Title: Use of CRRT in ECMO: Is It Valuable
1Use of CRRT in ECMO Is It Valuable?
- James D. Fortenberry MD, FCCM, FAAP
- Associate Professor of Pediatrics
- Emory University School of Medicine
- Director, Critical Care Medicine and
- Pediatric ECMO/Advanced Technologies
- Childrens Healthcare of Atlanta at Egleston
2CRRT and ECMO
- What are potential benefits?
- What is the experience?
- How do you do it?
- What are the risks?
- What more do we need to know?
3CRRT on ECMO Potential Benefits
- Management of fluid balance
- Decreasing fluid overload
- Removal of inflammatory mediators
- Enhanced nutritional support
- Control of electrolyte abnormalities
- Decreased use of furosemide
4Is Fluid Overload Bad?
- Remember fluid is good in resuscitation!
- Early goal directed therapy outcome benefits
- However, multiple studies (adults, pediatric)
suggest survival benefit with decreased fluid
overload in critical illness
5Fluid Overload
- Texas Childrens Hospital
- 21 pediatric ARF patients
- Survival benefit remains even after adjusted for
PRISM scores
Percent Fluid Overload
Goldstein SL, et al Pediatrics 1071309-1312,
2001
6Fluid Overload
- Childrens Healthcare of Atlanta at Egleston
- 113 pediatric patients on CVVH
- Multivariate analysis
- Percent fluid overload independently associated
with survival in 3 organ MODS
Percent Fluid Overload
-Foland JA, Fortenberry et al. Crit Care Med,
2004
7Fluid Overload Decreased in 3 Organ MODS CRRT
Survivors
-Foland JA et al. Crit Care Med, 2004
8Fluid Overload and ECMO Neonates
- As weight gain decreases, ECMO flow decreases ?
which comes first? - As weight reduces, ECMO flow reduces
-Kelley RE, et al. J Pediatr Surg, 1991
9Fluid Overload and Outcome
- Seattle Childrens Hospital
- 77 pediatric patients
- If pre-CRRT percent fluid overload gt10
- 3.02 times greater risk of mortality (95 CI
1.5-6.1, p0.002)
Gillespie RS, et al. Pediatr Nephrol
191394-1399, 2004
10Fluid Overload/Oliguria is Common on ECMO
- Children's Healthcare of Atlanta
- 30 consecutive neonates meeting ECMO criteria
- 18 VV ECMO, 12 conventional management
- Patients who went onto ECMO had
- Greater fluid overload
- Lower UOP
- Higher BUN
- Higher creatinine
-Roy BJ, Pediatrics 1995
11ECMO and Urine Output
-Roy BJ, Pediatrics 1995
12Requisite Bad Humour Slide
Blood
Phlegm
Black Bile
Yellow Bile
13Good Humours
14(No Transcript)
15Hemofiltration Cytokine Clearance
- Childrens Healthcare of Atlanta at Egleston
- 6 pediatric patients with culture proven
bacterial septic shock and ARF - 2 on ECMO
- Compared to 3 ARF patients without septic shock
- 1 on ECMO
-Paden M et al., submitted 2008
16Absolute cytokine changes in septic shock/ARF
patients
p0.04
plt0.02
Log Concentration (pg/ml)
-Paden et al., submitted 2008
17CVVH Associated With Decreased Cytokines in
Children with Septic Shock
plt0.05
Septic ARF Patients
Non-septic ARF Patients
-Paden et al., submitted 2008
18Cytokine Results Sample CVVH Patient-Nonseptic
Note Scale
24 Hours off CVVH
End of CVVH
12 Hours
24 Hours
Pre-CVVH
48 Hours
19Cytokine Results in Sample CVVH Patient Septic
24 Hours off CVVH
End of CVVH
24 Hours
12 Hours
48 Hours
Pre-CVVH
20ECMO/CVVH Produces Cytokine Reduction
- In vitro study
- Increased cytokine levels overall due to ECMO
membrane activation - Adding a hemofiltration circuit significantly
reduced - IL-1beta
- IL-1ra
- IL-6
- IL-8
-Skogby M, et al. Scand Cardiovasc J. 2000
21IL 8 Reduction with CRRT in ECMO
Skogby M, et al. Scand Cardiovasc J. 2000
Jun34(3)315-20
22Is Avoiding Lasix Overuse Important?
- Potential ototoxicity-particularly in neonates
- Lasix use associated with worsened outcomes in
adult renal failure
23Diuretics and Critical Illness
- 4 University of California Hospitals
- 552 adults
- Use of diuretics increased risk of death or renal
non-recovery in adults with ARF - Overall 1.77 times greater risk
-Mehta RL, et al. JAMA 2002
24CRRT and ECMO
- What are potential benefits?
- What is the experience?
- How do you do it?
- What are the risks?
- What more do we need to know?
