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Objectives: Neonates with respiratory failure are ideally supported with veno-venous rather than veno-arterial extracorporeal membrane oxygenation due to the reduced rate of neurologic complications. However, the proportion of neonates supported with veno-venous extracorporeal membrane oxygenation is declining. We report multisite veno-venous extracorporeal membrane oxygenation, accessing the neck, returning to the inferior vena cava via the common femoral vein in neonates and children less than 10 kg., Design: Retrospective case series with 1 year minimum follow-up., Patients: Patients less than 10 kg supported with veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein., Setting: A 30-bed pediatric intensive care delivering extracorporeal membrane oxygenation to approximately 20 children annually., Interventions: Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was delivered using two single lumen cannulae., Measurements and Main Results: January 2015 to August 2019, 11 patients underwent veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein with median weight of 3.6 kg (interquartile range 2.8-6.1 kg), and median corrected gestational age of 13 days (interquartile range, 2-175 d). The smallest patient weighed 2.1 kg. Seven patients had comorbidities. Extracorporeal membrane oxygenation was technically successful in all patients with median flows of 126 mL/kg/min (interquartile range, 120-138 mL/kg/min) and median arterial oxygenation saturation of 94% (interquartile range, 91-98%) at 24 hours. Nine survived to home discharge, and two were palliated. Common femoral vein occlusion was observed in all patients on ultrasound post decannulation. There was no clinical or functional deficit in the cannulated limb at follow-up, a minimum of 1 year post extracorporeal membrane oxygenation., Conclusions: Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was performed safely in patients under 10 kg with the smallest patient weighing 2.1 kg. Although occlusion of the common femoral vein was observed in patients post decannulation, subsequent follow-up demonstrated no clinical implications. We challenge current practice that veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein cannot be performed in nonambulatory patients and suggest that this strategy is preferred over veno-arterial extracorporeal membrane oxygenation in infants requiring extracorporeal membrane oxygenation for respiratory failure., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: Neonates with respiratory failure are ideally supported with venovenous rather than venoarterial extracorporeal membrane oxygenation due to the reduced rate of neurologic complications. However, the proportion of neonates supported with venovenous extracorporeal membrane oxygenation is declining. We aimed to explore the factors behind this decline., Design: We conducted a survey in order to understand current practice across the United Kingdom, exploring barriers to neonatal venovenous extracorporeal membrane oxygenation in addition to collecting U.K.-wide retrospective data from 2000 onwards., Patients: Neonates with respiratory failure supported with extracorporeal membrane oxygenation in the United Kingdom., Setting: All 11 pediatric U.K. extracorporeal membrane oxygenation centers provided data., Interventions: None., Measurements and Main Results: The percentage of neonates with respiratory failure supported with venovenous extracorporeal membrane oxygenation has declined from 58% to 16% over the last decade, reflected internationally with a decrease of 1.3% per year. Nine extracorporeal membrane oxygenation centers are able to offer pediatric venovenous extracorporeal membrane oxygenation, but only four offer neonatal venovenous extracorporeal membrane oxygenation. Of those able to provide neonatal venovenous extracorporeal membrane oxygenation, three centers use dual lumen cannulae and one uses neonatal multisite cannulation. The most frequently cited barriers to neonatal venovenous extracorporeal membrane oxygenation were the lack of availability of a suitable dual lumen cannula with concerns of cardiac perforation and challenges of multisite cannulation due to small caliber femoral veins., Conclusions: The majority of U.K. centers are unable to provide venovenous extracorporeal membrane oxygenation for neonates due to concerns with availability and suitability of dual lumen cannulae. An alternative to be considered is the use of multisite cannulation, which has been used historically and is currently being used in centers internationally and in the United Kingdom.

We describe our novel technique of Pump Controlled Retrograde Trial Off that relies on the retrograde flow to maintain circuit integrity and allow a longer trial off from venoarterial extracorporeal membrane oxygenation support without circuit clot formation or significant patient hemodynamic compromise. This technique avoids the insertion of an arteriovenous bridge and the need to clamp the circuit. We present data on five neonatal patients who were trialled off using this method.

Background: Congenital tracheal stenoses are rare and life-threatening anomalies, associated with considerable variation in both morphology and prognosis. They have been classified previously according to the length of the stenosis or the severity of the symptoms, but not according to bronchial involvement. Methods: Data from patients who underwent slide tracheoplasty for long-segment (>50%) congenital tracheal stenosis were collected. We identified four different types of bronchial arborization (normal, n = 52; tracheal right upper lobe bronchus, n = 10; carina with “trifurcation,” n = 14; and unilateral bronchial and lung agenesis, n = 8). Each type included congenital tracheal (above the carina) or tracheobronchial (extending below the carina) stenosis. Results: Eighty-four children were enrolled in the study. Preoperative ventilation was necessary in 44 patients (52.4%; 75% in patients with a single lung), and preoperative extracorporeal membrane oxygenation was needed in 10 patients (11.9%). Preoperative tracheostomy was present in 3 patients initially treated elsewhere (3.5%), and a left pulmonary artery sling was performed in 44% (37 of 84). The overall mortality was 13% (11 of 84), 7.9% in patients with tracheal stenosis and 28.6% with tracheobronchial stenosis. No deaths occurred in patients with right upper lobe bronchus anatomy. Endoscopic procedures after slide tracheoplasty were required in 34 patients (40.4%). Stents were placed in 18 patients (21.4%), with a higher incidence in those with bronchial trifurcation (42.8%, 6 of 12). Conclusions: This classification appears useful for the morphologic characterization of congenital airway stenosis and could be the benchmark for future prospective studies on the outcome of these patients. [Copyright &y& Elsevier]

Abstract: Objective: The aim of the study is to assess the surgical outcome of slide tracheoplasty in patients with congenital tracheal stenosis and single lung. Methods: Pre, intra- and postoperative data were collected. Anatomy and associated anomalies were described. Results: Seven patients (median age 5 months; range 39 days–1 year) with single lung underwent slide tracheoplasty. Single right lung was present in four patients. Associated anomalies were present in four patients (56%) including vascular ring, left pulmonary artery (LPA) sling, VACTERL (abnormalities of the vertebrae, anus, cardiovascular tree, trachea, oesophagus, renal system, and limb buds) syndrome, atrial septal defect (ASD) and aberrant left subclavian artery. Six patients (85%) needed preoperative ventilation and two (28%) needed preoperative extracorporeal membrane oxygenation (ECMO). Median postoperative ventilation was 7 days (6–35 days). Two patients needed postoperative ECMO, one of whom required preoperative ECMO. Complications occurred in five patients (71%): reintubation due to pneumothorax, pneumonia and several tracheal dilatations due to recurrent tracheal stenosis, which was eventually stented. There was one hospital death in a patient, who could not be weaned off ECMO due to severe distal malacia. At a median follow-up of 16 months (7 days–7 years), all survivors are in good clinical condition and without additional stenting. Conclusion: Slide tracheoplasty can be performed in patients with single lung and tracheal stenosis with a good surgical outcome. [Copyright &y& Elsevier]