Adaptation of an ECMO team in the era of successful alternative therapies for neonatal pulmonary failure

• Published in: Journal of pediatric surgery 1995-05, Vol.30 (5), p.674-678
• Main Authors: Haase, Gerald M, Kennaugh, Jan M, Clarke, David R
• Format: Article
• Language: English
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Costs and Cost Analysis; Emergency and intensive care: neonates and children. Prematurity. Sudden death; Extracorporeal Membrane Oxygenation - economics; Extracorporeal Membrane Oxygenation - statistics & numerical data; Humans; Infant, Newborn; Intensive care medicine; Medical sciences; Nitric Oxide - therapeutic use; Patient Care Team; Respiration, Artificial; Respiratory Insufficiency - therapy; Retrospective Studies
• ISSN: 0022-3468; 1531-5037
• DOI: 10.1016/0022-3468(95)90688-6

Neonates with persistent pulmonary hypertension show severe hypoxemia that requires a variety of therapeutic modalities. When patients do not respond to conventional medical management that includes hyperventilation, inotropic support, and vasodilating agents, treatment with extracorporeal membrane oxygenation (ECMO) may be used. More recently, high-frequency oscillatory ventilation and nitric oxide inhalation have been used in these infants and have impacted the need for ECMO. In light of these changes in therapy, the authors reviewed the 6-year clinical experience of an ECMO team to assess trends in patient population and outcome and document adaptation of the medical professionals to a new treatment era. Between 1988 and 1993, 88 neonates who met the institutional criteria were placed on venoarterial ECMO. Oscillatory ventilation was locally introduced in 1991 and nitric oxide treatment in 1992. Patient outcomes for the 1988 to 1990 period were compared with those for 1991 to 1993. Analyses included indication for ECMO therapy, length and complexity of the run, length of hospital stay, and cost of patient care. During the first 3 years, 65 patients were placed on ECMO, compared with 23 patients during the 3 years after introduction of oscillatory ventilation and nitric oxide therapy ( P < .001). The length of ECMO therapy increased from a mean of 128 hours to 190 hours ( P = .005), and the average hospital stay, likewise, increased from 27 days to 42 days. The total cost of care increased by approximately $40,000 per patient. During the 1991 to 1993 period, hyaline membrane disease and primary persistent pulmonary hypertension of the newborn became less of an indication for ECMO and were replaced by an increase in incidence of patients with sepsis and congenital diaphragmatic hernia. Fifty-five of the 65 (85%) patients during the first period survived, compared with 16 of the 23 (70%) patients during the second. With the advent of alternative therapies for severe neonatal pulmonary failure, the need for ECMO decreased in this pediatric tertiary care center. To maintain expertise, the ECMO team was integrated into a hospital-wide critical cardiopulmonary support team. Extracorporeal life support techniques became relevant only within a broader clinical setting created by the new therapeutic environment.