**4. Feasibility of ECMO with asphyxiated newborns treated with hypothermia**

The major complications during an ECMO course are hemorrhagic and/or thromboembolic, with an increased risk of intracranial hemorrhage. Asphyxiated newborns treated with hypothermia are already at an increased risk of hemodynamic instability, thrombocytopenia, and coagulopathy, which are risk factors for intracranial bleeding [35, 36] and further brain injury [10, 17] (**Figure 1**). These complications may be due to the primary asphyxial event or the consequence of the therapeutic hypothermia [8]. Thus, questions have been raised about whether providing ECMO treatment for these asphyxiated newborns may worsen their outcome and increase their risk of intracranial bleeding.

**5. Short- and long-term outcomes in asphyxiated newborns treated** 

Hypothermia treatment has improved the prognosis of asphyxiated newborns, making neonatal encephalopathy a "reversible" condition in one of seven treated newborns [37, 38]. However, due to their risk of irreversible brain injury, clinicians often are concerned about offering ECMO to these newborns [39]. Data on the outcome of asphyxiated newborns who received ECMO during the first 72 h of life are scarce [9–11] (**Table 1**). Shah et al. [11] reported on two asphyxiated newborns treated with hypothermia and ECMO who survived, but they did not mention their outcome. Massaro et al. [9] reported on five asphyxiated newborns treated with hypothermia and ECMO: they all survived and three of them were developmentally age appropriate at follow-up at 6–21 months; one had increased tone at 3 months but then was lost to follow up; and one had significant motor and cognitive delay. Cuevas Guaman et al. [10] studied 78 asphyxiated newborns treated with hypothermia and ECMO and reported a 15% mortality, 22% neurological complications (e.g., brain hemorrhage or infarction), and 12% seizure rate; however, they did not report on the long-term outcomes of these newborns. Thus, current evidence suggests that the outcome of asphyxiated newborns

**Figure 1.** Schematic explaining indications of hypothermia treatment, and potential complications of birth asphyxia and

Extracorporeal Membrane Oxygenation Use in Asphyxiated Newborns…

http://dx.doi.org/10.5772/intechopen.78761

69

In addition, to achieve optimal results, early rather than later consideration of ECMO during the course of therapeutic hypothermia is probably important for these critically ill newborns,

**with hypothermia and ECMO**

hypothermia.

treated with hypothermia and ECMO is not always poor.

To date, only a limited number of studies reported on the use of ECMO with asphyxiated newborns treated with hypothermia [9–11]. The Cuevas Guaman et al. [10] study is the largest of these studies, which included 187 asphyxiated newborns treated with ECMO. They did not find any difference in the incidence of bleeding or mortality in the 78 asphyxiated newborns treated with hypothermia during the ECMO course, compared to the 109 not-cooled asphyxiated newborns treated only with ECMO. These two groups also did not differ in their incidence of cardiopulmonary, renal, neurological, and metabolic complications. Therefore, according to the currently limited available evidence, it appears that ECMO therapy may be run safely with asphyxiated newborns treated with hypothermia.

#### Extracorporeal Membrane Oxygenation Use in Asphyxiated Newborns… http://dx.doi.org/10.5772/intechopen.78761 69

treatment down to 34°C for 12 h while on ECMO without worsening their survival rate, hemodynamic instability, bleeding risk, and thromboembolic complications. Horan et al. [32] found that newborns who were more than 33 weeks of gestation and who were treated with ECMO for severe respiratory failure could receive hypothermia treatment down to 34°C for 48 h during ECMO without worsening their cardiovascular status, nor having major bleeding. Of note, newborns with severe encephalopathy were excluded from both studies. The safety of maintaining hypothermia down to 34°C during ECMO also was observed in 37 newborns after cardiac surgery by Lou et al. [33]; none of the newborns treated with ECMO and hypothermia developed intracranial hemorrhage or a worsening of hemodynamic instability. In addition, Field et al. [22, 34] found that mild hypothermia down to 34°C could be safely maintained during ECMO for 72 h with newborns with meconium aspiration, persistent pulmonary hypertension, or severe cardiorespiratory failure. When they compared the outcomes at 2 years of age of their 45 newborns treated with mild hypothermia to 34°C for 48–72 h during ECMO to the outcomes of their 48 newborns treated only with ECMO, the mild hypothermia treatment did not improve the outcomes of these 45 newborns [22]. However, given the heterogeneity of the initial diagnoses in this studied population of newborns, these results cannot be extrapolated directly to asphyxiated newborns, in whom hypothermia, not in the context of ECMO, has been shown to be of benefit [6, 7]. Therefore, as of now, no evidence exists that the incidence of significant bleeding and the need for inotropes were worsened when hypothermia was provided to

**4. Feasibility of ECMO with asphyxiated newborns treated with** 

The major complications during an ECMO course are hemorrhagic and/or thromboembolic, with an increased risk of intracranial hemorrhage. Asphyxiated newborns treated with hypothermia are already at an increased risk of hemodynamic instability, thrombocytopenia, and coagulopathy, which are risk factors for intracranial bleeding [35, 36] and further brain injury [10, 17] (**Figure 1**). These complications may be due to the primary asphyxial event or the consequence of the therapeutic hypothermia [8]. Thus, questions have been raised about whether providing ECMO treatment for these asphyxiated newborns may worsen their outcome and

To date, only a limited number of studies reported on the use of ECMO with asphyxiated newborns treated with hypothermia [9–11]. The Cuevas Guaman et al. [10] study is the largest of these studies, which included 187 asphyxiated newborns treated with ECMO. They did not find any difference in the incidence of bleeding or mortality in the 78 asphyxiated newborns treated with hypothermia during the ECMO course, compared to the 109 not-cooled asphyxiated newborns treated only with ECMO. These two groups also did not differ in their incidence of cardiopulmonary, renal, neurological, and metabolic complications. Therefore, according to the currently limited available evidence, it appears that ECMO therapy may be

newborns during the ECMO course.

68 Advances in Extra-corporeal Perfusion Therapies

increase their risk of intracranial bleeding.

run safely with asphyxiated newborns treated with hypothermia.

**hypothermia**

**Figure 1.** Schematic explaining indications of hypothermia treatment, and potential complications of birth asphyxia and hypothermia.
