Morbidity and Mortality in Late Preterm Infants with Severe Hypoxic Respiratory Failure on Extra-Corporeal Membrane Oxygenation

Abstract-Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension. Key Words: AHA Scientific Statements ◼ bronchopulmonary dysplasia ◼ congenital diaphragmatic hernia ◼ congenital heart disease ◼ genetics ◼ persistent pulmonary hypertension of the newborn ◼ sickle cell disease © 2015 by the American Heart Association, Inc., and the American Thoracic Society.Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0000000000000329 †Deceased. The American Heart Association and the American Thoracic Society make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.This document was approved by the American Heart Association Science Advisory and Coordinating Committee on May 12, 2015, the American Heart Association Executive Committee on July 22, 2015, and the American Thoracic Society on July 24, 2015.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000329/-/DC1. The American Heart Association requests that this document be cited as follows: Abman SH, Hansmann G, Archer SL, Ivy DD, Adatia I, Chung WK, Hanna BD, Rosenzweig EB, Raj JU, Cornfield D, Stenmark KR, Steinhorn R, Thébaud B, Fineman JR, Kuehne T, Feinstein JA, Friedberg MK, Earing M, Barst RJ, Keller RL, Kinsella JP, Mullen M, Deterding R, Kulik T, Mallory G, Humpl T, Wessel DL; on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Surgery and Anesthesia, and the American Thoracic Society. Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society. Circulation. 2015;132:2037-2099 Copies: This document is available on the World Wide Web site of the American Heart Associat...

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“…197,198 Moreover, severe PPHN requiring ECMO support is more prevalent in late-preterm and early-term infants than in full-term infants. 199 …”

Section: Persistent Ph Of the Newbornmentioning

confidence: 99%

Pediatric Pulmonary Hypertension

Abman¹,

Hansmann²,

Archer³

et al. 2015

Circulation

948

405

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“…The following candidate variables were identified: patient age (17, 18), gestational age (15, 19), birth weight (14, 17, 19–21), sex (15, 19), primary diagnosis (17–23), pre-ECMO renal failure (24), comorbid conditions (15, 16), pre-ECMO cardiac arrest (17, 22) and pre-ECMO measures including arterial blood pH (19, 21) the arterial partial pressure of carbon dioxide (PaCO 2 ) (21), and the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PF ratio) (14), oxygenation index (OI) (25), Apgar (14, 15, 19, 21), mean arterial pressure (14), and pre-ECMO use of inhaled nitric oxide (22) or surfactant (18). …”

Section: Methodsmentioning

confidence: 99%

“…Categories were chosen based on previous reports (1, 18, 19, 25). If a neonate had a primary diagnosis of acute respiratory failure or respiratory arrest, the second diagnosis was used to categorize the patient.…”

Section: Methodsmentioning

confidence: 99%

Development and Validation of the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support

Barbaro

Bartlett

Chapman

et al. 2016

The Journal of Pediatrics

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Objective To develop and validate the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Neo-RESCUERS), which estimates the risk of in-hospital death for neonates prior to receiving respiratory extracorporeal membrane oxygenation (ECMO) support. Study design We used an international ECMO registry (2008–2013); neonates receiving ECMO for respiratory support were included. We divided the registry into a derivation sample and internal validation sample, by calendar date. We chose candidate variables a priori based on published evidence of association with mortality; variables independently associated with mortality in logistic regression were included in this parsimonious model of risk adjustment. We evaluated model discrimination with the area under the receiver operating characteristic curve (AUC) and we evaluated calibration with the Hosmer-Lemeshow goodness-of-fit test. Results During 2008–2013, 4,592 neonates received ECMO respiratory support with mortality of 31%. The development dataset contained 3,139 patients treated in 2008–2011. The Neo-RESCUERS measure had an AUC of 0.78 (95% confidence interval: 0.76–0.79). The validation cohort had an AUC=0.77 (0.75–0.80). Patients in the lowest risk decile had an observed mortality of 7.0% and a predicted mortality of 4.4%, and those in the highest risk decile had an observed mortality of 65.6% and a predicted mortality of 67.5%. Conclusions Neo-RESCUERS offers severity-of-illness adjustment for neonatal respiratory failure patients receiving ECMO. This score may be used to adjust patient survival to assess hospital-level performance in ECMO-based care.

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“…Infants with PPHN develop hypoxemia and increased risk of death and long-term disabilities (1, 2, 3). Late preterm birth is an important cause of respiratory failure and PPHN in newborn infants (4–6). PPHN occurs in association with surfactant deficiency and ventilation/perfusion mismatch in late preterm gestation neonates (6).…”

Section: Introductionmentioning

confidence: 99%

Antenatal betamethasone improves postnatal transition in late preterm lambs with persistent pulmonary hypertension of the newborn

et al. 2013

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BackgroundPersistent pulmonary hypertension of the newborn (PPHN) is associated with increased oxidative stress in pulmonary arteries (PA). Betamethasone decreases the oxidative stress and improves anti-oxidant balance in PPHN. We investigated whether antenatal betamethasone improves pulmonary vasodilation and postnatal oxygenation in late preterm lambs with PPHN.MethodsPPHN was induced by constriction of fetal ductus arteriosus from 128 to 136d gestation. Ewes were given 2 i.m. doses of betamethasone or saline at 24h and 12h before Cesarian-section delivery at 136d gestation, simulating late preterm birth. Newborn lambs were mechanically ventilated for 8h with monitoring of blood gas and hemodynamic variables. Lungs were harvested post mortem to determine oxidative stress markers and in vitro responses of PA.ResultsPostnatal arterial partial pressure of oxygen and pH were higher and the oxygenation index and arterial partial pressure of carbon dioxide lower in betamethasone treated lambs. PA pressure was lower and systemic pressure higher in betamethasone lambs. Betamethasone decreased the oxidative stress markers and increased endothelial nitric oxide synthase expression in ventilated PPHN lungs.ConclusionAntenatal betamethasone decreases oxidative stress and improves postnatal transition in late preterm lambs with PPHN. This study suggests a potential benefit for antenatal betamethasone in late preterm births.

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Morbidity and Mortality in Late Preterm Infants with Severe Hypoxic Respiratory Failure on Extra-Corporeal Membrane Oxygenation

Cited by 48 publications

References 33 publications

Pediatric Pulmonary Hypertension

Pediatric Pulmonary Hypertension

Development and Validation of the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support

Antenatal betamethasone improves postnatal transition in late preterm lambs with persistent pulmonary hypertension of the newborn

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