42

i
s,mal
ena,nausea,v
omi
ti
ng,t
ast
eper
ver
sion,wei
ghtl
oss/
gai
n

 Hemat
ologi
c:anaemi
a,hemor
rhage

 Neur
omuscul
ar:
weakness,
par
est
hesi
a

 Ocul
ar:
Ambl
yopi
a

 Respi
rat
ory
:cough,
rhi
nit
is

 Mi
scel
l
aneous:
all
ergi
creact
ion,
drugdependence.

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c)ECMOt
her
apy

 Extracorpor
ealmembraneoxygenation(ECMO)istheappli
c-
ati
onofamodi f
iedcar
diopul
monar ybypassforneonatesi
n
cardiacorrespi
rat
oryf
ail
urenotrespondingt
oconv ent
ional
measur esort r
eatment
s.

I
ndi
cat
ions:

 Respi
rat
oryf
ail
ure:

 Meconium aspi
rat
ionsyndrome,congeni
taldiaphr
agmati
c
herni
a( CDH),per
sist
entpulmonaryhy pert
ensionofthe
neonate,r
espi
rat
orydist
resssyndr
omemayr equir
eECMO.

 Oxygenati
onindex(OI)i
sameasur eoft hesever
it
yof
respi
rat
ory fail
ure and is cal
culat
ed as f oll
ows:
OI=meanai r
waypressur
e(MAP)×Fi O2/PaO2×100.
ECMOi sindi
catedwhen:

 2OI
sof>40ar
eseenwi
thi
n1hour

 1OIof60onhi
gh-
fr
equencyv
ent
il
ati
on

 1OIof40combi
nedwi
thcar
diov
ascul
ari
nst
abi
l
ity
.

 Forneonat
eshospi
talizedwhereECMOi snotav ail
able,
anOIof20shouldpromptear l
youtreacht oanECMO
cent
erforpot
enti
altransferbecauseprolongedv enti
la-
ti
onathighvent
il
atorset t
ingsmaywor senv entil
ator-

MDPaedi
atr
icsExami
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i
nducedl
ungi
njur
yandwor
sent
heov
eral
lout
come.

I
n any neonat e wi
threspi
ratoryfail
ure,hypoxi
a,and
bi
later
alopacit
iesonchestXray,t
otalanomalouspulmo-
naryvenousret
urn(TAPVR)shouldbeexcl udedpriort
o
i
niti
ati
ngECMO suppor t
.

 Car
diacf
ail
ure:

 ECMO provi
desbi v
entri
cul
arsupportforneonateswith
cardi
acf
ail
ure.I
tisusedi nl
owcardiacoutputsyndr
ome
despi
temaximalhemody nami
csupportorcar di
acarr
est
wit
hapotenti
all
yrever
sibl
eunder
lyi
ngcondi
tion.

 ECMO f orcongenit
alheartdef
ectscanbeof fer
edasa
bri
dgetodef i
nit
ivetreat
mentunti
ltheneonat
alcondi
ti
on
hasstabil
i
zed.

 Othercar
diacindicat
ionsar
ef ai
l
uretoweanfr
om car
dio-
pulmonar
yby pass,cardi
omyopathy
,andpul
monar
yhyper-
tensi
on.

 Rapi
d-response ECMO [
ECMO-
car
diopul
monar
yresusci
tat
-
i
on(E-CPR) ]
:

I
nt he sett
ing ofa wit
nessed cardi
orespirat
oryarrest
,
ECMO canbeof fer
edincenter
swi t
har apidresponse
team.Responsetimesfr
om thearresttocannul at
ionare
i
deall
y15-30minutes.

Areadi
l
y“cl
ear
-pr
imedcircui
t”(
anECMO circui
tprimed
wit
hnor
malsal
i
nerat
herthanwit
hbl
oodproducts)andan
ECMO t
eam mustbeavail
abl
e24hours/
dayi norderto
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icsExami
nat
ion,
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er2015,
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of
ferE-
CPR.

