adult ecmo

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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Neonatal

Pediatric

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)

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100M

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lity

<25% 25- 50% 50- 75% >75%

Mortality Risk Group

ECMO patients

Non- ECMO patients

-Green et al., CCM 1996

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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

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Pediatric ECLS Liver

Transplant

Bone Marrow

Transplant

Heart

Transplant

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

Diagnosis Number Survival % ELSO Survival %

ARDS 14 71 51

Bacterial Pneumonia 33 85 79

Viral Pneumonia 7 86 53

Trauma 3 100 63

Burns 4 75 52

Total 74 77% 62%

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 ECMOBasic 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?

Other

40%

bacterial pneumonia

9%

viral pneumonia

30%

intrapulmonary hemorrhage

1%

aspiration

8%

ARDS

11%pneumocystis

1%

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 Fi O2 x 100

PaO2

Pediatric and Adult ECMOIndications

• Lung disease that is: acute life threatening reversible unresponsive to conventional

therapy

Pediatric and Adult ECLSSelection 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 ECLSSelection Criteria

• Respiratory failure shunt > 30% on an FiO2 of > 0.6 compliance < 0.5 ml/cmH2O/kg

• Severe, life threatening hypoxemia

• Lack of recruitment inadequate SpO2/PaO2 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 ECLSExclusion Criteria

• Absolute: contraindication to anticoagulation terminal disease underlying moderate to severe

chronic lung disease PaO2/FiO2 ratio < 100 for > 10 days

(> 5 days in adult) MODS: >2 organ system failure

Pediatric and Adult ECLSExclusion Criteria

• Absolute: uncontrolled metabolic acidosis central nervous system injury/

malfx immunosuppression chronic myocardial dysfunction

Adult ECLSExclusion Criteria

• Relative contraindications: mechanical ventilation > 6 days septic shock severe pulmonary hypertension

(MPAP > 45 or > 75% systemic)

Adult ECLSExclusion 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 InitiationSurgical Team

VAVA

ECMOECMO

VVVVvs.

Selection of TechniqueSelection 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

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VV ECMOVA ECMO

Equipment

Size of Circuit Components Based on Patient Weight

Weight (kg) 2–8 8–12 12- 20 20- 30 >30

Tubing size 1/ 4” 3/ 8” 3/ 8” 3/ 8” 1/ 2”

Race way tubing 1/ 4” 3/ 8” 3/ 8” 3/ 8” 1/ 2”

Bladder 1/ 4” 3/ 8” 3/ 8” 3/ 8” 3/ 8”

Oxygenator (sqm) 0.8 1.5 2.5 3.5 4.51

Venous cannula2 10-14 16 18 20 22

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 ELSApproach 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??