Surgical By Hirikati
Complications Extracorporeal S. Nagaraj,
and Procedures in Neonates Membrane Oxygenation
Kristin A. Mitchell,
Mary
on
E. Fallat, Diller B. Groff, and Larry N. Cook
Louisville, Kentucky l We report our experience from May 1985 to January 1991 with surgical complications and procedures performed in neonates on extracorporeal membrane oxygenation (ECMO) (218 venoarterial and 7 venovenous bypass). Eleven children older than 1 month were excluded. Total complications were 96 in 67 patients and included: bleeding (37), problems with initial cannula placement (17). thrombus formation (15), hemothorax, pneumothorax, or effusions (11). mechanical problems (11). and miscellaneous (5). Forty-eight procedures were performed in 37 patients while on ECMO. These were recannulation or reposition of cannulas (14). tube thoracostomy (II), cardiac surgery (6). cardiac catheterization (4), repair of congenital diaphragmatic hernia (5). thoracotomy (4), and others. Twenty-eight complications occurred in 15 of the 27 patients who died. Mortality rate was 12% for the entire group. Primary causes of death were hypoplastic lung (11). cardiac (8). sepsis (4). intraventricular hemorrhage (2), and pulmonary hypertension (2). No deaths were due solely to complications except for the two patients with intraventricular hemorrhage. Mortality in neonates who had complications while on ECMO was significantly higher (P < .005) than in patients without complications. Hemorrhagic and thoracic complications were associated with higher mortality (P < .oOl). Mortality was not affected by mechanical problems, thrombus formation, or catheterrelated problems. While on ECMO cardiac defects, diaphragmatic hernia, lobar emphysema, and other conditions can be safely corrected. The use of echocardiography to position the cannulas, better control of coagulation factors and improvement in equipment may ultimately decrease complications. Copyright o 1992 by W.B. Saunders Company
patients. Improvement in outcome may allow extrapolation to the use of ECMO in the management of pediatric cardiac patients and older children with reversible cardiorespiratory failure, whose outcome is less optimistic. In this report we review our experience with surgical complications and procedures in neonates on ECMO. MATERIALS
AND
METHODS
From the Depatiment of Surgery and Division of Pediatric Surgery, University of Louisville School of Medicine, Louisville, KY. Presented at the 43rd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, New Orleans, Louisiana, October 26-27, 1991. Address reprint requests to Hirikati S. Nagaraj, MD, Kosair Children S Hospital, PO Box 35070, Louisville, KY40232-5070. Copyright D 1992 by W.B. Saunders Company 0022-3468/92/2708-0034$03.00/0
We retrospectively reviewed 236 patients treated on ECMO between May 1985 and January 1991 at Kosair Children’s Hospital. Eleven children older than 1 month were excluded. Data collected on 225 newborns included birth history, pre-ECMO diagnosis, details of cannula placement, operative procedures performed while on ECMO, surgical complications, and follow-up. ECMO criteria for our institution are listed in Table 1. The criteria select a patient population associated with a mortality above 80% on conventional management.4 Standard venoarterial ECMO (218 patients) or venovenous ECMO (7 patients) was performed as described by Bartlett et al?-s During cannulation, diathermy was used after making a neck incision. All vessels over 2 mm were carefully ligated. Thrombin-soaked gelfoam was used to pack the wound prior to closing the skin incision. Venoarterial ECMO cannula sizes 8F to 12F were used for the carotid artery and 8F to 16F for the jugular vein. Initially we used argyle, silastic, Elecath catheters; and in recent patients, Biomedicus catheters. Kendal 14F catheters were used in venovenous ECMO patients. Patients were maintained on continuous heparin to keep the whole blood activated clotting time (ACT) between 250 and 350 seconds (ACTESTER) and between 200 and 250 seconds (HEMOCHRON) to prevent thrombosis in the circuit. Platelet count was kept over 50,000, and in recent patients, platelet transfusions were given to maintain the platelet count close to 100,000 for 75% of the day. Extracorporeal flow was maintained to totally support gas exchange (120 ml/kg/h). To minimize barotrauma, ventilatory settings were reduced to “lung rest” conditions (respiratory rate 20, F,Oz 40% and pressure setting 20/4). If a chest tube was inserted prior to ECMO, chest suction was maintained at 10 cm H20. Extracorporeal flow was decreased during lung recovery and ECMO discontinued when gas exchange was adequate on low ventilatory settings. Patients were awake while on ECMO, with morphine, phenobarbital, and fentanyl used for sedation as appropriate. Systemic arterial pressure was recorded continuously by either infrarenal umbilical artery, posterior tibia1 artery, or left radial artery catheter. Arterial blood gases were obtained hourly. Transcutaneous oxygen saturation, venous oxygen saturation, electrocardiography, and temperature were monitored constantly. Chest roentgenogram and cranial ultrasound were performed daily and whenever necessary. These procedures along with twodimensional Doppler study for echocardiography were available 24 hours a day. Echocardiography was used to check proper position and blood flow in cannulas when indicated, and was always used to determine proper position of the cannula in venovenous bypass during cannulation. Statistical analysis was performed using the x2 test.