 Exut
eroi
ntr
apar
tum t
reat
ment(
EXI
T)t
oECMOpr
ocedur
e:

 Thevessel
sarecannulat
ed duri
ng acesarean sect
ion
whi
let
heneonat
eremainsonplacent
alsuppor
t.

I
ndicati
onsinclude:sever
eCDH,lungt umor
s,andairway
obstr
ucti
ng lesions such as l
arge neck masses and
mediasti
nal
tumor s.

Cont
rai
ndi
cat
ions:

 ECMO shoul d onl

y be offered forr ev
ersibl
e condi
tions.
Contr
aindi
cati
onsareconsi deredtobel ethalchr
omosomal
di
sorder (i
ncl
uding tr
isomi es 13 and 18 but not 21) ,
i
rrev
ersibl
ebraindamage,andi nt
ravent
ri
cularhemorrhage
(I
VH)grade≥3ori nt
raparenchy malhemorrhage.

 Relati
vecontrai
ndi cati
onsincludewei ght<1,500gduet o
cannulasizelimitations(exceptforthoraciccannulati
ons)
,
gestati
onalage<34weeksduet oi ncr
easedriskofI VH,
severecoagulopathy ,pr
ogressivechroniclungdisease,and
conti
nuousCPRf or>1hourbef oreECMOsuppor t.

Pr
ocedur
e:

 Pre-
ECMO:In preparat
ion f
orcannulat
ion,t he fol
l
owing
shoul
d be avai
labl
e:centralvenous access,postductal
art
eri
alcat
het
er,cross-
matched bl
ood i
nt he blood bank,
MDPaedi
atr
icsExami
nat
ion,
Wint
er2015,
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vedPaper
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tYadav
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a
 46

complet
ebl ood count,coagul
ati
onprofi
l
e,head USG.An
echocar
diogram shoul
dbedonebef oreECMO inor dert
o
rul
eoutst ruct
uralcardi
acabnormal
it
ies.

 The procedur
er equi
ressophist
icated i
nstr
umentati
on f
or
cardi
ac bypass and si
l
icon membr ane oxygenat
orofan
2 2
appropri
atesize(0.8m or1. 5m )f ortheneonate.The
resul
ti
ngtotalvol
umeofaneonatal ECMOci r
cuitis600ml .

 Thebloodf l
owismaintai
nedthroughtheECMOcircui
twith
anon- pulsat
il
epump.ECMO pumpf l
ow rat
eis~ 100-120
ml/kg/mi nut
e.Asaf
etychecki sconductedever
y4hour s.
Thissaf etycheckincl
udessear chi
ng f
orbloodcl
otsand
ci
rcuitinspecti
onforleaks.

 Pri
ming:Neonateswhoarepl
acedonECMOemer gent
lycan
bestar
tedonasal i
ne-
pri
medci r
cuit
,whil
efornon-emergent
casescanbeblood-pr
imedci
rcui
tisused.

 Thebloodisdrawnbyi nser
tingacatheteri
ntother
ight
j
ugul
arvei
norr i
ghtatr
ium.Itispassedthr
oughthemembr-
anef
oroxygenat
ionandremov alofCO2.

 Theoxy genat
edbl oodisret
urnedt otheneonat
evi
ari
ght
common car oti
d arter
y(v
enoarter
ial
)ort hefemor
alv
ein
(veno-
venous).

 Theneonat eiskepthepar i
nizedandv enti
l
atedatresti
ng
vent
il
atorsett
ingli
kepeakinspirat
orypressureof25cmH2O,
peakendexpirator
ypressure5cmH2O, rate10breat
hs/min,
i
nspir
atoryti
me1secandFi O2of0. 4.

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 Condi t
ioning( chall
engingt heneonatebyr educingtheECMO
suppor ttoev aluatethegasexchangeaccompl ished bythe
l
ungs) ,cy cl
ing( t
ransientl
yr emov i
ngthepat i
entf r
om the
ECMO ci rcuit
)and decannul at
ion are considered as t
he
neonat ei mpr oves,ori ft he disease process becomes
i
rreversible,adv erse neurologic event
s occurort hereis
multisystem or gandy sfuncti
on.

