Neonatal ECMO in 2019: Where Are We Now? Where Next?

About this Research Topic

Background

Extracorporeal membrane oxygenation (ECMO) is a temporary cardio-respiratory bypass, which provides partial or complete support to the native cardiac and/or pulmonary function. The technique was developed in the early '50s from cardiopulmonary bypass technology, and it was subsequently used to support neonatal respiratory failure. The main indications were: meconium aspiration syndrome, pulmonary hypertension, respiratory distress syndrome, pneumonia, sepsis, and congenital diaphragmatic hernia. Since the early 1970s, ECMO has spread rapidly among intensive care units, with peak activity in 2009 due to influenza A H1N1 pandemic. In the neonatal area, especially in the last two decades, technological and pharmacological progress (surfactant, nitric oxide, high-frequency ventilation) has led to a reduction of the need for respiratory ECMO, while the use of cardiac ECMO has remained stable over time.

Despite this, advances in fetal surgery and perinatal management of certain conditions (i.e., CDH) contributed to the survival of patients with increasing clinical complexity. Data from the Extracorporeal Life Support Organization (ELSO) registry shows that in 2017 around 600 neonates required respiratory ECMO worldwide. The overall mean survival rate is 83% at the procedure and 72% at discharge, with a large variability based on the underlying disease (50% in congenital diaphragmatic hernia vs. 93% in meconium aspiration syndrome). The survival is lower in both cardiac ECMO (64% at the procedure; 41% at discharge) and extracorporeal cardiopulmonary resuscitation - ECPR (66% at the procedure; 40% at discharge).

This Research Topic aims to collect the experience available on specific “open issues” in the fields of neonatal ECMO, such as:

1. Neonatal Respiratory ECMO:
a. ECMO in CDH: Timing of ECMO deployment, early vs. late? CDH ELSO Indications vs. CDH EURO Consortium Consensus criteria; Timing of surgical intervention: Before, during or after ECMO? Type of support: VV vs. VA?
b. ECMO in meconium aspiration syndrome in low and high-income country.
c. ECMO during pulmonary or tracheal surgery: which evidence?

2. Neonatal Respiratory/Cardiac ECMO:
a. Ventilation management during ECMO
b. Pump type: roller vs. Centrifugal
c. ECMO monitoring: advances in cardiorespiratory, hemostatic and neurological evaluation
d. Fluid management: Slow continuous ultrafiltration (SCUF) or Continuous veno-venous hemodiafiltration (CVVHDF)
e. Anticoagulation strategies: heparin and beyond (bivalirudin, lepirudin, and argatroban), monitoring and management of anticoagulation (TEG, ROTEM, ACT vs. lab control coagulation), surface coated circuits systems and low dose of heparin, heparin-induced thrombocytopenia
f. ECMO for septic shock
g. Nutrition during ECMO
h. Pharmacotherapy during ECMO
i. Short- and Long-term outcomes
j. Mechanical Complications
k. Ethical issues in resource restricted area’s
l. ECMO research agenda

3. Neonatal ECPR: Is Neonatal ECPR really useful?

The collection of evidence across the multidisciplinary fields of ECMO management will provide a comprehensive resource for the care of neonatal ECMO patients and will suggest plans for future research commitment.

Keywords: Extracorporeal membrane oxygenation, Newborn, Pharmacotherapy, Follow-up, Ventilation Management, CRRT, Anticoagulation., ECPR, Monitoring

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