1106
JournalofPediatric
INDEX WORDS: Extracorporeal (ECMO), neonates.
membrane
oxygenation
T
HE MANAGEMENT of selected neonates with respiratory insufficiency has become more sophisticated over the past 16 years, with the introduction of extracorporeal membrane oxygenation (ECMO).’ The overall survival rate of neonates managed on ECMO is 8O%2 to 94%3 in selected series. The decrease in mortality has allowed attention to be focused on morbidity, including treatment of complications and long-term outcome of these
Surgery, Vol27, No 8
(August), 1992:
pp 1106-l 110
SURGICAL COMPLICATIONS
& PROCEDURES ON ECMO
Table 1. ECMO Criteria for Kosair Children’s Hospital Contraindications
Indications
Severe congenital anomalies
PaOZ < 50 for four hours AaDO* > 627 for four hours Oxygenation index > 40 for four Acute decompensation
Complications Extracorporeal S. Nagaraj,
and Procedures in Neonates Membrane Oxygenation
Kristin A. Mitchell,
Mary
on
E. Fallat, Diller B. Groff, and Larry N. Cook
Louisville, Kentucky l We report our experience from May 1985 to January 1991 with surgical complications and procedures performed in neonates on extracorporeal membrane oxygenation (ECMO) (218 venoarterial and 7 venovenous bypass). Eleven children older than 1 month were excluded. Total complications were 96 in 67 patients and included: bleeding (37), problems with initial cannula placement (17). thrombus formation (15), hemothorax, pneumothorax, or effusions (11). mechanical problems (11). and miscellaneous (5). Forty-eight procedures were performed in 37 patients while on ECMO. These were recannulation or reposition of cannulas (14). tube thoracostomy (II), cardiac surgery (6). cardiac catheterization (4), repair of congenital diaphragmatic hernia (5). thoracotomy (4), and others. Twenty-eight complications occurred in 15 of the 27 patients who died. Mortality rate was 12% for the entire group. Primary causes of death were hypoplastic lung (11). cardiac (8). sepsis (4). intraventricular hemorrhage (2), and pulmonary hypertension (2). No deaths were due solely to complications except for the two patients with intraventricular hemorrhage. Mortality in neonates who had complications while on ECMO was significantly higher (P < .005) than in patients without complications. Hemorrhagic and thoracic complications were associated with higher mortality (P < .oOl). Mortality was not affected by mechanical problems, thrombus formation, or catheterrelated problems. While on ECMO cardiac defects, diaphragmatic hernia, lobar emphysema, and other conditions can be safely corrected. The use of echocardiography to position the cannulas, better control of coagulation factors and improvement in equipment may ultimately decrease complications. Copyright o 1992 by W.B. Saunders Company
patients. Improvement in outcome may allow extrapolation to the use of ECMO in the management of pediatric cardiac patients and older children with reversible cardiorespiratory failure, whose outcome is less optimistic. In this report we review our experience with surgical complications and procedures in neonates on ECMO. MATERIALS
AND
METHODS
From the Depatiment of Surgery and Division of Pediatric Surgery, University of Louisville School of Medicine, Louisville, KY. Presented at the 43rd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, New Orleans, Louisiana, October 26-27, 1991. Address reprint requests to Hirikati S. Nagaraj, MD, Kosair Children S Hospital, PO Box 35070, Louisville, KY40232-5070. Copyright D 1992 by W.B. Saunders Company 0022-3468/92/2708-0034$03.00/0
