ECMO and the Neonate Flashcards
Most common neonatal pulmonary disorders
Meconium Aspiration Syndrome Congenital Diaphragmatic Hernia Hyaline Membrane Disease Sepsis Pulmonary Hyptertenion (PPHN) (may be primary or secondary)
MAS
Meconium aspiration syndrome
Which neonatal pulmonary disorders have a >90% survival rate?
Meconium Aspiration Primary Pulmonary Hypertension Respiratory Distress Syndrome Pneumonia Massive Air Leak
Which neonatal pulmonary disorders have a 60% survival rate?
Congenital Diaphragmatic Hernia
Sepsis
Physiological Factors
Surfactant
Lung development
Fetal shunts
What does surfactant do/
Keeps alveoli open
What secretes surfactant?
Via type II alveolar cells
Phospholipid based
What are some fetal shunts
PFO
PDA
Ductus venosis
Meconium Aspiration syndrome (MAS)
the passage of meconium before birth secondary to hypoxia or stress
Meconium is in ____% of all deliveries.
10
What does MAS lead to?
PPHN
MAS: ECMO Notes
Straight forward cases
Do very well
VV if not severe cardiac suppression (VV conversion to VA)
Short duration
What is the most challenging pulmonary disorder to manage?
Congenital Diaphragmatic Hernia (CDH)
CDH
malformation of diaphragm herniation of abdominal contents into thoracic cavity stomach, intestines, spleen and liver L>R presents as SEVERE Respiratory distress
CDH Treatment
Resuscitation Gastric decompression Head up ECMO Surgical intervention on/off ECMO may turn heparin off B/U Circuit ready
CDH: ECMO Notes
UGLY cases
some times there is not enough lung to support life
a synthetic diaphragm does not assist ventilation as a phsyiological one
Be prepared to be on ECMO–>doing surgery –> NO heparin–> giving Amicar –> giving platelets –> waiting to clot
HMD
Hyaline Membrane Disease
Hyaline Membrane Disease
characterized by lack of surfactant (atelectasis) Turned off via hypoxia/acidosis Decreased Qp = hypoxia nad hypercapnia -anaerobic glycolysis --> lactate
HMD Predisposition
Premature kids Asphyxia / hypoxia Acidosis (can be severe) Hypotension diabetes Male > female
HMD Treatment
Surfactant PEEP IMG HFOV ECMO (VV)
HMD Effects
Thick alveolar walls (tough gas exchange)
Atelectasis
Necrosis
HMD: ECMO Notes
Expect VV
Short pump run
Pulmonary Hypertension Causes (PPHN)
Hypoxia stress acidosis hypotension vasospasm PA constriction
PPHN Characteristics
Elevated PVR
Low Qp/Qs
R–> L shunts (PDA/PFO cyanotic)
preductal/post ductal gases differ
High PVR=
more desaturated aortic blood
PPHN Tx
Prevent hypoxia iNO Maintain Qs and pressure HFOV ECMO (VV or VA)
PPHN: ECMO Notes
Good success rate
treat the cause
get rid of the symptomology
very broad causal range of phsyiology
Sepsis in the Neonate: Early Onset
Infection via the mother
- Group B streptococcus infection during pregnancy
- preterm delivery
- water breaking (rupture of membranes) that lasts longer than 24 hours before birth
- infection of hte placenta tissues and amniotic fluid (chorioamnionitis)
Sepsis in the Neonate: Late Onset
Infection druing/after delivery -coagulase-negative staphylococcus E coli klebsiella pseudomonas enterbacter candida GBS Serratia
Sepsis: Pediatric Septic Shock
Hypothermia or hyperthermia
Altered mental status
peripheral vasodilation (warm shock)
Cool extremities (cold shock)
Why choose VA ECMO over VV ECMO in sepsis?
provides cardiac and respiratory support
decreases right ventricular preload
no risk of recirculation
better oxygen delivery
Why NOT chose VA ECMO?
increases left ventricular afterload lowers pulse pressure coronary oxygenation by LV blood "Cardiac Stun" decreased cerebral autoregulation
Why choose VV ECMO?
avoids major arterial cannulation provides direct pulmonary oxygenation improves coronary oxygneation limits neurological complications maintains pusality/CO vasopressors not contraindication
Why NOT choose VV ECMO?
may have inadequate oxygen delivery
dose not provide direct cardiac suppo
increased incidence of recirculation
Conclusions
VV ECMO may be preferred with sepsis
decresaed mortality versus VA ECMO
most pronounced in neonatal period
