Feasibility of sedation and analgesia interruption following cannulation in neonates on extracorporeal membrane oxygenation.

PURPOSE: In most extracorporeal membrane oxygenation (ECMO) centers patients are heavily sedated to prevent accidental decannulation and bleeding complications. In ventilated adults not on ECMO, daily sedation interruption protocols improve short- and long-term outcome. This study aims to evaluate safety and feasibility of sedation interruption following cannulation in neonates on ECMO. METHODS: Prospective observational study in 20 neonates (0.17-5.8 days of age) admitted for ECMO treatment. Midazolam (n = 20) and morphine (n = 18) infusions were discontinued within 30 min after cannulation. Pain and sedation were regularly assessed using COMFORT-B and visual analog scale (VAS) scores. Midazolam and/or morphine were restarted and titrated according to protocolized treatment algorithms. RESULTS: Median (interquartile range, IQR) time without any sedatives was 10.3 h (5.0-24.1 h). Median interruption duration for midazolam was 16.5 h (6.6-29.6 h), and for morphine was 11.2 h (6.7-39.4 h). During this period no accidental extubations, decannulations or bleeding complications occurred. CONCLUSIONS: This is the first study to show that interruption of sedatives and analgesics following cannulation in neonates on ECMO is safe and feasible. Interruption times are 2-3 times longer than reported for adult ICU patients not on ECMO. Further trials are needed to substantiate these findings and evaluate short- and long-term outcomes.

[Neurological defects and developmental disorders following neonatal extracorporeal membrane oxygenation: results of a follow-up study after 5 years]. / Neurologische afwijkingen en ontwikkelingsstoornissen na extracorporele membraanoxygenatie van pasgeborenen: resultaten van een follow-uponderzoek na 5 jaar.

OBJECTIVE: Descriptive study of the development of children 5 years after neonatal extracorporeal membrane oxygenation (ECMO). DESIGN: Descriptive. METHOD: 98 treated children were subjected to a paediatric, neurological, psychological, physiotherapeutic and logopaedic examination. The children came from 2 Dutch ECMO-centres (the Erasmus MC-Sophia Children's Hospital in Rotterdam and the University Medical Centre St Radboud in Nijmegen, The Netherlands). RESULTS: Neurological disorders were found in 17 of the 98 investigated children, and in 6 cases these were serious. Among the remaining 92 children, 24 had motor disorders and 11 had delayed cognitive development. The average IQ (100.5) was within the normal range. CONCLUSION: A significant proportion ofthe children that had been treated with ECMO had long-term morbidity in the form of neurological defects and developmental disorders.

Gut hormone profiles in critically ill neonates on extracorporeal membrane oxygenation.

OBJECTIVES: The objective of this study was to gain insight into the hormonal responses to enteral nutrition in critically ill newborns requiring venoarterial extracorporeal membrane oxygenation (ECMO) by analyzing plasma gut hormone levels of gastrin, cholecystokinin and peptide-YY in relation to enteral nutrition. METHODS: In 24 consecutive neonates treated with venoarterial ECMO intestinal hormone secretions were determined by radioimmunoassay at 2-day intervals. Twelve received parenteral nutrition only. In 12 enteral nutrition was introduced later. The findings in these patients were compared with those of 16 measurements in eight non-ECMO treated age-matched controls. Mixed model analysis of variance was used for statistical analysis. RESULTS: Concentrations of gastrin, cholecystokinin and peptide-YY were significantly higher in ECMO patients receiving enteral nutrition compared with ECMO patients who received parenteral nutrition (62, 3.8 and 59.4 pmol/L versus 46, 3.1 and 34.7 pmol/L, respectively). Overall, plasma hormone levels did not differ from those in age-matched controls. CONCLUSIONS: Intestinal hormone levels showed normal responses after introduction of enteral feeding, comparable with those in age-matched controls without ECMO. These results do not provide an argument for withholding enteral nutrition even in the most severely ill neonates on venoarterial ECMO.

Does V-A ECMO increase the likelihood of chylothorax after congenital diaphragmatic hernia repair?

BACKGROUND: The authors noticed a relatively large number of patients with congenital diaphragmatic hernia (CDH) repair after extracorporeal membrane oxygenation (ECMO) who had a chylothorax (CT). The data are reviewed. METHODS: The charts of patients from 1990 until 2000 with CDH, treated with or without ECMO, together with the charts of patients treated with ECMO for other reasons and patients with esophageal atresia (EA) repair were reviewed. The diagnosis of CT was made if aspirated fluid appeared chylous and contained more than 90% lymphocytes or if the triglyceride level was more than 1.50 mmol/L. RESULTS: Eighty-nine patients with CDH were analyzed. Postoperatively, 10% had a CT-21% in CDH patients with ECMO treatment and 6% in CDH patients without ECMO treatment. This difference appeared to be significant (P <.05). The presence of a patch as independent variable for the development of CT also showed significance (P <.05). CONCLUSIONS: Chylothorax presented in almost all cases as a left-sided fluid accumulation, and a patch was present in the majority of patients with CDH. Therefore, CT should be considered the result of the severity of the defect rather than the consequence of ECMO as a therapeutic modality.

Diagnosis of nonpsychotic patients in community clinics.

OBJECTIVE: Diagnosis-specific, proven efficacious treatments are a major recent advance in psychiatry. Appropriate use of such treatments presupposes patients who meet the diagnostic criteria and clinicians who have accurately diagnosed the target disorder and comorbid conditions. Since little is known about whether these prerequisites are commonly met, the authors conducted a study at two community treatment sites to determine the frequency of various axis I diagnoses and the concordance between the diagnoses recorded in patient charts and those obtained by a structured interview. Given that a DSM diagnosis may not be sufficient to understand a patient's problems, the authors also obtained ratings of interpersonal functioning. METHOD: The subjects were 164 nonpsychotic patients who were seen at a rural (N=114) or urban (N=50) community treatment facility. Raters trained to reliably use the Structured Clinical Interview for DSM-IV (SCID) conducted diagnostic interviews. Clinical charts were reviewed to obtain clinical diagnoses. Patients completed questionnaires regarding interpersonal functioning. RESULTS: Most (N=145, 88%) of the patients met the SCID criteria for a current axis I diagnosis, and 53% (N=87) met the criteria for two or more disorders. Clinical and SCID diagnoses had poor agreement. Evidence was found for interpersonal dysfunction. CONCLUSIONS: Most patients met the diagnostic criteria for conditions for which there are proven treatments; however, inaccurate diagnosis proved common. This barrier to optimal treatment could be ameliorated with the use of structured interviews for common diagnoses. Scores on social/interpersonal measures support the premise that DSM symptoms provide only part of the relevant information about patients' conditions.