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ECMO in CRRT – What are the Data? Jason S. Frischer, MD Director, ECMO Program Division of Pediatric General & Thoracic Surgery Cincinnati Children's Hospital.

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Presentation on theme: "ECMO in CRRT – What are the Data? Jason S. Frischer, MD Director, ECMO Program Division of Pediatric General & Thoracic Surgery Cincinnati Children's Hospital."— Presentation transcript:

1 ECMO in CRRT – What are the Data? Jason S. Frischer, MD Director, ECMO Program Division of Pediatric General & Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati, OH 1 st International Symposium on AKI in Children at the 7 th International Conference on Pediatric Continuous Renal Replacement Therapy Cincinnati, OH September 27-30, 2012

2 Thank You, STU

3 Background As many as 30 definitions of renal failure exist in the literature – Difficult to compare: Incidence Therapeutics Outcomes – pRIFLE – AKIN – Neonatal definition even more difficult

4 Background 2 sources of data – Single center reviews Details available Able to control variables – ELSO Renal complications – Serum Cr – Need for dialytic therapy – No data on indication, practice based on local expert opinion Until this year

5 AKI Neonates – Single center incidence: 22-71% – ELSO based publications: 10-22% Pediatric – Single center incidence: 12-30% ECMO, Extracorporeal Cardiopulmonary Support in Critical Care, 4 th Ed

6 AKI – Neonatal/Cardiac ELSO, July 2012 Neonatal Respiratory – 75% overall survival Neonatal Cardiac – 39% overall survival

7 AKI – Pediatric/Cardiac ELSO, July 2012 Pediatric Respiratory – 56% overall survival Pediatric Cardiac – 47% overall survival

8 ELSO registry review – Non-cardiac patients –

9 ELSO review - Neonates AKI + RRT 28% survival AKI Ø RRT 45.7% survival ØAKI + RRT 58.1% survival ØAKI Ø RRT 80.1% survival.

10 ELSO review - Pediatric AKI + RRT 32.2% survival AKI Ø RRT 41.3% survival ØAKI + RRT 48.3% survival ØAKI Ø RRT 72.3% survival.

11 ELSO review - Conclusions AKI and RRT are independent predictors of mortality Even after controlling for comorbidity variables

12 RRT in Critically Ill Patients Using RIFLE definition in ECMO patients – AKI incidence: CDH – 71% : associated with mortality Cardiac – 71% Adults respiratory – 78% Adults post-cardiotomy – 81% Clin J Am Soc Nephrol Aug;7(8):

13 RRT in Critically Ill Patients Indications for RRT on ECMO – Issue with ELSO database – Fluid Overload (FO) – 43% – AKI – 35% – Electrolyte – 4% Cumulative FO and failure to return to dry weight – Associated with higher mortality and prolonged ECMO run Clin J Am Soc Nephrol Aug;7(8):

14 Used to define current practice – 65 centers – 23% reported NO RST – 43% use for FO – 16% for FO prevention – 35% AKI – 4% Electrolyte

15 KIDMO

16 KIDMO - Indication

17 KIDMO – Mode employed Predominant mode convection – CVVH – SCUF

18 Single center retrospective review July 2006 – October U of M Hemofiltration through 2008, then CVVH 203 total ECMO – 57 CRRT (28%), 4 prior to run

19 FO and ECMO/RRT 33 neonates FO indication in 48/53 patients

20 FO and ECMO/RRT Outcomes: 58% overall survival – CRRT – 34% – Filter vs CVVH : 25 vs 53% Improved institutional practices? – Median initiation of FO Significantly lower in survivors 24.5% survivors vs 38% nonsurvivors, P=.006

21 FO and ECMO/RRT Outcomes: Cardiac – Degree of FO at CRRT initiation significantly higher in nonsurvivors – 38% vs 14%, P=.039 Degree of fluid removal and rate of removal: NO improvement in outcome

22 FO and ECMO/RRT Outcomes: Univariate Analysis – Significant association b/w initiation and discontinuation of FO and mortality – For each 1% increase in FO -odds of mortality increase 4% Multivariate Analysis – Borderline significance with initiation FO and mortality – Significant increased mortality with dicontinuation level of FO – Examined % change in FO, NOT significantly associated with mortality

23 FO and ECMO/RRT Conclusions: “These data suggest that PREVENTION of significant FO is likely to be more effective at improving outcomes than attempting fluid removal once significant FO is established.”

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25 Single center retrospective review 378 total ECMO with 66% survival 154 (41%) concomitant CVVH

26 Recovery CVVH has a lower survival rate – Similar to non-ECMO patients

27 Renal Outcomes 52% FO 37% ARF 18/68 (26%) survivors required ongoing RRT following decannulation 65/68 (96%) no RRT by hospital discharge – 30/31 FO and 20/23 AKI

28 Recovery - Conclusions Confirms higher risk of CRRT compared with ECMO use alone In the absence of primary renal disease at presentation, CRF did not occur in ECMO pts. treated with CVVH.

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30 Biomarkers 10 pediatric cardiac patients – 50% survive to d/c from ICU Increased NGAL on ECMO day #1 who needed CVVH – NGAL remained higher while on CVVH – Cr levels equivalent b/w groups

31 ECMO in CRRT – What are the Data? Pubmed: ECMO and anticoagulation: 161 ECMO and RRT: 11 1 st International Symposium on AKI in Children at the 7 th International Conference on Pediatric Continuous Renal Replacement Therapy Cincinnati, OH September 27-30, 2012 is

32 Conclusions Consensus definitions of AKI will help future studies – ELSO registry We have insufficient data to answer some basic questions – True incidence – Best mechanical practice Site of connection Equipment Mode (convection vs diffusion)

33 Thank you


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