Pediatric ECMO and CRRT NJ Maxvold MD Assoc Prof of Pediatrics, MSU DeVos Children’s Hospital...

Pediatric ECMO and CRRT

NJ Maxvold MDAssoc Prof of Pediatrics, MSU

DeVos Children’s HospitalGrand Rapids, MI


• I would like to thank Dr Picca and Dr Bunchman for this conference

• I would like to thank Dr Askenazi for the incorporation of some of his slides into today’s presentation


Objectives:Review of ECMO in Pediatrics Indications/Limitations/Complications Survival Data• Review of CRRT tandem to ECMO Indications/Limitations/Complications Survival Data

ExtraCorporeal Membrane Oxygenation

Respiratory Failure vs Cardiac FailureReticent to Mechanical Ventilatory Equipment (HFOV,HFJV,BiLevel/APRV,NO/Surfactant, etc) Limit Vent-Induce Further Lung InjuryReticent Arrhythmias / CO

unresponsive to meds or volume status/ noncandidates for VAD/Post Cardiac Surgery

Limit End Organ Ischemia


ECMO Limitations: Patient Size: Cannula/Catheters for

Preterm/Small Infants Highly Catabolic-Hypermetabolic States

Exceeding Flow Delivery Coagulopathy not correctable by therapeutic

supports, or recent Intracranial Bleed Contraindications to system heparinization Irreversible Lung or Cardiac Failure not

deemed a Transplant Candidate


ECMO Complications:• Bleeding: Heparin Anticoagulation• Embolic Events: Microemboli / Air emboli from the circuit• Catheter Displacement• Heparin induced thrombocytopenia• ?? End Organ/Renal Effect of

Continuous Flow


Russell et al Circulation 2009 End Organ Function Continuous Flow LVAD N= 309 pts, HeartMate II, 6 mo Follow Interval Two Group Analysis: Normal and Above Normal

Laboratory ValuesBUN / Cr 37 / 1.8 23 / 1.4 mg/dL AST/ALT 121 / 171 36 / 31 IUT Bilirubin 2.1 0.9 mg/dL

Conclusions: Continuous flow maintained or improved end organ function

ExtraCorporeal Membrane Oxygenation Ingyinn et al Perfusion 2004Compared VV to VA Effect on Renal Flow in Lambs 3 Parameters: Systemic Blood Pressure, Renal Blood Flow,

Plasma Renin Activity LevelsVA and VV Partial Flow (120 mls/kg/min)VA Full Flow (200 mls/kg/min)No difference at partial flow between VV and VA parametersFull VA Flow Significant Increase of Blood PressureFull VA Flow Flashing/Unclamp of ECMO Bridge BP Renal

FlowConclusion: Potential cause of the Hypertension that is seen

in some newborns after VA ECMO


Mussaro et al Pediatr Crit Care Med 2009Evaluated Bloodless Bridge on VA ECMO (No

Flashing/Unclamping) Retrospective comparison to the Earlier Bridge ECMO SetupParameters: BUN, Cr, Fld Balance, Urine Ouput, Average and max SBP, mean BPNo Difference in BUN, Cr, Fld Balance, Urine OutputLower % of HTN (Mean BP> 60), Lower SBP on Days 2, 3 Conclusion: Less HTN with the new bridge design that

did not require flashing therefore improved maintenance of Renal flow


Basic ECMO Design / Setup:Venovenous Design: Outflow and Inflow

catheters in Venous SystemVenoArterial Design / Setup: Outflow

from Venous (R Atrium), Inflow Arterial (Aortic Arch)

VA vs. VVDL Cannulation

Typical VVDL catheter placement

ECMO Centrifugal Pump Setup

Centrifugal circuit design


ECMO Neonatal/Pediatric Survival Data: ELSO Registry 1998-2008

Neonates ( </= 30 days old) N= 8958 Survival: 5776 (72.6%) NonSurvival: 2182 (27.4%)


