Lejeune, Thierry

Pfister, Riccardo

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SHORT REPORTThierry Lejeune Æ Riccardo E. PﬁsterSurfactant lavage for extracorporeal membrane oxygenation-requiringmeconium aspiration syndrome —a cheap alternativeReceived: 7 October 2004 / Revised: 13 December 2004 / Accepted: 15 December 2004 / Published online: 22 February 2005 Springer-Verlag 2005A full-term newborn girl presenting with typical verysevere meconium aspiration syndrome (MAS) fulﬁllingthe criteria for extracorporeal membrane oxygenation(ECMO) was successfully treated by surfactant lavage.We wish to draw attention to this alternative treatmentoption.The patient’s 32-year-old G1P0 mother was admittedto the labour ward at 41 weeks gestation for induction oflabour. Pregnancy was uneventful and fetal anatomyand biometry were normal on ultrasound. A thickmeconium-stained amniotic ﬂuid was noted whenmembranes ruptured. Fetal tachycardia necessitated acaesarean section 2 h later. A baby girl was deliveredwho was cyanotic, hypotonic and non reactive. Theheart rate was over 100/min (APGAR 2 at 1 min, 6 at5 min and 7 at 10 min). Birth weight was 3170 g (P10–P50), length 50 cm (P50) and cranial circumference35.5 cm (P50–P90). Arterial and venous umbilical cordblood gases were pH 7.07, BE -9 and pH 7.17, BE -7.8respectively. In the absence of spontaneous breathing,she was immediately intubated and the endotracheal(ET) cannula withdrawn again under continuous suc-tioning. Copious amounts of meconium were withdrawnand as the heart rate remained above 100/min, a secondET aspiration was performed through an ET tube but nomore meconium was removed. As the baby establishedspontaneous breathing thereafter, nasal CPAP (PEEP8 cm H2O) was initiated at FiO2 1.0 and rapidly reducedto 0.6. Umbilical catheters were inserted and 10% glu-cose was started concomitantly with antibiotics beforethe baby was transferred to the neonatal intensive careunit.At 3 h of life, respiratory and cardiovascular condi-tions worsened. Hypotension was treated with volumeexpansion (0.9% NaCl, 10 ml/kg i.v.) and a continuousdopamine infusion (10 lg/kg per min) as well as addi-tion of dobutamine to stabilise blood pressure. Respi-ratory distress worsened considerably with oxygenrequirements increasing to FiO2 1.0 to achieve a satu-ration of 85%–90%. A chest X-ray ﬁlm showed typicalsigns of severe MAS with a patchy pulmonary paren-chyma and zones of hyperinﬂation and atelectasis.Arterial blood gases with paO2 of 40.7 mmHg and pCO2of 68 mmHg, BE -4.3 (OI 19.6) [6] required re-intuba-tion after induction with morphine (0.1 mg/kg), mi-dazolam (0.05 mg/kg) and pancuronium (0.1 mg/kg).Ventilation was started on high frequency oscillation byﬁrst intention (MAP 23 cm H2O; Delta P 45 cm H2O;FiO2 1.0, Sensormedics). The baby further deterioratedand pulmonary hypertension was suspected on diﬀer-entials of more than 10% between pre- and post-ductaloxygen saturations and conﬁrmed on heart scan with aright to left shunt over the ductus arteriosus.At 9 h of life, FiO2 was still 0.8, MAP 23.5 cm H2Oand Delta P 52 cm H2O to achieve a paO2 of25.6 mmHg and BE -2.3 (OI 73.4) (Fig. 1). Inhaled ni-tric oxide (NO) was started at 5 ppm and rapidly raisedto 20 ppm. Intravenous morphine and repeated singledoses of pancuronium were given to optimise sedation.Good but transitory improvement was noted afterstarting NO. Despite deep sedation, pH >7.3 and NO,respiratory distress worsened again and severe pulmo-nary hypertension persisted.At 26 h of life, the clinical condition showed noimprovement (FiO2 1.0, MAP 19.5 cm H2O, Delta P55 cm H2O to achieve a paO2 of 36.4 mmHg, BE -3.3,OI 53.6). The chest X-ray ﬁlm revealed a further increasein hyperinﬂation.MAS with OI >40 despite full conventional therapyover several hours, is generally considered an indicationfor ECMO [1]. However, ECMO in newborns is stillassociated with a high morbidity and was unavailable inSwitzerland at that time. Furthermore, as the baby wastoo unstable for transport to the closest European ECMOcentre, we opted for a