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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? 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
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
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
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
AKI – Neonatal/Cardiac • Neonatal Respiratory – 75% overall survival • Neonatal Cardiac – 39% overall survival ELSO, July 2012
AKI – Pediatric/Cardiac Pediatric Respiratory – 56% overall survival Pediatric Cardiac – 47% overall survival ELSO, July 2012
ELSO registry review • Non-cardiac patients • 1998 - 2008
ELSO review - Neonates • AKI + RRT 28% survival • AKI Ø RRT 45.7% survival • ØAKI + RRT 58.1% survival • ØAKI Ø RRT 80.1% survival .
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 .
ELSO review - Conclusions • AKI and RRT are independent predictors of mortality • Even after controlling for comorbidity variables
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.
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.
Used to define current practice • 65 centers • 23% reported NO RST • 43% use for FO • 16% for FO prevention • 35% AKI • 4% Electrolyte
KIDMO – Mode employed • Predominant mode convection • CVVH • SCUF
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
FO and ECMO/RRT • 33 neonates • FO indication in 48/53 patients
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
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
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
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.”
Single center retrospective review • 378 total ECMO with 66% survival • 154 (41%) concomitant CVVH
Recovery • CVVH has a lower survival rate • Similar to non-ECMO patients
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
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.
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
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
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)