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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
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> 1
986
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Neonatal
Pediatric
Number of neonatal and pediatric ECLS treatments on an annual basis reported to
ELSO registry
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)
0102030405060708090
100M
orta
lity
<25% 25- 50% 50- 75% >75%
Mortality Risk Group
ECMO patients
Non- ECMO patients
-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
4.19
43.5
62.5
26.9
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usan
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f D
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ife-
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Pediatric ECLS Liver
Transplant
Bone Marrow
Transplant
Heart
Transplant
Vats et al.
Crit Care Med 1998; 26:1587-1592
Cost/life-year-saved of pediatric extracorporeal life support (ECLS) with adult therapies
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 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?
Other
40%
bacterial pneumonia
9%
viral pneumonia
30%
intrapulmonary hemorrhage
1%
aspiration
8%
ARDS
11%pneumocystis
1%
Diagnoses for Pediatric ECLS
From: Registry of the Extracorporeal Life Support Organization(ELSO, Ann Arbor, MI, USA).
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 ECMOIndications
• Lung disease that is: acute life threatening reversible unresponsive to conventional
therapy
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
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
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 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
Pediatric and Adult ECLSExclusion Criteria
• Absolute: uncontrolled metabolic acidosis central nervous system injury/
malfx immunosuppression chronic myocardial dysfunction
Adult ECLSExclusion Criteria
• Relative contraindications: mechanical ventilation > 6 days septic shock severe pulmonary hypertension
(MPAP > 45 or > 75% systemic)
Adult ECLSExclusion 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 InitiationSurgical Team
VAVA
ECMOECMO
VVVVvs.
Selection of TechniqueSelection of Technique
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 after-load, improved coronary oxygenation
• Patient safety: emboli
Use of VV and VV ECMO: Egleston Pediatric Experience
Year
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
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VV ECMOVA ECMO
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
Venous cannula2 10-14 16 18 20 22
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 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!
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) 180-200; 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??