Author: Nicholas Houska, DO - University of Colorado, Children’s Hospital Colorado
A 2-day-old boy born at 31 weeks of gestation with a congenital diaphragmatic hernia develops severe hypoxemia despite utilization of high-frequency oscillatory ventilation. The patient is deemed NOT to be a candidate for extracorporeal membrane oxygenation according to institutional policy. Which of the following adverse outcomes is the MOST likely reason why this patient is not a candidate for extracorporeal membrane oxygenation?
EXPLANATION
The Extracorporeal Life Support Organization (ELSO) Guidelines for Neonatal Respiratory Failure provide evidence-based guidelines on patient selection, modes of support, and technical considerations for extracorporeal membrane oxygenation (ECMO) in neonates. These 2020 guidelines state that postmenstrual age <34 weeks and weight <2 kg are relative contraindications for ECMO, where postmenstrual age is defined as the sum of gestational age and chronologic age. The reason for this is the historically high rate of intracranial hemorrhage (ICH) (36%) and mortality (62%) in neonates <35 weeks gestational age (GA) versus 12% rate of ICH and 49% mortality in those over 35 weeks gestation.
With improvements in mortality trends and the rates of ICH in neonates <34 weeks GA, there is increasing utilization of ECMO in this population. Survival in patients <34 weeks GA who are offered ECMO has increased from 21% to between 48-76%. As survival outcomes continue to improve, certain centers are considering younger and smaller patients as candidates for ECMO. In a 2023 article, Burgos et al suggest that ECMO should be considered for patients at 32 to 33 weeks GA when restricted to high-volume neonatal ECMO centers with close reporting to ELSO, targeted oxygen delivery, and continuous technology development. Despite this, prematurity and extremely low birth weight remain high risk factors for morbidity and mortality with ECMO.
The correct answer is B. The risk of intracranial bleeding is the major reason to avoid ECMO in the patient described in the stem. While thromboembolism and infection are both causes of morbidity and mortality in premature infants on ECMO, it is the risk of intracranial hemorrhage due to anticoagulation that is the basis for a relative contraindication to ECMO in patients < 34 weeks postmenstrual age.
REFERENCES
Wild KT, Rintoul N, Kattan J, Gray B. Extracorporeal Life Support Organization (ELSO): Guidelines for Neonatal Respiratory Failure. ASAIO J. 2020;66(5):463-470.
Upp JR Jr, Bush PE, Zwischenberger JB. Complications of neonatal extracorporeal membrane oxygenation. Perfusion. 1994;9(4):241-56.
Burgos CM, Rintoul N, Broman LM. ECMO for premature neonates- Are we there yet? Seminars in Pediatric Surgery. 2023;32(4):151335
