SCCM Resource Library-Frontiers in ECMO: Is It Wizardry or Witchcraft?

Video Transcription

Good morning, afternoon, ladies and gentlemen. My name is Nama Kim Campbell and I'm from the UPMC Children's Hospital of Pittsburgh. And I will be moderating this session.  Before we begin, a few housekeeping remarks. Like please move to the center of the row. Fill in all seats and store your personal belongings on the seat next to you.  Don't store your personal belongings on the seat next to you. Please note the location of the exit doors, which are there. Please silence your cell phone.  If you wish to leave the session for any reason, please exit quietly. And please, once the session has concluded, please exit quickly  as the next session will follow this one immediately. If speakers and attendees would like to continue to discuss the topic, please go to one of the designated,  continue the conversation areas outside the session rooms. And full Congress attendees will gain access to Congress on demand for continued learning.  If you missed a session and would like to listen to a particular session again, you will receive an email with access instructions approximately two weeks after Congress has ended.  Information about continuing education credit is available on the Congress app. All speakers will disclose any conflicts. Please do not publish digital photographs  of slides displaying the no social media icon into the public domain. And be mindful that while social media provides an open air forum  for the presenters, conference attendees and the public, good manners and respect should prevail. This room is dedicated to topics that relate to pediatric topics.  If you would like to continue the conversation about any session on Twitter, you can use the hashtag PSICU along with the meeting hashtag CCC49.  We have three wonderful speakers today in this session called Frontiers in ECMO. Our first is Bradley Cooch. He is the Director of the Critical Care Transport Team  at the UPMC Children's Hospital of Pittsburgh as well as the Director of Respiratory Therapy. Prior to that, he was the ECMO Coordinator and Researcher with the Heart Institute.  Thank you.  Okay. Good afternoon, everyone. Thank you for the great introduction. I'm very happy to be here today. One of my passions is ECMO for sure.  I don't get to partake as much as I once did, but I'm still very much involved. So I was kind of very excited to be able to get back into this. ECMO is physics, just so you know.  So when you look at the ECMO circuit, we're going to talk a lot about physics because when I think you, when we look at cannulation and how we initiate support,  it's going to be really very much about what device, what catheter, what cannula, what size and how you're going to manage that. So we're going to talk a little bit about that,  which is the fun part of it. So I have no real or perceived associations or relationships to disclose. So as I kind of mentioned earlier, the first thing we're  going to talk about is the physics of arterial and venous catheters because they're different. And we'll talk a little bit about the beginning and end  of the circuit and how all that works. We're going to discuss the benefits and limitations of percutaneous versus open. So, you know, in pediatrics we're really not doing  that necessarily yet, but there's a lot of things that are kind of coming about right now with technology. I had the honor of being the ECMO coordinator back  when polymethylpentane oxygenators were coming out and we were able to use circuits that were biocoded and we could miniaturize circuits where we went  from a prime volume of 670 cc's for a baby and we took it down to about 220 cc's. That's priming a circuit with, instead of using a whole unit of blood,  we were using half a 60 cc syringe of packed cells for a hemoglobin of 10. It was really a neat time. So it's very exciting right now what technology's going to push.  And then we're going to talk about some complications, just really briefly talk a little bit about those that do occur and why. So right off the bat, I love this.  This is actually from the New Yorker and when I do present ECMO I always put this up. What does ECMO seem like to you? Again, it's a lot of stuff going on. We've gotten better.  However, I feel sometimes when you walk into that room there's every machine, every device, every catheter, every alarm that's in that room. And I feel we are moving in a direction  where ECMO will become kinder and gentler, where we're going to look at things slightly different than it used to be. And I was actually talking to a colleague of mine  and we were talking about what ECMO was 20 years ago to where we are now. We are better. We understand it a lot better. And part of that is being able to make our pieces  and parts work better together. So right off the bat, I really do like this. And I'm calling it ECMO cannulas 101. And it's about successful ECMO begins and ends with a cannula.  