Haemofiltration in newborns treated with extracorporeal membrane oxygenation a case-comparison study...
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Haemofiltration in newborns treated with extracorporeal membrane oxygenation
a case-comparison study
Karin Blijdorp, research studentKarlien Cransberg, pediatric nephrologist
Erasmus MC Sophia, Rotterdam, The Netherlands
ECMO treatment in The Netherlands
since 1994, in 2 centers
University Medical Center, Nijmegen
Erasmus MC Sophia, Rotterdam:
40 ECMO runs yearly
Indication: acute reversible
cardiovascular or respiratory failure with
an expected mortality of > 80%:
congenital diaphragmatic hernia
meconium aspiration syndrome
other
Systemic inflammatory response syndrome
due to primary disease and/or ECMO system:
generalised edema by capillary leakage
low blood pressure
multi-organ failure
prior investigations:
hemofiltration added to cardiopulmonary bypass:
less SIRS
less pulmonary edema with shorter assisted ventilation time
improved cardiac function
Huang et al, Ann Thorac Surg 2003Journois et al,Anesthesiology 1994
Journois et al, Anesthesiology 1996Rivera et al, J Am Coll Cardiol 1998
Davies et al, J Thorac Cardiovasc Surg 1998
Aim of the study
Clinical outcome of ECMO treated infants with haemofiltration
compared to without.
Primary endpoints:
Duration of ECMO
Duration of assisted ventilation
after weaning from ECMO
Secondary endpoints:
Mortality
Fluid balance
Vasopressorscore
Maximal serum creatinine
Transfusion red blood cells & platelets
Costs
Methods
Retrospective case-comparison study 1:3
Cohort 2004-2006: with hemofiltration (n=15)
Inclusion: age < 30 days
Exclusion: co-treatment with diuretics
start hemofiltration > 3 hrs after start
ECMO
Cohort 2002-2004: control group without hemofiltration
(n=45)
Matched for age, weight, diagnosis and mode of ECMO
Haemofiltration in ECMO circuit
ECMO-pump
clamp
Haemofiltration in ECMO circuit
ECMO-pump
clamp
heparin
substitution fluid
Pressure gradient over haemofilter of 40 mmHg
Methods: hemofiltration
Filter: Multiflow 100, AN 69
Filtration:
1st 6 hours 100 ml/kg/hr
after that 50 ml/kg/hr
Standard substitution fluid,
with addition of Na/K PO4 -> [PO4] = 1.5 mmol/l
Extra filtration if necessary and possible
Isovolemic thrombocyte and blood transfusions
Results: patient characteristics
control group HF group
(n=45) (n=15) p-value
n (%) n (%)
ECMO-mode veno-arterial 44 (97) 13 (87) 0.22
diagnosis CDH 16 (35) 3 (20)
MAS 16 (35) 5 (33)
other 14 (30) 7 (47) 0.73
median (min - max) median (min - max)
weight (kg) 3.3 (1.9 - 5.0) 3.5 (2.5 - 5.0) 0.31
age (days) 1.7 (0.5 - 18) 2.2 (0.9 - 6.7) 0.28
scores PRISM III 37 (14 - 90) 35 (17 - 51) 0.29
OI 20 (1 - 30) 20 (10 - 20) 0.82
AaDO2 25 (14-39) 20 (14 - 40) 0.18
Results: duration of ECMO and assisted ventilation after ECMO (median values)
* *
* p-value <0.05
time on ECMO time till extubation
hr
Results: fluid balance and need of transfusion (median values)
**
** p-value <0.001
-140
-120
-100
-80
-60
-40
-20
0
20
40
60
fluid balance diuresis blood transfusion plateletstransfusion
ml/k
g/d
ay
HF control
** **
Results: costs
per unit control group HF group
ECMO treatment (+28 hrs) € 4,328.00 € 5,050.00
ICU + ventilation (+55 hrs) € 1,480.00 € 3,392.00
blood transfusion (5.4 U) € 178.00 € 964.00
HF Multiflow filters, n=1 or 2 € 90.00 € 135.00
substitution fluid (3*5 liters) € 45.00 € 45.00
€ 9,406.00 € 180.00
Conclusion
Hemofiltration during ECMO:
decreases time on ECMO
decreases time until extubation after weaning from ECMO
decreases need of blood transfusion
saves € 9000,- per ECMO run
Conclusion
Hemofiltration during ECMO:
decreases time on ECMO
decreases time until extubation after weaning from ECMO
decreases need of blood transfusion
saves € 9000,- per ECMO run
No significant differences found in:
mortality
max serum creatinine
vasopressorscore
extra fluid requirement
Discussion
Effect of HF due to
More fluid removal?
Removal inflammatory mediators?
Take home message
Hemofiltration added to ECMO
improves clinical outcome
and is cost effective
All ECMO nurses on the pediatric ICU
D Tibboel,
pediatric intensivist, head of PICU
SJ Gischler,
pediatric intensivist
ED Wildschut,
pediatric intensivist
ED Wolff,
pediatric nephrologist
Acknowledgements:
Limitations of study
More CDH in control group (n.s.)
However no difference in ‘severity of illness’ score
Groups treated in different time frame
Only clinical parameters
Prospective study of inflammatory parameters not
studied yet
Results: other
Controle groepMedian (range)
HF groepMedian (range)
Mann-Whitney U test
P-waarde
Vulling (mL/kg/dag) 6 (0-37) 4 (0-30) 0.25
Vasopressor score 7 (0-56) 5 (0-41) 0.83
Kreatinine (µmol/l) 58 (14-91) 49 (28-105) 0.17
Median (percentile) Median (percentile)
Mortaliteit 7 (16%) 3 (21%) 0.61