Joseph B. Zwischenberger MD

Transcription

1 Neurologic Complications in Adult ECMO Joseph B. Zwischenberger MD Johnston-Wright Professor Chairman: Department of Surgery Surgeon-in-Chief UK Healthcare (mobile) The University of Kentucky Lexington, Kentucky

2 Presenter Disclosure Information Joseph B. Zwischenberger, M.D. Research supported in part through Competitive funding: National Institutes of Health (SBIR,STTR,T-32) Contracts: MC3, Ann Arbor Mi Exotherm, Lexington Ky W-Z Biotek, Lexington Ky Maquet Patent: Avalon Elite (4 more, 3 pending) Novalung Free App: Zwisch Me

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4 Z-Bergerism #12 Innovation is never evidence-based

5 Stroke In ECMO Multi-institutional study of ECMO in pediatric patients CNS Injury = Brain death, stroke, hemorrhage Ischemic stroke in 7% Hemorrhagic stroke in 7% Barrett et al. Pediatr Crit Care (4):

6 Neurologic Complications in Adult ECMO? Neurologic sequelae: Seizures Hemorrhage: Intraventricular, intracerebral, subdural Stroke Brain death Multifactorial: thromboembolic events, hemorrhage, anticoagulation Neurologic sequelae patient selection and management ECMO Red Book

7 Incidence of ECMO Neurologic Complications Downward trend (last 10 yrs) attributed to experience, technology, and patient selection/management Neurologic complications underestimated due to: lack of diagnostic imaging in critically ill patients limited participation in registries (voluntary) lack of standardized reporting ECMO Red Book

8 Neurologic Complications (VV/VA) ECMO runs (VV/VA) runs 121 / / 1769 Brain Death % 5.8 / * / 2.9 Seizures (EEG) % 2.5 / * / 0.9 Seizures (Clinical) % 1.7 / / 1.1 CNS Infarction % 5.0 / * / 3.8 CNS Hemorrhage 2.0 / / 1.4* Table ECMO Red Book

9 Neurologic Risk Factors ECMO circumstances: Pre-existing decreased cerebral oxygenation ECMO assisted CPR: up to 50% neurologic events Resuscitation. 2017;121: Pre-existing neurologic pathologies ECMO circuit configuration TABLE 52-2 Veno-arterial (VA) ECMO versus veno-venous (VV) ECMO ELSO Registry shows no major differences Peripheral cannulation thought to decrease risk Carotid artery cannulation highest stroke risk in adults (~3-5%) J Pediatr Surg. 2012;47:68-75

10 Neurologic Complications and Survival Neurologic Complications VV (9102) n % Survival % VA (7850) n % Survival % Brain Death (Clinical) Seizures (EEG) * Seizures (Clinical) * CNS Infarction (US / CT) * CNS Hemorrhage (US / CT) * * 9 Table ECMO Red Book

11 Time IS Brain As many as 14 billion synapses may be lost during every one minute that a stroke goes untreated The average stroke patient loses approximately 32,000 brain cells every one second Saver, J., 2005

12 General Considerations Supplemental Oxygen to keep O 2 saturation at 94% + Cardiac monitoring for arrhythmias (atrial fibrillation) Addressing cause, while lowering (elevated) temperature Glucose goal Pneumatic compression devices (and/or pharmacologic means) to prevent deep venous thromboses Early mobilization No oral intake to avoid aspiration pneumonia Mechanical intravascular or neurosurgical intervention for thrombectomy in select cases Early intervention Jauch, et. al., 2013

13 Metabolic Disorders o Hypoglycemia Migraine Seizures, Todd s Paralysis Bell s Palsy Syncope Transient Global Amnesia Peripheral Nerve Disorders Intracranial Masses Hypertensive Crisis Psychogenic Presentations Stroke Mimics

14 Treatment Windows from Recognition Intravenous (IV) Activase (Alteplase) (rt-pa) is FDA approved within 3 hours and recommended by AHA and AAN within 4.5 hrs Mechanical thrombectomy is recommended with large vessel occlusion within 6 hours Neuro-interventionalists are increasingly using imaging rather than time to determine candidacy for intervention Demaerschalk, et. al., 2016 Powers, et. al., 2015

15 Acute Focal Neurologic Deficit Ischemic Stroke Hemorrhagic Stroke No Yes No Yes Dx & manage Is the patient a candidate for IV-tPA? Dx & manage No Yes IV-tPA Protocol Is the patient a candidate for endovascular Rx? Initiate Secondary Prevention Prevent Complications Recovery No Yes General Measures Endovascular Protocol Modified from Goldstein Methodist DeBakey Cardiovascular Journal. 2014;10:39-44

16 Modified from 2018 AHA Guidelines for Early Management of Patients with AIS

17 Ischemic Stroke: Large Vessel Occlusion

18 Large Ischemic Stroke

19 Efficacy of tpa by Stroke Subtype % with good outcome tpa Placebo Small vessel Large vessel Cardioembolic

20 Thrombectomy Turk AS. J Neurointerv Surg

21 Thrombectomy

22 Thrombectomy

23 Thrombectomy

24 ELVO Trials MR-CLEAN EXTEND-IA SWIFT PRIME Halted early for efficacy ESCAPE

25 ELVO - Time is Brain STUDY Time to IVt-PA Time to Groin Time to Recan TICI 2b-3 MRS 0-2 Medical MRS 0-2 IA MR CLEAN min 260 min N/A 58.7% 19.1% 32.6%* ESCAPE (1) EXTEND IA (2) SWIFT PR. (3) min min min 185 min 241 min 72.4% 29.3% 53%* 210 min 248 min 86% 40% 71%* 184 min 213 min 88% 35.5% 60.2%* (2) Campbell, B. C. V., et al NEJM doi: /nejmoa (1) Goyal, M., et al. NEJM 2015, doi: /nejmoa (3) Saver, J., et al Presented at ISC Nashville, TN

26 Stroke Intake Process ED Prenotification to Stroke Pager From Bay/Pad to CT NIHSS and quick history outside/inside CT CT/CTA performed NIR attending called from CT Thrombectomy pager? tpa?

