ECMO Primer A View to the Future

Todd J. Kilbaugh Assistant Professor of Anesthesiology, Critical Care

Medicine, and Pediatrics Director of The ECMO Center at the Children’s

Hospital of Philadelphia

Disclosures

• I have no disclosures or conflicts for this presentation

Not If…When?

Image Permission from Family

Video 1: Grace

Concept: Extracorporeal Life Support

Veno Arterial • Video of VA

Veno Venous • Video of VV

Practice: Types of Extracorporeal Life Support

• Veno Arterial Support – Heart and Lung Bypass – Heart Failure

• Congenital Heart Disease • Myocarditis • Congestive Failure prior

to Transplant • Shock

– Hemorrhagic – Sepsis

• Myocardial Infarction (?)

• Veno Venous Support – Lung Bypass (Also

Affords Heart Rest) – Respiratory Failure

• Acute Failure – Hypoxemia – Hypercarbia

• Chronic Failure – Prior to Transplant

ECMO Indications over 15 years

0%

20%

40%

60%

80%

100% Card (16 years and over)

Card (1 year < 16 years)

Card (31 days < 1 year)

Card (0 - 30 days)

Adult Pulm

Ped Pulm

Neo Pulm

ELSO Registry July 2015

ECMO: Pediatric Pulmonary Failure

Neonatal ECMO

Only 1 randomized, controlled trial Collaborative UK ECMO Trial: Follow-up to 1 Year of

Age UK Collaborative ECMO Group

Pediatrics 1998 – Only report of a RCT of an ECMO policy – Principal Endpoint: death or severe disability at one year of age

• Both reduced

– Follow up at 4 and 7 years of age • Beneficial influence of an ECMO policy still present

ECMO: Neonatal Intensive Care

• Meconium Aspiration Syndrome – Most common indication (30-40%) – Shortest runs (5 – 7 days) – Best survival (94%)

• Pulmonary Hypoplasia – CDH, lung lesions

• Sepsis • Pneumonia

ECMO: Congenital Heart Disease • Three major “routes”:

– Inability to separate from cardiopulmonary bypass in the cardiac OR

– Planned bridge from low cardiac output: • preoperative stabilization • bridge to recovery (post-operative, myocarditis,

intractable arrhythmias, respiratory failure) • bridge to alternate mechanical support (VAD – Berlin

Heart, Thoratec, Heartmate or Syncardia) • bridge to transplantation (usually via VAD support)

– Rescue from sudden cardiac arrest with E-CPR

Inability to separate from bypass

• Prolonged cross clamp • Arrhythmia • Myocardial protection • Pulmonary hypertension • Coronary perfusion (ASO, Norwood) • Residual lesions (rule out using echo/cath) • Preoperative myopathy (ALCAPA, late MR, late

AI)

CHD: Post-operative Low Cardiac Output:

• Both with and without important residual defects of the repair

• Ventricular dysfunction • Pulmonary hypertension (eg TAPVR) • Intractable arrhythmias (JET) • Generally RIJ/RCA cannulation • Supported days, then decannulated • Decreased flow trials with echocardiogram to aid

decision making for separation

CHD: Post-operative Low Cardiac Output

CHD: Extracorporeal CPR • E-CPR for children with cardiac disease

have superior outcomes (survival to d/c) than other groups

• Cardiac patients may benefit from: – Invasive monitoring pre-arrest – Recent surgery – easier access for cannulation – Familiarity of cardiac surgeons with cannulation

techniques – Differences in etiology of arrest

Pediatric ECMO

• Respiratory Failure • Sepsis and Systemic Inflammatory Syndromes • Extracorporeal CPR • Pre-operative Lung Transplant

Lung Rescue

Survived ECLS Survived to DC

ELSO DATABASE 2005-2012

Image Permission from Family

ECMO: Progressive Mobility

Sepsis and Systemic Inflammatory Response Syndrome

• Larger Cannulas = More Flow = Central Cannulation

• Sepsis and Multi Organ Failure: Indicated MacLaren, PCCM 2011

Pediatric ECPR

• ECPR Criteria – Witnessed Arrest and

Initiation of CPR – Quality Metrics of CPR – ECPR activation at 5

minutes

– Crystalloid Primed Circuits

– O Negative If Needed

When is Starting NOW: Anesthesiologists are Leading the Way • Refractory Cardiac Arrest

– Pre-Hospital ECMO • Team

– Anesthesiologist – Nurse – Paramedic – Medical Command

» Anesthesiologist – ED Hybrid Room ECMO

• Tokyo – CHOP ECPR Program and

Mobile Rescue • Building an ICU without

Walls

CHOP and Penn Mobile Lung Rescue Programs

• Video • Patients with ARDS – WE will come to you for

cannulation

• Patients placed on ECMO – WE will come to you for

transport

ECMO Optimizing Neuroresuscitation

• Neuromonitoring – EEG – Diffuse Optical

Spectrocopy • Cerebral Blood Flow • Cerebral Oxygen

Saturation • Cerebral oxygen

extraction fraction

• Adjuvant Therapy Delivery – Hypothermia – Mitochondrial

Resuscitation

Oxygen &

Metabolic substrates

Increase delivery/supply meet demand

Which Rx ? Death

ATP

Mitochondrial Directed Therapies

ECMO Adjuvant Therapies • Hemodialysis • Plasmapheresis • Leukoreduction • Rapid Temperature

Regulation

Video 2: Sean

Notes • Pre-hospital system of ECPR

– Pierre Carli – On Ambulance one day, ICU

next day, medical command are all anesthesiologist

– “ICU without walls” • Japan

– Tokyo – Thumper in field – Hybrid Room – Straight to ECMO

• Ken Nagao

• PICU • NICU • CHD • Near Future

– ECPR – Lung Rescue (CHOP/Penn) – Delivery of Adjuvant

Therapies