broncho-alveolar lavage withT. Lejeune Æ R. E. Pﬁster (&)Neonatology and Paediatric Intensive Care,Department of Paediatrics, University Hospital of Geneva,Rue Micheli-du-Crest 24, 1211 Geneva 14, SwitzerlandE-mail: riccardo.pﬁster@hcuge.chTel.: +41-22-3824351Fax: +41-22-3824315Eur J Pediatr (2005) 164: 331–333DOI 10.1007/s00431-005-1624-0diluted exogenous surfactant based on a small publishedtrial [3] using a protocol with a total volume of 15 ml/kg(Curosurf 5 mg/ml diluted with 0.9%NaCl). We injected24·2 ml aliquots of diluted surfactant through the side-port of a 3.5 ET tube (Abbott) and re-aspirated throughtheET tube as soon as ventilation parameters restabilised.Short desaturations and transiently reduced ventilationrequired a brief adaptation of ventilator settings, but nohaemodynamic or pulmonary complications resultedfrom the procedure. Almost immediately after the pro-cedure, the baby started to improve (OI 36.9 after 3 h; OI7.8 after 24 h). Hyperinﬂation and atelectasis had disap-peared on the chest X-ray ﬁlm 3 h later (Fig. 2) and it waspossible to wean and stop NO 16 h after the procedure.The baby was extubated at 4 days of life (50 h after theprocedure); oxygenwas stopped on day 7 and nasal CPAPon day 9. Brain scans remained normal as well as oto-acoustic emissions. The baby was discharged home at 15days of life.Two randomised controlled trials have demonstrateda reduction in the severity of the respiratory disease andin the number of infants requiring ECMO after surfac-tant replacement for severe MAS [2, 4]; however, mor-tality remained unchanged. In cases with high mortality,as indicated by ECMO criteria, broncho-alveolar lavagemay be superior to replacement therapy and present avaluable alternative, particularly in situations andcountries where ECMO is not readily available fornewborns as well as in critical situations when the babyis not stable enough for transport to an ECMO centre.Little is known about surfactant lavage but it is cheapand may prove as eﬀective as ECMO for the treatmentof severe MAS [5] when conventional therapy includinghigh frequency oscillation and NO fail. The eﬃcacy ofthe treatment has been reported in several case reportsand in a small, randomised controlled trial [7] but forestablishment of the technique, randomisation versusthe standard ECMO technique is required. Nevertheless,Fig. 2 Chest X-ray ﬁlms 20 hbefore and 3 h after surfactantlavageFig. 1 The course of OI frombirth to extubation332this approach is worth considering when ECMO isunavailable for the treatment of severe MAS.References1. Cook LN (2004) Update on extracorporeal membrane oxygen-ation. Paediatr Respir Rev 5[Suppl A]: S329–S3372. Findlay RD, Taeusch HW, Walther FJ (1996) Surfactantreplacement therapy for meconium aspiration syndrome. Pedi-atrics 97: 48–523. Lam BC, Yeung CY (1999) Surfactant lavage for meconiumaspiration syndrome: a pilot study. Pediatrics 103: 1014–10184. Lotze A, Mitchell BR, Short BL (1998) Multicenter study ofsurfactant (Beractant) use in the treatment of term infants withsevere respiratory failure. J Pediatr 132: 40–475. Mo¨ller JC, Kohl M, Reiss I, Wiebke D, Nitsche EM, Go¨pel W,Gortner L (1999) Saline lavage with substitution of bovine sur-factant in term neonates with meconium aspiration syndrome(MAS) transferred for extracorporeal membrane oxygenation(ECMO): a pilot study. Crit Care 3:19–226. Ortiz RM, Cilley RE, Bartlett RH (1987) Extracorporeal mem-brane oxygenation in pediatric respiratory failure. Pediatr ClinNorth Am 34: 39–467. Wiswell TE, Knight GR, Finer NN (2002) A multicenter, ran-domized, controlled trial comparing Surfaxin (lucinactant) la-vage with standard care for treatment of meconium aspirationsyndrome. Pediatrics 109: 1081–1087333

Surfactant lavage for extracorporeal membrane oxygenation-requiring meconium aspiration syndrome —a cheap alternative

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Surfactant lavage for extracorporeal membrane oxygenation-requiring meconium aspiration syndrome —a cheap alternative

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