Neonatal respiratory extracorporeal membrane oxygenation and primary diagnosis: trends between two decades.

OBJECTIVE: Examine changing neonatal respiratory extracorporeal membrane oxygenation (ECMO) practice trends and outcomes. STUDY DESIGN: Retrospective cohort study comparing neonatal respiratory ECMO in the 1990 and 2010 decades (1994-1995 and 2014-2015). Patients ≤ 30 days of life, reported to the Extracorporeal Life Support Organization registry, were included. RESULTS: Four thousand one hundred and twenty-five patients met inclusion criteria. ECMO cases decreased by 33%. The primary ECMO diagnosis changed significantly over time (p < 0.0001). Survival to discharge decreased (76 vs 67%, p < 0.0001) and ECMO duration increased (131 vs 158 h, p < 0.001). Lung recovery was the most common reason to discontinue ECMO although family request for withdrawal and a diagnosis considered "incompatible with life" was increasingly common in the 2010s. CONCLUSION: Although the use of ECMO for neonatal respiratory diagnoses has decreased over time, its use has increased for patients with more complex diagnoses and ECMO duration is longer. ECMO continues to be an important supportive therapy, improved understanding of which patients would benefit most is needed.

Acidity of Enteral Feeding Tube Aspirate in Neonates: Do pH Values Meet the Cutoff for Predicting Gastric Placement?

BACKGROUND: Enteral feeding tubes (EFTs) are commonly used in neonatal practice, but complications from tube misplacement remain a concern. Measuring the pH of EFT aspirate is a recommended method to evaluate EFT placement. A pH value of ≤5.5 is considered predictive of gastric placement. Using this method in infants has been questioned. It is unclear whether infants can produce adequate gastric acid to achieve a pH 5 or less and whether feedings and medications influence pH. PURPOSE: To report EFT aspirate pH values in infants and to evaluate factors potentially influencing pH values. METHODS: A retrospective descriptive study was conducted with 1024 infants with 6979 pH values. Demographic and clinical data were collected including type of EFT, pH of gastric aspirate, feeding method, time of last feeding, and administration of acid suppression medications. The frequency of measured pH values of 5 or less was calculated for each covariate. FINDINGS/RESULTS: The majority (97.51%) of pH values were 5 or less. Orogastric tubes, continuous feeding, a 4-hour or more feeding interval, exposure to medications (proton pump inhibitor, histamine-2 receptor antagonist, or multiple medications) were associated with an increased likelihood of pH values of more than 5. However, with each study variable the majority of pH values were 5 or less. IMPLICATIONS FOR PRACTICE: These findings suggest EFT pH, a recommended method to evaluate the likelihood of gastric placement, can be successfully used in the neonatal population. IMPLICATIONS FOR RESEARCH: Future research should prospectively evaluate EFT pH in infants when compared with clinically indicated radiographs. Other factors that might influence pH should be explored including severity of illness, feeding type, and other medications.

Outcome after recannulation and a second course of extracorporeal membrane oxygenation.

BACKGROUND/PURPOSE: Controversy surrounds the justification of a second course of extracorporeal membrane oxygenation (ECMO) for patients that deteriorate after initial decannulation. The authors' experience with a small number of patients requiring recannulation led them to investigate the results of a second ECMO course from all institutions that report to the ELSO registry. METHODS: The ELSO neonatal registry for patients that underwent multiple ECMO courses was reviewed and mortality and complication rates between first and second courses were compared. Complications were classified according to the following ELSO registry defined categories: hemorrhagic, mechanical, metabolic, infectious, renal, pulmonary, neurologic, and cardiac. RESULTS: Of the 16,450 patients in the ELSO neonatal registry in January 2000, 205 patients (1.25%) have required multiple ECMO courses. There have been 201 patients (1.22%) who have needed 2 courses of ECMO and 4 patients (0.024%) have undergone 3 ECMO runs. A total of 557 complications occurred during the first ECMO course in these 205 patients, and 672 complications developed during the second course. This represents an increase in the complication rate by 20.6% during the second ECMO course. Although mechanical complications were the most common, there was no change in the incidence between first and second courses. However, the frequency of complications increased in all other classifications during the second course when compared with the first. The largest increases occurred with neurologic and infectious complications (134% and 79% increases, respectively). Renal and metabolic complications also were markedly elevated (35% and 24%, respectively). Seventy-six of 201 (38%) patients who required 2 courses of ECMO and 1 of 4 patients undergoing 3 runs survived. Survival was more likely for patients with meconium aspiration. Primary pulmonary hypertension and total anomalous pulmonary venous return had low survival rates. CONCLUSIONS: A small subset of patients may require recannulation and a second ECMO course. Although survival may be achieved in more than one third of these patients, complication rates are increased during the second course. Specifically, neurologic, infectious, renal, and metabolic complication rates are increased. Long-term consequences of recannulation are unknown. Selection criteria identifying patients that may benefit from recannulation have not been established.