Fellow`s Conference: Medical management of Neonatal ECMO
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Transcript Fellow`s Conference: Medical management of Neonatal ECMO
Management of Infants
requiring Venovenous ECMO
Sixto F. Guiang, III
Dept. of Pediatrics
University of Minnesota
Neonatal ECMO = 73 % of all ECMO
VV ECMO = 20% of all Neonatal Pulmonary
University of Michigan
JAMA 2000;283:904-908
N= 1000
Newborns N=586
Survival
MAS
CDH
Others
90% veno-venous
9% IVH
88%
98%
68%
84-93%
VV ECMO
Respiratory Mode for all ages
Infants
20% of all Respiratory ECMO
Approximately 800 cases / yr
Pediatric 28% of all Respiratory ECMO
Approximately 200 cases / yr
Pediatric VV ECMO
Pediatr Crit Care Med 2003;4:291-298
Single Center 1991-2002
N = 82 ECMO for Respiratory Failure
Venovenous
Venoarterial
Unable to place VV
83%
17%
43%
Pediatric VV ECMO
Venovenous
Dx
ARDS
RSV bronchiolitis
Penumonia
Outcomes
Lower degree of respiratory failure
Shorter ECMO (212 hour vs 350 hours)
Higher survival (81% vs. 64%)
Pediatric VV ECMO
Pediatr Crit Care Med 2003;4:291-298
Infusion limb
Drainage limb
Inclusion / Exclusion
Guidelines- Same as VA
age of at least 34 weeks
Weight >1.5-2.0 kg
Potentially reversible process
Absence of uncorrectable cardiac defect
Absence of major intracranial hemorrhage
Absence of uncorrectable coagulopathy
Absence of lethal anomaly
Absence of prolonged mechanical ventilation with
high ventilatory settings
Oxygenation Failure
Criteria - VA and VV
Alveolar - arterial oxygen tension gradient
[760 - 47)-paCO2] - paO2
605 - 620 torr for greater than 4-12 hours
Oxygenation index
Mean Airway Pressure x FiO2 x 100/ paO2
> 35-60 for greater than 1-6 hours
Oxygenation Failure
Criteria - VA and VV
paO2
PaO2 < 35 for 2 hours
paO2 < 50 for 12 hours
Acute decompensation
paO2 < 30 torr
Myocardial Failure - VA Only
Refractory hypotension
Low cardiac output
pH <7.25 for 2 hours or greater
Uncontrolled metabolic acidosis secondary to
hemodynamic insufficiency
Cardiac arrest - CPR
Additional Exclusion Criteria Venovenous ECMO
Severe LV dysfunction
Severe hypotension
Cannulation during CPR
Desire to not have heparin
Bleeding
Additional Exclusion Criteria Venovenous ECMO
Use of vasopressors is NOT a
contraindication for VV ECMO
Isolated RV failure is NOT a
contraindication for VV ECMO
Vasopresor - VV ECMO
ASAIO Journal 2003;49:568-571
Neonatal ECMO-VA and VV
N = 43
Quantified inotropic support - Index
1 point = 1mcg/kgmin
Dopamine
Dobutamine
1 point = 0.01 mcg/kg/mon
Epinephrine
Norepinephrine
ASAIO Journal 2003;49:568-571
ASAIO Journal 2003;49:568-571
ASAIO Journal 2003;49:568-571
Infants with Inotropic Score > 10
ASAIO Journal 2003;49:568-571
ECMO Goals - VA and VV
Maintain adequate tissue oxygenation to
allow recovery from short term
cardiopulmonary failure
Adjust ventilator settings allowing for Lung
Rest minimizing further ventilator /oxygen
induced lung injury. Not necessarily lower
settings
ECMO Modes
Venoarterial - VA
Blood drains-venous system
Blood returns-arterial system
Complete cardiopulmonary support
Venovenous - VV
Blood drains-venous system
Blood returns-venous system
Pulmonary support only
Advantages of VA ECMO
Able to give full cardiopulmonary support
No mixing of arterial / venous blood
Good oxygenation at low ECMO flows
Allows for total lung rest
Disadvantages of VA ECMO
Ligation of the right carotid artery
Nonpulsatile arterial blood flow
Suboptimal conditions for LV function
Low preload
High afterload
High wall stress
Low coronary oxygenation
Disadvantages of VA ECMO
Systemic emboli
Air
thrombus
Advantages of VV ECMO
No ligation of carotid artery
Normal pulsatile blood flow
Optimize LV performance
More preload
Less afterload
Better coronary oxygenation
Less ventricular wall stress
No systemic emboli
Disadvantages of VV ECMO
Need a functioning LV
Mixing of blood
lower arterial saturation
Need increased ECMO flow
Need higher hemoglobin
Need to place a larger cannula
More difficulty monitoring adequacy of
oxygen delivery
Recirculation of ECMO flow
Disadvantages of VV ECMO
May need to convert to VA
Need to be fully heparinized
Cannula cannot be heparin bonded
VV ECMO -Double lumen
Newborns
>90% of VV ECMO - Double lumen
12F and 15F OriGen
Pediatric
35% of VV ECMO -double lumen
18F - largest OriGen cannula
65% internal jugular, femoral, sapphenous
VV ECMO -Double lumen
Cannula site
Internal jugular vein (15F double lumenpreferred)
Cannula tip low in the right atrium
