Presentation on theme: "Division of Congenital Cardiovascular Surgery"— Presentation transcript:
1Division of Congenital Cardiovascular Surgery PCRRT and ECMOA. Dodge-Khatami, MD, PhDK NDERSPITAL ZÜRICHUniversity Children‘s Hospital, University of Zürich, SwitzerlandDivision of Congenital Cardiovascular Surgery
2ExtraCorporeal Membrane Oxygenation: K NDERSPITAL ZÜRICHECMOExtraCorporeal 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.
5Oxygenation Index (OI)= mean airway pressure x ([FIO2 x 100]/PaO2) K NDERSPITAL ZÜRICHRespiratory ECMOindications:Oxygenation Index (OI)=mean airway pressure x ([FIO2 x 100]/PaO2)OI >25 without improvement under ttt or OI >40.
7bridge to myocardial recovery or pre-operative support. K NDERSPITAL ZÜRICHCardiac ECMObridge 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%.
8as standby: ALCAPA, TAPVD, HLHS K NDERSPITAL ZÜRICHCardiac ECMOcontraindications?,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
10K NDERSPITAL ZÜRICHECMOneck cannulation if chest closed: right carotid artery + ipsilateral internal jugular vein.confirm lack of need for a vent in the left atrium (possibilty of Rashkind in neonates).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.
12setup time (15-20 minutes), large priming volume (~300 ml). K NDERSPITAL ZÜRICHECMOsetup time (15-20 minutes), large priming volume (~300 ml).maintain ACT , 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
13ECMO Cost (CHF): ECMO system: 1860.- Blood unit (250 cc) : 218.- K NDERSPITAL ZÜRICHECMOCost (CHF):ECMO system:Blood unit (250 cc) : 218.-Cannulae (1A + 2V): 810.-Water prime/rinse: 15.-Total:Hemofilter:
14K NDERSPITAL ZÜRICHECMOduration: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.
15complications: mechanical and patient Mechanical: K NDERSPITAL ZÜRICHECMOcomplications: mechanical and patientMechanical:Circuit Clotting (19%)Cannulae placement/flow issues (9%)Air embolism (5%)Oxygenator failure (4%)Connector cracks,pump failure,heat exchanger malfunction (6%)
16Nosocomial infection 30% (risk factor for mortality). K NDERSPITAL ZÜRICHECMOcomplications:PatientBleeding (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
17indication for Hemofiltration: volume overload K NDERSPITAL ZÜRICHECMOsurvival:>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
18Hemofilter flow: max 10 ml/kg/hour (zero balance) K NDERSPITAL ZÜRICHECMOHemofilter flow: max 10 ml/kg/hour (zero balance)Placed BEFORE the oxygenatorChanged once a dayReduces plasma interleukins (IL-1ra, IL-6, IL-8) induced by cardiopulmonary bypass or ECMO.No adverse effects on platelet activation and consumption