ECMO FOR PEDIATRIC RESPIRATORY FAILURE Novik Budiwardhana * PCICU Harapan Kita National Cardiovascular Center Jakarta
Introduction Case D 8 month old baby with severe ARDS with fungal sepsis. He was on HFOV with the MAP of 24, amplitude of 56 and FiO2 of 90% Despite on the high support of ventilation he was only saturating at 76% with PCO2 of high 70s. PaO2 of 35
Introduction (2) A case like case D is something that we might find in everyday practice Several parameters to assess the severity of respiratory have been proposed by some researchers Aa DO2 Oxygen Index PaO2 / Fi O2 ratio Ventilator failure criterion Hypercarbia with ph < 7,0 on high ventilator support such as PIP > 40 cm H2O
More on the case Aa DO2 of this case Aa DO2 = FiO2 (Barometric pressure Water vapor pressure) PaCO2 / RQ PaO2 = (713 x 0.9) - 78/0,8 35 = 509 Oxygen index of this case OI = FiO2 x mean airway pressure (cmh2o) x 100 / PaO2 mmhg = 0,9 x 17,6 x 100 / 35 = 43,7
More on the case (2) PaO2 / FiO2 ratio: 35 / 0.9 = 38,8 Ventilator failure criterion PaCO2 = 78 (hypercarbia) with ph of 6,9 ventilated by HFOV with high mean airway pressure
Evidence AaDO2 has been historically used in neonatal respiratory failure. An Aa DO2 of > 610 for 8 hours correlated with 80% mortality in neonatal respiratory failure. Among pediatric patients AaDO2 the value of AaDO2 of > 470 was noted to be 81% predictive of death Timmons OD. Etal. Mortality rates and and prognostic variables in with adult respiratory distress syndrome. J Pediatr 1991; 119: 896-9
Evidence Oxygen index > 40 predicted mortality of > 80%, OI >40 over several hours is associated with high mortality in neonates, pediatric patients and adults In Pediatric respiratory failure, OI > 40 at 6 hours of ventilation was associated with mortality of 40% with increasing mortality risk over time Trachsel et al. Am J Respir Crit Care Med 2005; 172 : 206-11
Evidence
What is ECMO Frenckner B, Radell P. Seminars in pediatric surgery 2008
Severe ARDS ECMO? How is the result
Neonatal Respiratory ECMO Cumulative runs 27007 1986 Jan 2014
Pediatric respiratory ECMO Cumulative runs : 6149 1986 Jan 2014
ECMO centers in Indonesia: Pros and Cons How did we do? Is it worthwhile to develop ECMO centers based on PICU regionalization? Cardiac ECMO center and Respiratory ECMO centers Universal coverage era begins in 2014 Does it cover ECMO procedure?
ECMO centers ELSO guidelines for ECMO centers, 2010
This how we did it
This is how we did it Most cases will be respiratory other than cardiac or ECPR Harapan Kita National Cardiac Center is the only center who applied EMO as mechanical support for many cardiac cases. If we looked at the registry 2014 our cases are less than 6 times a year Harapan Kita s ECMO program mostly support cardiac because of it s general policy For neonatal and Pediatric respiratory ECMO it is necessary to develop some more ECMO centers
Pediatric respiratory failure on ECMO Registry review 1993-2007 3000 Older children (10 18 years) had a lower survival (50%) compared to Infants (57%), toddlers (61%) and children (55%) Comorbidities increased from 19% in 1993 47% in 2007 Without comorbidities noted to have improved survival over time, from 57% in 1993 to 72% in 2007. There is no significant decline in survival was noted until patients reached a duration of 14days of ventilation prior to ECMO
VV ECMO In pediatric ARDS lung improvement achieved by contracture eliminating high level alveolar dead space
Weaning and decanulation Stable on by pass ventilator settings are decreased to non-injurious level Pulmonary improvement will reflected by increased mixed venous saturation and may also be evident from increased PaO2 and sats The weaning continues until minimum blood flow of ECMO achieve satisfactory levels of parameters. The patient then can be decanulated afterwards
Summary ECMO is one of modalities to overcome severe ARDS and other respiratory problem in neonate and pediatric patients VV ECMO is now increasingly used for pediatric respiratory ECMO The result of neonatal and pediatric ECMO is considerably fair The development of ECMO centers in Indonesia should take into our considerations