Neurologic Complications in Adult ECMO...Neurologic Complications in Adult ECMO Joseph B....
Transcript of Neurologic Complications in Adult ECMO...Neurologic Complications in Adult ECMO Joseph B....
Neurologic Complications in Adult ECMO
Joseph B. Zwischenberger MD Johnston-Wright Professor
Chairman: Department of SurgerySurgeon-in-Chief UK Healthcare
859-229-6635 (mobile)[email protected]
The University of KentuckyLexington, Kentucky
Presenter Disclosure InformationResearch supported in part through Competitive funding:
National Institutes of Health (SBIR,STTR,T-32)Contracts:
MC3, Ann Arbor MiExotherm, Lexington Ky W-Z Biotek, Lexington KyMaquet
Patent: Avalon Elite™ (4 more, 3 pending)Novalung
Free App: “Zwisch Me”
Joseph B. Zwischenberger, M.D.
Z-Bergerism #12
Innovation is never evidence-based
Stroke In ECMO
Multi-institutional study of ECMO 1992-2005 in pediatric patients
CNS Injury = Brain death, stroke, hemorrhage
Ischemic stroke in 7%
Hemorrhagic stroke in 7%
Barrett et al. Pediatr Crit Care. 2009 10(4):445-51.
Neurologic Complications in Adult ECMO?• Neurologic sequelae:
SeizuresHemorrhage: Intraventricular, intracerebral, subduralStrokeBrain death
• Multifactorial: thromboembolic events, hemorrhage, anticoagulation
• Neurologic sequelae patient selection and managementECMO Red Book
Incidence of ECMO Neurologic Complications
• Downward trend (last 10 yrs) attributed to experience, technology, and patient selection/management
• Neurologic complications underestimated due to:lack of diagnostic imaging in critically ill patientslimited participation in registries (voluntary)lack of standardized reporting
ECMO Red Book
Neurologic Complications (VV/VA) 2006 2015
ECMO runs (VV/VA) runs 121 / 141 1568 / 1769Brain Death % 5.8 / 2.1 1.9* / 2.9Seizures (EEG) % 2.5 / 1.1 0.2* / 0.9Seizures (Clinical) % 1.7 / 1.4 1.1 / 1.1CNS Infarction % 5.0 / 2.8 2.1* / 3.8CNS Hemorrhage 2.0 / 1.4 3.2 / 1.4*
Table 52-1. ECMO Red Book
Neurologic Risk FactorsECMO circumstances:
Pre-existing decreased cerebral oxygenationECMO assisted CPR: up to 50% neurologic events
Resuscitation. 2017;121:166-171Pre-existing neurologic pathologies
ECMO circuit configuration TABLE 52-2Veno-arterial (VA) ECMO versus veno-venous (VV) ECMO
ELSO Registry shows no major differences
Peripheral cannulation thought to decrease riskCarotid artery cannulation highest stroke risk in adults (~3-5%)
J Pediatr Surg. 2012;47:68-75
Neurologic Complications and Survival 1991-2015Neurologic
Complications VV
(9102) VA
(7850) n % Survival
% n % Survival %
Brain Death (Clinical) 227 2.4 0 354 4.2 0Seizures (EEG) 36 0.4 47* 50 0.6 20Seizures (Clinical) 100 1.1 42* 135 1.6 24CNS Infarction (US / CT) 191 2.0 30* 322 3.8 23CNS Hemorrhage (US / CT) 352 3.8 21* 184 2.2* 9
Table 52-2. ECMO Red Book
Time IS BrainAs many as 14 billion synapses may be lost during every one minute that a stroke goes untreatedThe average stroke patient loses approximately 32,000 brain cells every one second
Saver, J., 2005
General Considerations• Supplemental Oxygen to keep O2 saturation at 94% +• Cardiac monitoring for arrhythmias (atrial fibrillation) • Addressing cause, while lowering (elevated) temperature• Glucose goal 140-180• Pneumatic compression devices (and/or pharmacologic
means) to prevent deep venous thromboses • Early mobilization • No oral intake to avoid aspiration pneumonia• Mechanical intravascular or neurosurgical intervention for
thrombectomy in select cases• Early intervention Jauch, et. al., 2013
Stroke Mimics• Metabolic Disorders
o Hypoglycemia• Migraine• Seizures, Todd’s Paralysis• Bell’s Palsy• Syncope• Transient Global Amnesia• Peripheral Nerve Disorders• Intracranial Masses• Hypertensive Crisis• Psychogenic Presentations
Treatment Windows from Recognition
• Intravenous (IV) Activase® (Alteplase) (rt-PA) is FDA approved within 3 hours and recommended by AHA and AAN within 4.5 hrs
• Mechanical thrombectomy is recommended with large vessel occlusion within 6 hours
• Neuro-interventionalists are increasingly using imaging rather than time to determine candidacy for intervention
Demaerschalk, et. al., 2016Powers, et. al., 2015
Ischemic Stroke
Is the patient acandidate for IV-tPA?
