ECMO CPR Ravi R. Thiagarajan MBBS, MPH Staff Intensivist Cardiac Intensive Care Unit Children s Hospital Boston PCICS 2008, Miami, FL
No disclosures Disclosures
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
Survival after Cardiac Arrest is Poor Cardiac Arrest Incidence : 1 5.5% PICU admits Author Year Survival Location Nadkarni VM 2006 27% In-hospital Slonim AD 1997 13.7% PICU Suominen P 2000 17.8% PICU Reis AG 2002 19% PICU Meaney PA 2006 22% PICU Parra DA 2000 44% PCICU Peddy SB 2007 46% PCICU
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 15-30 mins > 30 mins Duration of CPR Slonim AD et al; Crit Care Med 1997
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.
ECMO Circuit RA AO
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
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)
Lancet 2008, 372: 554
Circulation 2007; 116: 1693 1700
E-CPR users 1992 2005 ELSO registry data Variable n(%) ECMO runs (1992 2005) 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 (1.7 125) 615 (90%) Prior ECMO exposure 41 (6%) Survival to discharge 261 (38%) Thiagarajan RR et al. Circulation.2007
Diagnostic groups ELSO data N = 682 1992-2005 Sepsis 7% Pediatric Respiratory Disease 6% Neonatal Respiratory Disease 4% Accidental Injury 2% Cardiac Disease 76% Other 5% Thiagarajan RR et al. Circulation 2007
Predictors of Mortality after E-CPR Demographic and Pre-ECMO factors Variable Odds Ratio 95% CI Diagnostic Group - Other - Neonatal Resp disease (reference) 028 0.28 012 0.12 066 0.66 - Cardiac disease 0.51 0.31 0.82 Arterial ph prior to ECMO -< 6.9-6.9 7.17 (reference) 0.62 0.35 1.10 - > 7.17 0.50 0.45 0.94 White Race 0.65 0.45 0.94 Thiagarajan RR et al.. Circulation. 2007
Predictors of Mortality after E-CPR ECMO factors Variable Odds Ratio 95% CI Serum Creatinine > 1.5 1.89 1.17 3.03 Arterial ph < 7.2 on ECMO 2.23 1.23 4.06 Pulmonary Hemorrhage 2.23 1.11 4.50 Radiological CNS injury 2.79 1.55 5.02 CPR during ECMO 306 3.06 142 1.42 658 6.58 Thiagarajan RR et al.. Circulation. 2007
ELSO Data 1992-2005 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
J Thorac Cardiovasc Surg 2008, 136: 984-992
Cardiac E-CPR patients ELSO registry data (1992 2005) 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
Cardiac E-CPR Predictors of Mortality ELSO registry data (1992 2005) All Cardiac Patients: Odds Ratio (OR) Single Ventricle Diagnosis 1.6 Pre-ECMO ph < 7.01 2.2 Neck Cannulation 0.6 Cardiac Surgical Patients: RACHS 6 complexity 2.7 Neck Cannulation at 0.5 05 Complications on ECMO (CNS, Renal injury) Chan T et al. JTCVS. 2008
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
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)
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
Cardiac E-CPR Program Children s Hospital Boston
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
Equipment
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
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
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
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
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
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
Cardiac E-CPR Survival to Discharge CHB Data (N = 189) 1995-2008 Variable Cardiac ECMO runs (1984-2008) 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
Cardiac E-CPR Program Outcomes CHB data 1995-2008 100% 80% 60% 40% 20% 0% % of ECMO patients 1984-1992 1994 1996 1998 2000 0 2002 2 2004 2006 2008 ECLS years ECPR Non-ECPR
Cardiac E-CPR Initiation Site Data (N = 156): 1995-2006 Catheterization Lab 18% Emergency Department 1% In patient ward 5% CICU OR 75% 1%
CPR duration prior to ECMO Data (N = 189) 1995-2008 p = 0.12 40 min 37 min 30 min 26 min
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
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
Pediatric E-CPR use is Increasing Thiagarajan RR et al. Circulation.2007 200 10% of all ECMO uses reported to ELSO 50% 180 160 45% 40% ts No: of Patien 140 120 100 80 60 40 20 0 1992-1997 1998 1999 2000 2001 2002 2003 2004 2005 35% 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
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
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
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