management of infants requiring venovenous ecmo sixto f. guiang, iii dept. of pediatrics university...
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Management of Infants requiring Venovenous ECMO
Sixto F. Guiang, III
Dept. of Pediatrics
University of Minnesota
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Neonatal ECMO = 73 % of all ECMO
VV ECMO = 20% of all Neonatal Pulmonary
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University of MichiganJAMA 2000;283:904-908
N= 1000 Newborns N=586 Survival 88% MAS 98% CDH 68% Others 84-93% 90% veno-venous 9% IVH
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VV ECMO Respiratory Mode for all ages
Infants 20% of all Respiratory ECMO Approximately 800 cases / yr
Pediatric 28% of all Respiratory ECMO Approximately 200 cases / yr
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Pediatric VV ECMO Pediatr Crit Care Med 2003;4:291-298 Single Center 1991-2002 N = 82 ECMO for Respiratory Failure
Venovenous 83% Venoarterial 17%
Unable to place VV 43%
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Pediatric VV ECMO Venovenous
Dx ARDS RSV bronchiolitis Penumonia
Outcomes Lower degree of respiratory failure Shorter ECMO (212 hour vs 350 hours) Higher survival (81% vs. 64%)
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Pediatric VV ECMO
Pediatr Crit Care Med 2003;4:291-298
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Infusion limb
Drainage limb
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Inclusion / Exclusion Guidelines- Same as VA age of at least 34 weeks Weight >1.5-2.0 kg Potentially reversible process Absence of uncorrectable cardiac defect Absence of major intracranial hemorrhage Absence of uncorrectable coagulopathy Absence of lethal anomaly Absence of prolonged mechanical ventilation with
high ventilatory settings
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Oxygenation FailureCriteria - VA and VV Alveolar - arterial oxygen tension gradient
[760 - 47)-paCO2] - paO2 605 - 620 torr for greater than 4-12 hours
Oxygenation index Mean Airway Pressure x FiO2 x 100/ paO2 > 35-60 for greater than 1-6 hours
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Oxygenation FailureCriteria - VA and VV paO2
PaO2 < 35 for 2 hours paO2 < 50 for 12 hours
Acute decompensation paO2 < 30 torr
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Myocardial Failure - VA Only Refractory hypotension
Low cardiac output
pH <7.25 for 2 hours or greater
Uncontrolled metabolic acidosis secondary to hemodynamic insufficiency
Cardiac arrest - CPR
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Additional Exclusion Criteria - Venovenous ECMO Severe LV dysfunction Severe hypotension Cannulation during CPR
Desire to not have heparin Bleeding
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Additional Exclusion Criteria - Venovenous ECMO
Use of vasopressors is NOT a contraindication for VV ECMO
Isolated RV failure is NOT a contraindication for VV ECMO
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Vasopresor - VV ECMO ASAIO Journal 2003;49:568-571 Neonatal ECMO-VA and VV N = 43 Quantified inotropic support - Index 1 point = 1mcg/kgmin
Dopamine Dobutamine
1 point = 0.01 mcg/kg/mon Epinephrine Norepinephrine
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ASAIO Journal 2003;49:568-571
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ASAIO Journal 2003;49:568-571
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ASAIO Journal 2003;49:568-571
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Infants with Inotropic Score > 10
ASAIO Journal 2003;49:568-571
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ECMO Goals - VA and VV Maintain adequate tissue oxygenation to
allow recovery from short term cardiopulmonary failure
Adjust ventilator settings allowing for Lung Rest minimizing further ventilator /oxygen induced lung injury. Not necessarily lower settings
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ECMO Modes Venoarterial - VA
Blood drains-venous system Blood returns-arterial system Complete cardiopulmonary support
Venovenous - VV Blood drains-venous system Blood returns-venous system Pulmonary support only
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Advantages of VA ECMO Able to give full cardiopulmonary support
No mixing of arterial / venous blood
Good oxygenation at low ECMO flows
Allows for total lung rest
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Disadvantages of VA ECMO Ligation of the right carotid artery
Nonpulsatile arterial blood flow
Suboptimal conditions for LV function Low preload High afterload High wall stress Low coronary oxygenation
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Disadvantages of VA ECMO
Systemic emboli Air thrombus
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Advantages of VV ECMO No ligation of carotid artery
Normal pulsatile blood flow
Optimize LV performance More preload Less afterload Better coronary oxygenation Less ventricular wall stress
No systemic emboli
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Disadvantages of VV ECMO Need a functioning LV Mixing of blood lower arterial
saturation Need increased ECMO flow Need higher hemoglobin
Need to place a larger cannula More difficulty monitoring adequacy of
oxygen delivery Recirculation of ECMO flow
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Disadvantages of VV ECMO May need to convert to VA
Need to be fully heparinized Cannula cannot be heparin bonded
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VV ECMO -Double lumen Newborns
>90% of VV ECMO - Double lumen 12F and 15F OriGen
Pediatric 35% of VV ECMO -double lumen
18F - largest OriGen cannula 65% internal jugular, femoral, sapphenous
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VV ECMO -Double lumen
Cannula site
Internal jugular vein (15F double lumen- preferred)
Cannula tip low in the right atrium
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Drainage
