[Clinical analysis of neurologic complications in neonates during extracorporeal membrane oxygenation support]

Objective: To investigate the incidence, risk factors, and outcomes of neurological complications in neonates undergoing extracorporeal membrane oxygenation (ECMO). Methods: A retrospective cohort study was conducted. A total of 47 neonates who received ECMO support in the Division of Neonatology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, from March 2020 to August 2025 were included. Data on baseline characteristics, ECMO operational parameters, cranial imaging, electroencephalogram, and neurodevelopmental assessments were collected. Based on the presence of neurological injury, neonates were categorized into neurological injury and non-neurological injury groups. Independent samples t test, Mann-Whitney U test, χ² tests or Fisher exact tests were used to compare the difference between groups. Results: Among the 47 neonates, 35 cases (74%) were male, with a gestational age at birth of 39.4 (38.0, 40.0) weeks and a birth weight of 3 200 (2 855, 3 440) g. Primary etiologies from cardiopulmonary failure included persistent pulmonary hypertension of the newborn (17 cases (36%)), meconium aspiration syndrome (14 cases (30%)), neonatal sepsis (7 cases (15%)), and severe pneumonia (4 cases (9%)). Neurological injury occurred in 18 neonates (38%) with major neurological events including intracranial hemorrhage (13 cases), subclinical seizures (7 cases), markedly suppressed electroencephalographic activity (2 cases), and cerebral infarction (1 case). The change in arterial partial pressure of carbon dioxide (PCO₂) before and after ECMO initiation was greater in the neurological injury group than in the non-neurological injury group in 29 cases (P=0.023). No statistically difference was observed in baseline characteristics, ECMO operational parameters or anti-coagulation therapy (all P>0.05). The overall ECMO weaning success rate was 85% (40/47), with a survival-to-discharge rate of 72% (34/47). In the neurological injury group, 12 of 18 neonates were successfully weaned from ECMO and 7 survived to discharge, whereas in the non-neurological injury group, 28 of 29 neonates were successfully weaned and 27 survived to discharge. Both ECMO weaning success rate and survival to discharge rates were lower in the neurological injury group than in the non-neurological injury group (both P<0.05). Among 34 survivors followed up to 2 years of age, epilepsy occurred in 2 cases and cerebral palsy in 1 case, and 23 cases completed at least one neurodevelopmental assessment within 2 years of age, among whom 3 of 18 infants evaluated at 3 months of age showed abnormal neurodevelopmental findings. Conclusions: Neurological complications are prevalent during neonatal ECMO support, predominantly manifesting as intracranial hemorrhage and subclinical seizures, and are major contributors to mortality and adverse neurodevelopmental outcomes. Large fluctuations in PCO₂ around ECMO initiation may be a critical factor for neurological injury.