Extracorporeal circulation (ECMO) in neonatal respiratory failure.

Sixteen moribund newborn infants with respiratory failure were treated with extracorporeal membrane oxygenation (ECMO) for 1 to 8 days. Cannulation via the right jugular vein and carotid artery was used to establish venoarterial-cardiopulmonary bypass. High flow (80 percent of cardiac output) allowed decreasing FIO2 and airway pressure. Diagnoses and results were as follows: respiratory distress syndrome, four patients (two improved, one survived); meconium aspiration syndrome, eight patients (four improved, three survived); persistent fetal circulation (some with diaphragmatic hernia), four patients (three improved, two survived). Intracranial bleeding occurred in 43 percent, accounting for most of the deaths. In a parallel series of 21 infants treated with conventional ventilator therapy, the mortality rate was 90 percent and intracranial bleeding occurred in 57 percent. ECMO provided life support and gains time in newborn respiratory failure. In high mortality risk infants, the rate of survival is higher and intracranial bleeding lower with ECMO than with optimal ventilator management.

Extracorporeal membrane oxygenator support for cardiopulmonary failure. Experience in 28 cases.

We have used extracorporeal membrane oxygenation (ECMO) for 28 patients (14 children and 14 adults) over a 5 year period. Nine patients improved on ECMO and 5 were long-term survivors. ECMO was used for pulmonary insufficiency in 24 patients. Initially, only moribund patients were treated, but recently the combination of open lung biopsy and pulmonary insufficiency index (PII) has been used to select patients. The best results have been obtained in newborn cases and the adult capillary leak syndromes; the major problem has been progression to fibrosis despite ECMO support. ECMO was used for cardiac failure in 4 patients. Children with postoperative cardiac failure did the best; profound shock was not reversed with venoarterial bypass. ECMO support is lifesaving in selected cases of pulmonary insufficiency. Initial trials in cardiac failure and the infant age group in this series suggest that ECMO will have an even greater role in those applications.

Secondary anorectal surgery for the missed puborectalis muscle.

A detailed analysis and personal follow-up of 25 patients who underwent secondary anorectal surgery for incontinence suggests the following: (1) The puborectalis muscle is missed in pull-through surgery with greater frequency than is generally appreciated. (2) Direct visualization of the muscle at primary surgery can markedly reduce bowel misplacement. (3) Continence after secondary surgery improves with age, especially with the passage through puberty. (4) Secondary surgery improves sensation and thereby benefits continence. (5) No long term urinary problems appeared after reoperation. (6) Secondary surgery can restore a socially acceptable degree of continence in 3 out of 4 patients.

Prospective application of an index of neonatal necrotizing enterocolitis.

Fifty-five patients were scored 1 to 3 according to the criteria: the character of stools, abdominal findings on palpation, x-ray evidence of pneumatosis intestinalis, the development of pulmonary insufficiency, and the duration of symptoms to positive x-rays. Fifteen patients with scores of less than five were considered to have subclinical NEC with one late death. Twenty-nine of 30 patients with scores of 5-10 responded to medical management with 2 deaths related to recurrent bouts of sepsis without recurrent NEC. Eleven patients required surgery with index scores of 10-14 with 6 deaths occurring uniformly in those patients with scores of 12 or more. Two patients were scored inappropriately low due to the lack of the passage of a stool for analysis. One patient with a score of 4 did not pass a stool but had the other diagnostic criteria for the single false negative of the series. This index correctly determined the severity of NEC of 53 of 55 patients, identified the patients who required surgical intervention and predicted survival.

Candida endocarditis complicating glucose total intravenous nutrition.

A case of Candida albicans endocarditis is reported. The endocarditis occurred in a patient with a chronic illness who received intermittent glucose total intravenous nutrition for approximately 10 weeks. The patient developed severe aortic insufficiency with his valvular endocarditis and required emergency aortic valve replacement. Aggressive surgery and medical treatment appear to be the treatment of choice for these critically ill patients.

Extracorporeal membrane oxygenation (ECMO) cardiopulmonary support in infancy.

We have used prolonged extracorporeal membrane oxygenation (ECMO) in the treatment of 13 moribund infants (including 9 neonates), with 4 survivors (3 neonates). Successfully treated cases include post-operative cardiac failure, infant respiratory distress syndrome, massive meconium aspiration, and persistent fetal circulation. All cases have been managed with veno-arterial bypass at flow rates of 80-100 cc/Kg/min. Carotid cannulation for arterial access and careful control of heparin anticoagulation based on whole blood activated clotting time are among the techniques which have contributed to this success. Progressive pulmonary or cardiac failure has been the major problem in older infants, intracranial bleeding is the major problem in neonates. Both of these problems could be minimized by instituting ECMO earlier in the clinical course, but this awaits development of reliable early predictors of mortality.