Delayed institution of extracorporeal membrane oxygenation is associated with increased mortality rate and prolonged hospital stay,☆☆

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Abstract

Background/Purpose: Severe meconium aspiration syndrome (MAS) is a frequent indication for extracorporeal membrane oxygenation (ECMO). Trials of less invasive cardiopulmonary support may result in fewer infants treated with ECMO but could delay institution of ECMO. The authors hypothesized that those infants with severe MAS who are treated with ECMO early will have a lower mortality rate and a shorter hospital course than those who receive delayed ECMO. Methods: A retrospective review of all patients with MAS in the national extracorporeal life support (ELSO) registry for the decade 1989 through 1998 was performed. Data from the ELSO registry were examined for demographics, clinical parameters, and treatment course. Patients were divided into 3 groups based on the time from birth to institution of ECMO: group 1, 0 to 23 hours; group 2, 24 to 96 hours; and group 3, greater than 96 hours. These groups were compared for survival, duration of extracorporeal support, and duration of ventilatory support after ECMO. Statistical relevance was determined by analysis of variance (ANOVA) and Tukey's post-hoc test. Results: A total of 3,235 of 4,002 patients with MAS had complete information on duration of mechanical ventilation. Overall mortality rate was 5.8%. The mortality rate in group 1 (n = 1,266) was 4.8%, group 2 (n = 1,568) 6.0%, and group 3 (n = 401) 7.7%. An increased time to ECMO was associated with a significant increase in mortality rate (P <.05). This also was associated with significant increases in the length of the ECMO run (157 ± 4 v 130 ± 2 hours, P =.02) and duration of post-ECMO ventilation (157 ± 17 v 118 ± 3 hours; P <.001). Those patients in groups 1 and 2 who did not respond to a trial of high-frequency oscillatory ventilation had significantly longer ECMO runs (129 ± 2 v 113 ± 1 hours; P =.001) and longer post-ECMO ventilator courses (137 ± 2 v 114 ± 1 hours; P =.002) than those who did not. Conclusions: Delay in institution of ECMO for MAS results in prolonged ECMO and need for post-ECMO ventilation. Consideration should be given to instituting ECMO earlier in patients with severe MAS. J Pediatr Surg 37:7-10. Copyright © 2002 by W.B. Saunders Company.

Section snippets

Materials and methods

The national ECMO registry of the Extracorporeal Life Support Organization (ELSO, Ann Arbor, MI) contains voluntarily reported data on demographics, laboratory and diagnostic information, and clinical course for neonates treated with ECMO. This database was examined and a subset of data generated for those neonates treated with ECMO for MAS-induced respiratory failure and was restricted further to the 1989 through 1998 decade to include only those patients treated with the most current methods

Results

Overall mortality rate was 5.8%. A delay in the initiation of ECMO for more than 96 hours (group 3) was associated with a significant increase in mortality rate when compared with ECMO therapy instituted at less than 24 hours (4.8% v 7.7%, P <.05; Fig 1).

. Percent mortality by group. Group 1 = <24 hours, group 2 = 24 to 96 hours, group 3 = >96 hours. *P <.05 v group 1.

The increase in time to ECMO also was associated with a significant increase in the length of ECMO support in these same groups

Discussion

Our data show that delays in treating high-risk MAS infants with ECMO result in significantly longer time on mechanical ventilation. The increase in ventilator time is divided among increases in pre-ECMO ventilation, length of ECMO run, and duration of post-ECMO ventilator requirement. Trials of alternative therapies (HFOV and inhaled nitric oxide) also result in significantly longer ventilator requirements.

Recent data show that although fewer patients are being treated with ECMO overall, these

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The authors acknowledge the support of the ECMO registry of the Extracorporeal Life Support Organization (ELSO) of Ann Arbor, Michigan.

☆☆

Address reprint requests to Kevin P. Lally, Division of Pediatric Surgery, MSB 5.258, 6431 Fannin St, Houston, TX 77030.

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