Drainage
Infusion
High lateral RA
Mid Medial RA
Low lateral RA
Endhole
Optimal Cannula Placement
Adequate size
Correct depth
Correct Rotation
Low Right Atrium
Label visible
Drainage limb (Blue) posterior
Infusion limb (Red) anterior
Vertical orientation
Head - midline
No Kinks
Recirculation
Oxygenated ECMO blood returning to
the ECMO circuit immediately after
infusion
Recirculation factors
Head /cannula position
Changes with head rotation
Changes in lung volume / relative position
of the heart and cannula
ECMO flow
Right atrial size / intravascular volume
RV contractility
ECMO blood flow
to baby - 160
ECMO Flow reads 200
ECMO blood flow
to baby - 250
ECMO Flow reads 500
ECMO Flow -Recirculation
More ECMO flow will always increase
recirculation
More ECMO flow may either
Increase blood flow to baby
Decrease blood flow to baby
VA ECMO
ECMO flow rate is proportional to the level of
support
More flow
More support
Always advantageous if more flow is possible
More ECMO flow will always increase SvO2
Pulmonary Support - VV
Net ECMO blood flow of infant = measure
ECMO flow - recirculation flow
ECMO flow (flow probe) DOES NOT indicate
level of support
SvO2 DOES NOT reflect level of systemic
oxygen delivery
Circulatory Support
Net flow to baby assessed by
Infant color
Infant arterial saturation and PaO2
Assessment of Recirculation
More recirculation if
Decreasing baby arterial sat or PaO2
Increasing SvO2 on ECMO circuit
Decreasing color difference on drainage
and infusion limbs of circuit
Reducing Recirculation
Adjusting relative cannula position
Head position
Lung inflation
Decrease ECMO flow
Increase intravascular volume
Increase RV contractility
Volume
Vasopressors
Pulmonary vasodilators
VV - VA Conversion
Needed if
10-15% of cases
Hemodynamic support is inadequate
Respiratory support is inadequate
More problematic when ultrafiltration is used
VV ECMO - Specific Issues
ECMO Prime
Must have added heparin
Must have Ca added
Ionized Ca on circuit must be
checked prior to cannulation
Potassium must be checked
Heparin
If no heparin added
Addition of Ca binds citrate of blood
products
Loss of anticoagulant activity
Acute clotting of the entire circuit
Need to prime another circuit
Calcium
If no calcium added
Acute hypocalcemia - Ca binds to citrate of
blood products
Loss of LV and RV contractility
Acute hypotension
Cardiac arrest
Potasium
If potassium in prime is not checked
Possible higher serum K from the stored
PRBC
Acute hyperkalemia
Arrythmia
Cardiac arrest
Head / Cannula Position
Distal tip low in RA
Head in the midline with vertical orientation of
the drainage and infusion limbs
RA drainage ports
Lateral
Infusion ports
Medial
Keys to Management
VV ECMO- DL
Need to think in terms of NET blood flow
to the baby
Cannot quantify NET flow
SvO2 is not indicative of adequacy of
systemic oxygen delivery
Indirectly assessed with SaO2 and
PaO2 on the infant
To Improve oxygenation
Give PRBC
Increase ECMO flow
Decrease recirculation
Check cannula position
Increase ntravascular volume
Increase RV contractility
Rest Ventilator Settings
Pressures - similar to VA
FiO2 - able to wean to RA frequently
Better myocardial oxygenation via ECMO
flow than VA
Jugular venous drainage
11% of all double lumen VV
Small study suggested decrease IVH
Reduced cerebral venous pressure
Advantage
Additional drainage facilities flow
2 site venous drainage lessens
recirculation on VV ECMO
Improved oxygen delivery
Enables venous oxygen saturation
monitoring on VV ECMO
Jugular Venous Drainage
Cephalad Cannula
J Pediatr Surg 2004;39:672-676
Review of ELSO database
Neonatal Respiratory Failure VV ECMO
1989-2001
N = 2471
96% VV double lumem alone
3.7% with jugular venous drainage
Similar Outcomes
Operating Parameters
SaO2 - 85-95%
PaO2 40-65 torr
Blood pressure - similar to VA
ECMO flows - 130-150+ ml/kg/min
HgB 12-15 g/dl
Weaning of ECMO - VV
No clamp out needed
Increase ventilator
Decrease sweep gas flow rate and FiO2
Sweep gas flow can be completely stopped
SvO2 will reflect mixed venous saturation
No recirculation
Gas
Flow
NO Gas
Flow
VV ECMO Outcomes
Generally slightly better than VA, but
slightly different patient populations
Hemodynamically more stable
Less exposure to CPR
Better survival
Shorter duration of ECMO
Conversion VV to VA
12%
VA - VV Comparison studies
J Peds Surg1993;28:530-536
Multicenter data
N=243
VA = 135
VV = 108
Similar survival
10% conversion to VA
Shorter runs
Less Neurologic complications