1. Pediatric and Adult ECMO: Patient Selection and Management
James D. Fortenberry, MD
Clinical Director, Pediatric and Adult ECMO
Children’s Healthcare of Atlanta at Egleston

3. Number of neonatal and pediatric ECLS treatments on an annual basis reported to ELSO registry

4. All who drink of this treatment recover within a short time, except in those who do not. Therefore, it fails only in incurable cases Galen

5. Is ECMO of Proven Benefit for Respiratory Failure?
Neonatal respiratory failure
PPHN, meconium aspiration; CDH
UK study (Lancet, 1997)
Proven benefit in regionalized setting

6. Is ECMO of Proven Benefit in Respiratory Failure?
Children
No good prospective study
Retrospective data: benefit in higher risk (not moribund) patients with respiratory failure
ECMO decreased mortality from 47.2 to 26.4% (331 pts.-Green et al., CCM, 1996)

7. *
-Green et al., CCM 1996

8. Outcome in Pediatric ECMO: Predictors of Survival
Younger age (23 vs. 49 months)
Ventilator days pre-ECMO (5.1 vs. 7.3)
Lower PIP, lower A-a gradient (Moler et al., CCM, 1993)
No difference in survival if > 2 weeks on ECMO (Green et al., CCM, 1995)
Lung biopsy not necessarily predictive

9. Is ECMO of Proven Benefit in Adult Respiratory Failure?
Adult ELS NIH study: 1971
90% mortality: no benefit with VA ECMO in moribund patients
Gattinoni-nonrandomized experience
49% survival
Corroboration at other centers-U. of Michigan
Morris-AJRCCM 1992 (Utah)
No statistically significant survival benefit of ECMO vs. computerized vent management protocol

10. Cost/life-year-saved of pediatric extracorporeal life support (ECLS) with adult therapies
Vats et al.
Crit Care Med 1998; 26:

11. Pediatric ECMO - Children’s Healthcare of Atlanta

12. Are Pediatric and Adult ECMO Different?
More alike than different
Subtle differences in criteria
Difference in size = major difference in difficulty of nursing care

13. Adults are just Big Kids

14. Patient Selection for Pediatric/Adult ECMO Basic Principles
Is the pulmonary/cardiac disease life threatening?
Is the disease likely reversible?
Are other diseases relative to prognosis?
Is ECMO more likely to help than hurt?
Is preoperative support warranted??
VA or VV?

15. Diagnoses for Pediatric ECLS
From: Registry of the Extracorporeal Life Support Organization(ELSO, Ann Arbor, MI, USA).

16. ECMO: General Indications in Respiratory Failure
Lung disease that is:
Acute
Life threatening
Reversible
Unresponsive to conventional/alternative therapy

17. ECMO for Pediatric Respiratory Failure: Indications
Acute, potentially reversible respiratory (and/or cardiovascular) disease unresponsive to conventional/alternative arrangement
Oxygenation index >40 x 2 hours
Barotrauma
P/F ratio <200

18. Oxygenation Index
Mean airway pressure x Fi O2 x 100
OI=
PaO2

19. Pediatric and Adult ECMO Indications
Lung disease that is:
acute
life threatening
reversible
unresponsive to conventional therapy

20. Pediatric and Adult ECLS Selection CriteriaNo
malignancy
incurable disease
contraindication to anticoagulation
Intubation/ventilation for < 10 days;
< 6 days in adult
Hypercarbic respiratory failure with:
pH < 7.0, PIP > 40

21. Adult ECLS Selection Criteria
Respiratory failure
shunt > 30% on an FiO2 of > 0.6
compliance < 0.5 ml/cmH2O/kg
Severe, life threatening hypoxemia
Lack of recruitment
inadequate SpO2/PaO2 response to increasing PEEP

22. ECMO for Pediatric Respiratory Failure: Contraindications
Unlikely to be reversible in days
Terminal underlying condition
Mechanical ventilation >10 days
Multi-organ failure
Severe or irreversible brain injury
Significant pre-ECMO CPR

23. Pediatric and Adult ECLS Exclusion Criteria
Absolute:
contraindication to anticoagulation
terminal disease
underlying moderate to severe chronic lung disease
PaO2/FiO2 ratio < 100 for > 10 days (> 5 days in adult)
MODS: >2 organ system failure

24. Pediatric and Adult ECLS Exclusion Criteria
Absolute:
uncontrolled metabolic acidosis
central nervous system injury/ malfx
immunosuppression
chronic myocardial dysfunction

25. Adult ECLS Exclusion Criteria
Relative contraindications:
mechanical ventilation > 6 days
septic shock
severe pulmonary hypertension (MPAP > 45 or > 75% systemic)

26. Adult ECLS Exclusion Criteria
Relative contraindications:
cardiac arrest
acute, potentially irreversible myocardial dysfunction
> 35 years of age

27. Differences between Pediatric and Adult ECMO Criteria
Mechanical ventilation prior to ECMO; pediatric < 10 days vs. adult < 6 days
Age: adult vs. pediatric

28. “The key to the success of ECMO may be the time of initiation”
Plotkin et al., U of M, 1994

29. ECMO Initiation Surgical Team

30. Selection of TechniqueVA VV
vs.
ECMO

31. ECMO Veno-venous (VV) vs. Veno-arterial (VA) VA
Provides complete cardiorespiratory support
Negative impact on afterload VV
Preferred mode
Don’t sacrifice artery
Oxygenates blood to heart