ECMO and PCRRT Indications for CRRT tandem with ECMOSystems Set Up Design Publications reviewing PCRRT and

ECMO Survival and Longterm Renal Outcomes

PCRRT and ECMO

CRRT/ECMO Indications ?? Fluid Overload > 10% ( Michael et al Pediatr

Nephrol 2004)

pRIFLECr maxF (Akcan-Arikan et al Kidney Int 2007)

[Definition : eCCl by 75% or <35m/min/1.73m2]

• Nutritional Limitation ( Due to Inadequate Solute/ Fluid Clearance)

CRRT on ECMOCRRT on ECMO““Homemade” system connected to the Homemade” system connected to the

ECMO circuit ECMO circuit IV infusion pumps used to control IV infusion pumps used to control

ultrafiltrate ultrafiltrate (if replacement desired) IV infusion pump to (if replacement desired) IV infusion pump to

add replacement fluids add replacement fluids Several sites to hook into circuit each with Several sites to hook into circuit each with

drawbacks ( shunting, bubble trap, flows)drawbacks ( shunting, bubble trap, flows) IV pumps are not engineered to maintain IV pumps are not engineered to maintain

accuracy when flow/pressure above the accuracy when flow/pressure above the pump is variable.pump is variable.

ECMO/CRRT Arrangement: Homemade System

ECMO/CRRT Arrangement: RRT System

ECMO and CRRTECMO and CRRTHemofilter Hemofilter (Homemade)(Homemade)

CRRTCRRT

Ultrafiltration Ultrafiltration controlcontrol

IV pump IV pump controlledcontrolled

CRRT machine CRRT machine controlledcontrolled

Metabolic ControlMetabolic Control NONO YESYES

ECMO FlowECMO Flow Blood Shunt Blood Shunt -decrease ECMO decrease ECMO flow or decreased flow or decreased PaO2 to patient PaO2 to patient

NO systemic NO systemic changeschanges

Anti-coagulationAnti-coagulation HeparinHeparin HeparinHeparin

CRRT/ECMO in Tandem

CRRT/ECMO Centrifugal Pump Santiago et al Kidney Int 2009 N= 6 children on VA ECMO Inlet line after the Centrifugal Pump Outlet/return line before the Oxygenator Mean Filter Life = 138 hours

CRRT/ECMO in Tandem

CRRT/ECMO OutcomesCRRT/ECMO Outcomes

Meyer RJ, et al Pediatr Crit Care Med 2001 • 15/ 35 ( 42.9 %) neonatal and pediatric 15/ 35 ( 42.9 %) neonatal and pediatric

survivedsurvived14/15 (93%) RENAL RECOVERY14/15 (93%) RENAL RECOVERY1/15 (7%) – Wegener’s1/15 (7%) – Wegener’s

CRRT/ECMO in Cardiac NewbornsCRRT/ECMO in Cardiac Newborns Shah SA et al. ASAIO J 2005

41/ 84 (48.9%) 41/ 84 (48.9%) post-operative congenital heart post-operative congenital heart disease patients with AKIdisease patients with AKI CVVH NOT associated with :CVVH NOT associated with :

Ability to wean off ECMOAbility to wean off ECMO Survival to discharge Survival to discharge

Kolovos et al. Ann Thorac Surg 2003 26 / 74 (35%) post-operative congenital heart 26 / 74 (35%) post-operative congenital heart

disease patientsdisease patients Hemofiltration = 5.01 X increased risk of deathHemofiltration = 5.01 X increased risk of death

CRRT/ECMO – Noncardiac CRRT/ECMO – Noncardiac ChildrenChildrenHoover et al. Intensive Care Med (2008)

Case-control studyCase-control study Cases 26/86 - received CVVH for >24 hours Cases 26/86 - received CVVH for >24 hours Controls – no CVVHControls – no CVVH