No Yes
No
No Yes IV-tPA Protocol
Is the patient acandidate for endovascular Rx?
Yes EndovascularProtocolInitiate Secondary Prevention
Prevent ComplicationsRecovery
General Measures
Hemorrhagic Stroke
No Yes
Acute Focal Neurologic Deficit
Dx & manageDx & manage
Modified from Goldstein Methodist DeBakey Cardiovascular Journal. 2014;10:39-44
Modified from 2018 AHA Guidelines for Early Management of Patients with AIS
Ischemic Stroke: Large Vessel Occlusion
Large Ischemic Stroke
Efficacy of tPA by Stroke Subtype
0
10
20
30
40
50
60
70
80
% w
ith g
ood
outc
ome
tPAPlacebo
Small vessel Large vessel Cardioembolic
Thrombectomy
Turk AS. J Neurointerv Surg. 2013.
Thrombectomy
Thrombectomy
Thrombectomy
ELVO Trials
MR-CLEAN
EXTEND-IA
SWIFT PRIME
ESCAPE
Halted early for efficacy
ELVO - Time is BrainSTUDY Time to
IVt-PATime to Groin
Time to Recan
TICI 2b-3 MRS 0-2 Medical
MRS 0-2 IA
MR CLEAN 85-87 min
260 min N/A 58.7% 19.1% 32.6%*
ESCAPE (1)
110-125 min
185 min 241 min 72.4% 29.3% 53%*
EXTEND IA (2)
127-145 min
210 min 248 min 86% 40% 71%*
SWIFT PR. (3)
167.5 min
184 min 213 min 88% 35.5% 60.2%*
(2) Campbell, B. C. V., et al NEJM 2015. doi:10.1056/NEJMoa1414792(1) Goyal, M., et al. NEJM 2015, 150211090353006–12. doi:10.1056/NEJMoa1414905
(3) Saver, J., et al Presented at ISC 2015. Nashville, TN
Stroke Intake Process
ED Prenotification to Stroke Pager From Bay/Pad to CT NIHSS and quick history
outside/inside CT CT/CTA performed NIR attending called from CT
– Thrombectomy pager?– tPA?
