Pediatric and Adult

ECMO:
Patient Selection and
Management
James D. Fortenberry, MD
Clinical Director, Pediatric and Adult ECMO
Children’s Healthcare of Atlanta at Egleston
1600
Neonatal
1400
Pediatric
1200
1000
800
600
400
200
0
1988

1989

1992

1993

1994

1995
> 1986

1987

1990

1991

1996

1997
Number of neonatal and pediatric ECLS
treatments on an annual basis reported to
ELSO registry
All who drink of this treatment
recover within a short time,
except in those who do not.

Therefore, it fails only in

incurable cases
-Galen
Is ECMO of Proven Benefit for
Respiratory Failure?

• Neonatal respiratory failure

 PPHN, meconium aspiration;
CDH
 UK study (Lancet, 1997)
 Proven benefit in regionalized
setting
Is ECMO of Proven Benefit in Respiratory
Failure?

• Children
 No good prospective study
 Retrospective data: benefit in higher
risk (not moribund) patients with
respiratory failure
 ECMO decreased mortality from 47.2
to 26.4% (331 pts.-Green et al.,
CCM, 1996)
 100
90 ECMO patients
80 Non-ECMO patients
70
Mortality

60
50
40 *
30
20
10
0
<25% 25-50% 50-75% >75%

Mortality Risk Group

-Green et al., CCM 1996
Outcome in Pediatric ECMO: Predictors
of Survival

• Younger age (23 vs. 49 months)

• Ventilator days pre-ECMO (5.1 vs. 7.3)
• Lower PIP, lower A-a gradient (Moler et
al., CCM, 1993)
• No difference in survival if > 2 weeks on
ECMO (Green et al., CCM, 1995)
• Lung biopsy not necessarily predictive
Is ECMO of Proven Benefit in Adult
Respiratory Failure?

• Adult ELS NIH study: 1971

 90% mortality: no benefit with VA ECMO in
moribund patients
• Gattinoni-nonrandomized experience
 49% survival
• Corroboration at other centers-U. of Michigan
• Morris-AJRCCM 1992 (Utah)
 No statistically significant survival benefit of ECMO
vs. computerized vent management protocol
 70
62.5
60
Thousands of Dollars/Life-Year

50 43.5

40

30 26.9

20

10 4.19

0
Pediatric ECLS Liver Bone Marrow Heart
Transplant Transplant Transplant

Cost/life-year-saved of pediatric extracorporeal life support

(ECLS) with adult therapies
Vats et al.
Crit Care Med 1998;
26:1587-1592
Pediatric ECMO - Children’s Healthcare
of Atlanta
Diagnosis Number Survival % ELSO Survival %
ARDS 14 71 51
Bacterial Pneumonia 33 85 79
Viral Pneumonia 7 86 53
Trauma 3 100 63
Burns 4 75 52

Total 74 77% 62%

Are Pediatric and Adult ECMO
Different?
• More alike than different
• Subtle differences in criteria
• Difference in size = major difference
in difficulty of nursing care
Adults are just Big Kids
Patient Selection for Pediatric/Adult
ECMO
Basic Principles

• Is the pulmonary/cardiac disease life

threatening?
• Is the disease likely reversible?
• Are other diseases relative to prognosis?
• Is ECMO more likely to help than hurt?
• Is preoperative support warranted??
• VA or VV?
 Diagnoses for Pediatric ECLS
ARDS
pneumocystis
11%
1%

aspiration
8%
Other
intrapulmonary hemorrhage
40%
1%

viral pneumonia
30%

From: Registry of the Extracorporeal bacterial pneumonia

Life Support Organization(ELSO, Ann 9%
Arbor, MI, USA).
ECMO: General Indications in Respiratory
Failure

• Lung disease that is:

 Acute
 Life threatening
 Reversible
 Unresponsive to conventional/alternative
therapy
ECMO for Pediatric Respiratory Failure:
Indications

• Acute, potentially reversible respiratory

(and/or cardiovascular) disease unresponsive
to conventional/alternative arrangement
• Oxygenation index >40 x 2 hours
• Barotrauma
• P/F ratio <200
 Oxygenation Index

