ECLS – where are we now? Young ones by Dr Adrian Mattke
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Extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation (ECPR) is an effective therapy to improve outcomes for children who experience cardiopulmonary arrest. Survival after ECLS varies between 60% and 75%. For ECPR survival is lower, with 40% to 50% of children surviving ECPR. After ECPR good neurological outcomes are seen in 40% to 60% of children. This contrasts with adult patients where neurological outcomes after ECPR are poor. Given these findings the American Heart Association has included ECPR in their 2015 guidelines for children who experience an in hospital cardiac arrest (IHCA).
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ECLS – where are we now? Young ones by Dr Adrian Mattke
- 1. What’s new: ECPR in children Adrian C Mattke Lady Cilento Children’s Hospital Brisbane
- 2. Case Aurora 3 weeks old Presents shocked Intubated Brief period of bradycardia and CPR Suspected diagnosis of sepsis
- 3. TPCH - LCCH
- 4. ECMO initiation? Get team to TPCH Take child to LCCH TPCH to cannulate Transfer – knowing that child will arrest ECMO ready at LCCH During transfer PEA arrest Cannulation on arrival: trans-sternal cannulation
- 5. Diagnostic uncertainty During cannulation large coronaries noted ?Kawasaki ?ALCAPA CT angiogram directly after cannulation
- 7. Aurora 3 Days on ECMO IVIG and hydrocortisone Transferred to ward Home and thriving
- 8. What’s new in paediatric ECPR? What’s old in paediatric ECPR?
- 10. Overall Patient Outcomes ELSO Registry January 2018 Total Runs Survived ECLS Survived to DC Neonatal Pulmonary 27,238 22,793 83% 19,624 72% Cardiac 7,592 4,932 64% 3,158 41% ECPR 1,694 1,125 66% 694 40% Pediatric Pulmonary 8,617 5,830 67% 5,025 58% Cardiac 10,162 6,999 68% 5,301 52% ECPR 3,881 2,223 57% 1,643 42% Adult Pulmonary 15,677 10,460 66% 9,261 59% Cardiac 15,195 8,488 55% 6,378 41% ECPR 4,745 1,830 38% 1381 29% Total 94,801 64,680 68% 52,465 55%
- 11. ECPR in Children Is it just a very specialised field? Is there substantial progress? IHCA vs OHCA Questions remain What factors impact outcome after ECPR Percutaneous vs surgical vs hybrid cannulation Post resuscitation care: the big unknown Temperature BP goals Oxygenation goals Radical scavengers?
- 12. ECPR/ECMO in Children - a highly specialized field? Melbourne Sydney Brisbane Auckland Perth Indications vary within centres: Cardiac only vs Any child with arrest in hospital Annual data Melbourne: ~50 runs Brisbane: ~35 runs Sydney: ~20 runs Perth: ~10 runs (no ECPR) Auckland
- 13. Study n Cardiac Survival Mortality predictors Alsoufi Toronto 2007 80 91% 34% None Thiagarajan ELSO 2007 682 73% 38% Non-cardiac diagnosis, pre-ECMO acidosis Post-ECMO organ dysfunction, CPR, acidosis Raymond AHA registry 2010 199 84% 44% Non-cardiac diagnosis Pre-ECMO Renal dysfunction Kane Boston 2010 172 100% 51% Additional diagnosis Post-ECMO acidosis, organ injury, CPR Morris CHOP 2011 64 67% 33% Non-cardiac diagnosis Sivarajan Melbourne 2011 61 100% 38% CPR duration Huang Taipeh 2012 54 100% 46% Cardiac vs non cardiac no difference, higher lactate predictive Philip Houston 2014 59 100% 46% Pre-ECMO renal dysfunction, CPR duration, peripheral cannulation Mattke Brisbane 2015 28 68% 68% CPR duration, higher pH and lower serum HCO3 Kramer Berlin 2018 72 85% 36% Arrest location (OHCA and other than PICU), lactate, RRT, NOT duration
- 14. 2000-2007 NRCPR Database – 6288 Paediatric IHCPA
