ECMO Primer A View to the Future

Transcription

1 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

2 Disclosures I have no disclosures or conflicts for this presentation

3 Image Permission from Family Not If When?

4 Video 1: Grace

5 Concept: Extracorporeal Life Support Veno Arterial Video of VA Veno Venous Video of VV

6 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

7 ECMO Indications over 15 years 100% 80% 60% Card (16 years and over) Card (1 year < 16 years) Card (31 days < 1 year) Card (0-30 days) Adult Pulm Ped Pulm 40% Neo Pulm 20% ELSO Registry July %

8 ECMO: Pediatric Pulmonary Failure

9 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

10 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

11 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

12 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)

13 CHD: Post-operative Low Cardiac Output:

14 CHD: Post-operative Low Cardiac Output 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

15 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

16 Pediatric ECMO Respiratory Failure Sepsis and Systemic Inflammatory Syndromes Extracorporeal CPR Pre-operative Lung Transplant

17 Lung Rescue ELSO DATABASE Survived ECLS Survived to DC

18 ECMO: Progressive Mobility Image Permission from Family

19 Sepsis and Systemic Inflammatory Response Syndrome Larger Cannulas = More Flow = Central Cannulation Sepsis and Multi Organ Failure: Indicated MacLaren, PCCM 2011

20 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

21 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

22 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

23 ECMO Optimizing Neuroresuscitation Neuromonitoring EEG Diffuse Optical Spectrocopy Cerebral Blood Flow Cerebral Oxygen Saturation Cerebral oxygen extraction fraction Adjuvant Therapy Delivery Hypothermia Mitochondrial Resuscitation

24 Mitochondrial Directed Therapies Increase delivery/supply meet demand ATP Oxygen & Metabolic substrates Which Rx? Death

25 ECMO Adjuvant Therapies Hemodialysis Plasmapheresis Leukoreduction Rapid Temperature Regulation

26 Video 2: Sean

27 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