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

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)

* -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

Cost/life-year-saved of pediatric extracorporeal life support (ECLS) with adult therapies Vats et al. Crit Care Med 1998; 26:1587-1592

Pediatric ECMO - Children’s Healthcare of Atlanta

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 ECMO Basic 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?

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 Mean airway pressure x Fi O2 x 100 OI= PaO2

Pediatric and Adult ECMO Indications Lung disease that is: acute life threatening reversible unresponsive to conventional therapy

Pediatric and Adult ECLS Selection 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 ECLS Selection 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 ECLS Exclusion 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 ECLS Exclusion Criteria Absolute: uncontrolled metabolic acidosis central nervous system injury/ malfx immunosuppression chronic myocardial dysfunction

Adult ECLS Exclusion Criteria Relative contraindications: mechanical ventilation > 6 days septic shock severe pulmonary hypertension (MPAP > 45 or > 75% systemic)

Adult ECLS Exclusion 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 Initiation Surgical Team

Selection of Technique VA VV vs. ECMO

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 Avoiding carotid cannulation and ligation Cannulating only one vessel Possible percutaneous access RV preload and LV afterload myocardial efficiency LV wall distension myocardial oxygen consumption Coronary O2 delivery Air and other emboli filtered by lungs

Use of VV and VV ECMO: Egleston Pediatric Experience

Equipment

Size of Circuit Components Based on Patient Weight 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 ELS Approach 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??