Pulmonary Hypertension & Neonatal ECMO...– Coronaries perfused in diastole. • Maintains...
Transcript of Pulmonary Hypertension & Neonatal ECMO...– Coronaries perfused in diastole. • Maintains...
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© The Children's Mercy Hospital, 2017
John M. Daniel, IV, MD, MS
ECMO Executive Leadership Team, Children’s Mercy Kansas City
Clinical Assistant Professor of Pediatrics, UMKC - School of Medicine
Pulmonary Hypertension &
Neonatal ECMO
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Disclosures
• None
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Outline
• What is ECMO?
• Why do infants need ECMO?
• When to transfer to an ECMO Center.
• Risk and Benefits.
• Management while on ECMO.
• Long term developmental outcomes.
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Outline
• What is ECMO?
• Why do infants need ECMO?
• When to transfer to an ECMO Center.
• Risk and Benefits.
• Management while on ECMO.
• Long term developmental outcomes.
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What is ECMO?
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Two types of ECMO: VV and VA
Venovenous
• Improvement in cardiac
function.
– Coronaries perfused in
diastole.
• Maintains pulsatile flow
• “Less” invasive
– No carotid ligation
Venoarterial
• Respiratory and cardiac
support
• Improved oxygen delivery
• No recirculation
• Decreases preload
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Two types of ECMO: VV and VA
• Why pick on over the other?
– Need for cardiac support is the main determinate.
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The Circuit: Cannulas
• VV ECMO: One double lumen cannula
• VA ECMO: Two single lumen cannulas
• Cannulation Site
– VV ECMO: Right internal jugular vein.
– VA ECMO: Right internal jugular vein and right carotid artery.
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The Circuit: Cannulas
VVDLArterial
Venous
http://maquet-turkey.com.tr/page/urunler
VV Cannula
VA Cannulas
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The Cannulas: VVDL
http://www.annals.in/article.asp?issn=0971-9784;year=2011;volume=14;issue=3;spage=218;epage=229;aulast=Chauhan
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The Circuit: VVDL Cannula
Duel Lumen
Arterial Limb
Venous Limb
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The Circuit: VVDL Cannula
VVDL
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The Circuit: VA Cannulas
http://docplayer.cz/5723024-Ecmo-v-lecbe-septickeho-soku-u-deti.html
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The Circuit: VA Cannulas
Venous
Arterial
Tip
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The Circuit: The Pump
• Roller Pump
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The Circuit: The Pump
• Venous drainage and siphoning occurs mainly via gravity.
• The pump can generates negative pressure to help siphon blood out of patient.
• Provides positive pressure to push blood through oxygenator and back to patient.
Head
Head
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The Circuit: The Oxygenator
Quadrox-D Oxygenator by Maquet
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Outline
• What is ECMO?
• Why do infants need ECMO?
• When to transfer to an ECMO Center.
• Risk and Benefits.
• Management while on ECMO.
• Long term developmental outcomes.
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Why do infants need ECMO?
• Pulmonary Hypertension*** Survival
– Meconium Aspiration Syndrome….........................................94%
– Surfactant Deficiency/ Respiratory Distress Syndrome…......84%
– Idiopathic/Persistent Fetal Circulation…................................78%
– Congenital Diaphragmatic Hernia….......................................51%
• Infection
– Bacterial Sepsis......................................................................75%
– Pneumonia…..........................................................................54%
– Viral Sepsis...........................................................................<10%
• Congenital Heart Disease
– Pre-operative
– Post-operative: failure to wean from bypass in OR
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Why do infants need ECMO: Fetal
Circulation
• Decreased blood flow to lungs.– 10-13% of CO reaches lungs– Increased PVR– Shunting R L though the ductus
• Umbilical veins – Sats approximately 70-75%– PaO2 approximately 30-40mmHg
• Selective streaming of umbilical venous blood to the left heart– Right heart does most of the work in
the fetus– Left heart perfused the coronaries
and brain Shunts
PFO
PDA
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Slide courtesy of Satyan Lakshminrusimha, MD
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Outline
• What is ECMO?
• Why do infants need ECMO?
• When to transfer to an ECMO Center.
• Risk and Benefits.
• Management while on ECMO.
• Long term developmental outcomes.
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When to transfer to an ECMO Center?
• Many providers view the need for ECMO as a personal
failure of their management.
• The need for ECMO simply reflects and increasing
severity of disease process.
• ECMO is a tool and like any other tool it has a place in
management.
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When to transfer to an ECMO Center?
• All congenital diaphragmatic hernia (CDH) patients.
