From February 1985 through June 1987, 50 newborn infants in whom maximal ventilator therapy failed (80% predicted mortality) were treated with extracorporeal membrane oxygenation (ECMO) according to the following inclusion criteria: arterial oxygen tension less than 50 torr (alveolar-arterial oxygen gradient greater than 620 torr) for 2 hours or arterial oxygen tension less than 60 torr (alveolar-arterial oxygen gradient greater than 620 torr) for 8 hours. Criteria for exclusion from ECMO therapy included birth weight less than 2000 gm, gestational age less than 35 weeks, presence of intracranial hemorrhage, presence of other major congenital anomalies including cyanotic heart disease, and high levels of ventilatory support for more than 7 days. Mean birth weight was 3.28 ± 0.56 kg, mean gestational age was 39.6 ± 1.7 weeks, and mean age at the start of ECMO was 48.6 ± 36.9 hours. Meconium aspiration, usually associated with persistent pulmonary hypertension, was the most common cause of pulmonary failure (62%). Mean pre-ECMO arterial oxygen tension during maximal ventilatory and pharmacologic support was 34.5 ± 14.5 torr. Mean ventilatory support immediately before the institution of ECMO was as follows: peak inspiratory pressure 46.8 ± 9.9 cm H2O, positive end-expiratory pressure 4.6 ± 1.6 cm H2O, and intermittent mandatory ventilation rate 101.0 ± 22.7 breaths/min with all patients receiving an inspired oxygen fraction of 1.0. Lung management to prevent pulmonary atelectasis during ECMO consisted of moderate levels of positive end-expiratory pressure (mean 10.3 ± 2.6 cm H2O), range 8 to 14 in 94% of patients. Other mean ventilator parameters during ECMO were as follows: peak inspiratory pressure 22.8 ± 1.6 cm H2O, intermittent mandatory ventilation rate 11.8 ± 2.9, and inspired oxygen fraction 0.21. The overall long-term patient survival rate was 90%. Mean values for arterial blood gases and ventilator settings immediately after the discontinuation of ECMO were as follows: oxygen tension 78.4 ± 22.1 torr, pH 7.39 ± 0.10, carbon dioxide tension 37.4 ± 10.7 torr, peak inspiratory pressure 25.2 ± 3.9 cm H2O, positive end-expiratory pressure 5.6 ± 1.2 cm H2O, and intermittent mandatory ventilation rat 41.3 ± 12.6 with an inspired oxygen fraction of 0.42 ± 0.17. Despite slightly higher levels of ventilator support (peak inspiratory pressure 46.8 versus 45.0 cm H2O, not significant) mean pre-ECMO oxygen tension was significantly lower than that reported from the National ECMO Registry (34.5 versus 42.0 torr, p <0.01). Mean positive end-expiratory pressure maintained during ECMO was significantly greater than that reported by the National ECMO Registry (10.3 versus 4.5 cm H2O, p <0.01). Mean duration of ECMO support was significantly shorter than in the National ECMO Registry data base (84.3 versus 119.0 hours, p <0.01). Mean time to extubation and mean length of total hospital stay were 4.9 ± 9.7 days and 28.6 ± 17.8 days, respectively, and compare favorably with the National Registry experience. We conclude that ECMO is a remarkably effective modality to reverse severe neonatal failure and that excellent survival can be achieved, despite the critical condition of these patients. The use of moderate levels of positive end-expiratory pressure during neonatal ECMO minimized pulmonary atelectasis and may importantly decrease the necessary duration of ECMO support.
|Original language||English (US)|
|Number of pages||9|
|Journal||Journal of Thoracic and Cardiovascular Surgery|
|State||Published - 1989|
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine