Fragestellung: Fulminantes Leberversagen infolge Infektion, Intoxikation oder Autoimmundestruktion führt bei Säuglingen und Kleinkindern in kurzer Zeit zur irreversiblen Enzephalopathie. Da eine Transplantation innerhalb dieses Zeitfensters nicht immer möglich ist, sind Überbrückungsverfahren der hepatischen Elimination für ein defektfreies Überleben notwendig.
Abstract: Venoarterial extracorporeal membrane oxygenation (ECMO) in neonates commonly needs neck vessel cannulation leading to ligation of right common carotid artery (RCCA) in some cases. Quantitative electroencephalography (EEG) measurements provide reproducible data of cerebral function. The aim of this case‐control study was to test whether ligation of the RCCA results in EEG changes after ECMO weaning. Ten mechanically ventilated neonates not treated with ECMO were eligible as control patients. Seven ECMO patients receiving similar sedoanalgesia were investigated during and after ECMO and RCCA ligation. Dominant frequency, absolute alpha, theta, delta, and total powers of right and left frontocentral and temporooccipital derivations were calculated. Dominant frequency did not differ among groups. Power was found to be significantly decreased in all frequency bands during ECMO. After weaning from ECMO, EEG differences between the ECMO and control groups disappeared in spite of permanent RCCA ligation. It is concluded that ligation of the RCCA per se does not result in quantitative EEG changes.
Abstract: The case of a 17‐year‐old male patient with severe end‐stage dilated cardiomyopathy and a large thrombus formation within the cavum of the left ventricle is reported. After an acute thrombectomia combined with a partial left ventriculectomy (Batista procedure), the patient was successfully treated with an appropriate left ventricular assist device (LVAD) system using a centrifugal nonocclusive pump (Biomedicus, Medtronic, Anaheim, CA, U.S.A.). Mechanical support was removed on Day 9, and the patient was discharged from the hospital on Day 19. The effectiveness of emergency mechanical support in patients with very unfavorable prognoses is discussed.
Despite the established success of surfactant application in neonates, the use of surfactant in older children is still a matter of discussion. We hypothesized that surfactant application in children with acute respiratory distress syndrome (ARDS) secondary to a pulmonary or systemic disease or after cardiac surgery improves pulmonary function. We also asked whether repeated treatment could further improve pulmonary function. To answer these questions, we measured oxygenation index (OI) and hypoxemia score after the first and after a second application of surfactant (50-100 mg/kg body wt) at least 24 h later. We enrolled 19 children (older than 4 weeks) for a retrospective chart review study, and six of them underwent cardiac surgery. Demographic data were extracted. OI and hypoxemia score were estimated before and 2 and 24 h after surfactant application. Lung injury score was calculated before and 24 h after surfactant application. Outcome measures included survival, duration of mechanical ventilation, and pediatric ICU and hospital stay. The median patient age was 9.0 (quarter percentile 3.7/25) months. The median weight was 8.4 (4.1/11.5) kg. The median lung injury score before the first surfactant application was 2.3 (2.3/2.6). Hospital duration and pediatric ICU stay for all patients was 31.0 (20.0/49.5) days and 27.0 (15.5/32.5) days, respectively. The duration of mechanical ventilation was 24.0 (18.5/31.0) days. The overall mortality was 53%. Twenty-four hours after the first surfactant application, pulmonary function significantly improved. The median OI was 14 (5.5/26) before and 7 (4.5/14.5) 24 h after surfactant application (P= 0.027). The hypoxemia score was 91.7 (69.9/154.2) before and 148.4 (99.2/167.6) 24 h after surfactant application (P = 0.0026). Seven children received a second application, which did not further improve pulmonary function. The lung injury score was not influenced by either surfactant application. We conclude that a single surfactant application improves pulmonary function in children with ARDS. A second application of surfactant showed no further benefit. Outcome was not affected in our study population.
The treatment of acute respiratory failure in infants by means of extracorporeal membrane oxygenation (ECMO) is thought to be associated with a treatment-related inflammatory reaction, which may deteriorate the underlying disease process. The aim of this study was to compare the venoarterial (VA) and venovenous (VV) modality of ECMO with regard to their pulmonary and serological cytokine release during rescue from acute hypoxia. The inflammatory response was measured in piglets undergoing hypoxic ventilation with a gas mixture of 92% N2 and 8% O2, which were then rescued through VA- (n = 5) or VV-ECMO (n = 5). The effect of cannulation and anesthesia on the inflammatory response was deducted from regularly ventilated control animals (n = 5). The concentrations of the proinflammatory interleukins (IL)-1beta and IL-8 increased in the bronchoalveolar lavage fluid of all groups over a study period of 5 h but were significantly higher (P < 0.05) during VA-ECMO treatment, whereas the anti-inflammatory IL-10 concentrations were significantly higher in the bronchoalveolar lavage fluid of VV-treated animals (P < 0.001). No statistical difference between groups was found in the serum concentrations of cytokines. We conclude that in this animal model rescue from hypoxia by means of the VA modality of ECMO leads to a more pronounced inflammatory reaction of the lung than when applying the VV modality.
Abstract Introduction This study was performed to determine whether surfactant application during extracorporeal membrane oxygenation (ECMO) improves lung volume, pulmonary mechanics, and chest radiographic findings in children with respiratory failure or after cardiac surgery. Methods This was a retrospective chart review study in a pediatric intensive care unit (PICU). Seven patients received surfactant before weaning from ECMO was started (group S). They were compared to six patients treated with ECMO who did not receive surfactant (group C). These control patients were matched based on age, weight, and underlying diagnosis. Demographic data, ventilator settings, tidal volume, compliance of respiratory system (calculated from tidal volume/(peak inspiratory pressure – positive end-expiratory pressure), and ECMO flow were extracted. Chest radiographs were scored by two blinded and independent radiologists. Changes over time were compared between groups by repeated-measures analysis of variance (time*group interaction). Values are given as percentages of baseline values. Results The groups did not differ with regard to demographic data, duration of ECMO, ventilator settings, PICU and hospital days. After application of surfactant, mean tidal volume almost doubled in group S (from 100% before to 186.2%; p = 0.0053). No change was found in group C (100% versus 98.7%). Mean compliance increased significantly ( p = 0.0067) in group S (from 100% to 176.1%) compared to group C (100% versus 97.6%). Radiographic scores tended to decrease in group S within 48 h following surfactant application. ECMO flow tended to decrease in group S within 10 h following surfactant application but not in group C. Mortality was not affected by treatment. Conclusion Surfactant application may be of benefit in children with respiratory failure treated with ECMO, but these findings need confirmation from prospective studies.
