Clinics in perinatology
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Patient-triggered ventilation is a relatively recent development in neonatal mechanical ventilation. Advances in microprocessor-based technology, transducers, and monitoring have enabled patient-driven ventilator control and synchronization of mechanical ventilation with patient effort. The novelty of the newer ventilatory techniques has generated several controversies that remain to be resolved. Among these are signal detection and transduction, the optimal ventilatory modes, and weaning during patient-triggered ventilation.
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In the delivery room, pediatricians are frequently required to make immediate decisions about resuscitating infants. Is the baby too small, too immature, or too asphyxiated to be revived? To achieve the best outcome, resuscitation once initiated, must be performed expeditiously, safely, and with the utmost diligence. Not all the tools and medications have undergone the intense scrutiny that might otherwise be assumed. In this article, resuscitation topics are discussed and recommendation offered.
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Conventional mechanical ventilation continues to be the standard mode of support for neonates with respiratory failure. Controversies regarding the selection of optimal ventilatory strategies still abound. ⋯ Principles of gas exchange, pulmonary mechanics and control of breathing are reviewed in the context of their relevance during mechanical ventilation. The application of these concepts to the ventilatory strategies for the management of infants with respiratory distress is presented, and current controversies are emphasized.
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Clinics in perinatology · Mar 1998
ReviewExtracorporeal membrane oxygenation. Controversies in selection of patients and management.
This article reviews controversies associated with the selection of patients for extracorporeal membrane oxygenation (ECMO) and their management. Although there has been a raging debate regarding the use of ECMO in the management of hypoxic respiratory failure in the near-term and term newborn, the authors maintain that this issue is resolved and that ECMO is now a standard of care and should be offered to every neonate who is likely to fail conventional treatment. It is the authors' contention, that there is no apparent increase in morbidity associated with the use of ECMO and that better results might be achieved if ECMO were employed earlier in the patient's course, before hypoxic-ischemia organ damage occurs.
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Clinics in perinatology · Sep 1997
ReviewCerebrovascular complications and neurodevelopmental sequelae of neonatal ECMO.
A total of 355 infants have been treated with ECMO at our hospital between 1985 and 1996, 271 of whom have been enrolled in an ongoing prospective study; of the 271 infants enrolled, 223 (82%) survived, and most function within the normal range of development. Nevertheless, handicapping sequelae, including spastic forms of CP, hearing loss, and cognitive deficiencies at school age, have been noted in a significant minority of ECMO-treated survivors. The need for RCCA cannulation during venoarterial ECMO may increase the risk of a cerebrovascular injury, and lateralized CBF abnormalities have been noted on CDI and pulsed Doppler ultrasound studies during and after venoarterial bypass; however, post-ECMO CT scans, HUS, MR images, or clinical evaluations have not indicated selective or greater injury to the right, compared with the left, cerebral hemisphere in our survivors, nor was there a significant predilection for right, rather than left, cerebral hemispheric EEG abnormalities during or following venoarterial bypass. ⋯ The cause of isolated SNHL is unknown in most affected ECMO survivors, but in some very likely is associated with the complications and treatment of severe cardiorespiratory failure, including profound hypocarbia prior to ECMO. The results of our studies to date are consistent with the following conclusions: (1) hypotension before or during ECMO and the need for CPR before ECMO contribute to the pathogenesis of CP, probably through the mechanism of cerebral ischemia; (2) profound hypocarbia before ECMO and delayed ECMO treatment are associated with a significantly increased risk of hearing loss; (3) hypoxemia without hypotension does not result in CP; (4) the type and severity of neurologic and cognitive sequelae in ECMO survivors depends, in part, on the primary cause of the neonatal cardiorespiratory failure; (5) early neurodevelopment, except for severe deficits, may not predict school-age performance; and (6) abnormally low or borderline WPPSI-R IQ scores and academic deficiencies at early school age, without evidence of a congenital abnormality of brain or CP or SNHL, remain unexplained. The criteria for initiating ECMO in the neonate with severe cardiorespiratory failure include decreasing oxygenation despite mechanical hyperventilation with 100% oxygen. (ABSTRACT TRUNCATED)