7Neonates on ECMO UCLA – 17 consecutive neonates on VA ECMO Hypothesis –Pulmonary HTN goes away quicklyPulmonary edema secondary to Starling forces keeps you on ECMOAll got diuretics to maintain 3 cc/kg/hourKelley RE, et al. Journal of Pediatric Surgery, Vol 26(9);1991:
8Neonates on ECMO Results As weight reduces, ECMO flow reduces Kelley RE, et al. Journal of Pediatric Surgery, Vol 26(9);1991:
9ELSO GuidelinesThe 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.
10ELSO GuidelinesThe 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.
11Preventing Fluid Overload How many of you would start CRRT on an ECMO patient with a normal creatinine and no fluid overload?
12AKI and ECMO Neonates - 25% (Askenazi 2011) ELSO registry ~8000 non-cardiac neonatesCreatinine > 1.5 or RRTCongenital 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
13CHOA Ped Respiratory ECMO 6/2010-1/2012 Emergency airway for foreign bodyCancer – APMLRSV – retroperitoneal hemorrhageGoodpasteur’s syndromePertussis x 2Influenza H1N1Asthma x 2RSVCancer – ALLSmoke inhalationWegener’s granulomatosis x 2Near drowningPost-partum ARDSChronic granulomatous diseaseHemophagic lymphohistiocytosisRSV + MRSACancer – AMLSeptic shock x 2Multiple organ failurePulmonary embolus x 2
14Concomitant ECMO/CRRT Renal Outcomes University of Michigan35 CRRT/ECMO patients – 15 survivors (43%)14/15 (93%) with full renal recovery at D/CWegeners – ultimately transplantedChildren’s Healthcare of Atlanta154 CRRT/ECMO patients - 68 survivors (44%)65/68 (96%) with full renal recovery at D/C1 nosocomial enterococcus sepsis at transfer – normal 1 month later2 primary renal disease (Wegeners/polyangiitis) – Cr 13.7/6.5One ultimately transplanted / one with elevated Cr, no RRT
15“ECMO as a platform” Enhances cardiorespiratory stability Reduction of inotropes/vasoactive agentsProvides adequate vascular access to allow additional organ support therapiesCRRT, plasma exchange, etc.“Buys time” to allow new approaches/therapies to workAntibiotics, reduction of immunosuppressionConcept of “organ rest”Reduces inflammatory response from lung injury
16New equipment PMP Oxygenators Centrifugal pumps Smaller prime volume Shorter blood pathLess pressure drop across the membraneCentrifugal pumpsNew levitating impeller based designsContinuous flow - afterload dependentEliminates risk of raceway ruptureRisk of negative pressure generation
17Change in ECMO Equipment 2002 (Lawson et al. JECT 2004;36:16)95% roller head, 5% centrifugal97% silicone, 0% PMP2008 (Lawson et al. JECT 2008;40:166)82.5% roller head, 17.5% centrifugal67% silicone, 14% PMP2011 (P Rycus, personal communication)44% roller head, 56% centrifugal35% silicone, 65% PMP
18ECMO pumps Traditional design ECMO 2.0 Roller head pump Complex Positive pressure venous limbECMO 2.0Centrifugal pumpSimplifiedNegative pressure venous limb
21CVVH/ECMO “In-line” Schematic IV pumpsRegulate UF productionDeliver RFUrometer to measure UF productionInexpensiveInaccurate
22Pediatric ECMO / In-line CRRT Warning Sucosky et al., J Med Devices (2), 2008IV pumpsYour I/O’s are not accurateDelivers 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)
23ECMO/CRRT Traditional Design Schematic POSITIVEVENOUSPRESSUREIV pump/urometer based systemhemofiltermembrane oxygenatorroller pumpCommercial CRRT systemECMO bladder
25Managing pressureNo CRRT device is FDA approved/designed for use with ECMOPressure alarms are commonToo negative/positive drain pressuresToo negative/positive return pressuresNo uniform solution currently existsChanging/removing alarm parametersAdding flow restriction via tubing/clampsAltering circuit entry pointsA need exists for a CRRT device designed for use with other extracorporeal devices