That is placement. It's the right cannula. It's the having a skilled surgeon that can put it in the right place, make sure it's in the right place  and how we manage that with movement. It really is the success is beginning and end. So right off the bat, when we think about ECMO,  and I'm just really going to touch on this briefly, is we have several different types. And it's emerging. And they're being hybrid.  There's all kinds of different pieces and parts to ECMO that in the past we just didn't do. Veno-arterial, which we know is full support  or as close as we can get, we're seeing a lot more of it in the cardiac patient population. So we're seeing kids with heart disease where it used to be a relative contraindication.  Now these kids are surviving. We're using it differently. Veno-veno, we know in the adult population, it's jumped up immensely. We're not a big veno-veno hospital.  We know there's a lot of successes out there. That's predominantly lung. I call it CO2 scrubbing, where you're removing CO2  and adding a little bit of extra oxygen to the venous side. This is a classic. I'm just showing you where the veno-arterial cannulas sit.  And again, just briefly, looking at where they kind of sit in the heart. Again, venous cannulas, right atrium via the internal jugular. Arterial cannulas, the ascending aorta.  The position of those is really important. And why I love this slide, to be honest with you, is it gives you a little perspective of those drainage holes.  So when you think about those catheter, and I'm going to go a little bit, or cannulas, I'm going to go a little more into that.  Just think about those drainage holes and why they're there. Next slide I like a lot, too, is when you look at that open neck technique for cannulating.  This is another classic image. This looks at venous and arterial catheter. When you look at the arrows, one is red, and one is bluish-purple. That's the blood being pulled out.  Again, there's the islet. Vagus nerve sits in the middle, and then you have the catheter going back in. The one thing you can look  at is these vessels are not cut completely through. It's a half cut, and then we slide a cannula through. That's a big part of it because it does potentially allow you  to reconstruct those if you need to. ECMO cannulas are a couple, four basic components. One, they're thin-walled. Two, they're stiff for insertion.  They're kink-resistant, and they're radio-opaque. That's them in a nutshell. As we move into these, the venous cannulas, again, just as a reminder,  internal jugular into the right atrium. Lower portion has side ports for optimal drainage, and that's really important because drainage is really dependent on a couple pieces.  One is position. The most important part is, is it in the right place, and where are we sitting? The second is the diameter of the catheter, cannula, excuse me.  Finally is the RA pressure. The RA pressure tries to stay open, so you don't have that kind of vacuum to collapse around that catheter.  So that's a nice pocket, so you definitely want to be in there. And then if you go back 10, 15 years, is anybody still using bladder boxes, or is everybody going  to kind of transducers? A couple bladder boxes out there? Yeah. So what we used to do is hike the babies up on the bed really high and let gravity drain  down the bladder box, so you get a little better flow. Now there's multiple systems that use pressure transducers, which help with that.  The table on the right, this just looks at 8, 10, 12 French, and actually the max flow that you can get through there, 350 milliliters per minute, all the way up to 13,  and that just gives you a little bit of the idea of what can come out of that cannula, and I'm going to talk about how we calculate that. Then we have the arterial cannula,  sits in the aortic arch, source of the highest resistance. Again, source of the highest resistance, that's the jet component piece of it.  We do make them what I call stub nose, make them short so you decrease the resistance, but if you look at the internal diameter to those French size and correspond  to the weight, there's not a lot of opening there, that's for sure. One of the areas that is probably the most critical for cannulas, both arterial and venous, is the pressure drop.  We don't really think about this the way we should in medicine, it's forgotten. It's one of these pieces that's definitely forgotten.  It kind of came back to me when I started running ECMO again, thinking about that pressure drop, but pressure drop is in a lot of things we do.  High flow nasal cannulas, they have a pressure drop. If you drop that flow up, that is going to lose pressure across there. These cannulas are no different except they're longer.  So when we look at this, quite honestly it's defined as a change in pressure from pressure one to pressure two, and I love this, I love this image.  This actually comes from a research paper, but it's probably the first one that I actually looked at, that said this makes sense to me,  and the part I really want you guys to look at is P1 versus P2. They have a cannula in a tube, and they're looking at that second pressure on the back side of that cannula.  