The future of neonatal nursing...

  1. In a major step aimed at improving the survival odds for extremely premature infants, Children’s Hospital of Philadelphia researchers have created an artificial womb — a fluid-filled “BioBag” that kept fetal lambs alive and healthy outside their mothers until they could survive on their own.

    The animals received oxygen through their umbilical cords and continued to develop much as if they had remained in the uterus, leading the team to express hope that the procedure could be tried on the youngest human preemies within three to five years.

    The authors of the research stressed that they were not trying to enable the delivery of babies earlier than the current limit of viability, generally 22 to 23 weeks of pregnancy.
    full article here:
    Children's Hospital's 'artificial womb' raises hope for extreme preemies

    Scientists grow lamb fetus inside artificial womb - YouTube
    ...

    Thoughts everyone? They are starting human trials in 3-5 years (!!!)

    TL;DR: Children's hospital of Philadelphia is creating bio-bags to put in fetuses at the edge of viability at 22-23 weeks and then let them gestate until a more reasonable gestational age at less risk of all of the co-morbidities and mortality that 22-23 weekers face.

    This is huge. If they can get it to work, our work will never be the same. It will be revolutionary on par with the use of surfactant in the 80s, if not bigger. Who would manage them? MFM or neos or both?

    Extrapolating out in the far future- could this be a way for folks to have a baby instead of being pregnant? Go and visit your fetus every week until they deliver at term? Craziness.
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  2. 9 Comments

  3. by   adventure_rn
    We have a copy of that article hanging up in our break room. It's a pretty wild concept. I wonder if the researchers will have trouble convincing parents to consent to the treatment, except in the case of 22-weekers where the team will not consider resuscitation.

    I've always thought that the next step to lowering the age of viability would be some form of ECMO that could be delivered to preemies (even though they state that the goal isn't to lower the age of viability); this sounds a lot like umbilical ECMO, with additional environmental factors like the fluid filled sac.

    It's kind of hard to imagine what the nursing care would be like for these kids. I wonder if it would be similar in some ways to managing a kid on ECMO. Maybe there would even be 'BioBag techs' kind of like there are 'ECMO techs.'

    Thanks for sharing

    Edit: As another random thought, I wonder if the system has to be highly heparinized like ECMO to prevent clotting in the circuit. It seems like there could be issues with brain bleeds...
    Last edit by adventure_rn on Jun 15
  4. by   Guy in Babyland
    Quote from adventure_rn
    It's kind of hard to imagine what the nursing care would be like for these kids. I wonder if it would be similar in some ways to managing a kid on ECMO. Maybe there would even be 'BioBag techs' kind of like there are 'ECMO techs.'
    There would have to be somebody there to constantly monitoring the BioBags. This reminds me of many sci-fi movies of growing fetuses in bags.

    How would this logistically work in humans? Woman goes into preterm labor at 24 weeks, they do a C section and transfer the fetus to the BioBag?
  5. by   Luckyyou
    No thanks. Our neuro outcomes with regular neonatal ECMO (35ish weeks+ with some wiggle room depending on what surgeon is on) are ehhhhhh at best, I can't imagine what they would be like for the extremely premature. Also interested to see how the circuit will work -- there's a huge problem with hemolysis in small french ECMO cannulae (especially in a centrifugal pump), and I can't imagine that they would be using anything much different than a 5fr/3.5fr umbilical line? The flows would have to be pretty low too... we aim for 80-100ml/kg on full support, so these 500g ish kids would be flowing at such a low rate... that's a lot of nearly stagnant blood to anticoagulate.

    Even if this is perfected eventually, is it worth the number of the guinea pig babies it will take to get it right? I already have enough ethical problems with people begging us to save their 22-23 weekers without any clue what they're asking. Their baby won't be the one that's trached, g-tubed, VP shunted... their baby will be the miracle that gets on the news because they were born at 22 weeks and now they're graduating from Harvard at age 16. Everyone thinks their baby will be the exception to the rule. There's a reason there's a rule.