25CRRT on ECMO Published Experience with Use
- Michigan
- PICU
- Cardiac surgery
- Vanderbilt
- Atlanta
- Chile
26CRRT/ECMO Experience Michigan
- U of M ECMO Database
- 35 neonatal and pediatric patients who received
ECMO hemofiltration - 15 Survivors
- Renal recovery in 14 of 15 (93) survivors
- One had Wegeners as underlying cause of renal
failure-subsequently transplanted
-Meyer RJ, et al Pediatr Crit Care Med 2001
27CRRT/ECMO Experience Cardiac Surgery
- University of Michigan
- 74 post-operative congenital heart disease
patients - Use of hemofiltration in 35
- 5.01 times increased risk of death
- Use of hemofiltration indicative of longer ECMO
support time ? worse outcome was from duration,
not hemofiltration
-Kolovos et al. Ann Thorac Surg 2003
28CRRT/ECMO Experience Cardiac Surgery
- Vanderbilt University
- 84 post-operative congenital heart disease
patients - Temporary renal insufficiency in 41 patients
(48.9) - CVVH NOT associated with
- Ability to wean off ECMO
- Survival to discharge
-Shah SA et al. ASAIO J 2005
29ECMO/CVVH Experience Atlanta
- Childrens at Egleston ECMO Database
(11/97-12/05) - 95 neonatal and pediatric patients who received
ECMO CVVH - 55 survivors
- 14 came off ECMO on RRT (1 on prior to ECMO)
- 1 needed RRT chronically
- 1 with CRF but does not need RRT
- Renal recovery in 53/55 (96) survivors
- Both CRF patients had primary vasculitis
-Paden et al., CCM 2007 (abstr)
30Comparison of CVVH/ECMO vs. ECMO without CVVH
- 26/86 peds respiratory failure patients received
CVVH for gt24 hours - Case control comparison 26 CVVH/ECMO pts. and 26
pts. receiving ECMO without CVVH - No difference in survival or vent days during or
after ECMO - Significant differences in fluid balance
- Significant treatment differences
-Hoover et al., Intensive Care Medicine, in press
2008
31Fluid Balance With CVVH/ECMO vs. No CVVH/ECMO
-Hoover et al., Intensive Care Medicine, in press
2008
32Comparison of CVVH/ECMO vs. ECMO without CVVH
-Hoover et al., Intensive Care Medicine, in press
2008
33CRRT/ECMO Experience in Infants Chile
- 6 of 12 infants on ECMO received CRRT
- Observed complication excessive ultrafiltration
- Survival to discharge in 5 of 6 (83)
- All with normal renal function at discharge
-Cavagnaro et al., Int J Artif Organs 2007
34CRRT and ECMO
- What are potential benefits?
- What is the experience?
- How do you do it?
- What are the risks?
- What more do we need to know?
35CRRT on ECMO How to Perform It
- Options
- Parallel use of stand-alone CRRT devices (Gambro,
Braun) - Pros
- Cons
- Use of inline hemofilter with syringe pumps
- Pros
- Cons
36ECMO/CRRT Arrangement The Michigan Method
37Use of Standard CRRT Devices for Delivery on ECMO
38CRRT and ECMO
- What are potential benefits?
- What is the experience?
- How do you do it?
- What are the risks?
- What more do we need to know?
39CVVH/ECMO Are There Risks?
- Complexity of machinery
- Errors due to replacement fluids
- Underestimation of fluid removal
40Sometimes it gets a little crowded
41CRRT Error Rate Increases with Increasing
Flow/Pressure
-Sucosky, Paden et al., JMD, in press 2008
42Error Rate in CRRT/ECMO Circuits
- Potential error rate noted in stand-alone CVVH
- Ex vivo ECMO circuit
- Compared measured versus actual fluid removal
rates with inline hemofilter arrangement and with
Braun Diapact for CVVH - Significant excess fluid removal over expected
both for inline device and commercial device
-Paden et al., ppCRRT Conference 2008 (abstr)
43Potential Solutions
- Collaboration with GeorgiaTech
- Paden, Sucosky
- Development of fluid management/CRRT device
- High accuracy in delivery
- Patent pending
44What Further Work Needs to be done?
- Improved control of fluid management
- Randomized trial to compare CVVH/ECMO to ECMO
without routine CVVH - Potential use of biomarkers for initiation?
45Conclusions
- CRRT on ECMO can potentially provide a variety of
benefits - CRRT can be provided
- without worsening renal insufficiency
- with improved fluid balance
- with decreased furosemide exposure
- Potential risks of excessive fluid removal
- Further work to improve accuracy of fluid balance
and to determine if use translates into outcome
benefit
46Pediatric Patients Receiving CVVHFactors
Associated with Mortality
- Foland, Fortenberry et al., CCM 2004
47(No Transcript)