Sunrise Neonatal ECMO Education & Training Program Sunrise Children s Hospital Las Vegas, Nevada Martin J. Blahnik, MD Sunrise Neonatal ECMO Director Sunrise Neonatal Intensive Care Unit 2013
Sunrise Neonatal ECMO Education & Training Program DIDACTICS: ECMO Lecture Series 12 sessions 4 tests WET LAB: Primed ECMO Circuit 3 days 1 test ECMO Specialist Training Manual 3 rd Ed. Billie Lou Short, MD. Extracorporeal Cardiopulmonary Support in Critical Care 4 th ed. 2012 RED BOOK OBJECTIVE: documentation of special professional skills as ECMO healthcare providers
Sunrise Neonatal ECMO Education & Training Program SYLLABUS 1. Introduction to ECMO 2. The Pre-ECMO Patient 3. Concepts: Oxygenation, Oxygen Content, Oxygen Delivery 4. The Decision to go on ECMO 5. ECLS Physiology 6. VV & VA ECMO 7. ECMO Equipment & Devices 8. Management of the Neonate on ECMO 9. Anticoagulation & Blood Products 10. ECMO Complications 11. ECMO Team Members Responsibilities & Case Scenarios 12. Open Review
Sunrise Neonatal ECMO Education & Training Program SYLLABUS 1. Introduction to ECMO 2. The Pre-ECMO Patient 3. Concepts: Oxygenation, Oxygen Content, Oxygen Delivery 4. The Decision to go on ECMO 5. ECLS Physiology 6. VV & VA ECMO 7. ECMO Equipment & Devices 8. Management of the Neonate on ECMO 9. Anticoagulation & Blood Products 10. ECMO Complications 11. ECMO Team Members Responsibilities & Case Scenarios 12. Open Review
Sunrise Neonatal ECMO Education & Training Program OBJECTIVES Introduction to ECMO: 1. Explain what ECMO/ECLS is & what it s used for 2. Concept of cardiac shunts 3. Tour through the circuit components 4. Describe the indications & contra-indications 5. Understand the fundamental principles of management of the pre-ecmo patient 6. Selection criteria to go on ECMO 7. Describe the differences between VV & VA ECMO 8. Know the components of the ECMO circuit
Extra Corporeal Membrane Oxygenation What is ECMO? What is it used for? 1. Cardio-pulmonary bypass using external circuitry 1. Supports gas exchange i.e. lung function 2. Supports cardiac output VA ECMO 2. Oxygenation, ventilation, non-pulsatile CV support = ECLS: Extra Corporeal Life Support 3. Highest bypass is 80% cardiac output 4. VA ECMO: right-to-left cardio-pulmonary shunt in parallel cardiac output = shunt + native heart 5. Right-to-left intrapulmonary shunts (pneumonia) 6. Right-to-left cardiac shunt w/ PPHN (ductus) 7. VV ECMO: technically not bypass b/c the shunt is in series
SHUNTS 1. FETAL: ductus venosus; foramen ovale; ductus arteriosus 2. FETAL cardiac output in parallel = RV + LV 3. NEWBORN transition to cardiac output in series 4. VA ECMO: right-to-left cardio-pulmonary shunt in parallel cardiac output = shunt + native heart 5. VV ECMO: technically not bypass b/c the shunt is in series
Extra Corporeal Membrane Oxygenation HISTORY 1. Artificial lung, artificial cardiovascular support 2. Dr. Robert Bartlett, 1975, MAS w/ PPHN 3. 40 neonates by 1980 treated w/ ECMO 4. By 1986, 18 centers had an ECMO program 5. CHLA 1988 20 cases / yr 6. ECMO standard of care: neonatal hypoxic respiratory failure unresponsive to conventional therapy 7. ELSO = Extracorporeal Life Support Organization 1989: guidelines, textbooks, registry 8. Survival: 98% MAS, 55% CDH, 85% overall
Extra Corporeal Membrane Oxygenation ELSO Data on ECMO Centers
Extra Corporeal Membrane Oxygenation ECMO Changes Over Time 1. Drop in ECMO late 1990s 2. BPD: lung stretch & high Fi02 vs safer ECMO devices 3. New generation of membrane lungs, safe centrifugal pumps, etc vs 80% mortality risk 4. A new generation of ECMO therapy: These [new] devices make ECMO safe and simple enough to be managed by the regular ICU staff -- Dr. Robert Bartlett 5. Reversible neonatal hypoxemic lung disease and / or cardiovascular collapse, unresponsive to conventional therapy
VA ECMO Circuit: Vessel Anatomy VENOUS: internal jugular ARTERIAL: common carotid
VENOVENOUS
VENOVENOUS
VA ECMO Circuit
1. PUMP: centrifugal 2. OXYGENATOR: hollow fiber 3. polymethylpentene 4. Inlet pressure (servo-regulated) 5. Outlet pressure (servo-regulated) VA ECMO Circuit
Maquet: Rotaflow Centrifugal Pump 1. OUTLET PRESSURE servo-regulated: 300mmHg 2. Flow sensor / bubble detector 3. Pressure! flow! resistance! length! 1/r4 4. RPM / LPM
1. Low priming volume 32ml 2. Minimal stagnation zones 3. Low heat generation 4. Flow sensor / bubble detector Maquet: Rotaflow (Pump Head)
