ECMO CPR. Ravi R. Thiagarajan MBBS, MPH. Cardiac Intensive Care Unit

Transcription

1 ECMO CPR Ravi R. Thiagarajan MBBS, MPH Staff Intensivist Cardiac Intensive Care Unit Children s Hospital Boston PCICS 2008, Miami, FL

2 No disclosures Disclosures

3 Outline Outcomes for Pediatric in-hospital CPR ECMO to aid CPR (E-CPR) Outcomes for E-CPR All patients Children with Heart Disease Complications E-CPR Utilization, Building a Team & Program

4 Survival after Cardiac Arrest is Poor Cardiac Arrest Incidence : 1 5.5% PICU admits Author Year Survival Location Nadkarni VM % In-hospital Slonim AD % PICU Suominen P % PICU Reis AG % PICU Meaney PA % PICU Parra DA % PCICU Peddy SB % PCICU

5 Survival after Cardiac Arrest is Poor Duration of CPR and Survival Survi ival rate % 50% 40% 30% 20% 10% N = 205 PICU arrests 18.6% 12.2% 2% 5.6% 0% < 15 mins mins > 30 mins Duration of CPR Slonim AD et al; Crit Care Med 1997

6 Management of Cardiac Arrest Recognition, Intervention, Prevention are key Good Quality CPR is essential For patients who have a Cardiac Arrest & fail to respond to conventional CPR 2005 American Heart Association Guidelines: Consider extracorporeal CPR for in-hospital it cardiac arrest refractory to initial resuscitation attempts.

7 ECMO Circuit RA AO

8 ECMO to aid CPR (E-CPR) CPR PHASES PRE ARREST NO FLOW (Untreated Cardiac Arrest) LOW FLOW (Active CPR) POST RESUSCITATION ECMO Cardiac Output Gas-Exchange Post-Resuscitation Therapies

9 ECMO to aid CPR (E-CPR) Adult E-CPR first reported 1989 Adult E-CPR survival rate 0 43% ELSO registry Adult E-CPR survival rate 27%* Pediatric E-CPR first reported 1992 Pediatric E-CPR survival 30 40% E-CPR use is increasing * Thiagarajan RR et al (submitted)

10 Lancet 2008, 372: 554

11 Circulation 2007; 116:

12 E-CPR users ELSO registry data Variable n(%) ECMO runs ( ) 26,248 E-CPR runs 695 (2.6) No: patients 682 Age (median, range) 3 mo (0 215) Weight (median, range) ECMO mode (Veno-Arterial) 4.5 kg ( ) 615 (90%) Prior ECMO exposure 41 (6%) Survival to discharge 261 (38%) Thiagarajan RR et al. Circulation.2007

13 Diagnostic groups ELSO data N = Sepsis 7% Pediatric Respiratory Disease 6% Neonatal Respiratory Disease 4% Accidental Injury 2% Cardiac Disease 76% Other 5% Thiagarajan RR et al. Circulation 2007

14 Predictors of Mortality after E-CPR Demographic and Pre-ECMO factors Variable Odds Ratio 95% CI Diagnostic Group - Other - Neonatal Resp disease (reference) Cardiac disease Arterial ph prior to ECMO -< (reference) > White Race Thiagarajan RR et al.. Circulation. 2007

15 Predictors of Mortality after E-CPR ECMO factors Variable Odds Ratio 95% CI Serum Creatinine > Arterial ph < 7.2 on ECMO Pulmonary Hemorrhage Radiological CNS injury CPR during ECMO Thiagarajan RR et al.. Circulation. 2007

16 ELSO Data N = 421 E-CPR Non-survivors Time of Death after ECMO initiation < 72 hours 52% > 72hours 48% Death < 72 hours 72 hours Brain Death* 85% 15% ph < 6.9* 61% 39% Renal failure* 41% 59% * p < 0.05 Thiagarajan RR et al.. Circulation. 2007

17 J Thorac Cardiovasc Surg 2008, 136:

18 Cardiac E-CPR patients ELSO registry data ( ) Sub-analysis of the ELSO E-CPR data Cardiac Diagnosis: 492 Cardiac Surgical Procedure: 285 Overall Survival rate: 42% Median age: 80 days Chan T et al. JTCVS. 2008

19 Cardiac E-CPR Predictors of Mortality ELSO registry data ( ) All Cardiac Patients: Odds Ratio (OR) Single Ventricle Diagnosis 1.6 Pre-ECMO ph < Neck Cannulation 0.6 Cardiac Surgical Patients: RACHS 6 complexity 2.7 Neck Cannulation at Complications on ECMO (CNS, Renal injury) Chan T et al. JTCVS. 2008

20 Summary of E-CPR data from ELSO E-CPR promotes survival Diagnosis, i Quality of resuscitation ti impact survival ECMO complications impact survival Cardiac Surgical patients Single ventricle disease Surgical complexity Neurological and Long-term outcome data for survivors not available Thiagarajan RR et al.. Circulation. 2007

21 Creating an E-CPR program Patient Selection: Witnessed Arrest Reversible Cause Good Quality CPR Good prognosis from primary disease Mechanical Circulatory Support Device Easy to assemble Small priming volume Mobile Rapid Deployment (< 30 min of arrest)

