ADAPTATION OF AN ECMO TEAM IN THE ERA OF SUCCESSFUL ALTERNATIVE THERAPIES FOR NEONATAL PULMONARY FAILURE

Neonates with persistent pulmonary hypertension show severe hypoxemia that requires a variety of therapeutic modalities. When patients do no t respond to conventional medical management that includes hyperventil ation, inotropic support, and vasodilating agents, treatment with extr acorporeal membrane oxygenation (ECMO) may be used. More recently, hig h-frequency oscillatory ventilation and nitric oxide inhalation have b een used in these infants and have impacted the need for ECMO. In ligh t of these changes in therapy, the authors reviewed the B-year clinica l experience of an ECMO team to assess trends in patient population an d outcome and document adaptation of the medical professionals to a ne w treatment era. Between 1988 and 1993, 88 neonates who met the instit utional criteria were placed on venoarterial ECMO. Oscillatory ventila tion was locally introduced in 1991 and nitric oxide treatment in 1992 . Patient outcomes for the 1988 to 1990 period were compared with thos e for 1991 to 1993. Analyses included indication for ECMO therapy, len gth and complexity of the run, length of hospital stay, and cost of pa tient care. During the first 3 years, 65 patients were placed on ECMO, compared with 23 patients during the 3 years after introduction of os cillatory ventilation and nitric oxide therapy (P < .001). The length of ECMO therapy increased from a mean of 128 hours to 190 hours (P = . 005), and the average hospital stay, likewise, increased from 27 days to 42 days. The total cost of care increased by approximately $40,000 per patient. During the 1991 to 1993 period, hyaline membrane disease and primary persistent pulmonary hypertension of the newborn became le ss of an indication for ECMO and were replaced by an increase in incid ence of patients with sepsis and congenital diaphragmatic hernia. Fift y-five of the 65 (85%) patients during the first period survived, comp ared with 16 of the 23 (70%) patients during the second. With the adve nt of alternative therapies for severe neonatal pulmonary failure, the need for ECMO decreased in this pediatric tertiary care center. To ma intain expertise, the ECMO team was integrated into a hospital-wide cr itical cardiopulmonary support team. Extracorporeal life support techn iques became relevant only within a broader clinical setting created b y the new therapeutic environment. Copyright (C) 1995 by W.B. Saunders Company