PCRRT & ECLS Dr. Peter Skippen, PICU. BC Children’s Hospital, Vancouver. CANADA.

PCRRT & ECLSPCRRT & ECLS

Dr. Peter Skippen, PICU. Dr. Peter Skippen, PICU.

BC Children’s Hospital,BC Children’s Hospital,

Vancouver. CANADA.Vancouver. CANADA.

PCRRT & ECLSPCRRT & ECLS

OutlineOutline

• IndicationsIndications

• OptionsOptions

• SetupsSetups

• ConclusionsConclusions

PCRRT & ECLSPCRRT & ECLS

Clinical ScenariosClinical Scenarios

• Acute respiratory failure / acute cardiac failureAcute respiratory failure / acute cardiac failure

+ + acute inflammatory response to ECLS circuitacute inflammatory response to ECLS circuit

+ ongoing uncontrolled septic / inflammatory process + ongoing uncontrolled septic / inflammatory process

+ + single / multi-organ failuresingle / multi-organ failure

+ volume overload / ongoing fluid resuscitation+ volume overload / ongoing fluid resuscitation

+ + supporting nutritionsupporting nutrition

PCRRT & ECLSPCRRT & ECLS

IndicationsIndications

• volume overloadvolume overload

• electrolyte / acid - base disorders electrolyte / acid - base disorders

• mediator clearancemediator clearance

– hemofiltration post CPB / cardiac surgeryhemofiltration post CPB / cardiac surgery

• ““making room”making room”

• preparing to wean from ECLSpreparing to wean from ECLS

PCRRT & ECLSPCRRT & ECLS

OptionsOptions

• lasix infusionlasix infusion

• SCUFSCUF

• CVVHCVVH

• CVVHDCVVHD

• ““home made”home made”

• customized machinecustomized machine

• accessaccess

– ECLS circuitECLS circuit

– separate siteseparate site

PCRRT & ECLSPCRRT & ECLS

ECLS circuitsECLS circuits

• BiomedicusBiomedicus

– VAVA

– VVVV

• Roller pumpRoller pump

– VAVA

– VVVV

PCRRT & ECLSPCRRT & ECLS

Basic ECLS CircuitryBasic ECLS Circuitry

Venous line

Arterial line

H

PUMPOXYGENATOR

PCRRT & ECLSPCRRT & ECLS

Biomedicus System - diagramBiomedicus System - diagram

Venous line

Arterial line

H

PUMPOXYGENATOR

- + <+

Biomedicus System -photoBiomedicus System -photo

PCRRT & ECLSPCRRT & ECLS

Roller Pump System - diagramRoller Pump System - diagram

Venous line

Arterial line

H

PUMPOXYGENATOR

Venous reservoir (gravity fed)Venous reservoir (gravity fed)

++ <+

-

Rollerpump ECLS CircuitRollerpump ECLS Circuit

Filter

CRRT & RollerpumpCRRT & Rollerpump

PCRRT & ECLSPCRRT & ECLS

Options for PCRRTOptions for PCRRT

• customized systems eg. PRISMAcustomized systems eg. PRISMA

• home made systemshome made systems

– standard infusion pumps standard infusion pumps pressure limited pressure limited

– roller pumps roller pumps NOT pressure limited NOT pressure limited

PCRRT & ECLSPCRRT & ECLS

Home Made Systems & ECLS: ProblemsHome Made Systems & ECLS: Problems

• Infusion Pumps Infusion Pumps (max. 999mls/hr = 16.66mls/min)(max. 999mls/hr = 16.66mls/min)

– no safety features eg. micro-air detectorno safety features eg. micro-air detector

– may be unable to get adequate blood flow / dialysis may be unable to get adequate blood flow / dialysis

flow / filtration flows flow / filtration flows

• Roller Pump Systems Roller Pump Systems (litres/min)(litres/min)

– high pressure circuitry high pressure circuitry no pressure limits no pressure limits

– circuit rupture circuit rupture no pressure limits no pressure limits

– MUST incorporate bubble trap MUST incorporate bubble trap insert pre-oxygenator insert pre-oxygenator

PCRRT & ECLSPCRRT & ECLS

PRISMA & ECLSPRISMA & ECLS

• ProblemsProblems– high pressure return pre-oxygenator / high pressure high pressure return pre-oxygenator / high pressure

alarm of PRISMAalarm of PRISMA

– complexity of circuit?complexity of circuit?

– V-A shunt (depending on placement)V-A shunt (depending on placement)

PCRRT & BiomedicusPCRRT & Biomedicus

PCRRT & Roller pumpPCRRT & Roller pump

PCRRT & Roller pumpPCRRT & Roller pump

PCRRT & ECLSPCRRT & ECLS

TechniqueTechnique

• PRISMA: setup standardPRISMA: setup standard

• infusion pumps: limited by blood flow rate - SCUFinfusion pumps: limited by blood flow rate - SCUF

• roller pump circuit: allows flexibility at increased riskroller pump circuit: allows flexibility at increased risk

– high blood flowhigh blood flow

– anticoagulationanticoagulation • ECLS circuit already heparinizedECLS circuit already heparinized

PCRRT & ECLSPCRRT & ECLS

ConclusionsConclusions

• specific issues to be consideredspecific issues to be considered

– biomedicus vs rollerpumpbiomedicus vs rollerpump

– custom device vs. homemadecustom device vs. homemade

• allows optimized nutritional supportallows optimized nutritional support

• allows weaning from ECLSallows weaning from ECLS

• may reduce inflammatory responsemay reduce inflammatory response