 Thr
oughoutt
hepr
ocedur
e,nor
mot
her
miai
smai
ntai
ned.

 Theneonat
eiskeptni
lbymout
handpar
ent
eralnut
ri
ti
oni
s
gi
ven.

 Neonateswho ar eathighriskforbleedi
ng ar
egi venε-
aminocaproi
cacid(100mg/kgIVloadi
ngdose→ 30mg/ kg/
hrinfusi
on).Aft
er72hours,t heneonateisassessedfor
fur
therri
sksofbl
eeding.

 AllECMOcandidatesar egiv
enbr oadspect
rum ant
ibi
oti
cs,
Furosemideandinot
ropes.Painanddiscomfor
tarerel
iev
ed
bygivingnar
cot
icanalgesi
csandsedati
ves.

 Schedul
eforl
abor
ator
yst
udi
es:

 act
ivat
edcl
ott
ingt
imehour
ly

l
act
atel
evel
stwi
cedai
l
y

 complet
ebl
oodcount,
platel
ets,whol
ebloodel
ect
rol
ytes,
i
onizedCa,andcreat
ini
net wicedail
y

 ant
it
hrombi
nIIItwice dai
ly and pr
iort
ofresh f
rozen
pl
asma (FFP) admini
str
ati
on and 3 hour
s post-FFP

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tYadav
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admi
nist
rat
ion

l
iverfunct
iontests,
alkal
inephosphat
ase,
lact
atedehydro-
genase,bi
lir
ubin,
albumin,preal
bumin,and t
otalprotein
everyweek.

 HeadUSGisdoneseri
all
ydur
ingtheECMOrun.EEGisdone
whensei
zur
eacti
vit
yissuspect
ed.MRIbr
ainisconsider
ed
af
tertheECMO runiscompleted.

Mechani
sm:

 Theprocedureall
ows“l
ungrest”andl
ungsar
epr
otect
ed
fr
om f
urtheri
njur
yduet
obarot
raumaandO2.

 Theimpr
ovedoxy
genat
ionandmil
dalkal
osi
sareassoci
ated
wit
hdecr
easei
nthepul
monaryar
terypr
essur
e.

 Reduct
ion i
nint
rat
hor
aci
c pr
essur
e→ i
ncr
eased v
enous
ret
urnt
othehear
t.

Compl
i
cat
ions:

 Mechani cal:Thesei ncludecl ot

si nthecircui
t( oxygenator,
bladder,and br idge),cannulaproblems,oxygenatorf ail
ure,
airint heci rcuit
,andr uptureoftubi
ng.Poorv enousr et
urn
(due t o hy povolemia,pneumot horax,tamponade,poor
catheterposition,smallv enouscatheterdi
ameter,excessive
catheterlength,kinkedt ubi
ng,andi nsuff
ici
enthy drostati
c
columnl engtht otheci rcuit
)causesthepumpt oshutdown
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i
nor
dert
oav
oidai
rent
rai
nment
.

 Cardiovascular:Hemodynami
cinst
abi
li
tymaybear esul
tof
hypov olemia,vasodi
l
ati
onduri
ngsept
icinf
lammat
oryrespo-
nse,ar r
hythmias,andpulmonaryemboli
sm.

 Neur
ologi
c:I
ntr
acr
ani
alhemor
rhagemayoccur
.

 Renal
:Renal
fai
l
uremayoccur
.

 Thesur v
ivor
shav eincreasedr
iskofreacti
veairwaydisease,
neuromotorr et
ardati
on,deafness,attent
ion defi
cithyper-
acti
vit
ydisor
der.

MDPaedi
atr
icsExami
nat
ion,
Wint
er2015,
Sol
vedPaper
—IV Dr
.Anki
tYadav
endr
a