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ECMO in CRRT – What are the Data?

ECMO in CRRT – What are the Data?. Jason S. Frischer, MD Director, ECMO Program Division of Pediatric General & Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati , OH

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ECMO in CRRT – What are the Data?

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  1. ECMO in CRRT – What are the Data? Jason S. Frischer, MD Director, ECMO Program Division of Pediatric General & Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati, OH 1st International Symposium on AKI in Children at the 7th International Conference on Pediatric Continuous Renal Replacement Therapy Cincinnati, OH September 27-30, 2012

  2. Thank You, STU

  3. Background • As many as 30 definitions of renal failure exist in the literature • Difficult to compare: • Incidence • Therapeutics • Outcomes • pRIFLE • AKIN • Neonatal definition even more difficult

  4. Background • 2 sources of data • Single center reviews • Details available • Able to control variables • ELSO • Renal complications • Serum Cr • Need for dialytic therapy • No data on indication, practice based on local expert opinion • Until this year

  5. AKI • Neonates • Single center incidence: 22-71% • ELSO based publications: 10-22% • Pediatric • Single center incidence: 12-30% ECMO, Extracorporeal Cardiopulmonary Support in Critical Care, 4th Ed

  6. AKI – Neonatal/Cardiac • Neonatal Respiratory – 75% overall survival • Neonatal Cardiac – 39% overall survival ELSO, July 2012

  7. AKI – Pediatric/Cardiac Pediatric Respiratory – 56% overall survival Pediatric Cardiac – 47% overall survival ELSO, July 2012

  8. ELSO registry review • Non-cardiac patients • 1998 - 2008

  9. ELSO review - Neonates • AKI + RRT 28% survival • AKI Ø RRT 45.7% survival • ØAKI + RRT 58.1% survival • ØAKI Ø RRT 80.1% survival .

  10. ELSO review - Pediatric • AKI + RRT 32.2% survival • AKI Ø RRT 41.3% survival • ØAKI + RRT 48.3% survival • ØAKI Ø RRT 72.3% survival .

  11. ELSO review - Conclusions • AKI and RRT are independent predictors of mortality • Even after controlling for comorbidity variables

  12. RRT in Critically Ill Patients • Using RIFLE definition in ECMO patients • AKI incidence: • CDH – 71% : associated with mortality • Cardiac – 71% • Adults respiratory – 78% • Adults post-cardiotomy – 81% Clin J Am SocNephrol. 2012 Aug;7(8):1328-1336.

  13. RRT in Critically Ill Patients • Indications for RRT on ECMO • Issue with ELSO database • Fluid Overload (FO) – 43% • AKI – 35% • Electrolyte – 4% • Cumulative FO and failure to return to dry weight • Associated with higher mortality and prolonged ECMO run Clin J Am SocNephrol. 2012 Aug;7(8):1328-1336.

  14. Used to define current practice • 65 centers • 23% reported NO RST • 43% use for FO • 16% for FO prevention • 35% AKI • 4% Electrolyte

  15. KIDMO

  16. KIDMO - Indication

  17. KIDMO – Mode employed • Predominant mode convection • CVVH • SCUF

  18. Single center retrospective review • July 2006 – October 2010 @ U of M • Hemofiltration through 2008, then CVVH • 203 total ECMO • 57 CRRT (28%), 4 prior to run

  19. FO and ECMO/RRT • 33 neonates • FO indication in 48/53 patients

  20. FO and ECMO/RRTOutcomes: • 58% overall survival • CRRT – 34% • Filter vs CVVH : 25 vs 53% • Improved institutional practices? • Median initiation of FO • Significantly lower in survivors • 24.5% survivors vs 38% nonsurvivors, P=.006

  21. FO and ECMO/RRTOutcomes: • Cardiac • Degree of FO at CRRT initiation significantly higher in nonsurvivors • 38% vs 14%, P=.039 • Degree of fluid removal and rate of removal: • NO improvement in outcome

  22. FO and ECMO/RRTOutcomes: • Univariate Analysis • Significant association b/w initiation and discontinuation of FO and mortality • For each 1% increase in FO - odds of mortality increase 4% • Multivariate Analysis • Borderline significance with initiation FO and mortality • Significant increased mortality with dicontinuation level of FO • Examined % change in FO, NOT significantly associated with mortality

  23. FO and ECMO/RRTConclusions: • “These data suggest that PREVENTION of significant FO is likely to be more effective at improving outcomes than attempting fluid removal once significant FO is established.”

  24. Single center retrospective review • 378 total ECMO with 66% survival • 154 (41%) concomitant CVVH

  25. Recovery • CVVH has a lower survival rate • Similar to non-ECMO patients

  26. Renal Outcomes • 52% FO • 37% ARF • 18/68 (26%) survivors required ongoing RRT following decannulation • 65/68 (96%) no RRT by hospital discharge • 30/31 FO and 20/23 AKI

  27. Recovery - Conclusions • Confirms higher risk of CRRT compared with ECMO use alone • In the absence of primary renal disease at presentation, CRF did not occur in ECMO pts. treated with CVVH.

  28. Biomarkers • 10 pediatric cardiac patients • 50% survive to d/c from ICU • Increased NGAL on ECMO day #1 who needed CVVH • NGAL remained higher while on CVVH • Cr levels equivalent b/w groups

  29. is ECMO in CRRT – What are the Data? Pubmed: ECMO and anticoagulation: 161 ECMO and RRT: 11 1st International Symposium on AKI in Children at the 7th International Conference on Pediatric Continuous Renal Replacement Therapy Cincinnati, OH September 27-30, 2012

  30. Conclusions • Consensus definitions of AKI will help future studies • ELSO registry • We have insufficient data to answer some basic questions • True incidence • Best mechanical practice • Site of connection • Equipment • Mode (convection vs diffusion)

  31. Thank you

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