1、Management of Infants requiring Venovenous ECMOSixto F.Guiang,IIIDept.of PediatricsUniversity of MinnesotaNeonatal ECMO=73%of all ECMO VV ECMO=20%of all Neonatal PulmonaryUniversity of MichiganJAMA 2000;283:904-908nN=1000nNewborns N=586nSurvival88%nMAS 98%nCDH68%nOthers84-93%n90%veno-venousn9%IVHVV
2、ECMOnRespiratory Mode for all agesnInfants 20%of all Respiratory ECMOnApproximately 800 cases/yrnPediatric 28%of all Respiratory ECMOnApproximately 200 cases/yrPediatric VV ECMOnPediatr Crit Care Med 2003;4:291-298nSingle Center 1991-2002nN=82 ECMO for Respiratory FailurenVenovenous 83%nVenoarterial
3、17%nUnable to place VV 43%Pediatric VV ECMOnVenovenousnDxnARDSnRSV bronchiolitisnPenumonianOutcomesnLower degree of respiratory failurenShorter ECMO (212 hour vs 350 hours)nHigher survival(81%vs.64%)Pediatric VV ECMOPediatr Crit Care Med 2003;4:291-298Infusion limbDrainage limbInclusion/Exclusion Gu
4、idelines-Same as VAnage of at least 34 weeksnWeight 1.5-2.0 kgnPotentially reversible processnAbsence of uncorrectable cardiac defectnAbsence of major intracranial hemorrhagenAbsence of uncorrectable coagulopathynAbsence of lethal anomalynAbsence of prolonged mechanical ventilation with high ventila
5、tory settingsOxygenation FailureCriteria-VA and VVnAlveolar-arterial oxygen tension gradientn760-47)-paCO2-paO2n605-620 torr for greater than 4-12 hoursnOxygenation indexnMean Airway Pressure x FiO2 x 100/paO2n 35-60 for greater than 1-6 hoursOxygenation FailureCriteria-VA and VVnpaO2nPaO2 35 for 2
6、hoursnpaO2 50 for 12 hoursnAcute decompensationnpaO2 30 torrMyocardial Failure-VA OnlynRefractory hypotensionnLow cardiac outputnpH 10ASAIO Journal 2003;49:568-571ECMO Goals-VA and VVnMaintain adequate tissue oxygenation to allow recovery from short term cardiopulmonary failurenAdjust ventilator set
7、tings allowing for Lung Rest minimizing further ventilator/oxygen induced lung injury.Not necessarily lower settingsECMO ModesnVenoarterial-VAnBlood drains-venous systemnBlood returns-arterial system nComplete cardiopulmonary supportnVenovenous-VVnBlood drains-venous systemnBlood returns-venous syst
8、emnPulmonary support onlyAdvantages of VA ECMOnAble to give full cardiopulmonary supportnNo mixing of arterial/venous bloodnGood oxygenation at low ECMO flowsnAllows for total lung rest Disadvantages of VA ECMOnLigation of the right carotid arterynNonpulsatile arterial blood flownSuboptimal conditio
9、ns for LV functionnLow preloadnHigh afterloadnHigh wall stressnLow coronary oxygenationDisadvantages of VA ECMOnSystemic embolinAirnthrombusAdvantages of VV ECMOnNo ligation of carotid arterynNormal pulsatile blood flownOptimize LV performancenMore preloadnLess afterloadnBetter coronary oxygenationn
10、Less ventricular wall stressnNo systemic emboliDisadvantages of VV ECMOnNeed a functioning LVnMixing of bloodlower arterial saturationnNeed increased ECMO flownNeed higher hemoglobinnNeed to place a larger cannulanMore difficulty monitoring adequacy of oxygen deliverynRecirculation of ECMO flowDisad
11、vantages of VV ECMOnMay need to convert to VAnNeed to be fully heparinizednCannula cannot be heparin bondedVV ECMO-Double lumennNewbornsn90%of VV ECMO-Double lumenn12F and 15F OriGennPediatricn35%of VV ECMO-double lumenn18F-largest OriGen cannulan65%internal jugular,femoral,sapphenousVV ECMO-Double
12、lumennCannula sitenInternal jugular vein(15F double lumen-preferred)nCannula tip low in the right atriumDrainageEndholeHigh lateral RALow lateral RAInfusionMid Medial RAOptimal Cannula PlacementnAdequate sizenCorrect depthnLow Right AtriumnCorrect RotationnLabel visiblenDrainage limb(Blue)posteriorn
13、Infusion limb(Red)anteriornVertical orientationnHead-midlinenNo KinksRecirculationnOxygenated ECMO blood returning to the ECMO circuit immediately after infusionRecirculation factorsnHead/cannula positionnChanges with head rotationnChanges in lung volume/relative position of the heart and cannulanEC
