PCRRT and ECMO

A. Dodge-Khatami, MD, PhD

Division of Congenital Cardiovascular Surgery

University Children‘s Hospital, University of Zürich, Switzerland

K NDERSPITAL ZÜRICH

ECMO

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•ExtraCorporeal Membrane Oxygenation:

•life-saving mechanical circulatory assist device for the temporary support of the cardiac and/or pulmonary systems.

•through circulatory support, possibility to maintain homeostasis of all major vital organs, including renal function.

ECMO

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3 major groups:

•respiratory: neonatal & pediatric (82 %)•cardiac: neonatal & pediatric (14.2 %)•adult cardio-respiratory failure (3.8 %)

Respiratory ECMO

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•Congenital diaphragmatic hernia•Meconium aspiration syndrome•Respiratory Insufficiency/RDS•Persistent Fetal Circulation/PPHN•Sepsis/Pneumonia•Air leak syndrome

Respiratory ECMO

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indications:

•Oxygenation Index (OI)=mean airway pressure x ([FIO2 x 100]/PaO2)

•OI >25 without improvement under ttt or OI >40.

Respiratory ECMO

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Cardiac ECMO

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•bridge to myocardial recovery or pre-operative support.•bridge to heart or heart/lung transplantion.•post-operative support after cardiac surgery.

•survival to separation from ECMO 53%, and survival to discharge 39%.

Cardiac ECMO

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contraindications?,

•relative: age < 35 weeks, weight < 2kg, previous cerebral intraventricular hemorrhage, HLHS + TAPVD.

•absolute: profound neurologic deficit or syndrome preventing a meaningful life, against parent will.

•as standby: ALCAPA, TAPVD, HLHS

ECMO

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ECMO

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1. neck cannulation if chest closed: right carotid artery + ipsilateral internal jugular vein.

2. confirm lack of need for a vent in the left atrium (possibilty of Rashkind in neonates).

3. post-operative open chest after attemped repair or palliation of congenital heart disease gives direct access to aorta + right atrium + left atrium for left heart decompression.

ECMO

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ECMO

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•setup time (15-20 minutes), large priming volume (~300 ml).

•maintain ACT 180-220, platelets > 100‘000, fibrinogen > 100 mg/dl, AT III 100%.

•when running at lower flows, maximal anticoagulation vs. virtually no anticoagulation when temporarily running at supraphysiologic flows

ECMO

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Cost (CHF):

•ECMO system: 1860.-•Blood unit (250 cc) : 218.-•Cannulae (1A + 2V): 810.-•Water prime/rinse: 15.-•Total: 2903.-

•Hemofilter: 154.-

ECMO

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duration:

•for respiratory ECMO, successful ECMO can be maintained up to ~20 days.

•no study has shown survival after 300 hours (12.5 days) for cardiac ECMO; improvement of cardiac function beyond 250 hours is highly unlikely.

•when multiorgan failure or sepsis, consider discontinuation after 4 days.

ECMO

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complications: mechanical and patient

Mechanical:

Circuit Clotting (19%)Cannulae placement/flow issues (9%)Air embolism (5%)Oxygenator failure (4%)Connector cracks,pump failure,heat exchanger malfunction (6%)

ECMO

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complications:

Patient

•Bleeding (35%)•Ischemic or hemorrhagic cerebral lesions (~15% during, and 40% after decannulation) •Nosocomial infection 30% (risk factor for mortality).•Renal failure (25%): creatinine > 114 µmol/l, urine output < 1 ml/kg/h, or hemofiltration

ECMO

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survival:

•>5-fold risk for death in patients requiring hemoflitration on ECMO as opposed to those who do not (50-65% vs. 9-23%)•„…consideration should be given to discontinue ECMO when extrarenal support is required…“•IS HEMOFILTRATION STARTED TOO LATE, and WOULD EARLIER THERAPY CHANGE PROGNOSIS?•indication for Hemofiltration: volume overload

ECMO

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•Hemofilter flow: max 10 ml/kg/hour (zero balance)•Placed BEFORE the oxygenator•Changed once a day•Reduces plasma interleukins (IL-1ra, IL-6, IL-8) induced by cardiopulmonary bypass or ECMO.•No adverse effects on platelet activation and consumption