Haemofiltration in newborns treated with extracorporeal membrane oxygenation a case-comparison study Karin Blijdorp, research student Karlien 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 2003 Journois et al,Anesthesiology 1994 Journois et al, Anesthesiology 1996 Rivera 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 : with hemofiltration (n=15)  Inclusion: age < 30 days  Exclusion: co-treatment with diuretics start hemofiltration > 3 hrs after start ECMO  Cohort : 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 PO 4 -> [PO 4 ] = 1.5 mmol/l  Extra filtration if necessary and possible  Isovolemic thrombocyte and blood transfusions

Results: patient characteristics control groupHF group (n=45)(n=15)p-value n (%) ECMO-modeveno-arterial44(97)13(87)0.22 diagnosisCDH16(35)3(20) MAS16(35)5(33) other14(30)7(47)0.73 median (min - max) weight (kg)3.3( )3.5( )0.31 age (days)1.7( )2.2( )0.28 scoresPRISM III37( )35( )0.29 OI20(1 - 30)20( )0.82 AaDO225(14-39)20( )0.18

Results: duration of ECMO and assisted ventilation after ECMO (median values) * * * p-value <0.05 time on ECMOtime till extubation hr

Results: fluid balance and need of transfusion (median values) ** ** p-value <0.001 **

Results: costs per unitcontrol groupHF group ECMO treatment (+28 hrs)€ 4,328.00€ 5, ICU + ventilation (+55 hrs)€ 1,480.00€ 3, blood transfusion (5.4 U)€ € HF Multiflow filters, n=1 or 2€ 90.00€ substitution fluid (3*5 liters)€ € 9,406.00€

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 groep Median (range) HF groep Median (range) Mann-Whitney U test P-waarde Vulling (mL/kg/dag)6 (0-37)4 (0-30)0.25 Vasopressor score7 (0-56)5 (0-41)0.83 Kreatinine (µmol/l)58 (14-91)49 (28-105)0.17 Median (percentile) Mortaliteit7 (16%)3 (21%)0.61