Pediatric and Adult ECMO: Patient Selection and Management

1
Pediatric and Adult ECMOPatient Selection and
Management

• James D. Fortenberry, MD
• Clinical Director, Pediatric and Adult ECMO
• Childrens Healthcare of Atlanta at Egleston

2
(No Transcript)
3
Number of neonatal and pediatric ECLS treatments
on an annual basis reported to ELSO registry
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
5
Is ECMO of Proven Benefit for Respiratory Failure?

• Neonatal respiratory failure
• PPHN, meconium aspiration CDH
• UK study (Lancet, 1997)
• Proven benefit in regionalized setting

6
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)

7

-Green et al., CCM 1996
8
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 gt 2 weeks on ECMO
  (Green et al., CCM, 1995)
• Lung biopsy not necessarily predictive

9
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

10
Cost/life-year-saved of pediatric extracorporeal
life support (ECLS) with adult therapies
Vats et al. Crit Care Med 1998 261587-1592
11
Pediatric ECMO - Childrens Healthcare of Atlanta
12
Are Pediatric and Adult ECMO Different?

• More alike than different
• Subtle differences in criteria
• Difference in size major difference in
  difficulty of nursing care

13
Adults are just Big Kids
14
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?

15
Diagnoses for Pediatric ECLS
From Registry of the Extracorporeal Life Support
Organization(ELSO, Ann Arbor, MI, USA).
16
ECMO General Indications in Respiratory Failure

• Lung disease that is
• Acute
• Life threatening
• Reversible
• Unresponsive to conventional/alternative therapy

17
ECMO for Pediatric Respiratory Failure
Indications

• Acute, potentially reversible respiratory (and/or
  cardiovascular) disease unresponsive to
  conventional/alternative arrangement
• Oxygenation index gt40 x 2 hours
• Barotrauma
• P/F ratio lt200

18
Oxygenation Index
Mean airway pressure x Fi O2 x 100
OI
PaO2
19
Pediatric and Adult ECMOIndications

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

20
Pediatric and Adult ECLSSelection Criteria

• No
• malignancy
• incurable disease
• contraindication to anticoagulation
• Intubation/ventilation for lt 10 days
• lt 6 days in adult
• Hypercarbic respiratory failure with
• pH lt 7.0, PIP gt 40

21
Adult ECLSSelection Criteria

• Respiratory failure
• shunt gt 30 on an FiO2 of gt 0.6
• compliance lt 0.5 ml/cmH2O/kg
• Severe, life threatening hypoxemia
• Lack of recruitment
• inadequate SpO2/PaO2 response to increasing PEEP

22
ECMO for Pediatric Respiratory Failure
Contraindications

• Unlikely to be reversible in 10-14 days
• Terminal underlying condition
• Mechanical ventilation gt10 days
• Multi-organ failure
• Severe or irreversible brain injury
• Significant pre-ECMO CPR

23
Pediatric and Adult ECLSExclusion Criteria

• Absolute
• contraindication to anticoagulation
• terminal disease
• underlying moderate to severe chronic lung
  disease
• PaO2/FiO2 ratio lt 100 for gt 10 days (gt 5 days in
  adult)
• MODS gt2 organ system failure

24
Pediatric and Adult ECLSExclusion Criteria

• Absolute
• uncontrolled metabolic acidosis
• central nervous system injury/ malfx
• immunosuppression
• chronic myocardial dysfunction

25
Adult ECLSExclusion Criteria

• Relative contraindications
• mechanical ventilation gt 6 days
• septic shock
• severe pulmonary hypertension (MPAP gt 45 or gt 75
  systemic)

26
Adult ECLSExclusion Criteria

• Relative contraindications
• cardiac arrest
• acute, potentially irreversible myocardial
  dysfunction
• gt 35 years of age

27
Differences between Pediatric and Adult ECMO
Criteria

• Mechanical ventilation prior to ECMO pediatric lt
  10 days vs. adult lt 6 days
• Age adult vs. pediatric

28
The key to the success of ECMO may be the time
of initiation

• Plotkin et al., U of M, 1994

29
ECMO InitiationSurgical Team
30
Selection of Technique
VA
VV
vs.
ECMO
31
ECMO

• Veno-venous (VV) vs. Veno-arterial (VA)
• VA
• Provides complete cardiorespiratory support
• Negative impact on afterload

• VV
• Preferred mode
• Dont sacrifice artery
• Oxygenates blood to heart

32
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

33
Use of VV and VV ECMO Egleston Pediatric
Experience
34
Equipment
35
(No Transcript)
36
(No Transcript)
37
Size of Circuit Components Based on Patient Weight
1 Two oxygenators necessary in parallel or in
series 2 Minimal sizes of cannulas
38
Pediatric and Adult ECLSCannulation

• Cannulation frequently rocky
• Code drugs to bedside
• Patient on specialty bed
• Cannulation orders
• Heparin bolus available

39
Pediatric and Adult ECLSVenovenous 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

40
Pediatric and Adult ECLSVeno-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

41
Pediatric ECMO Management Pulmonary

• Basic goals
• decrease further lung damage
• reduce oxygen toxicity
• lung rest

42
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!

43
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

44
Pediatric ECMO Management Pulmonary

• Tolerate pCO2 55-65, SpO2 gt 88
• Time of rest depends on process
• 3-5 days minimum for ARDS
• Resolution of air leak (48-72 hours)
• Suctioning PRN
• Avoid bagging

45
Pediatric ECMO Management Pulmonary

• Pulmonary hygiene
• Daily chest radiographs-may signal recovery
• Re-recruitment
• Bronchoscopy may be beneficial
• May come off on HFOV

46
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

47
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

48
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

49
Surgeons give fluidIntensivists give Lasix(or
use CVVH)
50
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)

51
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

52
Pediatric ECMO Management Hematologic

• Maintain Hb/Hct gt 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

53
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

54
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

55
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

56
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

57
(No Transcript)
58
Questions??