Significant differences in fluid balanceSignificant differences in fluid balance Significant treatment differencesSignificant treatment differences No difference in survival or vent days No difference in survival or vent days

during or after ECMOduring or after ECMO

Askenazi et al Abstract CRRT 2009Askenazi et al Abstract CRRT 2009

ELSO Registry Data,1998-2008ELSO Registry Data,1998-2008 8958 patients age 8958 patients age ≤ 30 days≤ 30 days

Asked the Question:Asked the Question:Hypothesis: After controlling for Hypothesis: After controlling for

demographic, complications, severity demographic, complications, severity of illness, interventions, does AKI / RRT of illness, interventions, does AKI / RRT predict mortality in non-cardiac predict mortality in non-cardiac neonates who require ECLS?neonates who require ECLS?

ECMO/CRRTECMO/CRRT

AKI Categorically definedAKI Categorically defined Complication code of SCr Complication code of SCr ≥ 1.5 mg/dl or ≥ 1.5 mg/dl or ICD-9 code of Acute renal failureICD-9 code of Acute renal failure

DialysisDialysis CPT codes used CPT codes used

SurvivalSurvivalDemographics, Complications, Co-Demographics, Complications, Co-

Morbidities and InterventionsMorbidities and Interventions

Extracorporeal Life Support Extracorporeal Life Support Organization (ELSO) RegistryOrganization (ELSO) Registry

Askenazi et al. Abstract CRRT 2009

ELSO Registry - Neonates


74%

3%

5%

18%

NeitherAKIBothRRT

ELSO Registry - Neonates


Survival by AKI/RRT class

0

1000

2000

3000

4000

5000

Neither AKI Both RRT

Non-Survivors Survivors


ELSO Pediatric Registry 1998-2008 N = 2514 Survival = 1410 (56%) • ELSO Accumulative (1985-2008) N = 4065 Survival = 2247 (55.3%) Ped Pts Receiving Dialysis (1985-2008) N = 1616 (39%) Survival = 606 (37.5%)

ELSO 1985-2008 Cardiac Runs

Age Total Runs

Survival Dialysis Survival

0-30 days

N=3824 N=1430(37.4%)

N=1595(41.7%)

N=354(22.2%)

1-12 months

N=2428 N=1058(43.6%)

N=926(38%)

N=244(26.3%)

1-16 years

N=2034 N=975(47.9%)

N=783(38.5%)

N=273(34.9%)

>16 years

N=1113 N=388((34.9%)

N=533(47.9%)

N=118(22.1%)

CRRT/ECMO SummaryCRRT/ECMO Summary ECMO&CRRT Can be Safely done in a variety of setupsECMO&CRRT Can be Safely done in a variety of setups No additional regional Anti-coagulation is needed since No additional regional Anti-coagulation is needed since

the patient and the entire circuit is already heparinized for the patient and the entire circuit is already heparinized for ECMOECMO

Circuit prime for the CRRT can usually be salineCircuit prime for the CRRT can usually be salineDue to the relative size of the CRRT circuit in ratio to the Due to the relative size of the CRRT circuit in ratio to the

larger ECMO circuitlarger ECMO circuit• When starting Ultrafiltation careful monitoring of fluid When starting Ultrafiltation careful monitoring of fluid

goals over a time period will prevent goals over a time period will prevent Hct and viscosity Hct and viscosity changes that are unwantedchanges that are unwanted

• CRRT Support on ECMO Effect on Mortality is yet to be CRRT Support on ECMO Effect on Mortality is yet to be more clearly defined as to timing of Initiation of both more clearly defined as to timing of Initiation of both supports and Subsequent Outcomes. supports and Subsequent Outcomes.

Aortic Arch Right Atrium

Blood Return

Blood Drainage

Bridge

Membrane OxygenatorPump

Servo-regulation

Heat Exchanger

Heparin and Fluids

ECMO Circuit

Pediatric ECMO and CRRT NJ Maxvold MD Assoc Prof of Pediatrics, MSU DeVos Children’s Hospital...

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