES: Retrospective cohort analysis from the Extracorporeal Life Support Organization registry database during the years 2008-2013. STUDY SELECTION: All extracorporeal membrane oxygenation runs for infants less than or equal to 30 days of life for pulmonary reasons were included. DATA EXTRACTION: Ventilator type and ventilator settings used for lung rest at 24 hours after extracorporeal membrane oxygenation initiation were obtained. DATA SYNTHESIS: A total of 3,040 cases met inclusion criteria. Conventional mechanical ventilation was used for lung rest in 88% of cases and high frequency ventilation was used in 12%. In the conventional mechanical ventilation group, 32% used positive end-expiratory pressure strategy of 4-6 cm H2O (low), 22% used 7-9 cm H2O (mid), and 43% used 10-12 cm H2O (high). High frequency ventilation was associated with an increased mean (SEM) hours of extracorporeal membrane oxygenation (150.2 [0.05] vs 125 [0.02]; p < 0.001) and an increased mean (SEM) hours of mechanical ventilation after decannulation (135 [0.09] vs 100.2 [0.03]; p = 0.002), compared with conventional mechanical ventilation among survivors. Within the conventional mechanical ventilation group, use of higher positive end-expiratory pressure was associated with a decreased mean (SEM) hours of extracorporeal membrane oxygenation (high vs low: 136 [1.06] vs 156 [1.06], p = 0.001; mid vs low: 141 [1.06] vs 156 [1.06]; p = 0.04) but increased duration of mechanical ventilation after decannulation in the high positive end-expiratory pressure group compared with low positive end-expiratory pressure (p = 0.04) among survivors. CONCLUSIONS: Wide practice variation exists with regard to ventilator settings used for lung rest during neonatal respiratory extracorporeal membrane oxygenation. Use of high frequency ventilation when compared with conventional mechanical ventilation and use of low positive end-expiratory pressure strategy when compared with mid positive end-expiratory pressure and high positive end-expiratory pressure strategy is associated with longer duration of extracorporeal membrane oxygenation. Further research to provide evidence to drive optimization of pulmonary management during neonatal respiratory extracorporeal membrane oxygenation is warranted.

Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates.

BACKGROUND AND OBJECTIVE: Heated, humidified high-flow nasal cannula (HHHFNC) is commonly used as a noninvasive mode of respiratory support in the NICU. The safety and efficacy of HHHFNC have not been compared with other modes of noninvasive support in large randomized trials. The objective was to assess the efficacy and safety of HHHFNC compared with nasal continuous positive airway pressure (nCPAP) for noninvasive respiratory support in the NICU. METHODS: Randomized, controlled, unblinded noncrossover trial in 432 infants ranging from 28 to 42 weeks' gestational age with planned nCPAP support, as either primary therapy or postextubation. The primary outcome was defined as a need for intubation within 72 hours of applied noninvasive therapy. RESULTS: There was no difference in early failure for HHHFNC (23/212 [10.8%]) versus nCPAP (18/220 [8.2%]; P = .344), subsequent need for any intubation (32/212 [15.1%] vs 25/220 [11.4%]; P = .252), or in any of several adverse outcomes analyzed, including air leak. HHHFNC infants remained on the study mode significantly longer than nCPAP infants (median: 4 vs 2 days, respectively; P < .01), but there were no differences between study groups for days on supplemental oxygen (median: 10 vs 8 days), bronchopulmonary dysplasia (20% vs 16%), or discharge from the hospital on oxygen (19% vs 18%). CONCLUSIONS: Among infants ≥28 weeks' gestational age, HHHFNC appears to have similar efficacy and safety to nCPAP when applied immediately postextubation or early as initial noninvasive support for respiratory dysfunction.