ECMO Primer A View to the Future - SPA · ECMO Primer A View to the Future ... – Heart Failure...
Transcript of ECMO Primer A View to the Future - SPA · ECMO Primer A View to the Future ... – Heart Failure...
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ECMO Primer A View to the Future
Todd J. Kilbaugh Assistant Professor of Anesthesiology, Critical Care
Medicine, and Pediatrics Director of The ECMO Center at the Children’s
Hospital of Philadelphia
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Disclosures
• I have no disclosures or conflicts for this presentation
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Not If…When?
Image Permission from Family
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Video 1: Grace
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Concept: Extracorporeal Life Support
Veno Arterial • Video of VA
Veno Venous • Video of VV
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Practice: Types of Extracorporeal Life Support
• Veno Arterial Support – Heart and Lung Bypass – Heart Failure
• Congenital Heart Disease • Myocarditis • Congestive Failure prior
to Transplant • Shock
– Hemorrhagic – Sepsis
• Myocardial Infarction (?)
• Veno Venous Support – Lung Bypass (Also
Affords Heart Rest) – Respiratory Failure
• Acute Failure – Hypoxemia – Hypercarbia
• Chronic Failure – Prior to Transplant
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ECMO Indications over 15 years
0%
20%
40%
60%
80%
100% Card (16 years and over)
Card (1 year < 16 years)
Card (31 days < 1 year)
Card (0 - 30 days)
Adult Pulm
Ped Pulm
Neo Pulm
ELSO Registry July 2015
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ECMO: Pediatric Pulmonary Failure
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Neonatal ECMO
Only 1 randomized, controlled trial Collaborative UK ECMO Trial: Follow-up to 1 Year of
Age UK Collaborative ECMO Group
Pediatrics 1998 – Only report of a RCT of an ECMO policy – Principal Endpoint: death or severe disability at one year of age
• Both reduced
– Follow up at 4 and 7 years of age • Beneficial influence of an ECMO policy still present
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ECMO: Neonatal Intensive Care
• Meconium Aspiration Syndrome – Most common indication (30-40%) – Shortest runs (5 – 7 days) – Best survival (94%)
• Pulmonary Hypoplasia – CDH, lung lesions
• Sepsis • Pneumonia
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ECMO: Congenital Heart Disease • Three major “routes”:
– Inability to separate from cardiopulmonary bypass in the cardiac OR
– Planned bridge from low cardiac output: • preoperative stabilization • bridge to recovery (post-operative, myocarditis,
intractable arrhythmias, respiratory failure) • bridge to alternate mechanical support (VAD – Berlin
Heart, Thoratec, Heartmate or Syncardia) • bridge to transplantation (usually via VAD support)
– Rescue from sudden cardiac arrest with E-CPR
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Inability to separate from bypass
• Prolonged cross clamp • Arrhythmia • Myocardial protection • Pulmonary hypertension • Coronary perfusion (ASO, Norwood) • Residual lesions (rule out using echo/cath) • Preoperative myopathy (ALCAPA, late MR, late
AI)
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CHD: Post-operative Low Cardiac Output:
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• Both with and without important residual defects of the repair
• Ventricular dysfunction • Pulmonary hypertension (eg TAPVR) • Intractable arrhythmias (JET) • Generally RIJ/RCA cannulation • Supported days, then decannulated • Decreased flow trials with echocardiogram to aid
decision making for separation
CHD: Post-operative Low Cardiac Output
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CHD: Extracorporeal CPR • E-CPR for children with cardiac disease
have superior outcomes (survival to d/c) than other groups
• Cardiac patients may benefit from: – Invasive monitoring pre-arrest – Recent surgery – easier access for cannulation – Familiarity of cardiac surgeons with cannulation
techniques – Differences in etiology of arrest
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Pediatric ECMO
• Respiratory Failure • Sepsis and Systemic Inflammatory Syndromes • Extracorporeal CPR • Pre-operative Lung Transplant
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Lung Rescue
Survived ECLS Survived to DC
ELSO DATABASE 2005-2012
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Image Permission from Family
ECMO: Progressive Mobility
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Sepsis and Systemic Inflammatory Response Syndrome
• Larger Cannulas = More Flow = Central Cannulation
• Sepsis and Multi Organ Failure: Indicated MacLaren, PCCM 2011
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Pediatric ECPR
• ECPR Criteria – Witnessed Arrest and
Initiation of CPR – Quality Metrics of CPR – ECPR activation at 5
minutes
– Crystalloid Primed Circuits
– O Negative If Needed
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When is Starting NOW: Anesthesiologists are Leading the Way • Refractory Cardiac Arrest
– Pre-Hospital ECMO • Team
– Anesthesiologist – Nurse – Paramedic – Medical Command
» Anesthesiologist – ED Hybrid Room ECMO
• Tokyo – CHOP ECPR Program and
Mobile Rescue • Building an ICU without
Walls
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CHOP and Penn Mobile Lung Rescue Programs
• Video • Patients with ARDS – WE will come to you for
cannulation
• Patients placed on ECMO – WE will come to you for
transport
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ECMO Optimizing Neuroresuscitation
• Neuromonitoring – EEG – Diffuse Optical
Spectrocopy • Cerebral Blood Flow • Cerebral Oxygen
Saturation • Cerebral oxygen
extraction fraction
• Adjuvant Therapy Delivery – Hypothermia – Mitochondrial
Resuscitation
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Oxygen &
Metabolic substrates
Increase delivery/supply meet demand
Which Rx ? Death
ATP
Mitochondrial Directed Therapies
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ECMO Adjuvant Therapies • Hemodialysis • Plasmapheresis • Leukoreduction • Rapid Temperature
Regulation
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Video 2: Sean
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Notes • Pre-hospital system of ECPR
– Pierre Carli – On Ambulance one day, ICU
next day, medical command are all anesthesiologist
– “ICU without walls” • Japan
– Tokyo – Thumper in field – Hybrid Room – Straight to ECMO
• Ken Nagao
• PICU • NICU • CHD • Near Future
– ECPR – Lung Rescue (CHOP/Penn) – Delivery of Adjuvant
Therapies