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Extracorporeal Membrane Oxygenation for Nonneonatal Acute Respiratory Failure—Invited Critique

Extracorporeal Membrane Oxygenation for Nonneonatal Acute Respiratory Failure—Invited Critique The history of American surgery is replete with stories of initial failure, even abandonment of innovative technology, followed by eventual success through further improvisation, attention to detail, and persistence by the advocates that success was possible. The story of ECMO development is certainly a good example of the persistence principle, first in making neonatal ECMO a standard of care for the high-risk newborn with reversible pulmonary hypertension and congenital diaphragmatic hernia. Overall survival in this group now exceeds 70% based on recent Extracorporeal Life Support Organization data. The overall experience with nonneonatal ECMO appears to be following a similar pattern of improving success based on this report by Nehra and colleagues from the Massachusetts General Hospital. The authors attribute the overall 53% survival to a better understanding of underlying respiratory disease, earlier intervention in selected patients, careful monitoring, and knowledge of the natural history of specific disease. This is coupled with improved ECMO technology, better ECMO equipment, and the dedication of an ECMO team for fine adjustments throughout the ECMO run. Patient selection must be emphasized to prevent coagulopathy and to exclude patients with intracranial hemorrhage or advanced age. Most cannulations are venovenous to avoid carotid ligation or reconstruction with the increased risk of stroke or infarct in older patients. The poorest outcomes reported in patients with trauma and immunocompromise following organ transplant and chemotherapy are a reminder of the limitations of this application to patient care. Certain conditions such as ARF following a stem cell transplant may be beyond the scope of this modality. Also not mentioned are the enormous cost and dedication required to making nonneonatal ECMO successful, a reminder that only a few centers having a strong prior experience with neonatal ECMO should embark on the program. A multicenter trial with strict adherence to guidelines will help to clarify future directions. Correspondence: Dr Touloukian, Department of Pediatric Surgery, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510 (robert.touloukian@yale.edu). Financial Disclosure: None reported. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Extracorporeal Membrane Oxygenation for Nonneonatal Acute Respiratory Failure—Invited Critique

Archives of Surgery , Volume 144 (5) – May 18, 2009

Extracorporeal Membrane Oxygenation for Nonneonatal Acute Respiratory Failure—Invited Critique

Abstract

The history of American surgery is replete with stories of initial failure, even abandonment of innovative technology, followed by eventual success through further improvisation, attention to detail, and persistence by the advocates that success was possible. The story of ECMO development is certainly a good example of the persistence principle, first in making neonatal ECMO a standard of care for the high-risk newborn with reversible pulmonary hypertension and congenital diaphragmatic...
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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2009.44
Publisher site
See Article on Publisher Site

Abstract

The history of American surgery is replete with stories of initial failure, even abandonment of innovative technology, followed by eventual success through further improvisation, attention to detail, and persistence by the advocates that success was possible. The story of ECMO development is certainly a good example of the persistence principle, first in making neonatal ECMO a standard of care for the high-risk newborn with reversible pulmonary hypertension and congenital diaphragmatic hernia. Overall survival in this group now exceeds 70% based on recent Extracorporeal Life Support Organization data. The overall experience with nonneonatal ECMO appears to be following a similar pattern of improving success based on this report by Nehra and colleagues from the Massachusetts General Hospital. The authors attribute the overall 53% survival to a better understanding of underlying respiratory disease, earlier intervention in selected patients, careful monitoring, and knowledge of the natural history of specific disease. This is coupled with improved ECMO technology, better ECMO equipment, and the dedication of an ECMO team for fine adjustments throughout the ECMO run. Patient selection must be emphasized to prevent coagulopathy and to exclude patients with intracranial hemorrhage or advanced age. Most cannulations are venovenous to avoid carotid ligation or reconstruction with the increased risk of stroke or infarct in older patients. The poorest outcomes reported in patients with trauma and immunocompromise following organ transplant and chemotherapy are a reminder of the limitations of this application to patient care. Certain conditions such as ARF following a stem cell transplant may be beyond the scope of this modality. Also not mentioned are the enormous cost and dedication required to making nonneonatal ECMO successful, a reminder that only a few centers having a strong prior experience with neonatal ECMO should embark on the program. A multicenter trial with strict adherence to guidelines will help to clarify future directions. Correspondence: Dr Touloukian, Department of Pediatric Surgery, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510 (robert.touloukian@yale.edu). Financial Disclosure: None reported.

Journal

Archives of SurgeryAmerican Medical Association

Published: May 18, 2009

Keywords: extracorporeal membrane oxygenation,respiratory failure, acute

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