Pediatric ECMO and CRRT
NJ Maxvold MD
Assoc Prof of Pediatrics, MSU
DeVos Children’s Hospital
Grand Rapids, MI
Pediatric ECMO and CRRT
•
I would like to thank Dr Picca and Dr
Bunchman for this conference
•
I would like to thank Dr Askenazi for the
incorporation of some of his slides into
today’s presentation
Pediatric ECMO and CRRT
Objectives:
 Review of ECMO in Pediatrics
Indications/Limitations/Complications
Survival Data
• Review of CRRT tandem to ECMO
Indications/Limitations/Complications
Survival Data
ExtraCorporeal Membrane
Oxygenation
Respiratory Failure vs Cardiac Failure
Reticent to Mechanical Ventilatory Equipment
(HFOV,HFJV,BiLevel/APRV,NO/Surfactant, etc)
Limit Vent-Induce Further Lung Injury
Reticent Arrhythmias / CO unresponsive to
meds or volume status/ noncandidates for
VAD/Post Cardiac Surgery
Limit End Organ Ischemia
ExtraCorporeal Membrane
Oxygenation





ECMO Limitations:
Patient Size: Cannula/Catheters for
Preterm/Small Infants
Highly Catabolic-Hypermetabolic States
Exceeding Flow Delivery
Coagulopathy not correctable by therapeutic
supports, or recent Intracranial Bleed
Contraindications to system heparinization
Irreversible Lung or Cardiac Failure not
deemed a Transplant Candidate
ExtraCorporeal Membrane
Oxygenation
•
•
ECMO Complications:
Bleeding: Heparin Anticoagulation
Embolic Events:
Microemboli / Air emboli from the circuit
•
•
•
Catheter Displacement
Heparin induced thrombocytopenia
?? End Organ/Renal Effect of
Continuous Flow
ExtraCorporeal Membrane
Oxygenation
Russell et al
Circulation 2009
End Organ Function Continuous Flow LVAD
N= 309 pts, HeartMate II, 6 mo Follow Interval
Two Group Analysis: Normal and Above Normal
Laboratory Values
BUN / Cr
37 / 1.8 
AST/ALT 121 / 171 
T Bilirubin
2.1 
23 / 1.4 mg/dL
36 / 31 IU
0.9 mg/dL
Conclusions: Continuous flow maintained or
improved end organ function
ExtraCorporeal Membrane
Oxygenation
Ingyinn et al
Perfusion 2004
Compared VV to VA Effect on Renal Flow in Lambs
3 Parameters: Systemic Blood Pressure, Renal Blood Flow,
Plasma Renin Activity Levels
VA and VV Partial Flow (120 mls/kg/min)
VA Full Flow (200 mls/kg/min)
No difference at partial flow between VV and VA parameters
Full VA Flow Significant Increase of Blood Pressure
Full VA Flow Flashing/Unclamp of ECMO Bridge  BP  Renal
Flow
Conclusion: Potential cause of the Hypertension that is seen
in some newborns after VA ECMO
ExtraCorporeal Membrane
Oxygenation
Mussaro et al
Pediatr Crit Care Med 2009
Evaluated Bloodless Bridge on VA ECMO (No
Flashing/Unclamping)
Retrospective comparison to the Earlier Bridge ECMO Setup
Parameters: BUN, Cr, Fld Balance, Urine Ouput,
Average and max SBP, mean BP
No Difference in BUN, Cr, Fld Balance, Urine Output
Lower % of HTN (Mean BP> 60), Lower SBP on Days 2, 3
Conclusion: Less HTN with the new bridge design that
did not require flashing therefore improved
maintenance of Renal flow
ExtraCorporeal Membrane
Oxygenation
Basic ECMO Design / Setup:
 Venovenous Design: Outflow and Inflow
catheters in Venous System
 VenoArterial Design / Setup: Outflow
from Venous (R Atrium), Inflow Arterial
(Aortic Arch)
VA vs. VVDL Cannulation
Typical
VVDL
catheter
placement
ECMO Centrifugal Pump Setup
Centrifugal circuit design
ExtraCorporeal Membrane
Oxygenation
ECMO Neonatal/Pediatric Survival
Data: ELSO Registry 1998-2008
 Neonates ( </= 30 days old)
N= 8958
Survival: 5776 (72.6%)
NonSurvival: 2182 (27.4%)

ExtraCorporeal Membrane
Oxygenation
ECMO and PCRRT
Indications for CRRT tandem with
ECMO
 Systems Set Up Design
 Publications reviewing PCRRT and
ECMO Survival and Longterm Renal
Outcomes

PCRRT and ECMO
CRRT/ECMO Indications ??
 Fluid Overload > 10% ( Michael et al Pediatr
Nephrol 2004)

pRIFLECr maxF (Akcan-Arikan et al Kidney Int
2007)
[Definition :  eCCl by 75% or <35m/min/1.73m2]
•
Nutritional Limitation ( Due to
Inadequate Solute/ Fluid Clearance)
CRRT on ECMO

