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Pediatric and adult ecmo talk
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Pediatric and adult ecmo talk

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  • Avoiding carotid cannulation and ligation Cannulating only one vessel Possible percutaneous access RV preload and LV afterload myocardial efficiency LV wall distension myocardial oxygen consumption Coronary O 2 delivery Air and other emboli filtered by lungs

Pediatric and adult ecmo talk Pediatric and adult ecmo talk Presentation Transcript

  • Pediatric and Adult ECMO: Patient Selection and Management James D. Fortenberry, MD Clinical Director, Pediatric and Adult ECMO Children’s Healthcare of Atlanta at Egleston
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  • Number of neonatal and pediatric ECLS treatments on an annual basis reported to ELSO registry
  • All who drink of this treatment recover within a short time, except in those who do not. Therefore, it fails only in incurable cases -Galen
  • Is ECMO of Proven Benefit for Respiratory Failure?
    • Neonatal respiratory failure
      • PPHN, meconium aspiration; CDH
      • UK study (Lancet, 1997)
      • Proven benefit in regionalized setting
  • Is ECMO of Proven Benefit in Respiratory Failure?
    • Children
      • No good prospective study
      • Retrospective data: benefit in higher risk (not moribund) patients with respiratory failure
      • ECMO decreased mortality from 47.2 to 26.4% (331 pts.-Green et al., CCM, 1996)
  • -Green et al., CCM 1996 *
  • Outcome in Pediatric ECMO: Predictors of Survival
    • Younger age (23 vs. 49 months)
    • Ventilator days pre-ECMO (5.1 vs. 7.3)
    • Lower PIP, lower A-a gradient (Moler et al., CCM, 1993)
    • No difference in survival if > 2 weeks on ECMO (Green et al., CCM, 1995)
    • Lung biopsy not necessarily predictive
  • Is ECMO of Proven Benefit in Adult Respiratory Failure?
    • Adult ELS NIH study: 1971
      • 90% mortality: no benefit with VA ECMO in moribund patients
    • Gattinoni-nonrandomized experience
      • 49% survival
    • Corroboration at other centers-U. of Michigan
    • Morris-AJRCCM 1992 (Utah)
      • No statistically significant survival benefit of ECMO vs. computerized vent management protocol
  • Vats et al. Crit Care Med 1998; 26:1587-1592 Cost/life-year-saved of pediatric extracorporeal life support (ECLS) with adult therapies
  • Pediatric ECMO - Children’s Healthcare of Atlanta
  • Are Pediatric and Adult ECMO Different?
    • More alike than different
    • Subtle differences in criteria
    • Difference in size = major difference in difficulty of nursing care
  • Adults are just Big Kids
  • Patient Selection for Pediatric/Adult ECMO Basic Principles
    • Is the pulmonary/cardiac disease life threatening?
    • Is the disease likely reversible?
    • Are other diseases relative to prognosis?
    • Is ECMO more likely to help than hurt?
    • Is preoperative support warranted??
    • VA or VV?
  • Diagnoses for Pediatric ECLS From: Registry of the Extracorporeal Life Support Organization(ELSO, Ann Arbor, MI, USA).
