Transcript Pediatric and Adult ECMO Talk

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
1600
Neonatal
1400
Pediatric
1200
1000
800
600
400
Number of neonatal and pediatric ECLS
treatments on an annual basis reported to
ELSO registry
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
0
> 1986
200
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)
Mortality
100
90
80
70
60
50
40
30
20
10
0
ECMO patients
Non-ECMO patients
*
<25%
25-50% 50-75%
>75%
Mortality Risk Group
-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
Thousands of Dollars/Life-Year
70
62.5
60
50
43.5
40
26.9
30
20
10
4.19
0
Pediatric ECLS
Liver
Bone Marrow
Heart
Transplant
Transplant
Transplant
Cost/life-year-saved of pediatric extracorporeal life support
(ECLS) with adult therapies
Vats et al.
Crit Care Med 1998;
26:1587-1592
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
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
pneumocystis
1%
ARDS
11%
aspiration
8%
Other
intrapulmonary hemorrhage
40%
1%
viral pneumonia
30%
From: Registry of the Extracorporeal
Life Support Organization(ELSO, Ann
Arbor, MI, USA).
bacterial pneumonia
9%
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 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 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 ECLS
Exclusion 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 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
Selection of Technique
VA
vs.
ECMO
VV
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 afterload, improved coronary oxygenation
• Patient safety: emboli
Use of VV and VV ECMO: Egleston
Pediatric Experience
14
Number of patients
12
10
VV ECMO
VA ECMO
8
6
4
2
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
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
10-14
16
18
20
22
Venous cannula2
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) 180200; 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??