Transcript Document

Pediatricke ECMO
(pro koho, kdy a jak)
Ann Karimova
Great Ormond Street Hospital for Children, London
pediatricke ECMO - pro koho, kdy a jak
Novorozenecke
ECMO
Pediatricke
ECMO
(respiracni)
respiracni (MAS, CDH, PPHN)
Kardiologicke
“ECMO”
(kardiochirurgicke
myokarditidy
kardiomyopatie
arytmie…)
pediatricke ECMO - pro koho, kdy a jak
Novorozenecke
ECMO
respiracni (MAS, CDH, PPHN)
Pediatricke
ECMO
(respiracni)
pediatricke ECMO - pro koho, kdy a jak
Pediatricke
ECMO
(respiracni)
pediatricke ECMO - pro koho, kdy a jak
Pediatricke
ECMO
(respiracni)
600-800/ year
(decreasing)
200-250/ year
pediatricke ECMO - pro koho a kdy
Indications:
• severe AHRF refractory to conventional treatment (???)
(?how severe is severe enough? - patient likely to die)
• reversible cause of respiratory failure.
• less than (7) 10 (14) days invasive ventilation (???)
???
inclusion
exclusion
criteria for
pediatric
ECMO
???
inclusion
exclusion
criteria for
pediatric
ECMO
BMC Health Serv Res. 2006
pediatricke ECMO - pro koho a kdy
Exclusion criteria
• irreversible lung pathology such as fibrosis, pulmonary
hypertension,… (???)
• contraindication to heparinisation (low patelets !!!)
• evidence of severe neurological injury
• established multi-organ dysfunction of 4 or more organs
???
not so easy
to evaluate
on admisssion
!!!
pediatricke ECMO - pro koho a kdy
Exclusion criteria – cont.
• ??? approach to co-morbidity (pre-existing co-morbid condition is
acceptable if treatable and compatible with good quality of life)
• prolonged cardiac arrest (? how long is too long? 20 to 40 mins?)
ECMO
as
“ECPR”
…ECMO rescued 1/3 of
patients in whom death was
otherwise certain…
ECMO
as
“ECPR”
pediatricke ECMO - pro koho a kdy
ECMO
as
“ECPR”
pediatricke ECMO - jak
overal survival
in pediatric ECMO
is 50-60%
pediatricke ECMO - pro koho, kdy a jak
United Kingdom
population 60 million
4 ECMO centers
total ECMO
around 200 runs/ year
Great Ormond Street Hospital
Cardio-thoracic and ECMO unit
• 500-600 admission per year
• around 40-50 ECMO runs per
year
pediatricke ECMO - pro koho, kdy a jak
Retrospective review of all paediatric ECMO cases ( age 28
days to 18 years) at Great Ormond Street Hospital for Children
between 1992 – 2005 (primary cardiac patients excluded)
• total 124 paediatric respiratory ECMO cases were supported
(range 7-15 cases per year)
• median age was 10.1 months and a median weight of 8kg
• median number of pre-ECMO ventilation days was 2
• median worst pre-ECMO OI was 39.1
• median duration of ECMO support was 9 days
2008 Brown et al.: GOSH ECMO data
pediatricke ECMO - pro koho, kdy a jak
overall
1Figure
year 1: Outcome from Paediatric respiratory ECLS by
admission diagnosis
survival
Total
59%
viral infections
58 patients,
survival 66%
RSV (43)
pertussis 9 patients,
survival 55%
Viral pneumonia (non-RSV) (15)
Pertussis (9)
Bacterial pneumonia (14)
bacterial pneumonia 14
patients, survival 52%
Sepsis/septic shock (17)
Aspiration (3)
sepsis/ septic shock 17
patients,survival 53%
Overdose/poisoning (2)
Tracheal surgery (4)
Sickle Cell disease (2)
Interstitial lung disease (1)
aspiration 3 patients,all
survived
Post surgical ARDS (4)
Haem-oncology ARDS (2)
Idiopathic ARDS (8)
% survivors
% non-survivors
0
20
40
60
80
100
hemo-oncol 2(+1)
patients, all died
1 year
survival in %
Percentage
2008 Brown et al.: GOSH ECMO data
pediatricke ECMO - jak
VA 63% of patients
(46% mortality),
VV 27%
(24% mortality)
conversion VV to VA 10%
(50% mortality).
%
100
GOSH
VV versus VA
90
80
70
60
50
ELSO registry data
40
30
20
10
0
VV
VA
VV-VA
2008 Brown et al.: GOSH ECMO data
pediatricke ECMO - jak
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
pediatricke ECMO - pro koho, kdy a jak
RISK FACTORS for DEATH
1.septic shock (P=0.01)
2.oxygenation index (P=0.05)
3.pre-ECMO ventilation (P=0.08)
4.end-organ dysfunction (P=0.09)
For each 5 points
increment in OI the
risk of death
increased by 9%
Pre-ECMO OI
2008 Brown et al.: GOSH ECMO data
pediatricke ECMO - pro koho, kdy a jak
COMORBIDITIES
Rheumatology
2%
Post Surgical
2%
Spinal Defect
3%
Sickle Cell
5%
Tracheal
5%
CF
3%
Chromosomal
12%
CLD
5%
IDDM
2%
Cong cardiac
5%
Haem/onc
5%
Ex Prem
51%
53% children had
pre-existing co-morbidity
…pre-existing co-morbidities may
predispose children to develop
severe AHRF but do not reduce
survival
2008 Brown et al.: GOSH ECMO data
pediatricke ECMO - pro koho, kdy a jak
CONCLUSIONS:
… ECMO should be considered promptly in the deteriorating
child who does not respond to conventional treatment…
2008 Brown et al.: GOSH ECMO data
pediatricke ECMO - pro koho, kdy a jak
CONCLUSIONS:
… ECMO should be considered promptly in the deteriorating
child who does not respond to conventional treatment…
2008 Brown et al.: GOSH ECMO data
pediatricke ECMO - pro koho, kdy a jak
long term follow up:
CONCLUSIONS: ECLS is a complex
therapy which has been used in Australian
children for 18 years; a third of children
survived long term, and 96% of these had
a favourable outcome
pediatricke ECMO - pro koho, kdy a jak
long term follow up:
CONCLUSIONS: ECLS is a complex
therapy which has been used in Australian
children for 18 years; a third of children
survived long term, and 96% of these had
a favourable outcome