14、MO flownRight atrial size/intravascular volumenRV contractilityECMO Flow reads 200 ECMO blood flow to baby-160ECMO Flow reads 500 ECMO blood flow to baby-250ECMO Flow-RecirculationnMore ECMO flow will always increase recirculationnMore ECMO flow may either nIncrease blood flow to babynDecrease blood
15、 flow to babyVA ECMOnECMO flow rate is proportional to the level of supportnMore flowMore supportnAlways advantageous if more flow is possiblenMore ECMO flow will always increase SvO2Pulmonary Support-VVnNet ECMO blood flow of infant=measure ECMO flow-recirculation flownECMO flow(flow probe)DOES NOT
16、 indicate level of supportnSvO2 DOES NOT reflect level of systemic oxygen deliveryCirculatory SupportnNet flow to baby assessed bynInfant colornInfant arterial saturation and PaO2Assessment of RecirculationnMore recirculation if nDecreasing baby arterial sat or PaO2nIncreasing SvO2 on ECMO circuitnD
17、ecreasing color difference on drainage and infusion limbs of circuitReducing RecirculationnAdjusting relative cannula positionnHead positionnLung inflation nDecrease ECMO flownIncrease intravascular volumenIncrease RV contractilitynVolumenVasopressorsnPulmonary vasodilatorsVV-VA ConversionnNeeded if
18、 n10-15%of casesnHemodynamic support is inadequatenRespiratory support is inadequatenMore problematic when ultrafiltration is usedVV ECMO-Specific IssuesnECMO PrimenMust have added heparin nMust have Ca addednIonized Ca on circuit must be checked prior to cannulationnPotassium must be checkedHeparin
19、nIf no heparin addednAddition of Ca binds citrate of blood productsnLoss of anticoagulant activitynAcute clotting of the entire circuitnNeed to prime another circuitCalciumnIf no calcium addednAcute hypocalcemia-Ca binds to citrate of blood productsnLoss of LV and RV contractilitynAcute hypotensionn
20、Cardiac arrestPotasiumnIf potassium in prime is not checkednPossible higher serum K from the stored PRBCnAcute hyperkalemianArrythmianCardiac arrestHead/Cannula PositionnDistal tip low in RAnHead in the midline with vertical orientation of the drainage and infusion limbsnRA drainage portsnLateralnIn
21、fusion portsnMedialKeys to ManagementnVV ECMO-DLnNeed to think in terms of NET blood flow to the babynCannot quantify NET flownSvO2 is not indicative of adequacy of systemic oxygen deliverynIndirectly assessed with SaO2 and PaO2 on the infantTo Improve oxygenationnGive PRBCnIncrease ECMO flownDecrea
22、se recirculationnCheck cannula positionnIncrease ntravascular volumenIncrease RV contractilityRest Ventilator SettingsnPressures-similar to VAnFiO2-able to wean to RA frequentlynBetter myocardial oxygenation via ECMO flow than VAJugular venous drainagen11%of all double lumen VVnSmall study suggested
23、 decrease IVHnReduced cerebral venous pressurenAdvantagenAdditional drainage facilities flown2 site venous drainage lessens recirculation on VV ECMOnImproved oxygen deliverynEnables venous oxygen saturation monitoring on VV ECMOJugular Venous DrainageCephalad CannulanJ Pediatr Surg 2004;39:672-676nR
24、eview of ELSO databasenNeonatal Respiratory Failure VV ECMO 1989-2001nN=2471n96%VV double lumem alonen3.7%with jugular venous drainagenSimilar OutcomesOperating ParametersnSaO2-85-95%nPaO2 40-65 torrnBlood pressure-similar to VAnECMO flows-130-150+ml/kg/minnHgB 12-15 g/dlWeaning of ECMO-VVnNo clamp
25、out needednIncrease ventilatornDecrease sweep gas flow rate and FiO2nSweep gas flow can be completely stoppednSvO2 will reflect mixed venous saturationnNo recirculationVV ECMO OutcomesnGenerally slightly better than VA,but slightly different patient populationsnHemodynamically more stablenLess exposure to CPRnBetter survivalnShorter duration of ECMOnConversion VV to VAn12%VA-VV Comparison studiesnJ Peds Surg1993;28:530-536nMulticenter datanN=243nVA=135nVV=108nSimilar survivaln10%conversion to VAnShorter runsnLess Neurologic complications