    Nope nope nope. Just because we can doesn't mean we should.
  6. by   babyNP.
    If you read the original article in Nature they actually don't use much heparin at all compared to traditional ECMO and hope to use none in the future. They also don't have a flow rate- it's all passive so as not to overload the heart and go through the umbilical vessels.

    You can talk about guinea pigs...but that's how most things in neonatology get started, like the first runs of ECMO. Of course, the USA actually let the UK run the trials first and decided to do it based off of their results. I suppose if they can offer a better survival rate and better morbidity rate to parents than a traditional 22 or 23 weeker, then your benefits would outweigh the risks. Just imagine if we could grow these babies to 28 weeks- the drastically reduced mortality/morbidity rate effects would be phenomenal.
  7. by   adventure_rn
    Quote from babyNP.
    If you read the original article in Nature they actually don't use much heparin at all compared to traditional ECMO and hope to use none in the future. They also don't have a flow rate- it's all passive so as not to overload the heart and go through the umbilical vessels.
    So mimicking the passive circulation that the fetus experiences in utero? The biomechanics of how that would actually work are way over my head, but it's an awesome concept.

    Quote from babyNP.
    You can talk about guinea pigs...but that's how most things in neonatology get started, like the first runs of ECMO. Of course, the USA actually let the UK run the trials first and decided to do it based off of their results. I suppose if they can offer a better survival rate and better morbidity rate to parents than a traditional 22 or 23 weeker, then your benefits would outweigh the risks. Just imagine if we could grow these babies to 28 weeks- the drastically reduced mortality/morbidity rate effects would be phenomenal.
    I was thinking the same thing. I'm sure that 'back in the day' when our viability cut-off was much later and our current technologies were first being debuted, people probably had similar concerns. I agree that if it works, the benefits could be immense, since we wouldn't really have as many '23-weekers' anymore, as they could be grown to be more like '28-weekers'.

    Still lots of ethical concerns/considerations. Like I said in my first post, I doubt that many parents will consent unless that is their only option, and it would be pretty terrible if the human trials failed catastrophically.

    Quote from Guy in Babyland
    How would this logistically work in humans? Woman goes into preterm labor at 24 weeks, they do a C section and transfer the fetus to the BioBag?
    I was curious to know if there would be any concerns about fetal/neonatal transition occurring during the 'uterus to bag' transfer process. It seems like you'd want to keep PVR high and SVR low in the bag circuit, as in utero, and you could run into issues if the baby began to transition during the transfer. Presumably they figured out a way to get past that barrier in the fetal lamb model, but it does seem like it would present a potential challenge. I know it's possible to keep PDAs open, and for kids to be in PPHN (unintentionally), but is it even possible to medically induce a baby who is in neonatal circulation to revert back to fetal?
  8. by   babyNP.
    I'm curious how the transition works too- but keep in mind that they already do fetal surgery where a baby is practically "born" if they open up the mother's uterus but manage to put the baby back without transition. I wonder if it has something to do with placing the umbilical lines with the passive circuit as soon as they open up the mother to prevent the transition to extrauterine life.
  9. by   ThePrincessBride
    I have actually thought about this, and I do think in twenty years or so, we will start seeing artificial wombs being used in higher level NICUs. Isolettes will be replaced with artificial wombs and nurses will have to be trained on how to use such advanced technology.
  10. by   sergel02
    Something that I find fascinating about NICU (as an oncology nurse) is just how many new treatment modalities are started in NICU. The artificial womb is an interesting concept with of course has some ethical implications. If it could be used to aid premature babies (since we want to keep them in a womb-like environment as much as possible), mature a bit more, it could really do a lot of good for some patients.
  11. by   AnnieOaklyRN
    What do they do if the biobag springs a leak or starts growing microbes?? I'm just wondering if they have a way they can rapidly change the bag while keeping the ECMO part hooked up to the umbilical cord!

    ANnie

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