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Extracorporeal Membrane Oxygenation (ECMO) and its complications in newborns with congenital diaphragmatic hernia

  • Latoya A. Stewart
    Affiliations
    Columbia University Vagelos College of Physicians and Surgeons, 630W 168th Street, New York, NY 10032, United States
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  • Rafael Klein-Cloud
    Affiliations
    Division of Pediatric Surgery, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • Claire Gerall
    Affiliations
    Division of Pediatric Surgery, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • Weijia Fan
    Affiliations
    Department of Biostatistics, Columbia University Mailman School of Public Health, 722W 168th Street, New York, NY 10032, United States
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  • Jessica Price
    Affiliations
    Division of Pediatric Surgery, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • Rebecca R. Hernan
    Affiliations
    Department of Pediatrics, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • Usha S. Krishnan
    Affiliations
    Department of Pediatrics, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • Eva W. Cheung
    Affiliations
    Department of Pediatrics, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • William Middlesworth
    Affiliations
    Division of Pediatric Surgery, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • Diana Vargas Chaves
    Affiliations
    Department of Pediatrics, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • Russell Miller
    Affiliations
    Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622W 168th Street, PH 16, New York, NY 10032, United States
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  • Lynn L. Simpson
    Affiliations
    Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622W 168th Street, PH 16, New York, NY 10032, United States
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  • Wendy K. Chung
    Affiliations
    Department of Pediatrics, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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  • Vincent P. Duron
    Correspondence
    Corresponding author.
    Affiliations
    Division of Pediatric Surgery, NewYork Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, 2nd Floor, New York, NY 10032, United States
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      Highlights

      • Although 61.1% of CDH patients on ECMO survived, 70.4% of patients on ECMO suffered at least one complication, some leading to serious, long-lasting sequelae.
      • Mechanical complications (cannula problems, circuit thrombosis, oxygenator failure, circuit change) and renal complications (creatinine increase, hemodialysis requirement) were independently associated with mortality.

      Abstract

      Background

      Extracorporeal Membrane Oxygenation (ECMO) is offered to patients with congenital diaphragmatic hernia (CDH) who are in severe respiratory and cardiac failure. We aim to describe the types of complications among these patients and their impact on survival.

      Methods

      A single-center, retrospective review of CDH patients cannulated onto ECMO between January 2005 and November 2020 was conducted. ECMO complications, as categorized by the Extracorporeal Life Support Organization (ELSO), were correlated with survival status. Descriptive statistics were used to compare observed complications between survivors and non-survivors.

      Results

      In our cohort of CDH neonates, 21% (54/258) were supported with ECMO, of whom, 61% (33/54) survived. Survivors and non-survivors were similar in baseline characteristics except for birthweight z-score (p = 0.043). Seventy percent of CDH neonates experienced complications during their ECMO run, with the most common categories being metabolic (48.1%) and mechanical (38.9%), followed by hemorrhage (22.2%), neurological (18.5%), renal (11.1%), pulmonary (7.4%), and cardiovascular (7.4%). The median number of complications per patient was higher in the non-survivor group  (2 (IQR: 1–4) vs 1 (IQR: 0–2), p = 0.043). In addition, mechanical (57.1% vs 27.3%, p = 0.045) and renal (28.6% vs 0%, p = 0.002) complications were more common among non-survivors compared to survivors.

      Conclusion

      Complications occur frequently among ECMO-treated newborns with CDH, some of which have serious long-term consequences. Survivors had higher birth weight z-scores, shorter ECMO runs, and fewer complications per patient. Mechanical and renal complications were independently associated with mortality, emphasizing the utility of more focused strategies to target fluid balance and renal protection and to prevent circuit and cannula complications.

      Keywords

      Abbreviations:

      CDH (Congenital diaphragmatic hernia), CNS (Central nervous system), CVVH (Continuous venovenous hemofiltration), ECLS (Extracorporeal life support), ECMO (Extracorporeal membrane oxygenation), ELSO (Extracorporeal Life Support Organization), FETO (Fetoscopic Endotracheal Occlusion), GI (Gastrointestinal), LHR (Lung-to-head ratio), V-A (Venoarterial), V-V (Venovenous)
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      References