  • ECMO: General Indications in Respiratory Failure
    • Lung disease that is:
      • Acute
      • Life threatening
      • Reversible
      • Unresponsive to conventional/alternative therapy
  • ECMO for Pediatric Respiratory Failure: Indications
    • Acute, potentially reversible respiratory (and/or cardiovascular) disease unresponsive to conventional/alternative arrangement
    • Oxygenation index >40 x 2 hours
    • Barotrauma
    • P/F ratio <200
  • Oxygenation Index OI= Mean airway pressure x F i O 2 x 100 PaO 2
  • Pediatric and Adult ECMO Indications
    • Lung disease that is:
      • acute
      • life threatening
      • reversible
      • unresponsive to conventional therapy
  • Pediatric and Adult ECLS Selection Criteria
    • No
      • malignancy
      • incurable disease
      • contraindication to anticoagulation
    • Intubation/ventilation for < 10 days;
    • < 6 days in adult
    • Hypercarbic respiratory failure with:
      • pH < 7.0, PIP > 40
  • Adult ECLS Selection Criteria
    • Respiratory failure
      • shunt > 30% on an FiO 2 of > 0.6
      • compliance < 0.5 ml/cmH 2 O/kg
    • Severe, life threatening hypoxemia
    • Lack of recruitment
      • inadequate SpO 2 /PaO 2 response to increasing PEEP
  • ECMO for Pediatric Respiratory Failure: Contraindications
    • Unlikely to be reversible in 10-14 days
    • Terminal underlying condition
    • Mechanical ventilation > 10 days
    • Multi-organ failure
    • Severe or irreversible brain injury
    • Significant pre-ECMO CPR
  • Pediatric and Adult ECLS Exclusion Criteria
    • Absolute:
      • contraindication to anticoagulation
      • terminal disease
      • underlying moderate to severe chronic lung disease
      • PaO 2 /FiO 2 ratio < 100 for > 10 days (> 5 days in adult)
      • MODS: >2 organ system failure
  • Pediatric and Adult ECLS Exclusion Criteria
    • Absolute:
      • uncontrolled metabolic acidosis
      • central nervous system injury/ malfx
      • immunosuppression
      • chronic myocardial dysfunction
  • Adult ECLS Exclusion Criteria
    • Relative contraindications:
      • mechanical ventilation > 6 days
      • septic shock
      • severe pulmonary hypertension (MPAP > 45 or > 75% systemic)
  • Adult ECLS Exclusion Criteria
    • Relative contraindications:
      • cardiac arrest
      • acute, potentially irreversible myocardial dysfunction
      • > 35 years of age
  • Differences between Pediatric and Adult ECMO Criteria
    • Mechanical ventilation prior to ECMO; pediatric < 10 days vs. adult < 6 days
    • Age: adult vs. pediatric
  • “ The key to the success of ECMO may be the time of initiation” Plotkin et al., U of M, 1994
  • ECMO Initiation Surgical Team
  • VA ECMO VV vs. Selection of Technique
  • ECMO
    • Veno-venous (VV) vs. Veno-arterial (VA)
    • VA
      • Provides complete cardiorespiratory support
      • Negative impact on afterload
    • VV
      • Preferred mode
      • Don’t sacrifice artery
      • Oxygenates blood to heart
  • Why VV Might Be Better Than VA
    • Cannulation: ease
    • Effect on pulmonary blood flow: improved oxygenation
    • Cardiac effects: decreased LV after-load, improved coronary oxygenation
    • Patient safety: emboli
  • Use of VV and VV ECMO: Egleston Pediatric Experience
  • Equipment
  •  
  •  
  • Size of Circuit Components Based on Patient Weight 1 Two oxygenators necessary in parallel or in series 2 Minimal sizes of cannulas
  • Pediatric and Adult ECLS: Cannulation
    • Cannulation frequently rocky
    • Code drugs to bedside
    • Patient on specialty bed
    • Cannulation orders
    • Heparin bolus available
  • Pediatric and Adult ECLS: Venovenous cannulation
    • Dual cannulae: usually drain from right atrium via RIJ, return to femoral vein +/- cephalad cannula
    • Double lumen cannula: 12-18F in RIJ for smaller children
    • Cutdown vs. percutaneous
    • Blood vs. saline prime
  • Pediatric and Adult ECLS: Veno-arterial cannulation
    • Usually for cardiac ECMO
    • May convert VV to VA ECMO
    • Cannulae: Venous drain-RIJ to right atrium; arterial-usually common carotid to aorta
  • Pediatric ECMO Management: Pulmonary
    • Basic goals:
            • decrease further lung damage
            • reduce oxygen toxicity
            • “ lung rest”
  • Pediatric and Adult ELS Approach to the Patient
    • Fluids/nutrition: Feed ‘em!
    • Sedation/analgesia: Snow ‘em!