I really like how they did that. So you have the pump that's driving a flow through it, you have that pressure, and you can tell the pressure drop.  There's also a component of it, turbulent versus laminar. And then finally, fluid flow that is laminar, the flow can be maintained much easier.  Fluid flow dynamics, I'm not going to spend a lot of time on this formula, but this is a formula that is gas and fluid dynamics. Think about endotracheal tubes,  and think about airway resistance pieces, but the part with this, fluid flow is proportional to the fourth power of the radius, i.e. the smaller the  cannula, the less flow, more pressure is needed, and that can begin a lot of problems. So I love this slide. This is very user-friendly.  This is the one I used every day that I put a child on ECMO. This is an old-school pressure drop calculation, and what it looks like, I'm going to look at the left first,  is venous, and you have an 8 French, and you can see that spike that actually kind of goes up. You have pressure on the left and flow along the bottom,  and on the right side is arterial. And you have 8, 10, 12, and 14 French. That green line for venous, you don't want to lose any more than 40 torr.  If you're losing more than 40 torr, you're in trouble. You're going to have limitations of flow, and depending on a patient clinical situation, it's going to hinder you.  On the right, the arterial is 100, so when you force that blood through, it's the pressure drop of 100 is we don't go above it. So when I look at this, I try to understand  where my cardiac output I'm going to try to capture. If I'm looking at 150, an arterial cannula, a 12 will work just fine. Again, 150 liters, 1.5 liters per minute,  a 12 is not big enough. I need to go to a 14 to be able to pull enough blood. Why this is important, they'll decrease hemolysis, it's going to decrease blood trauma.  So besides those pressure drop, what else occurs during ECMO cannulation? First of all, it's high stress. We all know it is, and I feel outside of the ECPR piece,  a controlled cannulation is much better than quick we need to go now. So I think being prepared, having a team that communicates  and having those cut off is the key to decrease some of those because when you can communicate, support those patient and have a surgeon that's more relaxed  and with his team, it's much better. So first of all, if you have a problem with your cannula, and I've seen a lot of them, I've read about a lot of them, they do occur.  Inability to meet patient flow needs, that's why we're going on ECMO. If you can't meet their cardiac needs, you're in trouble. You need to both have drainage and reperfusion,  putting blood back in, hemolysis. These cannulas will cause hemolysis. If you're putting sheer blood through that, you'll cause blood trauma. It will also cause platelet activation  and vascular trauma as well. And also what I don't have up here is cavitation. If you're using a venous catheter and it's in and you're driving your negative pressure up,  you will actually suck air out of the solution. That's cavitation. You will see bubbles start showing up on areas where your catheter actually fits in.  And that can definitely be one of those pieces that can result in big problems. The anatomy of the cannula, real quick, arterial cannulas, it's here on the top. There is no holes.  It's a jet. It puts the flow directly in that direction. However, the venous cannula has multiple ports along the side. These are all drainage.  And I didn't know this, but I love it. Semi-lighthouse tip and lice house tip. Lighthouse tip. So that's going to be something I definitely take back looking at as well.  The one thing, and on the sake of time, I'm just going to briefly touch on this. So it's really interesting. When you look at these cannulas, they're looked at for flow  and the hemolysis perspective. But there's no other regulations that really look at them. So there's other pieces of these cannulas that need to kind of be looked at.  That's pressure drop. Is there a coating across it? And are they labeled the right way? So as we all know, neonatal pediatrics is predominantly VA, open neck approach.  In some situations, we do chest cannulation. We know for a fact when you do chest cannulation, you can drive up that flow. Situations that it's secondary  to cardiopulmonary bypass needing support. But the other part of it that's really important is in situations where the patient may have very high flow demands.  So you're putting them at cardiac index over three. VV support, dual lumens also. But size is always limitations. And I'm just going to touch on this real quick.  This is your adult ECMO. Look at the different variations. And I think it's fascinating. So you have VA, straight VA, which is one venous, one arterial.  Then you can go VVA, which is two venous and one arterial. Then you can do VAA, which is one venous and two arterial cannulas. And then you can do VAB ECMO as well.  All of these are out there and about and real. For the sake of time, I'm just going to move through. These are really great slides that I think really demonstrate a couple.  