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Use of CRRT in ECMO: Is It Valuable?

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 Children’s Healthcare of Atlanta at Egleston. CRRT and ECMO.

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Use of CRRT in ECMO: Is It Valuable?

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  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 Children’s 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 Children’s Hospital • 21 pediatric ARF patients • Survival benefit remains even after adjusted for PRISM scores * Percent Fluid Overload Goldstein SL, et al: Pediatrics 107:1309-1312, 2001

  6. Fluid Overload • Children’s 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 Children’s Hospital • 77 pediatric patients • If pre-CRRT percent fluid overload >10% • 3.02 times greater risk of mortality (95% CI 1.5-6.1, p=0.002) Gillespie RS, et al. Pediatr Nephrol 19:1394-1399, 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. Hemofiltration Cytokine Clearance • Children’s 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

  15. Absolute cytokine changes in septic shock/ARF patients * * p=0.04 p<0.02 Log Concentration (pg/ml) -Paden et al., submitted 2008

  16. CVVH Associated With Decreased Cytokines in Children with Septic Shock *p<0.05 * * Non-septic ARF Patients Septic ARF Patients -Paden et al., submitted 2008

  17. Cytokine Results: Sample CVVH Patient-Nonseptic Note Scale 24 Hours off CVVH End of CVVH 12 Hours 24 Hours Pre-CVVH 48 Hours

  18. Cytokine Results in Sample CVVH Patient: Septic 24 Hours off CVVH End of CVVH 24 Hours 12 Hours 48 Hours Pre-CVVH

  19. 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

  20. IL – 8 Reduction with CRRT in ECMO Skogby M, et al. Scand Cardiovasc J. 2000 Jun;34(3):315-20

  21. Is Avoiding Lasix Overuse Important? • Potential ototoxicity-particularly in neonates • Lasix use associated with worsened outcomes in adult renal failure

  22. 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

  23. 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?

  24. CRRT on ECMO: Published Experience with Use • Michigan • PICU • Cardiac surgery • Vanderbilt • Atlanta • Chile

  25. 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 Wegener’s as underlying cause of renal failure-subsequently transplanted -Meyer RJ, et al Pediatr Crit Care Med 2001

  26. 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

  27. 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

  28. ECMO/CVVH Experience: Atlanta • Children’s 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)

  29. Comparison of CVVH/ECMO vs. ECMO without CVVH • 26/86 peds respiratory failure patients received CVVH for >24 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

  30. Fluid Balance With CVVH/ECMO vs. No CVVH/ECMO -Hoover et al., Intensive Care Medicine, in press 2008

  31. Comparison of CVVH/ECMO vs. ECMO without CVVH * * * -Hoover et al., Intensive Care Medicine, in press 2008

  32. 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

  33. 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?

  34. 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

  35. ECMO/CRRT Arrangement: The “Michigan Method”

  36. Use of Standard CRRT Devices for Delivery on ECMO

  37. 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?

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

  39. Sometimes it gets a little crowded

  40. CRRT Error Rate Increases with Increasing Flow/Pressure -Sucosky, Paden et al., JMD, in press 2008

  41. 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)

  42. Potential Solutions • Collaboration with GeorgiaTech • Paden, Sucosky • Development of fluid management/CRRT device • High accuracy in delivery • Patent pending

  43. 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?

  44. 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

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

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