32. Why VV Might Be Better Than VA
Cannulation: ease
Effect on pulmonary blood flow: improved oxygenation
Cardiac effects: decreased LV after-load, improved coronary oxygenation
Patient safety: emboli
Avoiding carotid cannulation and ligation
Cannulating only one vessel
Possible percutaneous access
RV preload and LV afterload
myocardial efficiency
LV wall distension
myocardial oxygen consumption
Coronary O2 delivery
Air and other emboli filtered by lungs

33. Use of VV and VV ECMO: Egleston Pediatric Experience

34. Equipment

37. Size of Circuit Components Based on Patient Weight
1 Two oxygenators necessary in parallel or in series
2 Minimal sizes of cannulas

38. Pediatric and Adult ECLS: Cannulation
Cannulation frequently rocky
Code drugs to bedside
Patient on specialty bed
Cannulation orders
Heparin bolus available

39. Pediatric and Adult ECLS: Venovenous cannulation
Dual cannulae: usually drain from right atrium via RIJ, return to femoral vein +/- cephalad cannula
Double lumen cannula: 12-18F in RIJ for smaller children
Cutdown vs. percutaneous
Blood vs. saline prime

40. Pediatric and Adult ECLS: Veno-arterial cannulation
Usually for cardiac ECMO
May convert VV to VA ECMO
Cannulae: Venous drain-RIJ to right atrium; arterial-usually common carotid to aorta

41. Pediatric ECMO Management: Pulmonary
Basic goals:
decrease further lung damage
reduce oxygen toxicity
“lung rest”

42. Pediatric and Adult ELS Approach to the Patient
Fluids/nutrition: Feed ‘em!
Sedation/analgesia: Snow ‘em!
Antibiotics: Hold ‘em!
Invasive procedures: Bronch ‘em!
Weaning: Wean ‘em!
Decannulation: Cap ‘em!
Post-ECMO: Rehab ‘em!

43. Pediatric ECMO Management: Pulmonary
Optimal ventilator settings vary
Limit peak pressures to 30 cm H2O
Delivered tidal volumes 4-6 cc/kg
Rate 5-10 breaths/minute
PEEP cm H2O
Inspiratory time longer
Goal FiO2 0.21

44. Pediatric ECMO Management: Pulmonary
Tolerate pCO , SpO2 > 88%
Time of “rest” depends on process
3-5 days minimum for ARDS
Resolution of air leak (48-72 hours)
Suctioning PRN
Avoid bagging

45. Pediatric ECMO Management: Pulmonary
Pulmonary hygiene
Daily chest radiographs-may signal recovery
Re-recruitment
Bronchoscopy may be beneficial
May come off on HFOV

46. Pediatric ECMO Management: Flow
Infants: cc/kg/min
Children: cc/kg/min
Adults: cc/kg/min
Attempt to reach maximal flow early in run to determine buffer

47. Pediatric ECMO Management: Cardiovascular
VA ECMO generally required with cardiac failure
VV ECMO may improve cardiac function
Usually able to wean pressors
Milranone can be beneficial
Hypertension common in VV ECMO (69%)-try ACE inhibitors

48. Pediatric ECMO Management: CNS
Increased Vd, surface interaction, altered renal blood flow, CVVH
Morphine used due to oxygenator uptake of fentanyl; tolerance
Lorazepam, midazolam
NMB usually required in ped/adults-use pavulon, take holidays, watch with steroids

49. Surgeons give fluid Intensivists give Lasix (or use CVVH)

50. Pediatric ECMO Management: Fluids/Renal
Tendency to capillary leak
Oliguria often associated and worsened on ECMO
May be recalcitrant to Lasix
CVVH: helpful adjunct; simple inline in circuit; Renal consult
CVVH does not worsen outcome (Bunchman et al., PCCM 2001)

51. Pediatric ECMO Management: GI
Decreased catabolism = decreased infection
Enteral nutrition preferred: improved calories, decreased cost, similar complications (Pettignano, et,al, CCM, 1997)
Can give intragastric or transpyloric
Aggressive bowel regimens

52. Pediatric ECMO Management: Hematologic
Maintain Hb/Hct > 13/40
Hemolysis-monitor with serum free Hgb
Platelet consumption common-keep greater than 100,000
Activated clotting time (ACT) ; if expect significant bleeding

53. Pediatric ECMO Management: Hematologic
Amicar-inhibits fibrinolysis; can enhance hemostasis in high risk cases, post-op
Loading dose 100 mg/kg, infusion mg/kg/hour for no more than 96 hours
Aprotinin for active bleeding-generally avoid due to clot risk

54. Pediatric ECMO Management: Infectious
Routine antibiotic coverage not practiced
Strict asepsis during run
Need to have low index of suspicion for super-infection; may be difficult to assess

55. Adult ECMO Management: Specific Issues
ACLS requirements
Consultation: Adult Pulmonary, Ob/Gyn, Infectious Disease
Commitment to rapid return to referring institution post-ECMO
Age limits

56. ECMO Weaning and Decannulation
Improvement: diuresis, CXR improvement, lung compliance
Weaning of flow to 50 cc/kg/min
VV: “capping” - continue circuit flow with gas supply d/ced
Surgery decannulates
Issues of termination

58. Questions??