    • Antibiotics: Hold ‘em!
    • Invasive procedures: Bronch ‘em!
    • Weaning: Wean ‘em!
    • Decannulation: Cap ‘em!
    • Post-ECMO: Rehab ‘em!
  • Pediatric ECMO Management: Pulmonary
    • Optimal ventilator settings vary
    • Limit peak pressures to 30 cm H2O
    • Delivered tidal volumes 4-6 cc/kg
    • Rate 5-10 breaths/minute
    • PEEP 12-15 cm H2O
    • Inspiratory time longer
    • Goal FiO2 0.21
  • Pediatric ECMO Management: Pulmonary
    • Tolerate pCO2 55-65, SpO2 > 88%
    • Time of “rest” depends on process
    • 3-5 days minimum for ARDS
    • Resolution of air leak (48-72 hours)
    • Suctioning PRN
    • Avoid bagging
  • Pediatric ECMO Management: Pulmonary
    • Pulmonary hygiene
    • Daily chest radiographs-may signal recovery
    • Re-recruitment
    • Bronchoscopy may be beneficial
    • May come off on HFOV
  • Pediatric ECMO Management: Flow
    • Infants: 120-150 cc/kg/min
    • Children: 100-120 cc/kg/min
    • Adults: 70-80 cc/kg/min
    • Attempt to reach maximal flow early in run to determine buffer
  • Pediatric ECMO Management: Cardiovascular
    • VA ECMO generally required with cardiac failure
    • VV ECMO may improve cardiac function
    • Usually able to wean pressors
    • Milranone can be beneficial
    • Hypertension common in VV ECMO (69%)-try ACE inhibitors
  • Pediatric ECMO Management: CNS
    • Increased Vd, surface interaction, altered renal blood flow, CVVH
    • Morphine used due to oxygenator uptake of fentanyl; tolerance
    • Lorazepam, midazolam
    • NMB usually required in ped/adults-use pavulon, take holidays, watch with steroids
  • Surgeons give fluid Intensivists give Lasix (or use CVVH)
  • Pediatric ECMO Management: Fluids/Renal
    • Tendency to capillary leak
    • Oliguria often associated and worsened on ECMO
    • May be recalcitrant to Lasix
    • CVVH: helpful adjunct; simple inline in circuit; Renal consult
    • CVVH does not worsen outcome (Bunchman et al., PCCM 2001)
  • Pediatric ECMO Management: GI
    • Decreased catabolism = decreased infection
    • Enteral nutrition preferred: improved calories, decreased cost, similar complications (Pettignano, et,al, CCM, 1997)
    • Can give intragastric or transpyloric
    • Aggressive bowel regimens
  • Pediatric ECMO Management: Hematologic
    • Maintain Hb/Hct > 13/40
    • Hemolysis-monitor with serum free Hgb
    • Platelet consumption common-keep greater than 100,000
    • Activated clotting time (ACT) 180-200; 160-180 if expect significant bleeding
  • Pediatric ECMO Management: Hematologic
    • Amicar-inhibits fibrinolysis; can enhance hemostasis in high risk cases, post-op
    • Loading dose 100 mg/kg, infusion 20-30 mg/kg/hour for no more than 96 hours
    • Aprotinin for active bleeding-generally avoid due to clot risk
  • Pediatric ECMO Management: Infectious
    • Routine antibiotic coverage not practiced
    • Strict asepsis during run
    • Need to have low index of suspicion for super-infection; may be difficult to assess
  • Adult ECMO Management: Specific Issues
    • ACLS requirements
    • Consultation: Adult Pulmonary, Ob/Gyn, Infectious Disease
    • Commitment to rapid return to referring institution post-ECMO
    • Age limits
  • ECMO Weaning and Decannulation
    • Improvement: diuresis, CXR improvement, lung compliance
    • Weaning of flow to 50 cc/kg/min
    • VV: “capping” - continue circuit flow with gas supply d/ced
    • Surgery decannulates
    • Issues of termination
  •  
  • Questions??