• Markers of severe respiratory failure
– Failure to improve within 4-6 hours of high frequency ventilation
or nitric oxide to an OI <25
– An oxygenation Index (OI) >25
– Mean airway pressure of >15 cmH20
– Amplitude of >35cmH2O
• Markers of inadequate end organ perfusion
– A plasma lactate >25 mg/dl, and not improving on pressors
– pH <7.25
– Base deficit > 5
– Mixed venous saturation <70%
Courtesy of Children’s Hospital of Wisconsin
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When to transfer to an ECMO Center?
• All congenital diaphragmatic hernia (CDH) patients.
• Markers of severe respiratory failure
– Failure to improve within 4-6 hours of high frequency ventilation
or nitric oxide to an OI <25
– An oxygenation Index (OI) >25
– Mean airway pressure of >15 cmH20
– Amplitude of >35cmH2O
• Markers of inadequate end organ perfusion
– A plasma lactate >25 mg/dl, and not improving on pressors
– pH <7.25
– Base deficit > 5
– Mixed venous saturation <70%
Courtesy of Children’s Hospital of Wisconsin
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Outline
• What is ECMO?
• Why do infants need ECMO?
• When to transfer to an ECMO Center.
• Risk and Benefits.
• Management while on ECMO.
• Long term developmental outcomes.
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Risk and Benefits of ECMO
• Risk
– Bleeding• Intracranial hemorrhage
• Hemorrhagic stroke
– Clot formation• Ischemic stroke
– Vessel damage• Perforation
• Stenosis
• Benefits
– Allows for lung and cardiac
rest.
– Prevents high pressure
damage to lung tissue
– Allows for maximal end
organ perfusion
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Outline
• What is ECMO?
• Why do infants need ECMO?
• When to transfer to an ECMO Center.
• Risk and Benefits.
• Management while on ECMO.
• Long term developmental outcomes.
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Management while on ECMO
• Rest the lungs
• Fluid and nutrition
– Ensure adequate calories 50-60kcal/kg/day is usual for BMR
– Avoid fluid overload
• Coagulation Management
– Hematocrit and platelets
– Heparin vs. bivalrudin
• Sedation
– Not snowed, but not uncomfortable
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Management while on ECMO
• How do we know when they are ready to come off?
– Natural history of the disease
– Chest x-clear
– Oxygen challenge is good
• Trial off
– VA – low flow and clamp trial
– VV – unplug the oxygen
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Outline
• What is ECMO?
• Why do infants need ECMO?
• When to transfer to an ECMO Center.
• Risk and Benefits.
• Management while on ECMO.
• Long term developmental outcomes.
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Long Term Developmental Outcome
• Sensory neural hearing loss old data from the 1990s
• Normal intelligence
– Deficits not different than conventionally treated peers.• ECMO 68% normal cognitive function
• Conventional 70% normal cognitive function
• Attention problems
– Information retention and processing speed are slightly lower
• Developmental follow up is needed for these infants.
• The severity of disease, not the addition of the ECMO circuit,
seems to be the primary driver of neurologic outcomes.
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Closing Thoughts
• ECMO is a life saving therapeutic modality for critically
ill infants.
• Severity of illness is the major predictor of long term
developmental outcomes.
• Consider referring to ECMO center if signs of
diminished end organ perfusion despite maximal
conventional therapy.
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Regional ECMO Centers
…....………….…..1-800-GO-MERCY
..……..1-800-678-HELP
………………………....…1-800-833-3100
…………………..1-800-525-4871
(press 1 for Transfer Center)
………………...……….1-800-ACH-HELP
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References
• Brogan, T. V.; Lequier, L.; Lorusso, R.; MacLaren, G.; and Peek, G.
(Editors). 2017. Extrocorpeal Life Support: The ELSO Red Book, 5th
Edition. Extracorporeal Life Support Organization. Ann Arbor, MI, USA
• Lakshminrusimha S. and Kessler, M. 2015. Persistent Pulmonary
Hypertension of the Newborn. NeoReviews. 16 (12).
• Mahmood, B.; Newton, D.; Pallotto, E.K., 2018. Current trends in
Neonatal ECMO. Seminars in Perinatology. 42(2):80-88. doi:
10.1053/j.semperi.2017.12.003.
• Schiller, R.M, Madderom, M.J, Reuser, J.J.C.M, Steiner, K, Gischler,
S.J, Tibboel, D, I., Jsselstijn, H. (2016). Neuropsychological Follow-up
After Neonatal ECMO. Pediatrics (English Edition), 138(5), 1–11.
doi:10.1542/peds.2016-1313