This is VA ECMO. Again, pulling out right side of the heart, putting in the fem. It's an adult. You're putting it back into the fem.  But you can also pull out of the dual fems, where you're pulling out of the venous circulation on the right side and placing it back on the left into the artery as well.  And when you look at these, B, your venous return is about 80%, meaning the saturation is 80%, where if you pull off the superior vena cava, you're looking at more of 60.  One thing we know about this, did you guys, I don't know if you ever heard about some of the complications, Harlequin syndrome, which I think is fascinating.  Basically what happens is when you have decreased return and the heart's starting to recover, the heart will actually pump against that jet.  And you make the head, the heart and brain basically hypoxic because the blood's not getting to where it needs to be. It's a fact that happens.  I think this is a great little diagram. But that's a situation where the heart's functioning well, the lungs are not. This is a two cannula vena venous system.  Again, if you look at this, it's coming off the top, dropping back into fem. And this is pulling from the fem and dropping up.  And that's just two commonly used cannulation techniques for adults. Percutaneous is something that's popping out there as well. And, you know, it is quicker.  There's some decreased risk associated with it. However, I love this diagram because it is really true. And I think this is ECMO as a whole.  There's probably four areas of concern that can happen when you cannulate, hematologic, vascular, mechanical, infectious, and neurologic.  And cannulation is really going to play in those first two, which is hematologic and vascular. With high steer forces, hemolysis,  which can both come from the pump, depending on the head, or tubing as well. And those catheters can cause hemolysis which can start a whole cascade of things.  And vascular is obviously trauma. These are just two really good images looking at a percutaneous in an adult in the fem. So this is a two-person technique.  And they're actually getting ready to dilate to feed the catheter through. And on the right is an ultrasound-guided position of a return cannula, which would be arterial.  And you can actually see it sitting in the vessel. Right here is your cannula. We're not there with PEDs, but maybe in the near future, depending on how things move along.  So when you compare percutaneous insertion versus open in a fem, obviously percutaneous is a little more improved. So you have infection rates are lower.  Ability for cannulas with a skill set is widespread. So percutaneous is much easier. Bleeding risk is lower. Speed of insertion is fast. Other risk, decannulation, if it comes out,  you just put pressure on it and hold it. Where open, you have another set of problems. Here's a look at a data set looking at secondary issues  that happen to fem, PERC, and the highest was limb ischemia. Right off is the highest at 9.4%. I'll take any questions. I'm trying to stay on out of respect  for the other speakers on time. I'll take any questions you have. Do you have any? There are microphones on either side of the auditorium. Okay. Well, I have a question.  So you touched a little bit on the percutaneous cannulation, and it's not really something we do in pediatrics. That's right.  So what do you think are some of the limitations as to why like an intensivist at the bedside will not be able to do that or why there's some reluctance to do that?  I think it's much like the pediatric piece with other devices, just an endotracheal tube smaller. I think it's the same thing when you look at the vascular.  If you're trying to put a percutaneous catheter in that can flow at even two, cardiac index of two, it would be I think difficult and increase the risk.  Until we come up with something that is miniaturized that has a wider lumen, I think that's going to be an issue. I think it's going to be a flow problem. Okay, great.  One more question. Yep. In terms of reconstruction, do you know of any evidence of whether it's beneficial to reconstruct the vessels? I don't think I've seen any long-term studies  on the vessel health. There is no long-term studies. And when I was working with our cardiac group, we were talking about that. There is no long-term studies.  And in fact, I think there's maybe a study or two out there looking at some Doppler stuff in the neck. But we really don't know what the, does it stay patent? Does it clot off?  We don't know what that incidence is very well. Probably small data sets. But we really don't know, especially in the neck. Yeah, that's interesting to look at.  Well, thank you, Brad. Next, we have, next we have Sebastian Tume. He is the clinical director of the Pediatric Cardiac Critical Care Unit at Texas Children's Hospital.  Good morning, everyone. Thank you for coming. And thank you to the organizing committee for giving me an opportunity to share some of our experience  with mobilizing children on ECMO. So I'll have to give you guys a little bit of background. I was actually born in Poland. So I'm not that familiar with Harry Potter.  