Ранняя консультация по ЭКМО критически важна для спасения жизни недоношенных детей

Newswise — For decades, extracorporeal membrane oxygenation (ECMO) has often been considered a last resort in neonatal care. But waiting too long to consult an ECMO center can limit treatment options, increase transport risks, and potentially worsen outcomes. “We often get the call for ECMO after a baby has already been on escalating ventilator support or very high oxygen, when transfer becomes high risk and organ injury may already be occurring,” says Rachel Chapman, MD, Associate Chief of Neonatology and Director of the Neonatal ECMO Program in the Fetal and Neonatal Institute at Children’s Hospital Los Angeles. “Considering ECMO earlier, while a baby is more stable, can allow for safer transfer and access to therapies that may reduce the need for ECMO.” As a major ECMO referral center in the Southwestern U.S., Children’s Hospital Los Angeles treats approximately 30 neonates a year with ECMO, along with many other consultations. The program—which will mark its 40th year in 2027 and holds Gold-level designation from the Extracorporeal Life Support Organization (ELSO)—has a long history of caring for the most critically ill infants. That experience has given the team a close-up view of how timing influences both care and outcomes. Dr. Chapman and Asavari Kamerkar, DO, Medical Director of the ECMO Department at CHLA, share three moments in a neonate’s course when earlier ECMO consultation can change the trajectory. 1. Congenital diaphragmatic hernia Newborns with congenital diaphragmatic hernia (CDH) present one of the clearest opportunities for early ECMO consultation. “These are babies who can look OK for the first day or so, but then decompensate quickly,” says Dr. Chapman. “That early period, when they are still stable, is the best time to start the conversation.” Early consultation—particularly if the degree of pulmonary hypoplasia or pulmonary hypertension is unclear—allows time to plan for transfer. It also ensures access to the full range of resources CDH patients may require, including pediatric surgery, advanced cardiopulmonary support, and ECMO. “Large ECMO centers like CHLA also have a full range of neonatal specialists and advanced imaging, diagnostic, and treatment capabilities,” Dr. Kamerkar notes. “Our teams have the ability to better diagnose conditions and allow babies to get the appropriate treatment much more quickly.” When to call: If an infant with CDH has significant pulmonary hypoplasia, pulmonary hypertension, or worsening clinical status, call early while the baby is still stable for transport. 2. Pulmonary hypertension In neonates with pulmonary hypertension, often but not always complicating underlying lung disease, a pattern of escalating support and/or an unclear underlying diagnosis is a strong signal that ECMO consultation is needed. Clinicians may hesitate to make that call, in part because of concerns about transport and ECMO-related complications. But focusing only on those risks can overlook the potential downsides of continued escalation. “Prolonged exposure to high concentrations of oxygen or high ventilator settings can have long-term consequences,” says Dr. Kamerkar. “When you find yourself adding a second agent or increasing support across multiple fronts, that is the time to call.” Congenital heart disease, such as total anomalous pulmonary venous return (TAPVR), can also present similarly and be difficult to diagnose. Yet the treatment strategies may be very different, and ECMO can be used to stabilize the baby prior to operative repair. Early consultation can also expand what options are safely available. For example, pulmonary vasodilators may carry risks in hemodynamically unstable infants. “At CHLA, we can have ECMO ready to go as a backup, which allows us to more safely use those therapies,” Dr. Chapman says. When to call: If oxygen, ventilator, or vasoactive support is steadily escalating, call early. ECMO availability may allow clinicians to try therapies they otherwise couldn’t. 3. Sepsis With sepsis, it can be difficult to predict which infants will improve with treatment, and which will progress to severe shock and/or respiratory failure. “Physicians often think, ‘Let’s try one more thing,’ in the hopes of avoiding transport and ECMO,” says Dr. Kamerkar. “But by the time it becomes clear that the baby is not responding to treatment, the liver or kidneys may have already taken a hit.” In these infants, ECMO can provide not just respiratory support, but critical circulatory support—making timing especially important, Dr. Chapman notes. When to call: If shock is worsening despite antibiotics, fluids, and escalating vasoactive support, call early—before organ injury develops. The bottom line For neonatologists, the takeaway is clear: An early ECMO call doesn’t necessarily mean early ECMO treatment. Because ECMO candidacy is individualized and depends on multiple factors, early consultation can help determine the most appropriate course of care before a baby’s condition deteriorates. “Prolonged hypoxemia and prolonged low blood pressure are not good for perfusion to the organs, particularly the brain,” Dr. Chapman notes. “The goal of an early ECMO consultation is to try to prevent those consequences and preserve treatment options.” When to call: If you’re concerned about a baby’s trajectory, call early. Consultation does not obligate transfer, cannulation, or ECMO treatment.