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

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Presentation on theme: "ECMO and CRRT Matthew L. Paden, MD Assistant Professor of Pediatric Critical Care Director, Pediatric ECMO."— Presentation transcript:

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

2 Children’s Healthcare of Atlanta | Emory University Disclosures Funded by NIH/FDA for CRRT/ECMO device development Everything in ECMO is off label use I’m a believer… 2

3 Children’s Healthcare of Atlanta | Emory University Objectives Discuss usage cases for concomitant ECMO/CRRT Description of recent common changes in ECMO configurations Discuss technical aspects of concomitant ECMO/CRRT 3

4 Children’s Healthcare of Atlanta | Emory University Common indications Survey of ELSO centers – Fluid overload (43%) – AKI (35%) – Prevention of fluid overload (16%) – Electrolyte abnormalities (4%) 4 Fleming GM, et al. ASAIO J (4):

5 Children’s Healthcare of Atlanta | Emory University 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 Roy BJ, Cornish JD, Clark RH. Pediatrics 1995;95(4):573-8

6 Children’s Healthcare of Atlanta | Emory University ECMO and Urine Output

7 Children’s Healthcare of Atlanta | Emory University 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 Children’s Healthcare of Atlanta | Emory University Neonates on ECMO Results – As weight reduces, ECMO flow reduces Kelley RE, et al. Journal of Pediatric Surgery, Vol 26(9);1991:

9 Children’s Healthcare of Atlanta | Emory University 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. 9

10 Children’s Healthcare of Atlanta | Emory University 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. 10

11 Children’s Healthcare of Atlanta | Emory University Preventing Fluid Overload How many of you would start CRRT on an ECMO patient with a normal creatinine and no fluid overload? 11

12 Children’s Healthcare of Atlanta | Emory University 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 12

13 Children’s Healthcare of Atlanta | Emory University CHOA Ped Respiratory ECMO 6/2010-1/ 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 Children’s Healthcare of Atlanta | Emory University 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 14

15 Children’s Healthcare of Atlanta | Emory University “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 Children’s Healthcare of Atlanta | Emory University New equipment PMP Oxygenators – 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 16

17 Children’s Healthcare of Atlanta | Emory University 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 17

18 Children’s Healthcare of Atlanta | Emory University ECMO pumps Traditional design – Roller head pump – Complex – Positive pressure venous limb 18 ECMO 2.0 – Centrifugal pump – Simplified – Negative pressure venous limb

19 Children’s Healthcare of Atlanta | Emory University Traditional design 19

20 Children’s Healthcare of Atlanta | Emory University ECMO

21 Children’s Healthcare of Atlanta | Emory University CVVH/ECMO “In-line” Schematic IV pumps Regulate UF production Deliver RF Urometer to measure UF production Inexpensive Inaccurate

22 Children’s Healthcare of Atlanta | Emory University Pediatric ECMO / In-line CRRT Warning 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) Sucosky et al., J Med Devices (2), 2008 IV pumps

23 Children’s Healthcare of Atlanta | Emory University hemofilter membrane oxygenator roller pump ECMO bladder IV pump/urometer based system Commercial CRRT system POSITIVE VENOUS PRESSURE ECMO/CRRT Traditional Design Schematic

24 Children’s Healthcare of Atlanta | Emory University ECMO 2.0/CRRT Schematic 24 Kidney International. 2009;76:1289–1292. NEGATIVE VENOUS PRESSURE

25 Children’s Healthcare of Atlanta | Emory University 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 25

26 Children’s Healthcare of Atlanta | Emory University


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