Haemofiltration in newborns treated with extracorporeal membrane oxygenation

a case-comparison study

Karin Blijdorp, research studentKarlien Cransberg, pediatric nephrologist

Erasmus MC Sophia, Rotterdam, The Netherlands

ECMO treatment in The Netherlands

since 1994, in 2 centers

University Medical Center, Nijmegen

Erasmus MC Sophia, Rotterdam:

40 ECMO runs yearly

Indication: acute reversible

cardiovascular or respiratory failure with

an expected mortality of > 80%:

congenital diaphragmatic hernia

meconium aspiration syndrome

other

Systemic inflammatory response syndrome

due to primary disease and/or ECMO system:

generalised edema by capillary leakage

low blood pressure

multi-organ failure

prior investigations:

hemofiltration added to cardiopulmonary bypass:

less SIRS

less pulmonary edema with shorter assisted ventilation time

improved cardiac function

Huang et al, Ann Thorac Surg 2003Journois et al,Anesthesiology 1994

Journois et al, Anesthesiology 1996Rivera et al, J Am Coll Cardiol 1998

Davies et al, J Thorac Cardiovasc Surg 1998

Aim of the study

Clinical outcome of ECMO treated infants with haemofiltration

compared to without.

Primary endpoints:

Duration of ECMO

Duration of assisted ventilation

after weaning from ECMO

Secondary endpoints:

Mortality

Fluid balance

Vasopressorscore

Maximal serum creatinine

Transfusion red blood cells & platelets

Costs

Methods

Retrospective case-comparison study 1:3

Cohort 2004-2006: with hemofiltration (n=15)

Inclusion: age < 30 days

Exclusion: co-treatment with diuretics

start hemofiltration > 3 hrs after start

ECMO

Cohort 2002-2004: control group without hemofiltration

(n=45)

Matched for age, weight, diagnosis and mode of ECMO

Haemofiltration in ECMO circuit

ECMO-pump

clamp

Haemofiltration in ECMO circuit

ECMO-pump

clamp

heparin

substitution fluid

Pressure gradient over haemofilter of 40 mmHg

Methods: hemofiltration

Filter: Multiflow 100, AN 69

Filtration:

1st 6 hours 100 ml/kg/hr

after that 50 ml/kg/hr

Standard substitution fluid,

with addition of Na/K PO4 -> [PO4] = 1.5 mmol/l

Extra filtration if necessary and possible

Isovolemic thrombocyte and blood transfusions

Results: patient characteristics

control group HF group

(n=45) (n=15) p-value

n (%) n (%)

ECMO-mode veno-arterial 44 (97) 13 (87) 0.22

diagnosis CDH 16 (35) 3 (20)

MAS 16 (35) 5 (33)

other 14 (30) 7 (47) 0.73

median (min - max) median (min - max)

weight (kg) 3.3 (1.9 - 5.0) 3.5 (2.5 - 5.0) 0.31

age (days) 1.7 (0.5 - 18) 2.2 (0.9 - 6.7) 0.28

scores PRISM III 37 (14 - 90) 35 (17 - 51) 0.29

OI 20 (1 - 30) 20 (10 - 20) 0.82

AaDO2 25 (14-39) 20 (14 - 40) 0.18

Results: duration of ECMO and assisted ventilation after ECMO (median values)

* *

* p-value <0.05

time on ECMO time till extubation

hr

Results: fluid balance and need of transfusion (median values)

**

** p-value <0.001

-140

-120

-100

-80

-60

-40

-20

0

20

40

60

fluid balance diuresis blood transfusion plateletstransfusion

ml/k

g/d

ay

HF control

** **

Results: costs

per unit control group HF group

ECMO treatment (+28 hrs) € 4,328.00 € 5,050.00

ICU + ventilation (+55 hrs) € 1,480.00 € 3,392.00

blood transfusion (5.4 U) € 178.00 € 964.00

HF Multiflow filters, n=1 or 2 € 90.00 € 135.00

substitution fluid (3*5 liters) € 45.00 € 45.00

   

€ 9,406.00 € 180.00

Conclusion

Hemofiltration during ECMO:

decreases time on ECMO

decreases time until extubation after weaning from ECMO

decreases need of blood transfusion

saves € 9000,- per ECMO run

Conclusion

Hemofiltration during ECMO:

decreases time on ECMO

decreases time until extubation after weaning from ECMO

decreases need of blood transfusion

saves € 9000,- per ECMO run

No significant differences found in:

mortality

max serum creatinine

vasopressorscore

extra fluid requirement

Discussion

Effect of HF due to

More fluid removal?

Removal inflammatory mediators?

Take home message

Hemofiltration added to ECMO

improves clinical outcome

and is cost effective

All ECMO nurses on the pediatric ICU

D Tibboel,

pediatric intensivist, head of PICU

SJ Gischler,

pediatric intensivist

ED Wildschut,

pediatric intensivist

ED Wolff,

pediatric nephrologist

Acknowledgements:

Limitations of study

More CDH in control group (n.s.)

However no difference in ‘severity of illness’ score

Groups treated in different time frame

Only clinical parameters

Prospective study of inflammatory parameters not

studied yet

Results: other

Controle groepMedian (range)

HF groepMedian (range)

Mann-Whitney U test

P-waarde

Vulling (mL/kg/dag) 6 (0-37) 4 (0-30) 0.25

Vasopressor score 7 (0-56) 5 (0-41) 0.83

Kreatinine (µmol/l) 58 (14-91) 49 (28-105) 0.17

Median (percentile) Median (percentile)

Mortaliteit 7 (16%) 3 (21%) 0.61