1. Division of Congenital Cardiovascular Surgery
PCRRT and ECMO
A. Dodge-Khatami, MD, PhD
K NDERSPITAL ZÜRICH
University Children‘s Hospital, University of Zürich, Switzerland
Division of Congenital Cardiovascular Surgery

2. ExtraCorporeal Membrane Oxygenation:
K NDERSPITAL ZÜRICH
ECMO
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.

3. respiratory: neonatal & pediatric (82 %)
K NDERSPITAL ZÜRICH
ECMO
3 major groups:
respiratory: neonatal & pediatric (82 %)
cardiac: neonatal & pediatric (14.2 %)
adult cardio-respiratory failure (3.8 %)

4. Congenital diaphragmatic hernia Meconium aspiration syndrome
K NDERSPITAL ZÜRICH
Respiratory ECMO
Congenital diaphragmatic hernia
Meconium aspiration syndrome
Respiratory Insufficiency/RDS
Persistent Fetal Circulation/PPHN
Sepsis/Pneumonia
Air leak syndrome

5. Oxygenation Index (OI)= mean airway pressure x ([FIO2 x 100]/PaO2)
K NDERSPITAL ZÜRICH
Respiratory ECMO
indications:
Oxygenation Index (OI)=
mean airway pressure x ([FIO2 x 100]/PaO2)
OI >25 without improvement under ttt or OI >40.

6. K NDERSPITAL ZÜRICH
Respiratory ECMO

7. bridge to myocardial recovery or pre-operative support.
K NDERSPITAL ZÜRICH
Cardiac ECMO
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%.

8. as standby: ALCAPA, TAPVD, HLHS
K NDERSPITAL ZÜRICH
Cardiac ECMO
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

9. K NDERSPITAL ZÜRICH
ECMO

10. K NDERSPITAL ZÜRICH
ECMO
neck cannulation if chest closed: right carotid artery + ipsilateral internal jugular vein.
confirm lack of need for a vent in the left atrium (possibilty of Rashkind in neonates).
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.

11. K NDERSPITAL ZÜRICH
ECMO

12. setup time (15-20 minutes), large priming volume (~300 ml).
K NDERSPITAL ZÜRICH
ECMO
setup time (15-20 minutes), large priming volume (~300 ml).
maintain ACT , platelets > 100‘000, fibrinogen > 100 mg/dl, AT III 100%.
when running at lower flows, maximal anticoagulation vs. virtually no anticoagulation when temporarily running at supraphysiologic flows

13. ECMO Cost (CHF): ECMO system: 1860.- Blood unit (250 cc) : 218.-
K NDERSPITAL ZÜRICH
ECMO
Cost (CHF):
ECMO system:
Blood unit (250 cc) : 218.-
Cannulae (1A + 2V): 810.-
Water prime/rinse: 15.-
Total:
Hemofilter:

14. K NDERSPITAL ZÜRICH
ECMO
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.

15. complications: mechanical and patient Mechanical:
K NDERSPITAL ZÜRICH
ECMO
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%)

16. Nosocomial infection 30% (risk factor for mortality).
K NDERSPITAL ZÜRICH
ECMO
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

17. indication for Hemofiltration: volume overload
K NDERSPITAL ZÜRICH
ECMO
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

18. Hemofilter flow: max 10 ml/kg/hour (zero balance)
K NDERSPITAL ZÜRICH
ECMO
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