Venovenous extracorporeal membrane oxygenation in neonatal respiratory failure: does routine, cephalad jugular drainage improve outcome?

BACKGROUND/
PURPOSE: Extracorporeal membrane oxygenation (ECMO), may be life saving for infants with severe respiratory failure, and when possible, veno-venous bypass through a jugular double lumen cannula, can be expected to provide satisfactory support for most patients. Some ECMO centers favor routine placement of a cephalad jugular cannula for the theoretical benefits of augmented (desaturated) venous return, reduction of atrial recirculation, and cerebral venous decompression. The purpose of this study was to querie the ELSO registry for patients who had undergone VV-ECMO and compare outcomes for patients with a double lumen cannula only (VVDL), with those who had both a double lumen and cephalad jugular cannula (VVDL + V).
METHODS: With institutional review board (IRB) approval, the Extracorporeal Life Support Organization (ELSO) registry (Ann Arbor, MI) was queried from January 1, 1989 to December 31, 2001, and all "neonatal respiratory" patients undergoing VV-ECMO via either the VVDL or VVDL + V modes were identified. Group comparisons by age, diagnosis, hours on bypass, mean flow rates (Q) at 4 and 24 hours, mean airway pressures (MAP) at initiation and at 24 hours of bypass, complications (including neurologic and cannula-specific), need for conversion to veno-arterial (VA) ECMO, and survival were performed. A similar analysis was performed on a congenital diaphragmatic hernia (CDH) patient subgroup. Student's t tests were used to compare means between groups, with P values of less than.05 considered significant.
RESULTS: The querie generated a total of 2,471 patients: 2,379 (96.3%) VVDL, and 92 (3.7%) VVDL + V. The groups were comparable with the only significant differences being a higher mean airway pressure at 24 hours of bypass and a more frequent use of inotropes during extracorporeal life support (ECLS) in the VVDL + V group. Comparison of a CDH patient subset (280 from the VVDL group and 25 from the VVDL + V group) showed the following significant differences: more frequent use of inotropes, higher MAP at 24 hours, and higher mean flow rates at 4 and 24 hours, all in the VVDL + V group. Patient outcomes, including survival, complications, and rates of conversion to VA bypass were comparable between like groups.
CONCLUSIONS: The theoretical benefits of routine placement of a cephalad jugular cannula during VV-ECMO via a jugular double lumen cannula are not substantiated by critical analysis of ELSO data.