        • Langham M.R.
        • Kays D.W.
        • Ledbetter D.J.
        • et al.
        Congenital diaphragmatic hernia - epidemiology and outcome.
        Clin Perinatol. 1996; 23 (-&): 671
        • Style C.C.
        • Olutoye O.O.
        • Belfort M.A.
        • et al.
        Fetal endoscopic tracheal occlusion reduces pulmonary hypertension in severe congenital diaphragmatic hernia.
        Ultrasound Obstet Gynecol. 2019; 54: 752-758https://doi.org/10.1002/uog.20216
        • Clark R.H.
        • Yoder B.A.
        • Sell M.S.
        Prospective, randomized comparison of high-frequency oscillation and conventional ventilation in candidates for extracorporeal membrane oxygenation.
        J Pediatr. 1994; 124: 447-454https://doi.org/10.1016/s0022-3476(94)70374-4
      1. Inhaled nitric oxide and hypoxic respiratory failure in infants with congenital diaphragmatic hernia. The neonatal inhaled nitric oxide study group (NINOS).
        PediatricsPediatrics. 1997; 99: 838-845https://doi.org/10.1542/peds.99.6.838
        • Kinsella J.P.
        • Truog W.E.
        • Walsh W.F.
        • et al.
        Randomized, multicenter trial of inhaled nitric oxide and high-frequency oscillatory ventilation in severe, persistent pulmonary hypertension of the newborn.
        J Pediatr. 1997; 131: 55-62https://doi.org/10.1016/s0022-3476(97)70124-0
        • Boloker J.
        • Bateman D.A.
        • Wung J.T.
        • et al.
        Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea/spontaneous respiration/elective repair.
        J Pediatr Surg. 2002; 37: 357-366https://doi.org/10.1053/jpsu.2002.30834
        • Kays D.W.
        • Islam S.
        • Perkins J.M.
        • et al.
        Outcomes in the physiologically most severe congenital diaphragmatic hernia (CDH) patients: whom should we treat?.
        J Pediatr Surg. 2015; 50: 893-897https://doi.org/10.1016/j.jpedsurg.2015.03.005
        • Paden M.L.
        • Conrad S.A.
        • Rycus P.T.
        • et al.
        Extracorporeal life support organization registry report 2012.
        Asaio J. 2013; 59: 202-210https://doi.org/10.1097/MAT.0b013e3182904a52
        • Thiagarajan R.R.
        • Barbaro R.P.
        • Rycus P.T.
        • et al.
        Extracorporeal life support organization registry international report 2016.
        Asaio J. 2017; 63: 60-67https://doi.org/10.1097/mat.0000000000000475
        • Turek J.W.
        • Nellis J.R.
        • Sherwood B.G.
        • et al.
        Shifting risks and conflicting outcomes—ECMO for neonates with congenital diaphragmatic hernia in the modern era.
        J Pediatr. 2017; 190 (e4): 163-168https://doi.org/10.1016/j.jpeds.2017.08.010
        • Hintz S.R.
        • Suttner D.M.
        • Sheehan A.M.
        • et al.
        Decreased use of neonatal extracorporeal membrane oxygenation (ECMO): how new treatment modalities have affected ECMO utilization.
        Pediatrics. 2000; 106: 1339-1343https://doi.org/10.1542/peds.106.6.1339
        • Barbaro R.P.
        • Paden M.L.
        • Guner Y.S.
        • et al.
        Pediatric extracorporeal life support organization registry international report 2016.
        Asaio j. 2017; 63: 456-463https://doi.org/10.1097/mat.0000000000000603
        • Golden J.
        • Jones N.
        • Zagory J.
        • et al.
        Outcomes of congenital diaphragmatic hernia repair on extracorporeal life support.
        Pediatr Surg Int. 2017; 33: 125-131https://doi.org/10.1007/s00383-016-4002-2
        • Wynn J.
        • Krishnan U.
        • Aspelund G.
        • et al.
        Outcomes of congenital diaphragmatic hernia in the modern era of management.
        J Pediatr. 2013; 163 (e1): 114-119https://doi.org/10.1016/j.jpeds.2012.12.036
      2. ECLS registry form. Ann Arbor, MI: Extracorporeal Life Support Organization (ELSO). https://www.elso.org/Portals/0/Files/PDF/ELSOECLSRegistryForm8.0_2020.pdf, Accessed 2020.

