Presentation on theme: "PCRRT and ECMO A. Dodge-Khatami, MD, PhD Division of Congenital Cardiovascular Surgery University Childrens Hospital, University of Zürich, Switzerland."— Presentation transcript:
PCRRT and ECMO A. Dodge-Khatami, MD, PhD Division of Congenital Cardiovascular Surgery University Childrens 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.
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 , platelets > , 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: Blood unit (250 cc) :218.- Cannulae (1A + 2V):810.- Water prime/rinse:15.- Total: 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