Hemorrhagic Stroke
Hemorrhagic Stroke
Post Evacuation
BOTTOM LINE Interventions and outcomes are
time-dependent TIME IS BRAIN ECMO patients should be monitored
for neurological changes Any neurological change should
prompt a Stroke Alert (including rapid CT and CTA imaging)
Thiagarajan RR, et al. ASAIO 2017, 63(1):60-67
40%
30%
(26 patients)
54% neurologically intact survival
ECPR 13% increased 30-day survivalBetter neurological outcome
ECMO for cariogenic shock33% higher 30-day survival than IABPSimilar to Tandem Heart/Impella
Hemorrhage on ECMOCommon Cause
• Inflammation, altered coagulation, transfusionsManagement
• Monitor lab values ACT, aPTT, AT, Antifactor-Xa Assay, thromboelastography
ECMO Red Book• Ideal transfusion protocol not yet established
JCVA. 2017;31:1836–46.• Anticoagulation reversed, increase pump flow
ECMO Red BookOutcomes
• Intracranial hemorrhage mortality of 80-90% ELSO Registry
Seizures on ECMOCommon Cause
• Thromboembolic and bleeding eventsManagement
• Conventional to date• Clinically diagnosed, verified by EEG
Outcomes• Survival to discharge rate decreased to 30%
versus all ECMO patients 40-60% ECMO Red Book
Stroke on ECMOCommon Cause
• Thromboembolic events, rapid ↓PaCO2, sedation, hemodynamic instability, shock
Management• Monitor: Transcranial Doppler Sonography (TCD)
Cerebral Near-Infrared Spectroscopy (NIRS)Hemodynamics
• Optimal transfusion management not yet determinedECMO Red Book
Outcomes• Carotid artery cannulation highest stroke risk ~3-5%
J Pediatr Surg. 2012;47:68-75
Brain Death on ECMO
Most frequent in ECMO assisted CPRCommon Cause: Pre-ECMO insult, unrecognized decline during cannulationAfter resuscitation induce hypothermia with ECMO circuit heater-coolerMonitor clinical neurologic signs, cerebral oximetryNo standard criteria for diagnosis
CCM. 2016;44:e964-72
Risk/Benefit: Survival v. Quality of LifeELSO Registry: No functional neurologic outcomes, only
voluntary short-term data from single centers
Survival to discharge (Adults)• Highest: Viral ARDS (H1N1) Rx with VV ECMO: 70-80%• Lowest: ECMO assisted CPR: 25-35%
ECMO Red Book
Return to work: Single center study of 465 VA ECMO patients found a 25% return to work rate
Camboni and Schmid, not yet published
Future Directions
Adult ECMO use is rapidly expandingECMO use increased 650% 2001-2011
JCN. 2015;11:383-89Identify predictive markers
Optimize anticoagulation, transfusion, sedation strategies
Will play for drinks and tips
You should ALWAYS listen to a harmonica player
Neurologic Complications in Adult ECMO
Joseph B. Zwischenberger MD Johnston-Wright Professor
Chairman: Department of SurgerySurgeon-in-Chief UK Healthcare
859-229-6635 (mobile)[email protected]
The University of KentuckyLexington, Kentucky
References1. Camboni D, Schmid C. Neurologic and pulmonary complications in adult ECLS.
The ELSO Red Book. 5th edition. Ann Arbor, MI: Extracorporeal Life Support Organization (ELSO); 2012: 575-82
2. Table 52-1. Adapted from Extracorporeal Life Support: The ELSO Red Book. 5th
edition. Ann Arbor, MI: Extracorporeal Life Support Organization (ELSO); 2012: 576.3. Floerchinger, Philipp A, Camboni D, Foltan M, Lunz D, Lubnow M, Zausig Y, Schmid C.
NSE serum levels in extracorporeal life support patients-Relevance for neurological outcome? Resuscitation. 2017;121:166-171.
4. Rollins D, Hubbard A, Zabrocki L, Douglas BC, Bratton, SL. Extracorporeal membrane oxygenation cannulation trends for pediatric respiratory failure and central nervous system injury. J Pediatr Surg. 2012;47(1):68-75.
5. Table 52-2. Neurologic Complications and Survival 1991-2015. The ELSO Red Book.5th edition. Ann Arbor, MI: Extracorporeal Life Support Organization (ELSO); 2012: 577.
6. Xie A, Lo P, Yan TD, Forrest P. Neurologic complications of extracorporeal membrane oxygenation: a review. JCVA. 2017;31:1836–46.
7. Lorusso et al. In-Hospital Neurologic Complications in Adult Patients UndergoingVenoarterial Extracorporeal Membrane Oxygenation: Results From the ExtracorporealLife Support Organization Registry. Crit Care Med. 2016 Oct;44(10):e964-72
ECMO FUTURECatheter based Technology (Ambulatory)
– Recipient Support– Donor Support: DCD– Organ Block Support : Lung in a Box
Transplantation
Neonates, Children, Adults Acute Severe Respiratory failure Acute Cardiac support
ER Transport Resuscitation/Shock