Neonatal Respiratory Extracorporeal

Mexico illegally crossed the border into Orange County, California to deliver her baby. The mother was told that her full-term baby girl was certainly going to die and that the doctors would try something that had never worked before.  The mother was anxious and also afraid of being deported back, signed the consent, kissed the baby goodbye and disappeared. The mother was never seen again. The nurses named the baby  Esperanza,  meaning  “Hope”  in Spanish.

The neonatologists in the hospital called their surgeon Dr. Robert Barlett, who, at the time was doing a lot of work in Extracorporeal Membrane Oxygenation technology and had already saved a 2-year-old boy after open heart surgery using this technology in 1972. Due to meconium aspiration syndrome, the newborn’s oxygen levels were very low. Dr. Barlett and his team placed the baby on an ECMO machine. To achieve this, they cannulated the vein and artery in the neck, a technique they had perfected in the laboratory. After 72 hours, Esperanza’s lung got better and she was decannulated from ECMO, subsequently, she was weaned off the ventilator. She made a full recovery and was adopted by a foster family in Missouri. Esperanza is now in her early 40’s and has children.

The problem Esperanza had is not so uncommon in India and is called “Meconium Aspiration Syndrome”. The earliest stool in a newborn is called meconium. The fetus passes meconium in response to stress. This meconium mixes with amniotic fluid in the mother’s womb and surrounds the fetus. The baby might then breathe this meconium stained fluid (also called meconium stained liquor) into his/her lungs shortly before, during or soon after delivery.

Meconium stained fluid is seen in 10 to 15% of all deliveries (150 of 1000 deliveries). 10-15% of these aspirate meconium into their lungs (22 out of 1000 deliveries). The meconium blocks the breathing tree and also causes a chemical reaction in the lungs. 50% of these newborns (11 out of 1000 deliveries) develop a severe form called meconium aspiration syndrome (MAS). These babies need tertiary level neonatal intensive care, specialized ventilators, and a gas called nitric oxide to decrease high lung pressures. 10% of these babies (2 out of 1000 deliveries) will not respond to treatment and without further intervention will die. 94% of these newborns can be saved with ECMO technology.

The ECMO machine is similar to the heart-lung bypass machine used in open heart surgery but is used in Intensive Care Units. Extracorporeal Membrane Oxygenation or ECMO is the use of an artificial lung (membrane) located outside the body, (extracorporeal) that puts oxygen into the blood (oxygenation) and continuously pumps this blood into and around the body. By using this technology, the heart, lungs or both are allowed to rest while waiting for them to heal.

In March 2017, the neonatal intensive care unit (NICU) in Narayana Health City found its own Esperanza in the form of a baby boy. He was born via C-section in a nearby hospital and weighed 3.18 kilograms. 3 hours after birth he had difficulty breathing. Meconium aspiration was suspected and he was immediately referred to Narayana Health City. Within 6 hours of life he needed a machine to breathe, and in the next couple of days, his heart was being supported by potent medications. He was also started on nitric oxide. On day four of life, he stopped responding and his oxygen levels started to fall. The neonatologists promptly called the ECMO team for help. The Narayana Health City ECMO team has supported over 600 neonatal, paediatric or adult ECMOs since 2004. The team decided to put the baby on ECMO making it the first case of MAS at Narayana Health City to ever be put on ECMO. This had previously been attempted only twice before in India.

The paediatric cardiac surgeon and I had just joined the hospital after overseas experience with neonatal ECMO. After speaking to the father about the pros and cons of the procedure and obtaining consent, we initiated trans-cervical veno-arterial ECMO. The deoxygenated blood from the jugular vein was drained into the machine, the oxygenator cleaned the blood and pumped oxygenated blood back into the baby via the neck artery (carotid). This allowed us to wholly rest the lung so that it could heal. It also enabled us to take him of the strong medications and nitric oxide he was on.

After 3 days, his lungs had improved dramatically, so we weaned him off the ECMO machine. A few days later he was taken off the ventilator. He was discharged from the hospital at 21 days old. He is now a happy, healthy baby. Since then we have successfully treated another newborn with MAS and we are glad that he also is doing well.

ECMO, although life-saving, is not without risks. To circulate the blood in pipes outside the body we need to use a blood-thinning medication called heparin. Too much of it can cause bleeding and too little of it can cause clots in ECMO machine. Bleeding can occur in any organ, the brain being the most dangerous. Clots can travel to different organs of the body especially the brain. Infection is also a concern. Fortunately, due to the advancement in ECMO technology over the last 40 years, most complications of ECMO can be prevented or treated.

The largest randomized ECMO trial for neonatal ECMO was conducted in the United Kingdom from 1993 – 1995. The trial showed a significant survival difference when a newborn was referred to a regional ECMO center and also supported the superiority of ECMO as a treatment for neonatal respiratory failure. We at Narayana Health City have experience with over 600 ECMOs for cardiac indications, two-thirds of which are paediatric ECMO runs. We are now extending this expertise to non-cardiac ECMO services for neonates and the paediatric population.

Narayana Health City is considered to have one of the biggest paediatric cardiac centres in the world and operates one of the largest paediatric intensive care units internationally. Our mobile ECMO team is currently able to initiate ECMO in other hospitals, following which the team can safely transport the newborn to our Neonatal Intensive Care Unit (NICU) for further therapy. In addition to neonates with MAS/pulmonary hypertension of the newborn (PPHN), we plan to expand our ECMO service to treat arrhythmias, drowning, poisoning, congenital diaphragmatic hernia, and sepsis syndrome.

 

Dr Riyan Shetty

Head of Extracorporeal Life Support (ECLS)

Senior Consultant, Paediatric Intensive

Therapy Unit (PITU)

Narayana Institute of Cardiac Sciences

Bangalore

For further information & details write to us on info.nics@narayanahealth.org

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