Mean airway pressure x Fi O2 x 100

OI=
PaO2
Pediatric and Adult ECMO
Indications

• Lung disease that is:

 acute
 life threatening
 reversible
 unresponsive to conventional therapy
Pediatric and Adult ECLS
Selection Criteria

• No
 malignancy
 incurable disease
 contraindication to anticoagulation
• Intubation/ventilation for < 10 days;
• < 6 days in adult
• Hypercarbic respiratory failure with:
 pH < 7.0, PIP > 40
Adult ECLS
Selection Criteria

• Respiratory failure
 shunt > 30% on an FiO2 of > 0.6
 compliance < 0.5 ml/cmH2O/kg
• Severe, life threatening hypoxemia
• Lack of recruitment
 inadequate SpO2/PaO2 response to
increasing PEEP
ECMO for Pediatric Respiratory Failure:
Contraindications

• Unlikely to be reversible in 10-14 days

• Terminal underlying condition
• Mechanical ventilation >10 days
• Multi-organ failure
• Severe or irreversible brain injury
• Significant pre-ECMO CPR
Pediatric and Adult ECLS
Exclusion Criteria

• Absolute:
 contraindication to anticoagulation
 terminal disease
 underlying moderate to severe chronic
lung disease
 PaO2/FiO2 ratio < 100 for > 10 days
(> 5 days in adult)
 MODS: >2 organ system failure
Pediatric and Adult ECLS
Exclusion Criteria

• Absolute:
 uncontrolled metabolic acidosis
 central nervous system injury/ malfx
 immunosuppression
 chronic myocardial dysfunction
Adult ECLS
Exclusion Criteria

• Relative contraindications:
 mechanical ventilation > 6 days
 septic shock
 severe pulmonary hypertension (MPAP >
45 or > 75% systemic)
Adult ECLS
Exclusion Criteria

• Relative contraindications:
 cardiac arrest
 acute, potentially irreversible myocardial
dysfunction
 > 35 years of age
Differences between Pediatric and
Adult ECMO Criteria
• Mechanical ventilation prior to ECMO;
pediatric < 10 days vs. adult < 6 days
• Age: adult vs. pediatric
“The key to the success of
ECMO may be the time of
initiation”
Plotkin et al., U of M,
1994
ECMO Initiation
Surgical Team
 Selection of Technique

VA vs. VV

ECMO
ECMO

Veno-venous (VV) vs. Veno-arterial (VA)

• VA
 Provides complete cardiorespiratory support
 Negative impact on afterload

• VV
 Preferred mode
 Don’t sacrifice artery
 Oxygenates blood to heart
Why VV Might Be Better Than VA

• Cannulation: ease
• Effect on pulmonary blood flow: improved
oxygenation
• Cardiac effects: decreased LV after-load,
improved coronary oxygenation
• Patient safety: emboli
Use of VV and VV ECMO: Egleston
Pediatric Experience

14

12
VV ECMO
VA ECMO
10
Number of patients

0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year
Equipment
Size of Circuit Components Based on Patient
Weight
Weight (kg) 2–8 8–12 12-20 20-30 >30

Tubing size 1/4” 3/8” 3/8” 3/8” 1/2”

Race way tubing 1/4” 3/8” 3/8” 3/8” 1/2”

Bladder 1/4” 3/8” 3/8” 3/8” 3/8”

Oxygenator (sqm) 0.8 1.5 2.5 3.5 4.51

Venous cannula2 10-14 16 18 20 22

1
Two oxygenators necessary in parallel or in series
2
Minimal sizes of cannulas
Pediatric and Adult ECLS:
Cannulation

• Cannulation frequently rocky

• Code drugs to bedside
• Patient on specialty bed
• Cannulation orders
• Heparin bolus available
Pediatric and Adult ECLS:
Venovenous cannulation

• Dual cannulae: usually drain from

right atrium via RIJ, return to
femoral vein +/- cephalad cannula
• Double lumen cannula: 12-18F in
RIJ for smaller children
• Cutdown vs. percutaneous
• Blood vs. saline prime
Pediatric and Adult ECLS:
Veno-arterial cannulation

• Usually for cardiac ECMO

• May convert VV to VA ECMO
• Cannulae: Venous drain-RIJ to right
atrium; arterial-usually common carotid
to aorta
Pediatric ECMO Management: Pulmonary

• Basic goals:
» decrease further lung
damage
» reduce oxygen toxicity
» “lung rest”
Pediatric and Adult ELS
Approach to the Patient

• Fluids/nutrition: Feed ‘em!