Maquet: QUADROX Oxygenator 1. Hollow fiber non-microporous POLYMETHYLPENTENE: less plasma leakage; less micro-bubble formation 2. BIOLINE coating: less platelet activation; less thrombus formation; less complement / inflammatory stimulation
Maquet: QUADROX Oxygenator 1. Gas exchange surface area: 0.8m2 2. Low priming volume 81ml = less foreign SA / less blood bank 3. If high percentage SA w/ clot: high resistance, less efficiency
Maquet: QUADROX Oxygenator 1. Countercurrent gas-blood flow 2. Gas exchange: membrane partial pressure differences 3. RATED FLOW = maximum LPM to saturate blood 75% to 95%. 4. Sweep gas rate! PC02 clearance; use of carbogen
Extra Corporeal Membrane Oxygenation INDICATIONS Congenital diaphragmatic hernia Meconium aspiration syndrome Idiopathic PPHN GBS pneumonia E coli septic shock Air leak syndrome Respiratory distress syndrome Perinatal asphyxia TAPVR w/ PPHN CONTRA-INDICATIONS <2000g & <34wks gestation No significant IVH No severe HIE No severe CHD No severe syndrome No parental consent Inadequate conventional therapy Prolonged mechanical ventilation
The Pre-ECMO Patient Principles of Management 1. CONCEPT: the provision of oxygen delivery to end organs 2. Persistent pulmonary hypertension of the newborn 1. DELIVERY: CDH, no breathes, Vygon, UV access 2. DELIVERY: Neonatal Resuscitation Program 3. NEURO: sedation, paralysis, minimize external stimuli 4. RESPIRATORY: optimize VQ, reduce PVR (vent, surfactant, ino) 5. CARDIO-VASCULAR: MBP (pressors, volume, steroids) 3. Sepsis +/- shock w/ DIC: 1. Antibiotics 2. Fluid, pressors, steroids 3. DIC management 4. Pneumothorax: chest tubes
The Pre-ECMO Patient Principles of Management 1. CONCEPT: the provision of oxygen delivery to end organs vs hypoxemia & lactic acidemia 2. Failure of PPHN conventional therapy 1. Hypoxemia & lactic acidemia = oxygen debt 2. Hypercarbia = respiratory acidosis 3. Hypotension w/ low UOP, poor perfusion, slow capillary refill, poor cardiac contractility on ECHO 4. Pneumothoraces 3. Sepsis w/ SIRS +/- shock w/ DIC: 1. Hypotension w/ capillary leak syndrome 2. DIC w/ bleeding 3. The Golden Hour 4. Pneumothorax: chest tubes
Entry Criteria for ECMO Therapy The Art of Medicine vs Evidence-Based 1. Historical 80% mortality risk 2. Candidacy 1. Reversible pathophysiology 2. No contra-indications 3. Objective parameters to predict mortality: 1. Alveolar arterial 02 gradient (A-aD02 = PA02 Pa02) -- >600+mmHg over time 2. Oxygenation Index (Fi02 x100 x MAP / Pa02) -- >40 for 2 hours 3. ph < 7.15 & Pa02 <40 for 2 hours 4. Subjective clinical judgment 1. Barotrauma & oxygen toxicity 2. Duration of max settings
VV vs VA ECMO VENOARTERIAL VENOVENOUS 1. Non-pulsatile CV support 2. Ligation of carotid artery 3. Cardiac stun 4. Lung rest settings 1. Rapid wean off ino & inotrophic support 2. Particles from the circuit enter the arterial circulation 1. CV support dependent on native CO 2. End organ pulsatile flow 3. High 02 content to pulmonary vasculature & coronary arteries 1. Recirculation catheter position 2. Risk for needing conversion 3. Greater bedside maintenance
VV vs VA ECMO VENOARTERIAL VENOVENOUS
VV vs VA ECMO VENOARTERIAL VENOVENOUS
What is A, B & C?
Describe This CXR
Describe This CXR
ECMO Circuit: tour through its components VENOVENOUS 1. Cannulas 2. Bridge / Bladder 3. Sensors & monitors: Flow / pressures Sats / gases / Hgb Bubbles Safety 4. Centrifugal pump vs roller pump 5. Med / fluid ports 6. Oxygenator
ECMO Circuit: tour through its components 1/4 PVC w/ plasticizers Biocompatible surfaces Closed circuit w/ servoregulation A-V bridge VBA = Very Bad Accident Cross clamp trial Bladder: VS pressure transducer Collapse w/ negative pressure Hypovolumemia Kinked cannula Vessel injury, cavitation & hemolysis
Tour of the Circuit -- ANTI-COAGULATION MONITORING -- 1. Point-of-care coagulation status monitoring: a. ACTs: ITC Hemochron Signature Elite b. PTT / Anti-factor Xa activity / AT III / TEG c. ELSO Anti-coagulation Task Force 2. Non-invasive measurement of critical real-time parameters -- Spectrum Medical: -- Sv02, Sa02 -- Gases -- Hct / hgb -- Flow / emboli detection
Sunrise Neonatal ECMO Education & Training Program SYLLABUS 1. Introduction to ECMO 2. The Pre-ECMO Patient 3. Concepts: Oxygenation, Oxygen Content, Oxygen Delivery 4. The Decision to go on ECMO 5. ECLS Physiology 6. VV & VA ECMO 7. ECMO Equipment & Devices 8. Management of the Neonate on ECMO 9. Anticoagulation & Blood Products 10. ECMO Complications 11. ECMO Team Members Responsibilities & Case Scenarios 12. Open Review