Endhole
High lateral RA
Low lateral RA
Infusion
Mid Medial RA
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Optimal Cannula Placement Adequate size Correct depth
Low Right Atrium Correct Rotation
Label visible Drainage limb (Blue) posterior Infusion limb (Red) anterior Vertical orientation Head - midline
No Kinks
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Recirculation Oxygenated ECMO blood returning to
the ECMO circuit immediately after infusion
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Recirculation factors Head /cannula position
Changes with head rotation Changes in lung volume / relative position of the
heart and cannula
ECMO flow
Right atrial size / intravascular volume
RV contractility
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ECMO Flow reads 200
ECMO blood flow to baby - 160
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ECMO Flow reads 500
ECMO blood flow to baby - 250
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ECMO Flow -Recirculation More ECMO flow will always increase
recirculation
More ECMO flow may either Increase blood flow to baby Decrease blood flow to baby
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VA ECMO ECMO flow rate is proportional to the level of
support
More flow More support Always advantageous if more flow is possible More ECMO flow will always increase SvO2
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Pulmonary Support - VV Net ECMO blood flow of infant = measure
ECMO flow - recirculation flow
ECMO flow (flow probe) DOES NOT indicate level of support
SvO2 DOES NOT reflect level of systemic oxygen delivery
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Circulatory Support Net flow to baby assessed by
Infant color Infant arterial saturation and PaO2
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Assessment of Recirculation More recirculation if
Decreasing baby arterial sat or PaO2 Increasing SvO2 on ECMO circuit Decreasing color difference on drainage
and infusion limbs of circuit
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Reducing Recirculation Adjusting relative cannula position
Head position Lung inflation
Decrease ECMO flow Increase intravascular volume Increase RV contractility
Volume Vasopressors Pulmonary vasodilators
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VV - VA Conversion Needed if 10-15% of cases
Hemodynamic support is inadequate Respiratory support is inadequate
More problematic when ultrafiltration is used
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VV ECMO - Specific Issues ECMO Prime
Must have added heparin Must have Ca added Ionized Ca on circuit must be
checked prior to cannulation Potassium must be checked
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Heparin If no heparin added
Addition of Ca binds citrate of blood products
Loss of anticoagulant activity Acute clotting of the entire circuit Need to prime another circuit
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Calcium If no calcium added
Acute hypocalcemia - Ca binds to citrate of blood products
Loss of LV and RV contractility Acute hypotension Cardiac arrest
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Potasium If potassium in prime is not checked
Possible higher serum K from the stored PRBC
Acute hyperkalemia Arrythmia Cardiac arrest
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Head / Cannula Position Distal tip low in RA Head in the midline with vertical orientation of
the drainage and infusion limbs RA drainage ports
Lateral Infusion ports
Medial
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Keys to Management
VV ECMO- DL Need to think in terms of NET blood flow
to the baby Cannot quantify NET flow SvO2 is not indicative of adequacy of
systemic oxygen delivery Indirectly assessed with SaO2 and
PaO2 on the infant
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To Improve oxygenation Give PRBC Increase ECMO flow Decrease recirculation
Check cannula position Increase ntravascular volume Increase RV contractility
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Rest Ventilator Settings Pressures - similar to VA FiO2 - able to wean to RA frequently
Better myocardial oxygenation via ECMO flow than VA
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Jugular venous drainage 11% of all double lumen VV Small study suggested decrease IVH
Reduced cerebral venous pressure Advantage
Additional drainage facilities flow 2 site venous drainage lessens recirculation
on VV ECMO Improved oxygen delivery Enables venous oxygen saturation monitoring
on VV ECMO
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Jugular Venous DrainageCephalad Cannula J Pediatr Surg 2004;39:672-676 Review of ELSO database Neonatal Respiratory Failure VV ECMO
1989-2001 N = 2471
96% VV double lumem alone 3.7% with jugular venous drainage
Similar Outcomes
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Operating Parameters SaO2 - 85-95% PaO2 40-65 torr Blood pressure - similar to VA ECMO flows - 130-150+ ml/kg/min HgB 12-15 g/dl
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Weaning of ECMO - VV No clamp out needed Increase ventilator Decrease sweep gas flow rate and FiO2 Sweep gas flow can be completely stopped
SvO2 will reflect mixed venous saturation No recirculation
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GasGasFlowFlow
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NO GasNO GasFlowFlow
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VV ECMO Outcomes Generally slightly better than VA, but
slightly different patient populations Hemodynamically more stable Less exposure to CPR Better survival Shorter duration of ECMO Conversion VV to VA
12%
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VA - VV Comparison studies J Peds Surg1993;28:530-536 Multicenter data N=243
VA = 135 VV = 108
Similar survival 10% conversion to VA Shorter runs Less Neurologic complications