The Science Journal of the American Association for Respiratory Care

2006 OPEN FORUM Abstracts

The Disposition of Neonatal Extracorporeal Membrane Oxygenation Referrals in a Children's Hospital

Lauren Perlman RRT-NPS, Peter Betit RRT-NPS, Anne Hansen MD, PhD.
Children's Hospital Boston and Harvard Medical School , Boston , MA

Introduction: Extracorporeal membrane oxygenation (ECMO) is used to support neonates with hypoxic respiratory failure (HRF) when advanced therapies such as high-frequency oscillatory ventilation (HFOV) and inhaled nitric oxide (INO) are unsuccessful. Neonates from tertiary NICUs who are transported to our center for potential ECMO are prospectively tracked as part of a QI program. Patients with congenital diaphragmatic hernia and cardiac disease are not included.

Methods:
  We reviewed our database over a 5-year period. We evaluated ventilator mode; conventional mechanical ventilation (CMV) or HFOV, INO use, need for ECMO, and survival from 01/01 to 12/05.

Results:
There were 101 patients referred to our center for possible ECMO; 2 CMV, 6 CMV+INO, 8 HFOV, and 85 HFOV+INO. Of the total referrals 20 (20%) required ECMO, all from the HFOV+INO subset. Overall 92 (91%) patients survived. The 9 (9%) deaths all occurred in the ECMO group; 3 multi-system organ failure,

3 intracranial hemorrhages, and 3 alveolar capillary dysplasia.

Year Pts. CMV CMV + INO HFOV HFOV + INO ECMO Survival
01 25 1 2 3 19 6 23 (92%)
02 28 0 0 0 28 7 25 (89%)
03 19 1 2 3 13 4 17 (89%)
04 17 0 2 1 14 1 17 (100%)
05 12 0 0 1 11 2 10 (83%)

Discussion: Advanced therapies such as HFOV and INO have reduced the need for ECMO in neonates with HRF however it has not eliminated its use. Our data suggests that the need for ECMO in neonates with HRF is 20%. The number of ECMO referrals decreased over the 5-year period which may reflect an increased availability and expertise with advanced therapies in non-ECMO centers. We consider the need for ECMO to be low, and speculate that because of the availability of ECMO, we were able to use higher HFOV mean airway pressures than the referring centers, and that this strategy may have improved alveolar recruitment and INO response. While most patients did not require ECMO, the morbidity associated with strategies used to prevent ECMO is not known and should be followed in the future. The high survival rate that we observed may be attributed to the referring center's timely referral. Treatment failure criteria, including the proximity to an ECMO center, should be established by tertiary NICUs using advanced therapies.

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