Hypertension during extracorporeal membrane oxygenation: cause, effect, and management

Area of Science:

• Neonatal Medicine
• Cardiovascular Physiology
• Critical Care

Background:

• Extracorporeal membrane oxygenation (ECMO) is vital for neonatal respiratory failure.
• Bleeding due to heparinization is a primary ECMO complication.
• Systolic hypertension is an emerging, serious side effect in neonates undergoing ECMO.

Purpose of the Study:

• To investigate the incidence and mediators of systolic hypertension in neonates on ECMO.
• To determine the association between systolic hypertension and intracranial hemorrhage (ICH).
• To evaluate the efficacy of aggressive antihypertensive management in preventing ICH.

Main Methods:

• Retrospective analysis of 41 neonates treated with ECMO.
• Measurement of systolic blood pressure and calculation of hypertension index (HI).
• Assay of biochemical mediators including plasma renin activity (PRA) and angiotensin-converting enzyme (ACE).
• Comparison of ICH incidence before and after implementing an aggressive medical management protocol.

Main Results:

• 38 of 41 neonates developed systolic hypertension (>90 mm Hg).
• Elevated PRA, aldosterone, epinephrine, norepinephrine, and prostaglandin E2 were observed.
• Patients with ICH had a significantly higher HI and PRA compared to those without ICH.
• An aggressive management protocol (hydralazine, nitroglycerine, captopril) reduced clinically significant ICH from 50% to 9%.

Conclusions:

• Systolic hypertension is frequent in neonatal ECMO and associated with ICH.
• Elevated PRA is implicated in the hypertension and ICH development.
• Aggressive management of hypertension, especially with ACE inhibitor captopril, significantly reduces ICH incidence.