The changing demographics of neonatal extracorporeal membrane oxygenation patients reported to the Extracorporeal Life Support Organization (ELSO) Registry

B J Roy, P Rycus, S A Conrad, R H Clark
Pediatrics 2000, 106 (6): 1334-8

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an important treatment tool in the management of near-term and term neonates with severe hypoxemic respiratory failure. To better understand how health care for patients treated with ECMO has changed, we studied the demographic and treatment data reported to the Extracorporeal Life Support Organization (ELSO) registry from January 1, 1988, through January 1, 1998.

METHODS: We used data stored in the ELSO registry and evaluated the changes in demographics, use of alternate therapies before ECMO, severity of illness, duration of ECMO therapy, and mortality over a 10-year period. All data on neonates reported between January 1, 1988, and January 1, 1998 were used. Verification checks were performed on all fields to eliminate nonsense outliers. We separated the neonates into 2 groups-those with and those without a congenital diaphragmatic hernia (CDH). All analyses were performed on the total group and each subgroup separately. Changes in continuous data were analyzed by year using analysis of variance. Year differences in categorical data were evaluated with chi(2) analysis. We also used the linear trend test and the Cochran-Armitage trend test to evaluate time-related changes.

RESULTS: We reviewed 12 175 neonates. Over the decade, there were no changes in mean gestational age, gender, age at which ECMO was started, pH, or PaCO(2) just before ECMO. The proportion of neonates with CDH increased from 18% to 26%, while the proportion with respiratory distress syndrome decreased from 15% to 4%. Other diagnostic categories remained constant. The use of surfactant, high-frequency ventilation, and inhaled nitric oxide increased from 0% in 1988 to 36%, 46%, and 24%, respectively, in 1997. The mean peak pressure being used just before ECMO decreased (47 +/- 10 in 1988 to 39 +/- 12 in 1997), and the mean PaO(2)/FIO(2) ratio increased (38 +/- 23 in 1988 to 48 +/- 36 in 1997). The primary mode of ECMO remains venoarterial; however, the use of venovenous ECMO increased from 1% to 32% over the decade. Duration of ECMO treatment increased overall, and this trend was seen for patients with and without CDH (124 +/- 67 to 141 +/- 104 hours for the non-CDH group, 161 +/- 99 to 238 +/- 141 hours for the CDH group). The number of centers reporting neonatal data to the ELSO registry increased from 52 in 1988 to a peak of 100 in 1993. In 1997, 96 centers reported data to ELSO. The average number of neonatal patients reported from each site decreased from a peak of 18 in 1991 to 9 in 1997. Mortality increased from 18% to 22%; however, when corrected for the relative increase in neonates with CDH, this trend disappeared. Diagnoses-specific mortality rates remained constant. The occurrence of intracranial hemorrhage and/or infarct also stayed constant at 16%.

CONCLUSIONS: The population of neonates treated with ECMO in 1997 was very different from patients treated in the 1980s and early 1990s. They were exposed to an ever-expanding group of new therapies, appeared to be healthier based on indices of gas exchange, and were cared for at centers that reported fewer cases per year.

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