Update on ECMO in paediatric patients

1. New Perspectives in ECMO 2012 III International meeting, 5 October, 2012 Milan Update on ECMO in paediatric patients Gianluca Brancaccio MD, PhD Ospedale Pediatrico Bambino Gesù, Rome, Italy

2. Background • ECLS is constantly improving since it was first used in critically ill patients with respiratory failure over 40 years ago. • To date over50.000 patientsweretreatedwith ECMO, beenneonates and infants the majority. • Aimofthisoverviewisto illustrate the changing in environment, equipment and management in ECLS overtime.

3. Runs by Year ELSO Registry July 2012

4. Neonatal Respiratory Cases Clark RH et al. N Engl J Med 342: 469-474, 2000 ELSO Registry July 2012

5. Cumulative Survival in Neonatal Respiratory Support ELSO Registry July 2012

6. Neonatal Cases by Year and Diagnosis ELSO Registry July 2012

7. Neonatal Diagnoses and Survival ELSO Registry July 2012

8. Initial Mode of Neonatal Respiratory Support ELSO Registry July 2012

9. Pediatric Respiratory Cases ELSO Registry July 2012

10. Pediatric Cases by Year and Diagnosis ELSO Registry July 2012

13. Initial Mode of Pediatric Respiratory Support ELSO Registry July 2012

14. Cardiac ECLS by Diagnosis 0 – 30 days old ELSO Registry July 2012

16. Cardiac Cases By Year0 – 30 days old ELSO Registry July 2012

17. Cumulative Survival in Cardiac Support 0 – 30 days old ELSO Registry July 2012

19. Cardiac Cases By YearUnder 16 years ELSO Registry July 2012

20. Cumulative Survival in Cardiac Support Under 16 years of age ELSO Registry July 2012

21. Cardiac Survival by Diagnosis and Year Under 16 years ELSO Registry July 2012

23. HOW HAS ECLS EQUIPMENT CHANGED • Tubings heparin-bounded • Pumps • Roller pump • Centrifugal pump • Cannulae (Avalon) • Plastic oxygenators • Silicone membrane oxygenators • Hollow-fiber membrane oxygenator (HFMO)

25. Avalon Elite™ Bi-Caval Dual Lumen - Triple lumen cannula • ↓ recirculation • Good flow dynamics • Sizes from 13 Fr to 31 Fr.

26. Conclusions • The field of ECMO is currently in a state of flux. Many patients denied ECMO support in the past are now being considered for ECMO support and obtaining long-term survival. • The experience and knowledge gained over the past 20 years or more of ECMO has resulted in making this therapy more accessible, safer, and efficient. • The revised interest in use of ECMO in cardiac arrest, sepsis and other populations may herald an increase in the use of ECLS in future days.

27. Experience OPBG • A total of 93 veno-arterial ECMOs were delivered to 90 patients: in 3 cases two separate ECMO sessions were necessary; 3 patients were bridged from ECMO to ventricular assist device

28. ECMO indications • low cardiac output syndrome (LCOS) in 10 cases • post-operative LCOS in 61 patients • respiratory support in 20 children • sepsis in 2 patients

29. Results • Children who survived on ECMO had a significantly shorter treatment duration: 4 (2.7-7) vs. 9 (5.7-16) days p<0.0001

30. Results-2 • Age, weight, RACHS score, indication to treatment, pump type, cannulation site, need for renal replacement therapy and the presence of univentricular anatomy were not significantly associated with an increased ICU mortality (p>0.05).

31. Overall Patient Outcomes ELSO Registry July 2012

32. Cannulation • Central vs. peripheral cannulation • Jugular-carotid • Femoro-femoral VA ECMO • Femoro-femoral VV ECMO • Veno-venous vs. veno-arterial ECMO • Percutaneous cannulation

33. Results-3 • However, a trend to increased mortality was evident in RRT patients. Furthermore, in our patients, respiratory ECMOs showed a better chance to be weaned off than cardiac ECMOs (75% vs 43%, OR 3.8, 95% C.I. 1.7-11, p:0.01). However, ICU survival was not significantly different (55% vs 40%, OR 1.9, 95% C.I. 0.7-5.3, p:0.2).