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Pediatric and Adult ECMO: Patient Selection and Management

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. Number of neonatal and pediatric ECLS treatments on an annual basis reported to ELSO registry.

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Pediatric and Adult ECMO: Patient Selection and Management

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  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. Number of neonatal and pediatric ECLS treatments on an annual basis reported to ELSO registry

  3. 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. Is ECMO of Proven Benefit for Respiratory Failure? • Neonatal respiratory failure • PPHN, meconium aspiration; CDH • UK study (Lancet, 1997) • Proven benefit in regionalized setting

  5. 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)

  6. * -Green et al., CCM 1996

  7. 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

  8. 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

  9. Cost/life-year-saved of pediatric extracorporeal life support (ECLS) with adult therapies Vats et al. Crit Care Med 1998; 26:1587-1592

  10. Pediatric ECMO - Children’s Healthcare of Atlanta

  11. Are Pediatric and Adult ECMO Different? • More alike than different • Subtle differences in criteria • Difference in size = major difference in difficulty of nursing care

  12. Adults are just Big Kids

  13. 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?

  14. Diagnoses for Pediatric ECLS From: Registry of the Extracorporeal Life Support Organization(ELSO, Ann Arbor, MI, USA).

  15. ECMO: General Indications in Respiratory Failure • Lung disease that is: • Acute • Life threatening • Reversible • Unresponsive to conventional/alternative therapy

  16. 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

  17. Oxygenation Index Mean airway pressure x Fi O2 x 100 OI= PaO2

  18. Pediatric and Adult ECMOIndications • Lung disease that is: • acute • life threatening • reversible • unresponsive to conventional therapy

  19. 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

  20. 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

  21. 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

  22. 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

  23. Pediatric and Adult ECLSExclusion Criteria • Absolute: • uncontrolled metabolic acidosis • central nervous system injury/ malfx • immunosuppression • chronic myocardial dysfunction

  24. Adult ECLSExclusion Criteria • Relative contraindications: • mechanical ventilation > 6 days • septic shock • severe pulmonary hypertension (MPAP > 45 or > 75% systemic)

  25. Adult ECLSExclusion Criteria • Relative contraindications: • cardiac arrest • acute, potentially irreversible myocardial dysfunction • > 35 years of age

  26. Differences between Pediatric and Adult ECMO Criteria • Mechanical ventilation prior to ECMO; pediatric < 10 days vs. adult < 6 days • Age: adult vs. pediatric

  27. “The key to the success of ECMO may be the time of initiation” Plotkin et al., U of M, 1994

  28. ECMOInitiationSurgical Team

  29. Selection of Technique VA VV vs. ECMO

  30. 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

  31. 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

  32. Use of VV and VV ECMO: Egleston Pediatric Experience

  33. Equipment

  34. Size of Circuit Components Based on Patient Weight 1 Two oxygenators necessary in parallel or in series 2 Minimal sizes of cannulas

  35. Pediatric and Adult ECLS:Cannulation • Cannulation frequently rocky • Code drugs to bedside • Patient on specialty bed • Cannulation orders • Heparin bolus available

  36. 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

  37. 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

  38. Pediatric ECMO Management: Pulmonary • Basic goals: • decrease further lung damage • reduce oxygen toxicity • “lung rest”

  39. 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!

  40. 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

  41. 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

  42. Pediatric ECMO Management: Pulmonary • Pulmonary hygiene • Daily chest radiographs-may signal recovery • Re-recruitment • Bronchoscopy may be beneficial • May come off on HFOV

  43. 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

  44. 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

  45. 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

  46. Surgeons give fluidIntensivists give Lasix(or use CVVH)

  47. 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)

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