ECMO and the Neonate

Question 1

Most common neonatal pulmonary disorders

Answer 1

Meconium Aspiration Syndrome
Congenital Diaphragmatic Hernia
Hyaline Membrane Disease
Sepsis
Pulmonary Hyptertenion (PPHN) (may be primary or secondary)

Question 2

MAS

Answer 2

Meconium aspiration syndrome

Question 3

Which neonatal pulmonary disorders have a >90% survival rate?

Answer 3

Meconium Aspiration
Primary Pulmonary Hypertension
Respiratory Distress Syndrome
Pneumonia
Massive Air Leak

Question 4

Which neonatal pulmonary disorders have a 60% survival rate?

Answer 4

Congenital Diaphragmatic Hernia

Sepsis

Question 5

Physiological Factors

Answer 5

Surfactant
Lung development
Fetal shunts

Question 6

What does surfactant do/

Answer 6

Keeps alveoli open

Question 7

What secretes surfactant?

Answer 7

Via type II alveolar cells

Phospholipid based

Question 8

What are some fetal shunts

Answer 8

PFO
PDA
Ductus venosis

Question 9

Meconium Aspiration syndrome (MAS)

Answer 9

the passage of meconium before birth secondary to hypoxia or stress

Question 10

Meconium is in ____% of all deliveries.

Answer 10

10

Question 11

What does MAS lead to?

Answer 11

PPHN

Question 12

MAS: ECMO Notes

Answer 12

Straight forward cases
Do very well
VV if not severe cardiac suppression (VV conversion to VA)
Short duration

Question 13

What is the most challenging pulmonary disorder to manage?

Answer 13

Congenital Diaphragmatic Hernia (CDH)

Question 14

CDH

Answer 14

malformation of diaphragm
herniation of abdominal contents into thoracic cavity
stomach, intestines, spleen and liver
L>R
presents as SEVERE Respiratory distress

Question 15

CDH Treatment

Answer 15

Resuscitation
Gastric decompression
Head up
ECMO
Surgical intervention on/off ECMO
may turn heparin off
B/U Circuit ready

Question 16

CDH: ECMO Notes

Answer 16

UGLY cases
some times there is not enough lung to support life
a synthetic diaphragm does not assist ventilation as a phsyiological one

Be prepared to be on ECMO–>doing surgery –> NO heparin–> giving Amicar –> giving platelets –> waiting to clot

Question 17

HMD

Answer 17

Hyaline Membrane Disease

Question 18

Hyaline Membrane Disease

Answer 18

characterized by lack of surfactant 
(atelectasis)
Turned off via hypoxia/acidosis
Decreased Qp = hypoxia nad hypercapnia
-anaerobic glycolysis --> lactate

Question 19

HMD Predisposition

Answer 19

Premature kids
Asphyxia / hypoxia
Acidosis (can be severe)
Hypotension
diabetes
Male > female

Question 20

HMD Treatment

Answer 20

Surfactant
PEEP
IMG
HFOV
ECMO (VV)

Question 21

HMD Effects

Answer 21

Thick alveolar walls (tough gas exchange)
Atelectasis
Necrosis

Question 22

HMD: ECMO Notes

Answer 22

Expect VV

Short pump run

Question 23

Pulmonary Hypertension Causes (PPHN)

Answer 23

Hypoxia 
stress acidosis
hypotension
vasospasm
PA constriction

Question 24

PPHN Characteristics

Answer 24

Elevated PVR
Low Qp/Qs
R–> L shunts (PDA/PFO cyanotic)
preductal/post ductal gases differ

Question 25

High PVR=

Answer 25

more desaturated aortic blood

Question 26

PPHN Tx

Answer 26

``` Prevent hypoxia iNO Maintain Qs and pressure HFOV ECMO (VV or VA) ```

Question 27

PPHN: ECMO Notes

Answer 27

Good success rate treat the cause get rid of the symptomology very broad causal range of phsyiology

Question 28

Sepsis in the Neonate: Early Onset

Answer 28

Infection via the mother - Group B streptococcus infection during pregnancy - preterm delivery - water breaking (rupture of membranes) that lasts longer than 24 hours before birth - infection of hte placenta tissues and amniotic fluid (chorioamnionitis)

Question 29

Sepsis in the Neonate: Late Onset

Answer 29

``` Infection druing/after delivery -coagulase-negative staphylococcus E coli klebsiella pseudomonas enterbacter candida GBS Serratia ```

Question 30

Sepsis: Pediatric Septic Shock

Answer 30

Hypothermia or hyperthermia Altered mental status peripheral vasodilation (warm shock) Cool extremities (cold shock)

Question 31

Why choose VA ECMO over VV ECMO in sepsis?

Answer 31

provides cardiac and respiratory support decreases right ventricular preload no risk of recirculation better oxygen delivery

Question 32

Why NOT chose VA ECMO?

Answer 32

``` increases left ventricular afterload lowers pulse pressure coronary oxygenation by LV blood "Cardiac Stun" decreased cerebral autoregulation ```

Question 33

Why choose VV ECMO?

Answer 33

``` avoids major arterial cannulation provides direct pulmonary oxygenation improves coronary oxygneation limits neurological complications maintains pusality/CO vasopressors not contraindication ```

Question 34

Why NOT choose VV ECMO?

Answer 34

may have inadequate oxygen delivery dose not provide direct cardiac suppo increased incidence of recirculation

Question 35

Conclusions

Answer 35

VV ECMO may be preferred with sepsis decresaed mortality versus VA ECMO most pronounced in neonatal period