Oxigenación de Membrana Extracorpórea en Falla Respiratoria Hipoxémica de Infantes

Estudios recientes del registro internacional muestran una disminución en el uso del soporte de vida extracorpórea neonatal, presumiblemente por la efectividad de los tratamientos descritos previamente como el ONI y la administración exógena de surfactante en infantes cercanos al término.

Sin embargo, no todos los infantes responderán a estos nuevos tratamientos.

La oxigenación de membrana extracorpórea se usa para tratar la falla respiratoria aguda cuando otras modalidades de tratamiento han fallado. El ECMO había demostrado que mejoraba la sobrevida en infantes a término y cercanos al término con falla respiratoria severa en al menos dos estudios clínicos controlados de instituciones individuales.

En forma subsecuente, el estudio aleatorizado colaborativo del Reino Unido de ECMO Neonatal y los estudios de seguimiento muestran que el ECMO en forma significativa reduce el riesgo de muerte sin aumentar el de secuelas severas. En este estudio, 30 de 93 infantes en el grupo de ECMO murieron comparado con 54 de 92 en el grupo de cuidado convencional.

Los infantes con hernia diafragmática, no son propensos a responder al óxido nítrico y tienen más pobre desenlace que otros pacientes que reciben oxigenación de membrana extracorpórea con una sobrevida del 62% comparado con 83% en infantes sin hernia diafragmática.

Sin embargo, sin ECMO, infantes con hernia diafragmática que desarrollan hipoxemia refractaria tienen una alta mortalidad.

En un reciente estudio británico, ninguno de los 17 infantes con HDC enrolados y aleatorizados al grupo control sobrevivieron mientras que 4 de 18 infantes que recibieron ECMO sobrevivieron. El ECMO venovenoso, que es usado menos frecuentemente, es preferible al ECMO venoarterial en la falla respiratoria aguda, puesto que evita la canulación de la arteria carótida y parece tener menores complicaciones.

Nuevas técnicas de intercambio gaseoso extracorpóreo, como el método de la cánula de luz única de empuje y halado, conocido como AREC (asistencia respiratoria extracorpórea), provee soporte efectivo en neonatos y es más rápido de aplicar puesto que la canulación es generalmente percutánea y más fácil de operar.

La consideración de la terapia con ECMO debe incluir una evaluación de los riesgos versus los beneficios por la naturaleza invasiva de la terapia y la necesidad de heparinización. Los criterios usuales para el soporte con ECMO incluyen:

• Más de 34 semanas de gestación.
• Peso mayor de 2000 grs.
• Ecografía transfontanelar sin hemorragia intracraneana mayor.
• Enfermedad pulmonar reversible y soporte con ventilación mecánica durante no más de 14 días.
• Sin evidencia de anomalías congénitas letales.

El momento de referencia al centro de ECMO es crítico.

Tan reciente como hace 15 años la mortalidad por la FHRN era del 40% con una incidencia de secuelas neurológicas mayores del 15-60%.

Si todas las terapias de rescate disponibles incluyendo el ECMO se utilizan, la mortalidad es actualmente menor del 20-25% y la incidencia de secuelas neurológicas mayores para los infantes sobrevivientes es aproximadamente del 15-20%.

La referencia y transporte al centro de ECMO neonatal debe realizarse antes de hipoxemia refractaria.

La consulta temprana y la discusión con el centro de ECMO se recomienda fuertemente.

Guías para consulta están publicadas en la página web de la organización de soporte de vida extracorpórea (http://www.elso.med.umich.edu/).

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