“Homemade” system connected to the
ECMO circuit

IV infusion pumps used to control
ultrafiltrate
 (if replacement desired) IV infusion pump to
add replacement fluids
 Several sites to hook into circuit each with
drawbacks ( shunting, bubble trap, flows)
 IV pumps are not engineered to maintain
accuracy when flow/pressure above the
pump is variable.
ECMO/CRRT Arrangement: Homemade System
ECMO/CRRT Arrangement: RRT System
ECMO and CRRT
Hemofilter
(Homemade)
Ultrafiltration
IV pump
control
controlled
Metabolic Control NO
CRRT
CRRT machine
controlled
YES
ECMO Flow
Blood Shunt
NO systemic
-decrease ECMO changes
flow or decreased
PaO2 to patient
Anti-coagulation
Heparin
Heparin
CRRT/ECMO in Tandem
CRRT/ECMO Centrifugal Pump
Santiago et al
Kidney Int 2009
N= 6 children on VA ECMO
Inlet line after the Centrifugal Pump
Outlet/return line before the Oxygenator
Mean Filter Life = 138 hours
CRRT/ECMO in Tandem
CRRT/ECMO Outcomes

Meyer RJ, et al Pediatr Crit Care Med 2001
• 15/ 35 ( 42.9 %) neonatal and pediatric
survived
 14/15
(93%) RENAL RECOVERY
 1/15 (7%) – Wegener’s
CRRT/ECMO in Cardiac Newborns

Shah SA et al. ASAIO J 2005
 41/ 84 (48.9%) post-operative congenital heart
disease patients with AKI

CVVH NOT associated with :



Ability to wean off ECMO
Survival to discharge
Kolovos et al. Ann Thorac Surg 2003
 26 / 74 (35%) post-operative congenital heart
disease patients

Hemofiltration = 5.01 X increased risk of death
CRRT/ECMO – Noncardiac
Children

Hoover et al. Intensive Care Med (2008)
 Case-control study

Cases 26/86 - received CVVH for >24 hours
 Controls – no CVVH

Significant differences in fluid balance
 Significant treatment differences
 No difference in survival or vent days
during or after ECMO
ECMO/CRRT

Askenazi et al
Abstract CRRT 2009
ELSO Registry Data,1998-2008
8958 patients age ≤ 30 days
Asked the Question:
 Hypothesis: After controlling for
demographic, complications, severity
of illness, interventions, does AKI / RRT
predict mortality in non-cardiac
neonates who require ECLS?
Extracorporeal Life Support Organization
(ELSO) Registry

AKI Categorically defined
Complication code of SCr ≥ 1.5 mg/dl or
 ICD-9 code of Acute renal failure


Dialysis

CPT codes used
Survival
 Demographics, Complications, CoMorbidities and Interventions

Askenazi et al. Abstract CRRT 2009
ELSO Registry - Neonates
18%
5%
3%
74%
Neither
AKI
Both
RRT
Askenazi et al. Abstract CRRT 2009
ELSO Registry - Neonates
Survival by AKI/RRT class
5000
4000
3000
2000
1000
0
Neither
AKI
Non-Survivors
Both
RRT
Survivors
Askenazi et al. Abstract CRRT 2009
ExtraCorporeal Membrane
Oxygenation
ELSO Pediatric Registry 1998-2008
N = 2514
Survival = 1410 (56%)

ELSO Accumulative (1985-2008)
N = 4065
Survival = 2247 (55.3%)
Ped Pts Receiving Dialysis (1985-2008)
N = 1616 (39%) Survival = 606 (37.5%)
•
ELSO 1985-2008 Cardiac Runs
Age
Total
Runs
0-30
days
N=3824 N=1430
(37.4%)
N=2428 N=1058
(43.6%)
N=2034 N=975
(47.9%)
N=1113 N=388
((34.9%)
1-12
months
1-16
years
>16
years
Survival Dialysis Survival
N=1595
(41.7%)
N=926
(38%)
N=783
(38.5%)
N=533
(47.9%)
N=354
(22.2%)
N=244
(26.3%)
N=273
(34.9%)
N=118
(22.1%)
CRRT/ECMO Summary
ECMO&CRRT Can be Safely done in a variety of
setups
 No additional regional Anti-coagulation is needed
since the patient and the entire circuit is already
heparinized for ECMO
 Circuit prime for the CRRT can usually be saline
Due to the relative size of the CRRT circuit in ratio to
the larger ECMO circuit
• When starting Ultrafiltation careful monitoring of fluid
goals over a time period will prevent  Hct and
viscosity changes that are unwanted
• CRRT Support on ECMO Effect on Mortality is yet to
be more clearly defined as to timing of Initiation of
both supports and Subsequent Outcomes.

ECMO Circuit
Aortic Arch
Right Atrium
Blood Return
Heat
Exchanger
Blood
Drainage
Bridge
Servo-regulation
Pump
Heparin
and Fluids
Membrane
Oxygenator