        • Oluyomi-Obi T.
        • Kuret V.
        • Puligandla P.
        • et al.
        Antenatal predictors of outcome in prenatally diagnosed congenital diaphragmatic hernia (CDH).
        J Pediatr Surg. 2017; 52: 881-888https://doi.org/10.1016/j.jpedsurg.2016.12.008
        • Fenton T.R.
        • Kim J.H.
        A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants.
        BMC Pediatr. 2013; 13: 59https://doi.org/10.1186/1471-2431-13-59
      3. Growth chart training. Atlanta, GA: Centers for Disease Control and Prevention. https://www.cdc.gov/nccdphp/dnpao/growthcharts/resources/sas-who.htm, Accessed 2020.

        • Okochi S.
        • Cheung E.W.
        • Barton S.
        • et al.
        An analysis of risk factors for hemolysis in children on extracorporeal membrane oxygenation.
        Pediatr Crit Care Med. 2018; 19: 1059-1066https://doi.org/10.1097/PCC.0000000000001699
        • Gupta P.
        • Carlson J.
        • Wells D.
        • et al.
        Relationship between renal function and extracorporeal membrane oxygenation use: a single-center experience.
        Artif Organs. 2015; 39: 369-374https://doi.org/10.1111/aor.12379
        • Brown K.L.
        • Sriram S.
        • Ridout D.
        • et al.
        Extracorporeal membrane oxygenation and term neonatal respiratory failure deaths in the United Kingdom compared with the United States: 1999 to 2005.
        Pediatr Crit Care Med. 2010; 11: 60-65https://doi.org/10.1097/PCC.0b013e3181b0644e
        • Dalton H.J.
        • Garcia-Filion P.
        • Holubkov R.
        • et al.
        Association of bleeding and thrombosis with outcome in extracorporeal life support.
        Pediatr Crit Care Med. 2015; 16: 167-174https://doi.org/10.1097/pcc.0000000000000317
        • Kays D.W.
        • Islam S.
        • Richards D.S.
        • et al.
        Extracorporeal life support in patients with congenital diaphragmatic hernia: how long should we treat?.
        J Am Coll Surg. 2014; 218: 808-817https://doi.org/10.1016/j.jamcollsurg.2013.12.047
        • Hinton C.F.
        • Siffel C.
        • Correa A.
        • et al.
        Survival disparities associated with congenital diaphragmatic hernia.
        Birth Defects Res. 2017; 109: 816-823https://doi.org/10.1002/bdr2.1015
        • Ong M.-.S.
        • Abman S.
        • Austin E.D.
        • et al.
        Racial and ethnic differences in pediatric pulmonary hypertension: an analysis of the pediatric pulmonary hypertension network registry.
        J Pediatr. 2019; 211: 63https://doi.org/10.1016/j.jpeds.2019.04.046
        • Guner Y.S.
        • Harting M.T.
        • Fairbairn K.
        • et al.
        Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: a propensity score approach.
        J Pediatr Surg. 2018; 53: 2092-2099https://doi.org/10.1016/j.jpedsurg.2018.06.003
        • Seetharamaiah R.
        • Younger J.G.
        • Bartlett R.H.
        • et al.
        Factors associated with survival in infants with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: a report from the Congenital Diaphragmatic Hernia Study Group.
        J Pediatr Surg. 2009; 44: 1315-1321https://doi.org/10.1016/j.jpedsurg.2008.12.021
        • Jancelewicz T.
        • Brindle M.E.
        • Harting M.T.
        • et al.
        Extracorporeal membrane oxygenation (ECMO) risk stratification in newborns with congenital diaphragmatic hernia (CDH).
        J Pediatr Surg. 2018; 53: 1890-1895https://doi.org/10.1016/j.jpedsurg.2018.04.014
        • Jancelewicz T.
        • Paton E.A.
        • Jones J.
        • et al.
        Risk-stratification enables accurate single-center outcomes assessment in congenital diaphragmatic hernia (CDH).
        J Pediatr Surg. 2019; 54: 932-936https://doi.org/10.1016/j.jpedsurg.2019.01.020
        • Sekhon M.K.
        • Fenton S.J.
        • Yoder B.A.
        Comparison of early postnatal prediction models for survival in congenital diaphragmatic hernia.
        J Perinatol. 2019; 39: 654-660https://doi.org/10.1038/s41372-019-0335-8
        • Skarsgard E.D.
        • MacNab Y.C.
        • Qiu Z.
        • et al.
        SNAP-II predicts mortality among infants with congenital diaphragmatic hernia.
