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Use of CRRT in ECMO: Is It Valuable?

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Use of CRRT in ECMO: Is It Valuable? James D. Fortenberry MD, FCCM, FAAP Associate Professor of Pediatrics Emory University School of Medicine Director, Critical Care ... – PowerPoint PPT presentation

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Title: Use of CRRT in ECMO: Is It Valuable?


1
Use of CRRT in ECMO Is It Valuable?
  • James D. Fortenberry MD, FCCM, FAAP
  • Associate Professor of Pediatrics
  • Emory University School of Medicine
  • Director, Critical Care Medicine and
  • Pediatric ECMO/Advanced Technologies
  • Childrens Healthcare of Atlanta at Egleston

2
CRRT and ECMO
  • What are potential benefits?
  • What is the experience?
  • How do you do it?
  • What are the risks?
  • What more do we need to know?

3
CRRT on ECMO Potential Benefits
  • Management of fluid balance
  • Decreasing fluid overload
  • Removal of inflammatory mediators
  • Enhanced nutritional support
  • Control of electrolyte abnormalities
  • Decreased use of furosemide

4
Is Fluid Overload Bad?
  • Remember fluid is good in resuscitation!
  • Early goal directed therapy outcome benefits
  • However, multiple studies (adults, pediatric)
    suggest survival benefit with decreased fluid
    overload in critical illness

5
Fluid Overload
  • Texas Childrens Hospital
  • 21 pediatric ARF patients
  • Survival benefit remains even after adjusted for
    PRISM scores


Percent Fluid Overload
Goldstein SL, et al Pediatrics 1071309-1312,
2001
6
Fluid Overload
  • Childrens Healthcare of Atlanta at Egleston
  • 113 pediatric patients on CVVH
  • Multivariate analysis
  • Percent fluid overload independently associated
    with survival in 3 organ MODS


Percent Fluid Overload
-Foland JA, Fortenberry et al. Crit Care Med,
2004
7
Fluid Overload Decreased in 3 Organ MODS CRRT
Survivors
-Foland JA et al. Crit Care Med, 2004
8
Fluid Overload and ECMO Neonates
  • As weight gain decreases, ECMO flow decreases ?
    which comes first?
  • As weight reduces, ECMO flow reduces

-Kelley RE, et al. J Pediatr Surg, 1991
9
Fluid Overload and Outcome
  • Seattle Childrens Hospital
  • 77 pediatric patients
  • If pre-CRRT percent fluid overload gt10
  • 3.02 times greater risk of mortality (95 CI
    1.5-6.1, p0.002)

Gillespie RS, et al. Pediatr Nephrol
191394-1399, 2004
10
Fluid Overload/Oliguria is Common on ECMO
  • Children's Healthcare of Atlanta
  • 30 consecutive neonates meeting ECMO criteria
  • 18 VV ECMO, 12 conventional management
  • Patients who went onto ECMO had
  • Greater fluid overload
  • Lower UOP
  • Higher BUN
  • Higher creatinine

-Roy BJ, Pediatrics 1995
11
ECMO and Urine Output
-Roy BJ, Pediatrics 1995
12
Requisite Bad Humour Slide
Blood
Phlegm
Black Bile
Yellow Bile
13
Good Humours
14
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15
Hemofiltration Cytokine Clearance
  • Childrens Healthcare of Atlanta at Egleston
  • 6 pediatric patients with culture proven
    bacterial septic shock and ARF
  • 2 on ECMO
  • Compared to 3 ARF patients without septic shock
  • 1 on ECMO

-Paden M et al., submitted 2008
16
Absolute cytokine changes in septic shock/ARF
patients


p0.04
plt0.02
Log Concentration (pg/ml)
-Paden et al., submitted 2008
17
CVVH Associated With Decreased Cytokines in
Children with Septic Shock
plt0.05


Septic ARF Patients
Non-septic ARF Patients
-Paden et al., submitted 2008
18
Cytokine Results Sample CVVH Patient-Nonseptic
Note Scale
24 Hours off CVVH
End of CVVH
12 Hours
24 Hours
Pre-CVVH
48 Hours
19
Cytokine Results in Sample CVVH Patient Septic
24 Hours off CVVH
End of CVVH
24 Hours
12 Hours
48 Hours
Pre-CVVH
20
ECMO/CVVH Produces Cytokine Reduction
  • In vitro study
  • Increased cytokine levels overall due to ECMO
    membrane activation
  • Adding a hemofiltration circuit significantly
    reduced
  • IL-1beta
  • IL-1ra
  • IL-6
  • IL-8

-Skogby M, et al. Scand Cardiovasc J. 2000
21
IL 8 Reduction with CRRT in ECMO
Skogby M, et al. Scand Cardiovasc J. 2000
Jun34(3)315-20
22
Is Avoiding Lasix Overuse Important?
  • Potential ototoxicity-particularly in neonates
  • Lasix use associated with worsened outcomes in
    adult renal failure

23
Diuretics and Critical Illness
  • 4 University of California Hospitals
  • 552 adults
  • Use of diuretics increased risk of death or renal
    non-recovery in adults with ARF
  • Overall 1.77 times greater risk

-Mehta RL, et al. JAMA 2002
24
CRRT and ECMO
  • What are potential benefits?
  • What is the experience?
  • How do you do it?
  • What are the risks?
  • What more do we need to know?