22 Creating an E-CPR Program ECMO equipment Cannula, Pump, Circuit, Oxygenator E-CPR team In-House, Personnel Process of care Who, Does What, & How Team training Medical Simulation Quality assurance & Bench Marking Quality Measures, Outcome

23 Cardiac E-CPR Program Children s Hospital Boston

24 Equipment Standard ECMO circuit -<15 kg Neonatal circuit with Membrane Oxygenator (wet primed) - > 15 kg Adult circuit with Hollow fiber or Quadrox Oxygenator (de-aired) ECMO Pump: Roller Pump Crystalloid prime solution

25 Equipment

26 E-CPR team Cardiac Surgeon Intensive Care Physician i Nursing Staff ECMO technician i (primer) Respiratory Care OR staff (optional) ICU physician is the Event Manager Charge Nurse mobilizes resources Specific Roles for Team Members

27 Process of Care Cardiopulmonary Resuscitation in progress ICU team decides to initiate E-CPR ECMO STAT Page ECMO primer Cardiac Surgeon STAT paged Blood Bank notified ECMO Equipment moved to the bedside Surgical Equipment moved to bedside Time Out # 1 Access and Cannulation plan

28 Vascular Access Occluded Yes No? Femoral Vein Right Left VASCULAR Femoral Artery Left ACCESS Internal Jugular Vein Right Left INFORMATION SHEET ANATOMY Aortic arch Right Right Left CICU CH- BOSTON SVC Right Left Bilateral IVC Interrupted Dextrocardia Heterotaxy Asplenia Polysplenia Airway Difficult intubation

29 Process of Care ECMO cannulation Thoracic or Peripheral Heparin Bolus (50 units/kg) ECMO Arterial & Venous limbs connected Time Out # 2 before unclamping the circuit ECMO Flow initiated iti t (100ml/kg/min) / Echocardiogram Consider Left Atrial decompression

30 Process of Care Initiate ECMO with 21% FiO2 Hypothermia to 34 0 CX48h Hemo-concentration using Ultrafiltration Anticoagulation monitoring i ACT or Other (Heparin level; TEG) Anti-thrombin- III level Investigate & treat cause of arrest Antibiotic Prophylaxis Neurological assessment

31 Team Training & Quality Improvement ECMO Simulator Technical aspects of ECMO for surgeons Training to manage ECMO complications Teamwork training Monthly ECMO Conference Debrief events to identify deficiencies Mechanical Issues Time to Cannulation/ Time-outs ECMO issues and outcomes

32 Cardiac E-CPR Survival to Discharge CHB Data (N = 189) Variable Cardiac ECMO runs ( ) 430 Cardiac E-CPR runs 189 (44%) No: pf patients 182 Age (median, range) 7 mo (0-446) Survival to Hospital Discharge 92 (50%) n

33 Cardiac E-CPR Program Outcomes CHB data % 80% 60% 40% 20% 0% % of ECMO patients ECLS years ECPR Non-ECPR

34 Cardiac E-CPR Initiation Site Data (N = 156): Catheterization Lab 18% Emergency Department 1% In patient ward 5% CICU OR 75% 1%

35 CPR duration prior to ECMO Data (N = 189) p = min 37 min 30 min 26 min

36 Summary E-CPR promotes survival in Pediatric Cardiac Arrest Beneficial for Cardiac patients Good quality CPR is essential Creating a Process for E-CPR Deployment and may help decrease deployment times Quality assurance process necessary for program improvement Medical Simulation based Team training is essential Longer-term CNS outcomes should be studied

37 Acknowledgments Peter Laussen David Wessel Susan Bratton Peter Rycus Robert Bartlett Cindy Barrett Thomas Brogan Mark Scheurer Joshua Salvin Titus Chan Peter Betit Catherine Allan

38 Pediatric E-CPR use is Increasing Thiagarajan RR et al. Circulation % of all ECMO uses reported to ELSO 50% % 40% ts No: of Patien % 30% 25% 20% 15% Total ECMO cases X 10 E-CPR cases* E-CPR survival rate ** 10% 5% 0% % Survival Linear trend p value: E-CPR use < 0.001; E-CPR survival 0.32

39 E-CPR data from ELSO ECMO is used to aid CPR promoted survival Increasing trend for E-CPR use Survival has not improved with increasing experience Diagnosis, Quality of resuscitation impact survival ECMO complications impact survival Neurological and Long-term outcome data for survivors not available Thiagarajan RR et al.. Circulation. 2007

40 E-CPR users CHB Complications Complication n (%) CNS complications* 50 (39%) - Seizures 10 (8%) - HIE, Cerebral infarcts 24 (19%) - Intracranial Bleed 9 (7%) - Brain Death 7(6%) Multiple Organ Failure* 36 (28%) Mechanical Complications 15 (12%) Bleeding complications 48 (38%) *p <0.05 comparing survivors and non-survivors

41 Cardiac E-CPR patients ELSO Registry Data: N = 492 DIAGNOSIS GROUPS SURGICAL GROUP - COMPLEXITY 22% 38% 28% 2% 12% 0% 40% 10% 48% 2-ventricle RACHS-1 RACHS-2 1-ventricle RACHS-3 RACHS-4 Muscle Disease RACHS-5 RACHS-6 Chan T et al. JTCVS. 2008