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ECMO and CRRT Matthew L. Paden, MD

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Presentation on theme: "ECMO and CRRT Matthew L. Paden, MD"— Presentation transcript:

1 ECMO and CRRT Matthew L. Paden, MD
Assistant Professor of Pediatric Critical Care Director, Pediatric ECMO

2 Disclosures Funded by NIH/FDA for CRRT/ECMO device development
Everything in ECMO is off label use I’m a believer…

3 Objectives Discuss usage cases for concomitant ECMO/CRRT
Description of recent common changes in ECMO configurations Discuss technical aspects of concomitant ECMO/CRRT

4 Common indications Survey of ELSO centers Fluid overload (43%)
AKI (35%) Prevention of fluid overload (16%) Electrolyte abnormalities (4%) Fleming GM, et al. ASAIO J (4):

5 ECMO and Urine Output 30 consecutive neonates meeting ECMO criteria –
18 VV ECMO, 12 conventional management Only looked at first 108 hours Patients who went onto ECMO had: Greater fluid overload Lower UOP Higher BUN Higher creatinine No difference in BP, protein intake, albumin, or diuretics Roy BJ, Cornish JD, Clark RH. Pediatrics 1995;95(4):573-8

6 ECMO and Urine Output

7 Neonates on ECMO UCLA – 17 consecutive neonates on VA ECMO
Hypothesis – Pulmonary HTN goes away quickly Pulmonary edema secondary to Starling forces keeps you on ECMO All got diuretics to maintain 3 cc/kg/hour Kelley RE, et al. Journal of Pediatric Surgery, Vol 26(9);1991:

8 Neonates on ECMO Results As weight reduces, ECMO flow reduces
Kelley RE, et al. Journal of Pediatric Surgery, Vol 26(9);1991:

9 ELSO Guidelines The goal of fluid management is to return the extracellular fluid volume to normal (dry weight) and maintain it there. …spontaneous or pharmacologic diuresis should be instituted until patient is close to dry weight and edema has cleared. This will enhance recovery from heart or lung failure and decrease the time on ECLS. As with all critically ill patients, full caloric and protein nutritional support is essential.

10 ELSO Guidelines The hourly fluid balance goal should be set and maintained until normal extracellular fluid volume is reached (no systemic edema, within 5% of “dry” weight). Renal replacement therapy use to enhance fluid removal allowing adequate nutritional support is often performed. Despite the literature surrounding fluid overload (>10%) as a risk factor for death, review of the ELSO registry also finds that use of renal replacement therapy is also a risk factor for poor outcome. Even if acute renal failure occurs with ECLS, resolution in survivors occurs in >90% of patients without need for long-term dialysis.

11 Preventing Fluid Overload
How many of you would start CRRT on an ECMO patient with a normal creatinine and no fluid overload?

12 AKI and ECMO Neonates - 25% (Askenazi 2011)
ELSO registry ~8000 non-cardiac neonates Creatinine > 1.5 or RRT Congenital diaphragmatic hernia - 71% (Gadepalli 2011) Congenital hearts - 72% (Smith 2009) Pediatric respiratory - 63% (ELSO DB 2011) Adult cardiac – 81% (RIFLE)/85% (AKIN) Note limitations of single center / ELSO database / Different definitions of AKI

13 CHOA Ped Respiratory ECMO 6/2010-1/2012
Emergency airway for foreign body Cancer – APML RSV – retroperitoneal hemorrhage Goodpasteur’s syndrome Pertussis x 2 Influenza H1N1 Asthma x 2 RSV Cancer – ALL Smoke inhalation Wegener’s granulomatosis x 2 Near drowning Post-partum ARDS Chronic granulomatous disease Hemophagic lymphohistiocytosis RSV + MRSA Cancer – AML Septic shock x 2 Multiple organ failure Pulmonary embolus x 2

14 Concomitant ECMO/CRRT Renal Outcomes
University of Michigan 35 CRRT/ECMO patients – 15 survivors (43%) 14/15 (93%) with full renal recovery at D/C Wegeners – ultimately transplanted Children’s Healthcare of Atlanta 154 CRRT/ECMO patients - 68 survivors (44%) 65/68 (96%) with full renal recovery at D/C 1 nosocomial enterococcus sepsis at transfer – normal 1 month later 2 primary renal disease (Wegeners/polyangiitis) – Cr 13.7/6.5 One ultimately transplanted / one with elevated Cr, no RRT

15 “ECMO as a platform” Enhances cardiorespiratory stability
Reduction of inotropes/vasoactive agents Provides adequate vascular access to allow additional organ support therapies CRRT, plasma exchange, etc. “Buys time” to allow new approaches/therapies to work Antibiotics, reduction of immunosuppression Concept of “organ rest” Reduces inflammatory response from lung injury

16 New equipment PMP Oxygenators Centrifugal pumps Smaller prime volume
Shorter blood path Less pressure drop across the membrane Centrifugal pumps New levitating impeller based designs Continuous flow - afterload dependent Eliminates risk of raceway rupture Risk of negative pressure generation

17 Change in ECMO Equipment
2002 (Lawson et al. JECT 2004;36:16) 95% roller head, 5% centrifugal 97% silicone, 0% PMP 2008 (Lawson et al. JECT 2008;40:166) 82.5% roller head, 17.5% centrifugal 67% silicone, 14% PMP 2011 (P Rycus, personal communication) 44% roller head, 56% centrifugal 35% silicone, 65% PMP

18 ECMO pumps Traditional design ECMO 2.0 Roller head pump Complex
Positive pressure venous limb ECMO 2.0 Centrifugal pump Simplified Negative pressure venous limb

19 Traditional design

20 ECMO 2.0

21 CVVH/ECMO “In-line” Schematic
IV pumps Regulate UF production Deliver RF Urometer to measure UF production Inexpensive Inaccurate

22 Pediatric ECMO / In-line CRRT Warning
Sucosky et al., J Med Devices (2), 2008 IV pumps Your I/O’s are not accurate Delivers less replacement fluid than ordered. 10 kg child with 300 mL/hour UF rate – negative 288 mL per day (28 ml/kg) 45 kg adolescent with 2000 ml/hour UF rate – negative 1.9 L/day (42 ml/kg)

23 ECMO/CRRT Traditional Design Schematic
POSITIVE VENOUS PRESSURE IV pump/urometer based system hemofilter membrane oxygenator roller pump Commercial CRRT system ECMO bladder

Kidney International. 2009;76:1289–1292.

25 Managing pressure No CRRT device is FDA approved/designed for use with ECMO Pressure alarms are common Too negative/positive drain pressures Too negative/positive return pressures No uniform solution currently exists Changing/removing alarm parameters Adding flow restriction via tubing/clamps Altering circuit entry points A need exists for a CRRT device designed for use with other extracorporeal devices


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