Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs

To describe ventilation strategies used during extracorporeal membrane oxygenation (ECMO) for neonatal respiratory failure among level IV neonatal ICUs (NICUs). Design: Cross-sectional electronic survey. Setting: Email-based Research Electronic Data Capture survey. Patients: Neonates undergoing ECMO for respiratory failure at level IV NICUs. Interventions: A 40-question survey was sent to site sponsors of regional referral neonatal ECMO centers participating in the Children\u27s Hospitals Neonatal Consortium. Reminder emails were sent at 2- and 4-week intervals. Measurements and main results: Twenty ECMO centers responded to the survey. Most primarily use venoarterial ECMO (65%); this percentage is higher (90%) for congenital diaphragmatic hernia. Sixty-five percent reported following protocol-based guidelines, with neonatologists primarily responsible for ventilator management (80%). The primary mode of ventilation was pressure control (90%), with synchronized intermittent mechanical ventilation (SIMV) comprising 80%. Common settings included peak inspiratory pressure (PIP) of 16-20 cm H2O (55%), positive end-expiratory pressure (PEEP) of 9-10 cm H2O (40%), I-time 0.5 seconds (55%), rate of 10-15 (60%), and Fio2 22-30% (65%). A minority of sites use high-frequency ventilation (HFV) as the primary mode (5%). During ECMO, 55% of sites target some degree of lung aeration to avoid complete atelectasis. Fifty-five percent discontinue inhaled nitric oxide (iNO) during ECMO, while 60% use iNO when trialing off ECMO. Nonventilator practices to facilitate decannulation include bronchoscopy (50%), exogenous surfactant (25%), and noninhaled pulmonary vasodilators (50%). Common ventilator thresholds for decannulation include PEEP of 6-7 (45%), PIP of 21-25 (55%), and tidal volume 5-5.9 mL/kg (50%). Conclusions: The majority of level IV NICUs follow internal protocols for ventilator management during neonatal respiratory ECMO, and neonatologists primarily direct management in the NICU. While most centers use pressure-controlled SIMV, there is considerable variability in the range of settings used, with few centers using HFV primarily. Future studies should focus on identifying respiratory management practices that improve outcomes for neonatal ECMO patients

A New Actinopterygian Fish (Paleonisciformes) From The Upper Mississippian Bluestone Formation Of West virginia

Volume: 99Start Page: 584End Page: 60

Timing and duration of the Central Atlantic magmatic province in the Newark and Culpeper basins, eastern U.S.A.

International audienceNew major and trace element data and (40)Ar/(39)Ar plateau ages constrain the timing, duration and time-related geochemical evolution of the Central Atlantic magmatic province in the U.S.A. (Newark and Culpeper basins) and refine correlations with basaltic lava flows from other Late Triassic-Early Jurassic circum-Atlantic basins. The precise, statistically robust (40)Ar/(39)Ar plateau ages were obtained on biotite and on fresh plagioclase and calculated using the latest (40)K decay constants. These ages are supported by a general consistency of the Ca/K calculated from (37)Ar/(39)Ar of the plateau steps and the Ca/K obtained by detailed electron microprobe analyses on plagioclase phenocrysts. The ages of five analyzed basalt lava flows, from all three lava flow units in the Newark basins, and the ages of two sill samples are indistinguishable, indicating a brief magmatic peak phase at 201.8 +/- 0.7 Ma. Recalibrated (40)Ar/(39)Ar plateau ages from the entire province indicate a near-synchronous onset and peak volcanic activity at the Triassic-Jurassic boundary within the circum-Atlantic basins from the U.S.A., Canada and Morocco. The early erupted magmas (Moroccan Lower to Upper basalts, the Fundy basin North Mountain Basalt, and Orange Mountain and equivalent U.S.A. flows) yield an enriched geochemical signature (e.g., with relatively high La/Yb), whereas late magmas in the U.S.A. (Hook Mountain and Hampden basalts) and Morocco (Recurrent basalt) yield relatively depleted geochemical compositions (low La/Yb). A slight, but significant age difference for eruption of Hook Mountain and Hampden basalts (200.3 +/- 0.9 Ma) and Recurrent basalts (198.2 +/- 1.1 Ma) is interpreted as evidence of a diachronous northward rift-drift transition during break-up of Pangea. Our data indicate also a prolonged intrusive sequence that continued until about 195 Ma at the Palisades sill and is consistent with sporadic late CAMP magmatism for dykes from the south-eastern U.S.A. and for intrusions from Guinea