We retrospectively reviewed 236 patients treated on ECMO between May 1985 and January 1991 at Kosair Children’s Hospital. Eleven children older than 1 month were excluded. Data collected on 225 newborns included birth history, pre-ECMO diagnosis, details of cannula placement, operative procedures performed while on ECMO, surgical complications, and follow-up. ECMO criteria for our institution are listed in Table 1. The criteria select a patient population associated with a mortality above 80% on conventional management.4 Standard venoarterial ECMO (218 patients) or venovenous ECMO (7 patients) was performed as described by Bartlett et al?-s During cannulation, diathermy was used after making a neck incision. All vessels over 2 mm were carefully ligated. Thrombin-soaked gelfoam was used to pack the wound prior to closing the skin incision. Venoarterial ECMO cannula sizes 8F to 12F were used for the carotid artery and 8F to 16F for the jugular vein. Initially we used argyle, silastic, Elecath catheters; and in recent patients, Biomedicus catheters. Kendal 14F catheters were used in venovenous ECMO patients. Patients were maintained on continuous heparin to keep the whole blood activated clotting time (ACT) between 250 and 350 seconds (ACTESTER) and between 200 and 250 seconds (HEMOCHRON) to prevent thrombosis in the circuit. Platelet count was kept over 50,000, and in recent patients, platelet transfusions were given to maintain the platelet count close to 100,000 for 75% of the day. Extracorporeal flow was maintained to totally support gas exchange (120 ml/kg/h). To minimize barotrauma, ventilatory settings were reduced to “lung rest” conditions (respiratory rate 20, F,Oz 40% and pressure setting 20/4). If a chest tube was inserted prior to ECMO, chest suction was maintained at 10 cm H20. Extracorporeal flow was decreased during lung recovery and ECMO discontinued when gas exchange was adequate on low ventilatory settings. Patients were awake while on ECMO, with morphine, phenobarbital, and fentanyl used for sedation as appropriate. Systemic arterial pressure was recorded continuously by either infrarenal umbilical artery, posterior tibia1 artery, or left radial artery catheter. Arterial blood gases were obtained hourly. Transcutaneous oxygen saturation, venous oxygen saturation, electrocardiography, and temperature were monitored constantly. Chest roentgenogram and cranial ultrasound were performed daily and whenever necessary. These procedures along with twodimensional Doppler study for echocardiography were available 24 hours a day. Echocardiography was used to check proper position and blood flow in cannulas when indicated, and was always used to determine proper position of the cannula in venovenous bypass during cannulation. Statistical analysis was performed using the x2 test.
1106
JournalofPediatric
INDEX WORDS: Extracorporeal (ECMO), neonates.
membrane
oxygenation
T
HE MANAGEMENT of selected neonates with respiratory insufficiency has become more sophisticated over the past 16 years, with the introduction of extracorporeal membrane oxygenation (ECMO).’ The overall survival rate of neonates managed on ECMO is 8O%2 to 94%3 in selected series. The decrease in mortality has allowed attention to be focused on morbidity, including treatment of complications and long-term outcome of these
Surgery, Vol27, No 8
(August), 1992:
pp 1106-l 110
SURGICAL COMPLICATIONS
& PROCEDURES ON ECMO
Table 1. ECMO Criteria for Kosair Children’s Hospital Contraindications
Indications
Severe congenital anomalies
PaOZ < 50 for four hours AaDO* > 627 for four hours Oxygenation index > 40 for four Acute decompensation