27 Hemorrhagic Stroke

28 Hemorrhagic Stroke

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30 Post Evacuation

31 BOTTOM LINE Interventions and outcomes are time-dependent TIME IS BRAIN ECMO patients should be monitored for neurological changes Any neurological change should prompt a Stroke Alert (including rapid CT and CTA imaging)

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33 40% 30% Thiagarajan RR, et al. ASAIO 2017, 63(1):60-67

34 54% neurologically intact survival (26 patients)

35 ECPR 13% increased 30-day survival Better neurological outcome ECMO for cariogenic shock 33% higher 30-day survival than IABP Similar to Tandem Heart/Impella

36 Hemorrhage on ECMO Common Cause Inflammation, altered coagulation, transfusions Management Monitor lab values ACT, aptt, AT, Antifactor-Xa Assay, thromboelastography ECMO Red Book Ideal transfusion protocol not yet established JCVA. 2017;31: Anticoagulation reversed, increase pump flow ECMO Red Book Outcomes Intracranial hemorrhage mortality of 80-90% ELSO Registry

37 Seizures on ECMO Common Cause Thromboembolic and bleeding events Management Conventional to date Clinically diagnosed, verified by EEG Outcomes Survival to discharge rate decreased to 30% versus all ECMO patients 40-60% ECMO Red Book

38 Stroke on ECMO Common Cause Thromboembolic events, rapid PaCO 2, sedation, hemodynamic instability, shock Management Monitor: Transcranial Doppler Sonography (TCD) Cerebral Near-Infrared Spectroscopy (NIRS) Hemodynamics Optimal transfusion management not yet determined ECMO Red Book Outcomes Carotid artery cannulation highest stroke risk ~3-5% J Pediatr Surg. 2012;47:68-75

39 Brain Death on ECMO Most frequent in ECMO assisted CPR Common Cause: Pre-ECMO insult, unrecognized decline during cannulation After resuscitation induce hypothermia with ECMO circuit heater-cooler Monitor clinical neurologic signs, cerebral oximetry No standard criteria for diagnosis CCM. 2016;44:e964-72

40 Risk/Benefit: Survival v. Quality of Life ELSO Registry: No functional neurologic outcomes, only voluntary short-term data from single centers Survival to discharge (Adults) Highest: Viral ARDS (H1N1) Rx with VV ECMO: 70-80% Lowest: ECMO assisted CPR: 25-35% ECMO Red Book Return to work: Single center study of 465 VA ECMO patients found a 25% return to work rate Camboni and Schmid, not yet published

41 Future Directions Adult ECMO use is rapidly expanding ECMO use increased 650% JCN. 2015;11: Identify predictive markers Optimize anticoagulation, transfusion, sedation strategies

42 You should ALWAYS listen to a harmonica player Will play for drinks and tips

43 Neurologic Complications in Adult ECMO Joseph B. Zwischenberger MD Johnston-Wright Professor Chairman: Department of Surgery Surgeon-in-Chief UK Healthcare (mobile) The University of Kentucky Lexington, Kentucky

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45 References 1. Camboni D, Schmid C. Neurologic and pulmonary complications in adult ECLS. The ELSO Red Book. 5 th edition. Ann Arbor, MI: Extracorporeal Life Support Organization (ELSO); 2012: Table Adapted from Extracorporeal Life Support: The ELSO Red Book. 5 th edition. Ann Arbor, MI: Extracorporeal Life Support Organization (ELSO); 2012: Floerchinger, Philipp A, Camboni D, Foltan M, Lunz D, Lubnow M, Zausig Y, Schmid C. NSE serum levels in extracorporeal life support patients-relevance for neurological outcome? Resuscitation. 2017;121: Rollins D, Hubbard A, Zabrocki L, Douglas BC, Bratton, SL. Extracorporeal membrane oxygenation cannulation trends for pediatric respiratory failure and central nervous system injury. J Pediatr Surg. 2012;47(1): Table Neurologic Complications and Survival The ELSO Red Book. 5 th edition. Ann Arbor, MI: Extracorporeal Life Support Organization (ELSO); 2012: Xie A, Lo P, Yan TD, Forrest P. Neurologic complications of extracorporeal membrane oxygenation: a review. JCVA. 2017;31: Lorusso et al. In-Hospital Neurologic Complications in Adult Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Organization Registry. Crit Care Med Oct;44(10):e964-72

46 ECMO FUTURE Catheter based Technology (Ambulatory) Neonates, Children, Adults Acute Severe Respiratory failure Acute Cardiac support ER Transport Resuscitation/Shock Transplantation Recipient Support Donor Support: DCD Organ Block Support : Lung in a Box