25
CRRT on ECMO Published Experience with Use
  • Michigan
  • PICU
  • Cardiac surgery
  • Vanderbilt
  • Atlanta
  • Chile

26
CRRT/ECMO Experience Michigan
  • U of M ECMO Database
  • 35 neonatal and pediatric patients who received
    ECMO hemofiltration
  • 15 Survivors
  • Renal recovery in 14 of 15 (93) survivors
  • One had Wegeners as underlying cause of renal
    failure-subsequently transplanted

-Meyer RJ, et al Pediatr Crit Care Med 2001
27
CRRT/ECMO Experience Cardiac Surgery
  • University of Michigan
  • 74 post-operative congenital heart disease
    patients
  • Use of hemofiltration in 35
  • 5.01 times increased risk of death
  • Use of hemofiltration indicative of longer ECMO
    support time ? worse outcome was from duration,
    not hemofiltration

-Kolovos et al. Ann Thorac Surg 2003
28
CRRT/ECMO Experience Cardiac Surgery
  • Vanderbilt University
  • 84 post-operative congenital heart disease
    patients
  • Temporary renal insufficiency in 41 patients
    (48.9)
  • CVVH NOT associated with
  • Ability to wean off ECMO
  • Survival to discharge

-Shah SA et al. ASAIO J 2005
29
ECMO/CVVH Experience Atlanta
  • Childrens at Egleston ECMO Database
    (11/97-12/05)
  • 95 neonatal and pediatric patients who received
    ECMO CVVH
  • 55 survivors
  • 14 came off ECMO on RRT (1 on prior to ECMO)
  • 1 needed RRT chronically
  • 1 with CRF but does not need RRT
  • Renal recovery in 53/55 (96) survivors
  • Both CRF patients had primary vasculitis

-Paden et al., CCM 2007 (abstr)
30
Comparison of CVVH/ECMO vs. ECMO without CVVH
  • 26/86 peds respiratory failure patients received
    CVVH for gt24 hours
  • Case control comparison 26 CVVH/ECMO pts. and 26
    pts. receiving ECMO without CVVH
  • No difference in survival or vent days during or
    after ECMO
  • Significant differences in fluid balance
  • Significant treatment differences

-Hoover et al., Intensive Care Medicine, in press
2008
31
Fluid Balance With CVVH/ECMO vs. No CVVH/ECMO
-Hoover et al., Intensive Care Medicine, in press
2008
32
Comparison of CVVH/ECMO vs. ECMO without CVVH



-Hoover et al., Intensive Care Medicine, in press
2008
33
CRRT/ECMO Experience in Infants Chile
  • 6 of 12 infants on ECMO received CRRT
  • Observed complication excessive ultrafiltration
  • Survival to discharge in 5 of 6 (83)
  • All with normal renal function at discharge

-Cavagnaro et al., Int J Artif Organs 2007
34
CRRT and ECMO
  • What are potential benefits?
  • What is the experience?
  • How do you do it?
  • What are the risks?
  • What more do we need to know?

35
CRRT on ECMO How to Perform It
  • Options
  • Parallel use of stand-alone CRRT devices (Gambro,
    Braun)
  • Pros
  • Cons
  • Use of inline hemofilter with syringe pumps
  • Pros
  • Cons

36
ECMO/CRRT Arrangement The Michigan Method
37
Use of Standard CRRT Devices for Delivery on ECMO
38
CRRT and ECMO
  • What are potential benefits?
  • What is the experience?
  • How do you do it?
  • What are the risks?
  • What more do we need to know?

39
CVVH/ECMO Are There Risks?
  • Complexity of machinery
  • Errors due to replacement fluids
  • Underestimation of fluid removal

40
Sometimes it gets a little crowded
41
CRRT Error Rate Increases with Increasing
Flow/Pressure
-Sucosky, Paden et al., JMD, in press 2008
42
Error Rate in CRRT/ECMO Circuits
  • Potential error rate noted in stand-alone CVVH
  • Ex vivo ECMO circuit
  • Compared measured versus actual fluid removal
    rates with inline hemofilter arrangement and with
    Braun Diapact for CVVH
  • Significant excess fluid removal over expected
    both for inline device and commercial device

-Paden et al., ppCRRT Conference 2008 (abstr)
43
Potential Solutions
  • Collaboration with GeorgiaTech
  • Paden, Sucosky
  • Development of fluid management/CRRT device
  • High accuracy in delivery
  • Patent pending

44
What Further Work Needs to be done?
  • Improved control of fluid management
  • Randomized trial to compare CVVH/ECMO to ECMO
    without routine CVVH
  • Potential use of biomarkers for initiation?

45
Conclusions
  • CRRT on ECMO can potentially provide a variety of
    benefits
  • CRRT can be provided
  • without worsening renal insufficiency
  • with improved fluid balance
  • with decreased furosemide exposure
  • Potential risks of excessive fluid removal
  • Further work to improve accuracy of fluid balance
    and to determine if use translates into outcome
    benefit

46
Pediatric Patients Receiving CVVHFactors
Associated with Mortality
- Foland, Fortenberry et al., CCM 2004
47
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