Death by Neurologic Criteria in Neonates Undergoing Extracorporeal Membrane Oxygenation: Extracorporeal Life Support Organization Registry Study, 2010-2023

Objectives:To identify factors associated with the development of death by neurologic criteria (DNC) in neonates treated with extracorporeal membrane oxygenation (ECMO).Design:Retrospective registry study.Setting:Data reported to the Extracorporeal Life Support Organization registry from 2010 to 2023.Patients:Neonates (<= 28 d old) who were supported with ECMO, excluding those born before 37 weeks' gestation or with missing gestational age data. The final cohort comprised 14,970 neonates.Interventions:None.Measurements and Main Results:DNC occurred in 70 neonates in the cohort (0.5%), accounting for 2% of overall mortality rate. Pre-ECMO factors associated with greater relative risk ratio (RRR) of DNC included pre-ECMO cardiac arrest (RRR, 2.64), pH less than 7.08 (25th percentile: RRR, 2.06), and cardiac support type (RRR, 2.04). On-ECMO, factors independently associated with DNC included pH less than 7.35 (25th percentile: RRR, 2.76), Pao2 greater than 162 mm Hg (75th percentile: RRR, 2.75), and central cannulation (RRR, 2.36). We failed to identify an association between relative change in Paco2 greater than 50% and DNC, but it correlated with other causes of death. Most DNC diagnoses (84%) occurred after 24 hours of ECMO.Conclusions:DNC is rarely diagnosed in neonatal ECMO cases. Both pre-ECMO and on-ECMO factors associated with DNC included pre-ECMO cardiac arrest, severe metabolic acidosis, and cannulation type. These findings underscore the importance of optimizing pre-ECMO and on-ECMO management and may indicate certain modifiable risk factors such as optimization of cardiopulmonary resuscitation and hyperoxia. Future research should explore preventive strategies and interventions to mitigate the risk of DNC in neonates receiving ECMO.