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How low should we go? Outcomes of ECMO in neonates with low gestational age or birth weight
Faraz A Khan1, Humza Thobani1, Dan Neal2
1Division of Pediatric Surgery, Stanford University, Palo Alto, CA, USA.
Insights
Extracorporeal membrane oxygenation (ECMO) survival in neonates with low birth weight (BW) and gestational age (GA) is possible, though mortality increases with decreasing BW and GA. Even premature infants may survive ECMO.
Area of Science:
- Neonatal Medicine
- Pediatric Critical Care
- Cardiopulmonary Support
Background:
- Historically, low birth weight (BW) and gestational age (GA) were contraindications for ECMO.
- Recent data suggest improved outcomes in smaller neonates undergoing ECMO.
Purpose of the Study:
- To investigate the utilization and survival rates of ECMO in neonates with lower GA and BW.
- To analyze the association between GA and BW with mortality and adverse outcomes in neonates receiving ECMO.
Main Methods:
- Analysis of 14,167 neonates from the Extracorporeal Life Support Organization (ELSO) registry (2009-2019).
- Primary outcome: mortality. Secondary outcome: major adverse outcomes (composite of severe ECMO complications).
- Statistical analysis included univariate and multivariable tests to assess the impact of GA and BW.
Main Results:
- BW, GA, ECMO mode, pulmonary support, pH, and ventilator settings significantly predicted survival.
- Increasing GA and BW showed a significant linear relationship with decreased mortality (p < 0.001).
- Highest mortality (70-75%) observed in neonates with GA 30-31 weeks and BW 1.5-2.0 kg.
Conclusions:
- Decreasing GA and BW strongly correlate with increased mortality and ECMO complications.
- Survival is achievable in up to 25% of low GA or BW neonates treated with ECMO.
Purpose:
Initial recommendations for ECMO had relative contraindications for low birth weight (BW) or low gestational age (GA) babies. However, more recent literature has demonstrated improved and acceptable outcomes of ECMO in smaller neonates. The purpose of this study was to understand both utilization and survival in patients with lower GA and BW.
Methods:
All neonates captured in the Extracorporeal Life Support Organization (ELSO) registry who underwent a single ECMO run from 2009 to 2019 were included. The primary outcome measure was mortality and the secondary outcome measure was major adverse outcomes, defined as a composite outcome variable any severe ECMO complications. Univariate and multivariable statistical tests were performed to estimate the association between GA and BW with both outcome variables.
Results:
A total of 14,167 cases met inclusion criteria. Univariate analysis noted that birth weight, gestational age, ECMO mode, pulmonary support type, pH and ventilator settings were highly significant predictors of survival. Multivariable assessment noted significant linear relationship of mortality rates with increasing GA and BW (p < 0.001, OR = 0.82 GA, 0.51 BW). The highest ECMO-related mortality was observed in neonates with GA 30-31 weeks and BW 1.5-2.0 kg, with a 70-75% in-hospital mortality rate.
Conclusions:
Decreasing GA and BW were strongly correlated with increasing odds of mortality and/or ECMO-related complications. However, even in low GA or BW neonates, survival may be possible in up to a quarter of patients put on ECMO.
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