1. PCRRT & ECLS Dr. Peter Skippen, PICU. BC Children’s Hospital, Vancouver. CANADA.

2. PCRRT & ECLS Outline IndicationsIndications OptionsOptions SetupsSetups ConclusionsConclusions

3. PCRRT & ECLS Clinical Scenarios Acute respiratory failure / acute cardiac failureAcute respiratory failure / acute cardiac failure + acute inflammatory response to ECLS circuit + ongoing uncontrolled septic / inflammatory process + single / multi-organ failure + volume overload / ongoing fluid resuscitation + supporting nutrition

4. PCRRT & ECLS Indications volume overloadvolume overload electrolyte / acid - base disorderselectrolyte / acid - base disorders mediator clearancemediator clearance –hemofiltration post CPB / cardiac surgery “making room”“making room” preparing to wean from ECLSpreparing to wean from ECLS

5. PCRRT & ECLS Options lasix infusionlasix infusion SCUFSCUF CVVHCVVH CVVHDCVVHD “home made”“home made” customized machinecustomized machine accessaccess –ECLS circuit –separate site

6. PCRRT & ECLS ECLS circuits BiomedicusBiomedicus –VA –VV Roller pumpRoller pump –VA –VV

7. PCRRT & ECLS Basic ECLS Circuitry Venous line Arterial line H PUMP OXYGENATOR

8. PCRRT & ECLS Biomedicus System - diagram Venous line Arterial line H PUMP OXYGENATOR - + <+

9. Biomedicus System -photo

11. PCRRT & ECLS Roller Pump System - diagram Venous line Arterial line H PUMP OXYGENATOR Venous reservoir (gravity fed) + + <+ -

12. Rollerpump ECLS Circuit

13. Filter CRRT & Rollerpump

14. PCRRT & ECLS Options for PCRRT customized systems eg. PRISMAcustomized systems eg. PRISMA home made systemshome made systems –standard infusion pumps  pressure limited –roller pumps  NOT pressure limited

15. PCRRT & ECLS Home Made Systems & ECLS: Problems Infusion Pumps (max. 999mls/hr = 16.66mls/min)Infusion Pumps (max. 999mls/hr = 16.66mls/min) –no safety features eg. micro-air detector –may be unable to get adequate blood flow / dialysis flow / filtration flows Roller Pump Systems (litres/min)Roller Pump Systems (litres/min) –high pressure circuitry  no pressure limits –circuit rupture  no pressure limits –MUST incorporate bubble trap  insert pre-oxygenator

16. PCRRT & ECLS PRISMA & ECLS ProblemsProblems –high pressure return pre-oxygenator / high pressure alarm of PRISMA –complexity of circuit? –V-A shunt (depending on placement)

17. PCRRT & Biomedicus

18. PCRRT & Roller pump

20. PCRRT & ECLS Technique PRISMA: setup standardPRISMA: setup standard infusion pumps: limited by blood flow rate - SCUFinfusion pumps: limited by blood flow rate - SCUF roller pump circuit: allows flexibility at increased riskroller pump circuit: allows flexibility at increased risk –high blood flow –anticoagulation ECLS circuit already heparinizedECLS circuit already heparinized

21. PCRRT & ECLS Conclusions specific issues to be consideredspecific issues to be considered –biomedicus vs rollerpump –custom device vs. homemade allows optimized nutritional supportallows optimized nutritional support allows weaning from ECLSallows weaning from ECLS may reduce inflammatory responsemay reduce inflammatory response