        J Perinatol. 2005; 25: 315-319https://doi.org/10.1038/sj.jp.7211257
        • Guner Y.S.
        • Nguyen D.V.
        • Zhang L.
        • et al.
        Development and validation of extracorporeal membrane oxygenation mortality-risk models for congenital diaphragmatic hernia.
        ASAIO J. 2018; 64: 785-794https://doi.org/10.1097/MAT.0000000000000716
        • Seetharamaiah R.
        • Younger J.G.
        • Bartlett R.H.
        • et al.
        Factors associated with survival in infants with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: a report from the congenital diaphragmatic hernia study group.
        J Pediatr Surg. 2009; 44: 1315-1321https://doi.org/10.1016/j.jpedsurg.2008.12.021
        • Stevens T.P.
        • Chess P.R.
        • McConnochie K.M.
        • et al.
        Survival in early- and late-term infants with congenital diaphragmatic hernia treated with extracorporeal membrane oxygenation.
        Pediatrics. 2002; 110: 590-596https://doi.org/10.1542/peds.110.3.590
        • Nasr V.G.
        • Raman L.
        • Barbaro R.P.
        • et al.
        Highlights from the extracorporeal life support organization registry: 2006-2017.
        Asaio J. 2019; 65: 537-544https://doi.org/10.1097/mat.0000000000000863
        • Stocker C.F.
        • Horton S.B.
        Anticoagulation strategies and difficulties in neonatal and paediatric extracorporeal membrane oxygenation (ECMO).
        Perfusion. 2016; 31: 95-102https://doi.org/10.1177/0267659115590626
        • Kamdar A.
        • Rintoul N.
        • Raffini L.
        Anticoagulation in neonatal ECMO.
        Semin Perinatol. 2018; 42: 122-128https://doi.org/10.1053/j.semperi.2017.12.008
        • Thomas J.
        • Kostousov V.
        • Teruya J.
        Bleeding and thrombotic complications in the use of extracorporeal membrane oxygenation.
        Semin Thromb Hemost. 2018; 44: 20-29https://doi.org/10.1055/s-0037-1606179
        • Murphy D.A.
        • Hockings L.E.
        • Andrews R.K.
        • et al.
        Extracorporeal membrane oxygenation-hemostatic complications.
        Transfus Med Rev. 2015; 29: 90-101https://doi.org/10.1016/j.tmrv.2014.12.001
        • Maul T.M.
        • Aspenleiter M.
        • Palmer D.
        • et al.
        Impact of circuit size on coagulation and hemolysis complications in pediatric extracorporeal membrane oxygenation.
        Asaio J. 2020; 66: 1048-1053https://doi.org/10.1097/mat.0000000000001121
        • Guner Y.S.
        • Delaplain P.T.
        • Schomberg J.
        • et al.
        Risk factors for hemolysis during extracorporeal life support for congenital diaphragmatic hernia.
        J Surg Res. 2021; 263: 14-23https://doi.org/10.1016/j.jss.2021.01.007
        • Ostermann M.
        • Connor Jr., M.
        • Kashani K
        Continuous renal replacement therapy during extracorporeal membrane oxygenation: why, when and how?.
        Curr Opin Crit Care. 2018; 24: 493-503https://doi.org/10.1097/mcc.0000000000000559
        • Mahmood B.
        • Newton D.
        • Pallotto E.K.
        Current trends in neonatal ECMO.
        Semin Perinatol. 2018; 42: 80-88https://doi.org/10.1053/j.semperi.2017.12.003
        • Bhatia M.
        • Katz J.N.
        Contemporary comprehensive monitoring of veno-arterial extracorporeal membrane oxygenation patients.
        Can J Cardiol. 2020; 36: 291-299https://doi.org/10.1016/j.cjca.2019.10.031
        • IJ H.
        • Hunfeld M.
        • Schiller R.M.
        • et al.
        Improving long-term outcomes after extracorporeal membrane oxygenation: from observational follow-up programs toward risk stratification.
        Front Pediatr. 2018; 6: 177https://doi.org/10.3389/fped.2018.00177
        • Fletcher K.
        • Chapman R.
        • Keene S.
        An overview of medical ECMO for neonates.
        Semin Perinatol. 2018; 42: 68-79https://doi.org/10.1053/j.semperi.2017.12.002
        • Deprest J.A.
        • Nicolaides K.H.
        • Benachi A.
        • et al.
        Randomized trial of fetal surgery for severe left diaphragmatic hernia.
        N Engl J Med. 2021; https://doi.org/10.1056/NEJMoa2027030