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Extra corporeal membran oxygenation Indication and patients selection Because of the invasive nature of extra corporeal membrane

oxygenation ( ECMO), most notably the need to ligate the right common carotid artery in many patients and the risk not major hemorraghe resulting from systemic heparinization , ECMO continues to be reserved for neonate who do not respone to maximal conventional support and are believed to have a chance of survival of 20% or less. Because of the high risk of intracranial hemorraghe in babies born before 34 weeks gestation, ECMO is currently applicable only to term or near term infant. In general, to considered for ECMO therapy , a baby must have complete 34 weeks gestation, weight at least 2kg, and have a reversible cause of pulmonary or cardiac failure. Meconium aspiration syndrome is the most frequent cause of respiratory failure leading to ECMO. Other common underlying condition are diaphragmatic hernia, sepsis, congenital pneumoni, RDS, perinatal asphyxia. Persistent Pulmonary Hypertension of The Newborn (PPHN) is almost always a major contributing factor, usually accompanied by varying degrees of myocardial dysfunction. Primary cardiac failure is relatively rare indication for ECMO and the success of the procedure in these patient is limited. The survival rate for ECMO patient listed in the Extracorporeal Life Support Organization (ELSO) registry based at the University of Michigan as of july 1997 is 80.4 %. For the years 1973-82 the survival rate was 57,8 %, raising to 82,2 % in 1983-89. The survival rate declined slightly in 1990-97 to 79,8%, reflecting a change in the patient mix towards a greater proportion of more difficult cases. The prognosis for survival depends mainly on birth weight, gestasional age, and underlying diagnosis. Admission ph so be a useful prognostic feature. Serious complication of ECMO are not frequent but can be devastating. Of greatest concern are those related to systemic heparinization and to the ligation of the carotid and perhaps jugular vessel. Intracranial hemoraghe occurs in approximately 16% of patients and is more frequent in babies of 34-35 weeks gestasional. Other significant complication include internal hemorrhage , renal failure, and seizure. Cerebal infraction, predominantly involving the right hemisphere, is an occasional occurrence in patient who were hypotensive at the time of carotid artery ligation. Follow up data suggest that despite the extreme severity of their neonatal illness, most ECMO graduates survive the experience without appearance neurologic or development impairment. Transient feeding problems are the frequent occurance and may delay discharge. However, the rarely persistent beyond a few weeks, except in children with diaphragmatic hernia. Sensorial hearing loss is a common complication of ECMO and was notedin 29 in 112 (26%) ECMO graduates. The need of early, routine, audiologic evaluation throughout childhood for all ECMO graduates is apparent.

Jaundice Bilirubin is produced from breakdown of hemoglobin myoglobin cytochrome and other heme-containing compounds mainly in the liver, spleen, and bone marrow. The indirect bilirubin so formed is water-

“Wind-milling” movements of the extrimities have been reported. lethargy. apnea. poorly supervised breast feeding. and hence potentially toxic to the central nervous system. high pitched cry. and enamel hypoplasia. vomiting. the indirect bilirubin is transported across the placenta.g. Clinical manifestation of kernicterus in the full-term infant include temperature instability. . Most reports indicate that in term infants. Pulmonary or gastric hemorrhage may occur as a terminal event. and seizures . Long term sequel include the spastic or athetoid from a cerebral palsy. and increased tone may be the only acute manifestations. hemolysis) or when elimination is reduced. and inadequate follow-up most notably of late preterm infants (13-15 weeks gestation). In the fetus. kernicterus is unlikely to occur if the serum bilirubin is maintained below 25 mg/dl. without evidence of hemolysis. Hyperbilirubinemia is observed either when production of bilirubin is advanced (e. Subsequently irritability.may occur. and hypotonia. The search continues for a method of identifying infants all greatest risk to determine if and when encephalopathy is imminent. sunselting appearance of the eyes. There has been a resurgence of kernicterus in term and near-term infants attributable to early discharge. poor feeding. hearing loss (especially high tone).insoluble but fat-soluble. Hyperbilirubinemia is clinically relevant in the neonate because it has been associated with kernicterus (yellow stai ning of the basal ganglia and hippocampus). fisting. paralysis of upward gaze. An elevated bilirubin level (hyperbilirunbinemia) is the most common problem encountered in the fullterm neonate and is significant problem in the late preterm infant (36-38 weeks). Beta-glucurodinase present in human milk enhances the reabsorption of bilirubin from the gut. opisthotonus. although kernicterus has been reported autopsy in low birthweight infants where the serum bilirubin never exceed 10 mg/dl. In the preterm infant.