- 15. Raymond 2010
- 16. Study n Cardiac Survival Mortality predictors Alsoufi Toronto 2007 80 91% 34% None Thiagarajan ELSO 2007 682 73% 38% Non-cardiac diagnosis, pre-ECMO acidosis Post-ECMO organ dysfunction, CPR, acidosis Raymond AHA registry 2010 199 84% 44% Non-cardiac diagnosis Pre-ECMO Renal dysfunction Kane Boston 2010 172 100% 51% Additional diagnosis Post-ECMO acidosis, organ injury, CPR Morris CHOP 2011 64 67% 33% Non-cardiac diagnosis Sivarajan Melbourne 2011 61 100% 38% CPR duration Philip Houston 2014 59 100% 46% Pre-ECMO renal dysfunction, CPR duration, peripheral cannulation Mattke Brisbane 2015 28 68% 68% CPR duration, higher pH and serum HCO3
- 17. Factors influencing outcome after ECPR in children Non-modifiable Cardiac vs non-cardiac Cannulation under CPR pH Lactate HCO3 levels Modifiable Duration of CPR Type of cannulation (central vs neck) Post resuscitation care
- 18. Sivarajan, Int Care Med 2011; Huang Crit Care Med 2008; Morris PCCM 2004 Duration of CPR
- 19. ECPR is a complex treatment! 2014
- 20. was
- 21. Survival 41% Non ECPR survival at same institution: 36%
- 22. Lasa Circulation 2015 Does ECPR have a benefit? CPR registry analysis 3,700 paediatric arrests over 12 years
- 23. Location and duration of arrest IHCA established OHCA – very few centres only Kramer et al 2018: 6 OHCA, survival for whole group 36% Median duration of CPR 59 min
- 24. We have flow: What now? Post resuscitation care The big unknown Temperature – THAPCA trial Oxygenation targets? Flow targets Blood brain barrier
- 25. How to improve systems? Practice practice practice….
- 26. Be prepared Should every child admitted to hospital have a ECPR eligibility criteria filled in?
- 27. “ECMO used to support CPR rescued one third of patients in whom death was otherwise certain.” Paediatric Resusictation ECMO 15% 11% 8% 2% 5% 59% Congenital heart disease Myocarditis/cardiomyopathy Respiratory failure Sepsis Trauma Miscellaneous Thiagarajan, Circulation 2007 682 children with E-CPR 1992 – 2005 Who will you encounter?
- 28. How to improve systems? Practicalities Priming of the pump: easy in adults, difficult for small children Central cannulation for all patients? Conversion from central to neck/groin cannulation has high air embolism risk Percutanous cannulation?
- 29. Crit Care Medicine May 2015
- 31. Cannulation technique Percutaneous cannulation unusual in paediatrics Paed ECPR even more difficult If peripheral cannulation during ECPR, and reluctant to open chest VA-VV is option
- 32. Cannulation setup: Transsternal Trans-sternal vs neck or groin cannulation Sepsis with severe ARDS Complications with differential saturation and suboptimal DO2 with femoral cannulation VA via groin vessels, combined with Avalon VV circuit in neck
- 34. ECPR/ECMO in Children Should ECPR be offered in more centres? Canada: cannulation in centres that do not have ECMO program, with subsequent ECMO transport ECPR hugely more difficult than elective/semi-elective cannulation Practicalities? Surgeons to commit to cannulation in “peripheral” centres Practicalities of transport on ECMO
- 35. Conclusions ECPR is complex, and even more so in children Surgeon/intensivist interaction vital Cannulation site not a given High quality CPR seems more important than absolute CPR time?!? Its all about the framework – if the service is not equipped enough, outcomes will be poor IHCA established indication, OHCA not Once on think about coming off – does resting the heart exist?