胎粪吸入或持续性肺动脉高压新生儿从静脉-静脉 ECMO 转为静脉-动脉 ECMO 的发病率。

Division of Pediatric Surgery and Department of Surgery, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone.

Divisions of Neonatology and NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone.

J Pediatr Surg. 2021 Mar;56(3):459-464. doi: 10.1016/j.jpedsurg.2020.09.053. Epub 2020 Oct 6.

BACKGROUND

Outcomes in neonates receiving extracorporeal membrane oxygenation (ECMO) for meconium aspiration syndrome (MAS) and/or persistent pulmonary hypertension (PPHN) are favorable. Infants with preserved perfusion are often offered venovenous (VV) support to spare morbidities of venoarterial (VA) ECMO. Worsening perfusion or circuit complications can prompt conversion from VV-to-VA support. We examined whether outcomes in infants requiring VA ECMO for MAS/PPHN differed if they underwent VA support initially versus converting to VA after a VV trial, and what factors predicted conversion.

METHODS

We reviewed the Extracorporeal Life Support Organization registry from 2007 to 2017 for neonates with primary diagnoses of MAS/PPHN. Propensity score analysis matched VA single-runs (controls) 4:1 against VV-to-VA conversions based on age, pre-ECMO pH, and precannulation arrests. Primary outcomes were complications and survival. Data were analyzed using Mann-Whitney U and Fisher's exact testing. Multivariate regression identified independent predictors of conversion for VV patients.

RESULTS

3831 neonates underwent ECMO for MAS/PPHN, including 2129 (55%) initially requiring VA support. Of 1702 patients placed on VV ECMO, 98 (5.8%) required VV-to-VA conversion. Compared with 364 propensity-matched isolated VA controls, conversion runs were longer (190 vs. 127 h, P < 0.001), were associated with more complications, and decreased survival to discharge (70% vs. 83%, P = 0.01). On multivariate regression, conversion was more likely if neonates on VV ECMO did not receive surfactant (OR = 1.7;95%CI = 1.1-2.7;P = 0.03) or required high-frequency ventilation (OR = 1.9;95%CI = 1.2-3.3;P = 0.01) before ECMO.

CONCLUSION

Conversion from VV-to-VA ECMO in infants with MAS/PPHN conveys increased morbidity and mortality compared to similar patients placed initially onto VA ECMO. VV patients not receiving surfactant or requiring high-frequency ventilation before cannulation may have increased risk of conversion. While conversions remain rare, decisions to offer VV ECMO for MAS/PPHN must be informed by inferior outcomes observed should conversion be required.

LEVEL OF EVIDENCE

Level of evidence 3 Retrospective comparative study.

背景

接受体外膜肺氧合（ECMO）治疗胎粪吸入综合征（MAS）和/或持续性肺动脉高压（PPHN）的新生儿预后良好。通常为保留灌注的婴儿提供静脉-静脉（VV）支持，以避免静脉-动脉（VA）ECMO 的发病率。灌注恶化或回路并发症可促使从 VV 转为 VA 支持。我们研究了 MAS/PPHN 患儿因需要 VA ECMO 而最初接受 VA 支持与 VV 试验后转为 VA 支持的患儿结局是否不同，以及哪些因素可预测转为 VA。

方法

我们回顾了 2007 年至 2017 年期间体外生命支持组织（ELSO）登记处中主要诊断为 MAS/PPHN 的新生儿数据。根据年龄、ECMO 前 pH 值和预插管停搏，将 VA 单次运行（对照组）与 VV 至 VA 转换进行倾向性评分分析，4:1 匹配。主要结局为并发症和存活率。采用 Mann-Whitney U 和 Fisher 确切检验分析数据。多变量回归确定了 VV 患者转为 VA 的独立预测因素。

结果

3831 例新生儿因 MAS/PPHN 接受 ECMO 治疗，其中 2129 例（55%）最初需要 VA 支持。在 1702 例接受 VV ECMO 的患者中，98 例（5.8%）需要 VV 至 VA 转换。与 364 例匹配的孤立 VA 对照组相比，转换运行时间更长（190 小时 vs. 127 小时，P < 0.001），并发症更多，出院存活率降低（70% vs. 83%，P = 0.01）。多变量回归分析显示，在接受 VV ECMO 的新生儿中，如果未使用表面活性剂（OR = 1.7；95%CI = 1.1-2.7；P = 0.03）或 ECMO 前需要高频通气（OR = 1.9；95%CI = 1.2-3.3；P = 0.01），则更有可能转为 VA。

结论

与最初接受 VA ECMO 的 MAS/PPHN 相似患者相比，MAS/PPHN 患儿从 VV 转为 VA ECMO 会增加发病率和死亡率。在插管前未接受表面活性剂或需要高频通气的 VV 患者可能有更高的转换风险。虽然转换仍然很少见，但应告知因需要转换而接受 MAS/PPHN 行 VV ECMO 治疗的决策，因为应考虑到可能会出现较差的结局。