So it took a little bit of search to be able to put this together. So I typed in levitating. My children use my Google search. So Harry Potter popped up.  So I decided, okay, so that's pretty good. I typed in modern. That's Paul Kekias using my computer at work. We have a levitating glass of scotch.  Okay, so now we need to be a little bit more focused here. Right? Typed in an ECMO. Then I get an elf on the shelf that's fully cannulated on ECMO. Okay, where do I go from here?  He's still not mobilizing. So we need to do something. So sorcery reality. I'm more of a believer in reality. So if you're going to talk about reality  and people moving on ECMO, Santa Claus is probably the best one. Everybody believes in Santa Claus. And I think this would be the best example of optimal mobilization of ECMO.  Just quick disclosures. No relevant financial conflict of interest relationships to disclose. I believe in science, not wizardry. And hopefully I'll be able to delineate that.  And then progress is achieved by great teams and collaboration. The objectives of my talk will be identify potential benefits of early mobilization on ECMO in children.  We'll try to identify the optimal patients for that early mobilization. Review goals. And demonstrate the practical aspects of the mobilization program.  We know in the past 10 years the ECMO use in adults, children, especially in the respiratory setting, has accelerated exponentially. A significant growth over the past 10 years.  And that growth comes with significant experience. Brad nicely sort of delineated improvements to the ECMO circuits that have been made over the years.  And we all remember those patients laying on multiple mattresses to optimize drainage and optimize flows on ECMOs in those large circuits. Those have gone and we replaced those  with continuous flow centrifugal circuits. And then finally we're able to downsize them quite significantly. To be able to mobilize these patients.  Transfer them from institution to institution. Or for various intervention procedures. So I think we have to keep up with it. We're able to move these patients much more easily.  And I think we should be ready for a next stage of their therapies. So I think just to highlight sort of the next part of my talk.  I want to sort of bring you guys a common clinical vignette that occurs in many of our units. So we had a five-year-old female that was admitted with four-month history  of extremity pain, limping, intermittent fevers. On admission she was found in respiratory failure. So required an invasive positive pressure ventilation.  Obviously trying to work up her lung disease. At day five we decided to do a CT-guided lung biopsy. And a CT-guided and a lung biopsy.  Which revealed basically a severe institutional lung disease with diffused ground glass capacities and adenopathy. Suspicion for potential autoimmune disease.  Or a potential infectious agent. However, on day six or immediately after the biopsy returning to the unit. She deteriorated quite significantly.  Was difficult to oxygenate, ventilate. And was quickly transitioned to a high-frequency ventilation nitric oxide. Unfortunately she developed significant pneumothoraces,  subcutaneous emphysema. So the team decided to transition her to a VV ECMO. We utilized a single cannula with dual lumens. So Avalon cannula strategy with 19 French cannula.  And her support was fairly stable. However, on day three she developed a significant recirculation. So required reposition of the cannula on ECMO.  Had significant improvement in oxygenation. And day five she developed a little bit of her RV dysfunction. So we had to actually put her on epinephrine.  So I think we can all appreciate that prolonged intubation, sedation, poor nutritional status in our patients and ICU-acquired weakness are significant contributors  to a poor survival and poor outcome in our patients. So why do we need to wake them up and move them? We would like to reduce that sedation side effect.  We would like to reduce a muscle wasting. Improve the patient's neurocognition. Optimize their circulation. Prevent skin breakdown. And there is numerous transplant guidelines  that highlight the need for successful rehabilitation before implantation of organs such as heart or lungs. So it's very important to be able  to optimize their bridge to a candidacy. As well as technology is currently enabling us to do a lot of these movement and mobilization practices.  We also have to have an appreciation that use of sedation is associated with extended ICU length of stay. Increased ventilatory time. Age-independence.  And also neurocognitive delays in children. One of my colleagues, Dr. Acuff at our institutions, has actually found a really nice way to highlight for us  of how often these patients require significantly increased amount of rescue doses of sedation. Increased drips whenever they're placed on invasive devices  such as mechanical, such as intubation or ECMO. And whenever you take them off of these devices, they're actually able to significantly reduce the amount of sedation that's needed.  