New Perspectives in ECMO 2012
III International meeting, 5 October, 2012 Milan
Update on ECMO in
paediatric patients
Gianluca Brancaccio MD, PhD
Ospedale Pediatrico Bambino Gesù, Rome, Italy
Background
• ECLS is constantly improving since it was first used in
critically ill patients with respiratory failure over 40 years
ago.
• To date over 50.000 patients were treated with ECMO,
been neonates and infants the majority.
• Aim of this overview is to illustrate the changing in
environment, equipment and management in ECLS over
time.
Runs by Year
100%
Card (16 years and over)
80%
Card (1 year < 16 years)
Card (31 days < 1 year)
Card (0 - 30 days)
60%
Adult Pulm
Ped Pulm
Neo Pulm
40%
20%
0%
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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
4,361
38
Cardiac Arrest
77
26
Cardiogenic Shock
72
40
116
61
57
49
440
43
Congenital Defect
Myocardiopathy
Myocarditis
Other
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Cardiac Cases By Year
0 – 30 days old
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Cumulative Survival in Cardiac Support
0 – 30 days old
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Cardiac Cases By Year
Under 16 years
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Cumulative Survival in Cardiac Support
Under 16 years of age
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Cardiac Survival by Diagnosis and Year
Under 16 years
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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 venoarterial 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 patients (n.
per year)
2006
2010
2007
2011
2008
2012
2009
30
20
16
8
17
14
6
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
nsLC
OS
11%
sepsis
2%
resp
suppo
rt
21%
surg
LCO
S
66%
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).
ECMO patients and
UVH
survived
13
7
y
dead
37
33
n
Overall Patient Outcomes
Total
Neonatal
Respiratory
Cardiac
ECPR
Pediatric
Respiratory
Cardiac
ECPR
Adult
Respiratory
Cardiac
ECPR
Total
Surv ECLS
Surv to DC
25,746 21,765 85%
4,797 2,928 61%
784
496 63%
19,232 75%
1,912 40%
304 39%
5,457
5,976
1,562
3,556 65%
3,855 65%
843 54%
3,061 56%
2,913 49%
630 40%
3,280
2,312
753
2,094 64%
1,243 54%
276 37%
1,808 55%
891 39%
207 27%
50,667 37,056 73%
30,958 61%
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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).
survived
13
7
y
dead
37
33
n