The patient was a male, 2 d, 2.8 kg, G3P2 full-term neonate with gestational age 40 weeks, born by
Cesarean-section with Apgar score of 10 at 1 min. He was admitted due to severe
dyspnea with
oxygen desaturation and
heart murmur on the second day after birth. Physical examination showed clear consciousness,
cyanosis,
dyspnea, RR 70 bpm and a grade II/6
heart murmur. Bp was 56/45 mm Hg (1 mm Hg = 0.133 kPa) and SpO2 around 65%. Blood WBC 13.1 x 10(9)/L, N 46.1%, Hb 238 g/L, Plt 283 x 10(9)/L, CRP < 1 mg/L. Echocardiographic findings: TGA + ASD + PDA with left ventricular ejection fraction (LVEF) of 60%. After supportive care and
prostaglandin E1 (5 ng/kg/min) treatment, his condition became stable with SpO2 85 - 90%. On the 6(th) day of life, the baby underwent an
arterial switch procedure + ASD closing and PDA
ligation. The time of aorta clamp was 72 mins. The cool 4:1 blood
cardioplegia was given for 2 times during aortal clamp. Ultrafiltration was used. The internal and external volumes were almost equal and the
electrolytes and blood gas and hematocrit (36%) were normal during extracorporeal bypass. Due to a failure (severe
low cardiac output) to wean from
cardiopulmonary bypass (263 min) with
acidosis (
lactate 8.8 mmol/L),
low blood pressure (< 39/30 mm Hg), increased
LAP (> 20 mmHg), bloody phlegm, decreased urine output [< 1 ml/(kg.h)], a V-A ECMO was used for cardio-pulmonary support. ECMO setup: Medtronic pediatric ECMO package (CB2503R1), carmeda
membrane oxygenator and centrifugal pump (bio-console 560) were chosen. Direct cannulation of the ascending aorta (Edward FEM008A) and right atrium (TF018090) was performed using techniques that were standard for cardiopulmanory bypass. The ECMO system was primed with 400 ml blood, 5% CaCl(2)1g, 5%
sodium bicarbonate 1.5 g, 20%
mannitol 2 g,
albumin 10 g, and
heparin 5 mg. The blood was re-circulated until the temperature was 37 degrees C and blood
gases and the
electrolytes were in normal range. The patient was weaned from bypass and connected to V-A ECMO. Management of ECMO: the blood flow was set at 150 - 200 ml/kg/min. Venous saturation (SvO2) was maintained at the desired level (75%) by increasing and decreasing extracorporeal blood flow. Systemic blood pressure was maintained at 76/55 - 80/59 mm Hg by adjusting blood volume.
Hemoglobin was maintained between 120 - 130 g/L. Platelet count was maintained at > 75,000/mm3 and ACT was maintained at 120 - 190 s. The
mechanical ventilation was reduced to lung rest settings (FiO2 35%, RR 10 bpm, PIP 16 cm H(2)O, PEEP 5 cm H2O) to prevent alveolar collapse. Inotropic drug dosages were kept at a low level.
RESULTS: The patient was successfully weaned from ECMO following 87 hours treatment. LVEF on day 1, 2 and 3 following ECMO were 20%, 34% and 43% respectively. The circulation was stable after weaning from ECMO with Bp 75/55 mm Hg, HR 160 bpm and LAP 11 mm Hg under inotropic drug suppor with
epinephrine [(0.2 microg/(kg.min)],
dopamine [(8 microg/(kg.min)],
milrinone [(0.56 microg/(kg.min)]. The blood
gases after 1 h off-ECMO showed: pH 7.39, PaO2 104 mm Hg, PaCO2 45 mm Hg,
lactate 3.8 mmol/L, Hct 35%, K(+) 3.8 mmol/L, Ca(++) 1.31 mmol/L. The serum
lactate was normal after 24 h off-ECMO. On day 22 off-ECMO, the baby was successfully extubated and weaned from conventional
ventilator. On day 58, the patient was discharged. Serial ultrasound imaging studies revealed no
cerebral infarction or
intracranial hemorrhage during and after ECMO. At the time of hospital discharge, the patient demonstrated clear consciousness with good activity, normal function of heart, lung, liver and kidney. However, more subtle morbidities, such as behavior problems,
learning disabilities should be observed ria long term follow-up. The main ECMO complications were pulmonary
hemorrhage,
bleeding on the sternal
wound, tamponade,
hemolysis and
hyperbilirubinemia.
CONCLUSION: