Premature and Extracorporeal Life Support: Is it Time? A Systematic Review

Abstract

Early preterm birth < 34 gestational weeks (GA) and birth weight (BW) <2 kg are relative contraindications for extracorporeal membrane oxygenation (ECMO). However, with improved technology, ECMO is presently managed more safely and with decreasing complications. Thus, these relative contraindications may no longer apply. We performed a systematic review to evaluate the existing literature on ECMO in early and late (34–37 GA) prematurity focusing on survival to hospital discharge and the complication intracranial hemorrhage (ICH). Data sources: MEDLINE, PubMed, Web of Science, Embase, and the Cochrane Database. Only publications in the English language were evaluated. Of the 36 included studies, 23 were related to ECMO support for respiratory failure, 10 for cardiac causes, and four for congenital diaphragmatic hernia (CDH). Over the past decades, the frequency of ICH has declined (89–21%); survival has increased in both early prematurity (25–76%), and in CDH (33–75%), with outcome similar to late prematurity (48%). The study was limited by an inherent risk of bias from overlapping single-center and registry data. Both the risk of ICH and death have decreased in prematurely born treated with ECMO. We challenge the 34 week GA time limit for ECMO and propose an international task force to revise current guidelines. At present, gestational age < 34 weeks might no longer be considered a contraindication for ECMO in premature neonates.

Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative

“…There is accruing evidence regarding current age (<34 weeks’ gestation) and weight (<1.7–2 kg) exclusion criteria for ECLS, suggesting they be reconsidered under special circumstances. A systematic review of all premature patients treated with ECLS demonstrated that survival rates for premature babies with CDH supported with ECLS, although rarely offered, were similar to survival in the prematurely born infant with CDH without ECLS 89 90. The most recent ELSO dataset demonstrates an overall survival of 50% (n=7564), with a modest decline in infants <34 weeks’ GA (44%); survival is even lower in those infants <2 kg (29%).…”

Predictors of intracranial hemorrhage in neonatal patients on extracorporeal membrane oxygenation

“…Gestational age < 34 weeks has since been regarded as a strong relative contraindication for treatment with ECMO. Lately, this has been challenged in a recent review by Mesas Burgos et al 17 . As stated in their review, ECMO treatment has improved significantly over the past decades, with a lower rate of ICH complication and higher survival in early premature patients.…”

Incidence and predictors of brain infarction in neonatal patients on extracorporeal membrane oxygenation: an observational cohort study

“…To date, outcome modelling studies on ECMO treated neonates have largely focused on risk factors associated with hemorrhagic stroke, or combined ischemic and hemorrhagic stroke 9 – 11 . Previous studies suggest that prematurity, pre-ECMO severity of illness, pre-ECMO cardiac arrest and use of veno-arterial (VA) ECMO may be associated with an increase of neurological adverse events in neonates during ECMO support, including BI 6 , 7 .…”