Risk Factors for Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation

Abstract

Objective This study aimed to assess the association of clinical risk factors with severity of magnetic resonance imaging (MRI) brain injury in neonatal extracorporeal membrane oxygenation (ECMO) patients. Study Design This is a single-center retrospective study conducted at an outborn level IV neonatal intensive care unit in a free-standing academic children's hospital. Clinical and MRI data from neonates treated with ECMO between 2005 and 2015 were reviewed. MRI injury was graded by two radiologists according to a modified scoring system that assesses parenchymal injury, extra-axial hemorrhage, and cerebrospinal fluid spaces. MRI severity was classified as none (score = 0), mild/moderate (score = 1–13.5), and severe (score ≥ 14). The relationship between selected risk factors and MRI severity was assessed by Chi-square, analysis of variance, and Kruskal–Wallis tests where appropriate. Combinative predictive ability of significant risk factors was assessed by logistic regression analyses. Results MRI data were assessed in 81 neonates treated with ECMO. Veno-arterial (VA) patients had more severe injury compared with veno-venous patients. There was a trend toward less severe injury over time. After controlling for covariates, duration of ECMO remained significantly associated with brain injury, and the risk for severe injury was significantly increased in patients on ECMO beyond 210 hours. Conclusion Risk for brain injury is increased with VA ECMO and with longer duration of ECMO. Improvements in care may be leading to decreasing incidence of brain injury in neonatal ECMO patients. Key Points

Extracorporeal Membrane Oxygenation in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

“…Justification. There are no PARDS-specific studies comparing outcomes for venovenous and venoarterial ECMO (36), but there are several retrospective observational pediatric studies that report worse neurologic outcomes after venoarterial ECMO support as compared with venovenous ECMO support (41)(42)(43)(44). MRI data from 81 surviving neonates suggests receiving venoarterial ECMO had a 4.7 (95% CI, 1.4-15.7) higher odds of radiographic brain injury relative to venovenous ECMO (42) and similar findings were found in separate studies of pediatric respiratory ECMO support (42,44).…”

Neonatal brain magnetic resonance imaging: clinical indications, acquisition and reporting

“…Long-term neurodevelopmental impairment ranges from 15% to 50% in these infants. Those at higher risk for neurological complications include infants with a diagnosis of congenital diaphragmatic hernia, preterm infants, infants <3 kg, VA ECMO, longer duration of ECMO, pre-ECMO lactate and pre-ECMO cardiac arrest 46–50…”