Update on ECMO in paediatric patients

Update on ECMO in Update on ECMO in paediatric patientspaediatric patients

Gianluca Brancaccio MD, PhDGianluca Brancaccio MD, PhD

Ospedale Pediatrico Bambino Gesù, Rome, ItalyOspedale Pediatrico Bambino Gesù, Rome, Italy

New Perspectives in ECMO 2012 New Perspectives in ECMO 2012 III International meeting, 5 October, 2012 MilanIII International meeting, 5 October, 2012 Milan

BackgroundBackground• ECLS is constantly improving since it was first used in ECLS is constantly improving since it was first used in

critically ill patients with respiratory failure over 40 years critically ill patients with respiratory failure over 40 years ago.ago.

• To date overTo date over 50.000 patients were treated50.000 patients were treated with ECMO, with ECMO, been neonates and infants the majority.been neonates and infants the majority.

• Aim of this overview is to illustrate the changing in Aim of this overview is to illustrate the changing in environment, equipment and management in ECLS over environment, equipment and management in ECLS over time.time.

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Runs by Year

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

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Neonatal Respiratory Cases

Clark RH et al. N Engl J Med 342: 469-474, 2000

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Cumulative Survival in Neonatal Respiratory Support

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Neonatal Cases by Year and Diagnosis

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Neonatal Diagnoses and Survival

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Initial Mode of Neonatal Respiratory Support

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Pediatric Respiratory Cases

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Pediatric Cases by Year and Diagnosis

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Initial Mode of Pediatric Respiratory Support

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Cardiac ECLS by Diagnosis 0 – 30 days old

Runs % Survived Congenital Defect 4,361 38 Cardiac Arrest 77 26 Cardiogenic Shock 72 40 Myocardiopathy 116 61 Myocarditis 57 49 Other 440 43

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Cardiac Cases By Year0 – 30 days old

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Cumulative Survival in Cardiac Support

0 – 30 days old

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Cardiac Cases By YearUnder 16 years

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Under 16 years of age

Cumulative Survival in Cardiac Support

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Cardiac Survival by Diagnosis and Year Under 16 years

HOW HAS ECLS EQUIPMENT CHANGED

• Tubings heparin-bounded• Pumps

– Roller pump– Centrifugal pump

• Cannulae (Avalon)• Plastic oxygenators

– Silicone membrane oxygenators– Hollow-fiber membrane oxygenator (HFMO)

Avalon Elite™ Bi-Caval Dual Lumen

- Triple lumen cannula - ↓ recirculation - Good flow dynamics- Sizes from 13 Fr to 31

Fr.

Conclusions• The field of ECMO is currently in a state of flux. Many

patients denied ECMO support in the past are now being considered for ECMO support and obtaining long-term survival.

• The experience and knowledge gained over the past 20 years or more of ECMO has resulted in making this therapy more accessible, safer, and efficient.

• The revised interest in use of ECMO in cardiac arrest, sepsis and other populations may herald an increase in the use of ECLS in future days.

Experience OPBG• A total of 93 veno-

arterial ECMOs were delivered to 90 patients: in 3 cases two separate ECMO sessions were necessary; 3 patients were bridged from ECMO to ventricular assist device

ECMO indications

• low cardiac output syndrome (LCOS) in 10 cases

• post-operative LCOS in 61 patients

• respiratory support in 20 children

• sepsis in 2 patients

Results

• Children who survived on ECMO had a significantly shorter treatment duration: 4 (2.7-7) vs. 9 (5.7-16) days p<0.0001

Results-2• Age, weight, RACHS

score, indication to treatment, pump type, cannulation site, need for renal replacement therapy and the presence of univentricular anatomy were not significantly associated with an increased ICU mortality (p>0.05).

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Overall Patient Outcomes Total Surv ECLS Surv to DC

Neonatal Respiratory 25,746 21,765 85% 19,232 75% Cardiac 4,797 2,928 61% 1,912 40% ECPR 784 496 63% 304 39% Pediatric Respiratory 5,457 3,556 65% 3,061 56% Cardiac 5,976 3,855 65% 2,913 49% ECPR 1,562 843 54% 630 40% Adult Respiratory 3,280 2,094 64% 1,808 55% Cardiac 2,312 1,243 54% 891 39% ECPR 753 276 37% 207 27% Total 50,667 37,056 73% 30,958 61%

Cannulation• Central vs. peripheral cannulation

– Jugular-carotid– Femoro-femoral VA ECMO– Femoro-femoral VV ECMO

• Veno-venous vs. veno-arterial ECMO• Percutaneous cannulation

Results-3• However, a trend to

increased mortality was evident in RRT patients. Furthermore, in our patients, respiratory ECMOs showed a better chance to be weaned off than cardiac ECMOs (75% vs 43%, OR 3.8, 95% C.I. 1.7-11, p:0.01). However, ICU survival was not significantly different (55% vs 40%, OR 1.9, 95% C.I. 0.7-5.3, p:0.2).