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K NDERSPITAL ZÜRICH. PCRRT and ECMO. A. Dodge-Khatami, MD, PhD. University Children‘s Hospital, University of Zürich, Switzerland. D ivision of Congenital Cardiovascular Surgery. K NDERSPITAL ZÜRICH. ECMO. ExtraCorporeal Membrane Oxygenation: - PowerPoint PPT Presentation
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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
K NDERSPITAL ZÜRICH
•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
K NDERSPITAL ZÜRICH
3 major groups:
•respiratory: neonatal & pediatric (82 %)•cardiac: neonatal & pediatric (14.2 %)•adult cardio-respiratory failure (3.8 %)
Respiratory ECMO
K NDERSPITAL ZÜRICH
•Congenital diaphragmatic hernia•Meconium aspiration syndrome•Respiratory Insufficiency/RDS•Persistent Fetal Circulation/PPHN•Sepsis/Pneumonia•Air leak syndrome
Respiratory ECMO
K NDERSPITAL ZÜRICH
indications:
•Oxygenation Index (OI)=mean airway pressure x ([FIO2 x 100]/PaO2)
•OI >25 without improvement under ttt or OI >40.
Respiratory ECMO
K NDERSPITAL ZÜRICH
Cardiac ECMO
K NDERSPITAL ZÜRICH
•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
K NDERSPITAL ZÜRICH
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
K NDERSPITAL ZÜRICH
ECMO
K NDERSPITAL ZÜRICH
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
K NDERSPITAL ZÜRICH
ECMO
K NDERSPITAL ZÜRICH
•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
K NDERSPITAL ZÜRICH
Cost (CHF):
•ECMO system: 1860.-•Blood unit (250 cc) : 218.-•Cannulae (1A + 2V): 810.-•Water prime/rinse: 15.-•Total: 2903.-
•Hemofilter: 154.-
ECMO
K NDERSPITAL ZÜRICH
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
K NDERSPITAL ZÜRICH
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
K NDERSPITAL ZÜRICH
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
K NDERSPITAL ZÜRICH
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
K NDERSPITAL ZÜRICH
•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