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

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

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