Subject(s)
Ethics, Dental , Morals , Communication , Dentist-Patient Relations , Education, Dental , Humans , Philosophy, Dental , Social ResponsibilityABSTRACT
We studied the prognostic significance of electroencephalograms recorded serially at 2- to 4-day intervals during the acute neonatal course of 119 near-term infants with severe respiratory failure treated by venoarterial extracorporeal membrane oxygenation (ECMO). A poor prognosis was defined as early death (n = 27), an abnormally low developmental assessment score (n = 14), or cerebral palsy (n = 14) at 12 to 45 months of age. The only electroencephalographic abnormalities that were significantly related to a poor prognosis were burst suppression (B-S) and electrographic seizure (ES). The 30 infants with two or more recordings of B-S or ES, when compared with the 58 neonates without such electroencephalographic abnormalities, had an odds ratio for a poor prognosis of 6.6 (95% confidence limits, 2.2 to 20.2). The 31 infants with a single ES or B-S recording did not have a significantly increased risk for a poor prognosis. Cardiopulmonary resuscitation immediately before ECMO (n = 8) and the lowest systolic blood pressure before or during ECMO were significantly related to the occurrence of ES or B-S recordings. There was no significant predilection of ES for either cerebral hemisphere. We conclude that in near-term neonates with respiratory failure, serial electroencephalographic recordings are of predictive value, and may facilitate clinical care including the decision to initiate or to continue ECMO.
Subject(s)
Electroencephalography , Extracorporeal Membrane Oxygenation , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy , Acute Disease , Cardiopulmonary Resuscitation , Confidence Intervals , Humans , Infant, Newborn , Morbidity , Odds Ratio , Predictive Value of Tests , Prognosis , Regression Analysis , Respiratory Burst/physiology , Respiratory Insufficiency/complications , Respiratory Insufficiency/mortality , Risk Factors , Spasms, Infantile/etiology , Spasms, Infantile/physiopathology , Survival Rate , Time FactorsABSTRACT
OBJECTIVE: Right common carotid artery (RCCA) ligation after extracorporeal membrane oxygenation by venoarterial bypass may contribute to lateralized cerebral injury. Reconstruction of this artery after extracorporeal membrane oxygenation has proved feasible but has not been evaluated for neurologic outcome in any substantial series of infants. METHODS: We evaluated RCCA reconstruction in 47 infants treated with ECMO and compared their cerebrovascular and neuroanatomic imaging findings, electroencephalograms, and developmental outcomes with those of 93 infants who had no reconstruction. SUMMARY RESULTS: Color Doppler blood flow imaging revealed that carotid artery patency was usually obtained after RCCA reconstruction. Right internal carotid and bilateral anterior and middle cerebral arterial blood flow velocities were generally higher, and were more symmetrically distributed in infants with reconstructed RCCA. Electroencephalography did not disclose an increased risk of deterioration or marked abnormalities in infants after reconstruction, nor were neuroimaging findings consistent with an increased number of either focal or generalized abnormalities. Neurodevelopmental follow-up revealed no differences in the incidence of delays between those with a reconstructed RCCA and those with a ligated RCCA during the first year of life. CONCLUSIONS: Reconstruction of the RCCA after extracorporeal membrane oxygenation may facilitate normal distribution of cerebral blood flow through the circle of Willis, and may augment both left and right middle cerebral artery blood flow immediately after decannulation. The long-term consequences of either ligation or reconstruction of the RCCA will require careful scrutiny, however, before either course is recommended routinely.