Journal of pediatric surgery
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The retention of extracorporeal membrane oxygenation (ECMO) cannulae of ECMO is discontinued was originally developed to avoid reexploration of the neck in patients who may require a second course of ECMO. Because of the incidence, at the authors' institution, of thrombi noted on the ends of retained cannulae and their potential to cause significant morbidity, a critical review of this procedure was initiated. A telephone survey of 72 Extracorporeal Life Support Organization (ELSO) centers was conducted, and ELSO registry forms were requested for patients who had their cannulae retained. ⋯ Five of the 25 patients who required two courses of ECMO had serious complications from their retained cannulae and all were nonsurvivors. The authors conclude that patients with retained ECMO cannulae are at high risk for developing thrombi, which can lead to severe embolic events. Therefore, the procedure of retaining cannulae should only be used in patients at high risk for requiring a second course of ECMO and not for the convenience of surgical availability to remove the cannulae.
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A new heparin binding method was applied to a miniature extracorporeal membrane oxygenation (ECMO) system with a nonporous membrane oxygenator (the priming volume, 45 mL; the membrane surface area, 0.4 m2; maximal flow rate, 2 L/min) that is resistant to plasma leakage. The authors evaluated the stability of the immobilized heparin in vitro and the feasibility of this system in animals. Samples of hollow fibers and tubing were rinsed at 40 degrees C for 4 days in normal saline, Ringer's lactate, and 1 mol/L NaCl solution. ⋯ O2 transfer of the oxygenators at a flow rate of 300 mL/min were 12.3 +/- 0.4 mL/min at 30 minutes, 14.3 +/- 1.2 mL/min at 5 hours, and 14.7 +/- 1.7 mL/min at 10 hours (no statistical difference). Histological examination of the brains and the kidneys showed no evidence of thromboembolic sequela in any of the animals. These results suggest that this new system is a promising device for long-term ECMO in which the amount of systemic heparinization can be reduced with the minimal possibility of plasma leakage.
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Although blunt intestinal injury in children is uncommon, prompt recognition and treatment is imperative. Because the best method for diagnosis remains undetermined, the authors reviewed their experience with this injury in children to determine the most reliable diagnostic method and to identify factors associated with treatment delays. ⋯ The authors conclude that signs suggestive of major intestinal injury are present in children at the time of initial physical examination or shortly thereafter. The decision to operate can be based on this examination alone in the pediatric population. Abdominal CT scan is not reliable for the diagnosis of blunt intestinal injury in children. To expedite diagnosis and treatment, children who sustain blunt abdominal trauma should be examined immediately by a physician experienced in pediatric trauma care or be transferred to a designated trauma center where this service is available.
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Bleeding related to systemic heparinization has been considered one of the major complications associated with extracorporeal membrane oxygenation (ECMO). Development of the heparin-bonded system will be essential in reducing hemorrhagic complications, but has not yet been clinically proven. The authors chose an alternative approach of making a difference in the activated clotting time (ACT) values between the patient and the ECMO circuit, and decreased only the patient's ACT value, while keeping the value of the ECMO circuit at an ideal level. ⋯ The average difference in ACT values between both routes was 27.1 +/- 7.9 seconds. The bleeding was well controlled by FUT administration in 8 of 12 cases. This report may represent the first clinical use of FUT in neonatal ECMO, and serve as a preliminary study.
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Infants with congenital diaphragmatic hernia (CDH) show a wide range of anatomic and physiological abnormalities, making it difficult to compare the efficacy of management protocols between institutions. The purpose of this study was twofold: (1) to analyze the results of treatment of CDH in a large tertiary care pediatric center using conventional mechanical ventilation (CMV) with extracorporeal membrane oxygenation (ECMO) as rescue therapy, and (2) to compare these results with those of a parallel study by a similar large urban center that used high-frequency oscillating ventilation (HFOV) as rescue therapy without ECMO. All patients who had CDH diagnosed within the first 12 hours of life and were referred for treatment before repair (between 1981 and 1994) were included in the analysis (n = 196). ⋯ The two series differed in the number of associated anomalies, their impact on survival, and in the prognosis of right-sided CDH. From the individual and combined analyses the authors concluded: (1) CMV with ECMO as rescue produced an overall survival in CDH patients equivalent to CMV with HFOV in a parallel series, (2) neither HFOV nor ECMO has significantly improved outcome in CDH patients, (3) institution of permissive hypercapnia has resulted in a significant increase in survival, and (4) the leading causes of death in CDH patients appear to be associated anomalies and pulmonary hypoplasia, which are currently untreatable. Barotrauma, which may contribute in up to 25% of deaths in CDH patients is avoidable.