Transcript Kein Folientitel

PCRRT and ECMO
A. Dodge-Khatami, MD, PhD
K NDERSPITAL ZÜRICH
University Children‘s Hospital, University of Zürich, Switzerland
Division of Congenital Cardiovascular Surgery
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.
K NDERSPITAL ZÜRICH
ECMO
3 major groups:
•respiratory: neonatal & pediatric (82 %)
•cardiac: neonatal & pediatric (14.2 %)
•adult cardio-respiratory failure (3.8 %)
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Respiratory ECMO
•Congenital diaphragmatic hernia
•Meconium aspiration syndrome
•Respiratory Insufficiency/RDS
•Persistent Fetal Circulation/PPHN
•Sepsis/Pneumonia
•Air leak syndrome
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Respiratory ECMO
indications:
•Oxygenation Index (OI)=
mean airway pressure x ([FIO2 x 100]/PaO2)
•OI >25 without improvement under ttt or OI >40.
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Respiratory ECMO
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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%.
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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
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ECMO
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ECMO
1.
neck cannulation if chest closed: right carotid
artery + ipsilateral internal jugular vein.
2.
confirm lack of need for a vent in the left
atrium (possibilty of Rashkind in neonates).
3.
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.
K NDERSPITAL ZÜRICH
ECMO
K NDERSPITAL ZÜRICH
ECMO
•setup time (15-20 minutes), large priming volume
(~300 ml).
•maintain ACT 180-220, 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
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ECMO
Cost (CHF):
•ECMO system:
•Blood unit (250 cc) :
•Cannulae (1A + 2V):
•Water prime/rinse:
•Total:
1860.218.810.15.2903.-
•Hemofilter:
154.-
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.
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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%)
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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
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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
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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