• Sedation/analgesia: Snow ‘em!
• Antibiotics: Hold ‘em!
• Invasive procedures: Bronch ‘em!
• Weaning: Wean ‘em!
• Decannulation: Cap ‘em!
• Post-ECMO: Rehab ‘em!
Pediatric ECMO Management: Pulmonary

• Optimal ventilator settings vary

• Limit peak pressures to 30 cm H2O
• Delivered tidal volumes 4-6 cc/kg
• Rate 5-10 breaths/minute
• PEEP 12-15 cm H2O
• Inspiratory time longer
• Goal FiO2 0.21
Pediatric ECMO Management: Pulmonary

• Tolerate pCO2 55-65, SpO2 > 88%

• Time of “rest” depends on process
• 3-5 days minimum for ARDS
• Resolution of air leak (48-72 hours)
• Suctioning PRN
• Avoid bagging
Pediatric ECMO Management: Pulmonary

• Pulmonary hygiene
• Daily chest radiographs-may signal
recovery
• Re-recruitment
• Bronchoscopy may be beneficial
• May come off on HFOV
Pediatric ECMO Management: Flow

• Infants: 120-150 cc/kg/min

• Children: 100-120 cc/kg/min
• Adults: 70-80 cc/kg/min
• Attempt to reach maximal flow early in
run to determine buffer
Pediatric ECMO Management:
Cardiovascular

• VA ECMO generally required with

cardiac failure
• VV ECMO may improve cardiac function
• Usually able to wean pressors
• Milranone can be beneficial
• Hypertension common in VV ECMO
(69%)-try ACE inhibitors
Pediatric ECMO Management: CNS

• Increased Vd, surface interaction,

altered renal blood flow, CVVH
• Morphine used due to oxygenator
uptake of fentanyl; tolerance
• Lorazepam, midazolam
• NMB usually required in ped/adults-use
pavulon, take holidays, watch with
steroids
 Surgeons give fluid

Intensivists give Lasix

(or use CVVH)
Pediatric ECMO Management: Fluids/Renal

• Tendency to capillary leak

• Oliguria often associated and worsened
on ECMO
• May be recalcitrant to Lasix
• CVVH: helpful adjunct; simple inline in
circuit; Renal consult
• CVVH does not worsen outcome
(Bunchman et al., PCCM 2001)
Pediatric ECMO Management: GI

• Decreased catabolism = decreased

infection
• Enteral nutrition preferred: improved
calories, decreased cost, similar
complications (Pettignano, et,al, CCM,
1997)
• Can give intragastric or transpyloric
• Aggressive bowel regimens
Pediatric ECMO Management: Hematologic

• Maintain Hb/Hct > 13/40

• Hemolysis-monitor with serum free Hgb
• Platelet consumption common-keep
greater than 100,000
• Activated clotting time (ACT) 180-
200; 160-180 if expect significant
bleeding
Pediatric ECMO Management: Hematologic

• Amicar-inhibits fibrinolysis; can enhance

hemostasis in high risk cases, post-op
• Loading dose 100 mg/kg, infusion 20-30
mg/kg/hour for no more than 96 hours
• Aprotinin for active bleeding-generally
avoid due to clot risk
Pediatric ECMO Management: Infectious

• Routine antibiotic coverage not

practiced
• Strict asepsis during run
• Need to have low index of suspicion for
super-infection; may be difficult to
assess
Adult ECMO Management: Specific Issues

• ACLS requirements
• Consultation: Adult Pulmonary, Ob/Gyn,
Infectious Disease
• Commitment to rapid return to
referring institution post-ECMO
• Age limits
ECMO Weaning and Decannulation

• Improvement: diuresis, CXR

improvement, lung compliance
• Weaning of flow to 50 cc/kg/min
• VV: “capping” - continue circuit flow
with gas supply d/ced
• Surgery decannulates
• Issues of termination
Questions??