So the consequences of prolonged immobility cannot be underestimated. The ICU acquired weakness occurs in 25 to 100% adults that stay in ICU and around 30% of children.  Muscle loss is shown within first 48 hours of stay in ICU. And occurs at its greatest around two to three weeks of critical illness.  Up to 40% of muscles can occur in the first week of ICU stay. And then muscle weakness even persists after these children are discharged from the ICU.  So proximal distal muscle wasting happens in approximately 60% of kids. And almost 15% of them are not able to walk independently.  A lot of our colleagues around the country have actually attempted to alineate this and show us that we can actually start moving these patients.  We shouldn't just keep them intubated, sedated and laying in bed. And Chang and the group actually used a 25-patient cohort to describe that utilizing mobilization practices  in these patients had no significant adverse events and proved practical and safe. And then the group from Hopkins is actually utilizing a pick-you-up initiative that showed  that you can actually make significant improvements in ability to mobilize these patients. So 200 patients in their study described an increase  in occupational therapy consultations, physical therapy consultations. Number of therapies that they were able to achieve during the day. And time to first therapy.  So no adverse events were reported in their population. So I think we're getting there. And actually our Society of Critical Care Medicine  with its ICU liberation initiative is further highlighting the need for early mobilization of our patients through use of ABCDEF bundles.  And we're already seeing evidence that application of this in adult population shows reduction in duration of mechanical ventilation, length of stay, and costs.  So what's happening in children? As I mentioned in the beginning of this talk is the data that's available for children is very limited. On ECMO, certainly limited in regards  to mobilization of patients. I'll share with you guys a lot of the sort of my own personal experience with this patient population.  But one of the studies that's out there is by a colleague of mine, Jane Thomas, and his group from Dallas, who actually showed us that we can actually attempt  to extubate patients on ECMO and do it safely. They had an experience of around, with 16 patients. And that showed that when patients were extubated,  they required less sedation, were more interactive with the care providers and their families. And they dropped their use of fentanyl by as much as 60%  in midazolam, but more than 50%. They had a 68% survival in their cohort without any significant adverse events related to extubation. So I think extubation can be done,  but how do we do it safely? So we optimize the ECMO circuit and support. Obviously, the patient has to be in the optimal state. We actually have to consider the effect  of spontaneous breathing on circulation. We have to optimize the respiratory system. So you want to bronch these patients.  You want to do airway clearance before you actually take the tube out, instead of having to put the tube back in and perform these procedures.  And if it fails, we can always sort of take a next step of proceeding them to a tracheostomy to optimize their mobility. So patients that progressed in the study  by Jim Thomas were the patients that had excessive work of breathing, required airway clearance issues, or inability to control airways.  I think the cardiopulmonary interactions cannot be underestimated in this setting. We all know that extubation will help with your preload to the heart.  Okay? But it might actually shift you on your pulmonary vascular resistance curve to the left, increasing your afterload on the right heart.  And I think the intraventricular interactions must be appreciated. That can lead to a decreased stroke volume from the left ventricle due to shift intraventricular septum  and obviously compromised output. So we want to make sure that that right heart is really well protected once we start, when we consider an extubation.  So how do we choose the right patient to move them to the next stage? You have them extubated. You're trying to actually mobilize them in bed.  I think considering age of the patient is very important. Obviously, we're going to devise different therapies that will be designated towards infants versus older children.  We have to make sure that the ECMO support strategy is safe. So commonly in my unit, patients with an open chest central cannulation are not the best  candidates for doing an aggressive mobility therapy. So you want to have a patient with safe cannula position, safe securement of cannulas.  We want to make sure we minimize ECMO complications. So do not mobilize the patient that you're trying to replete with blood products because they're bleeding  from their ECMO sites, et cetera. We want to make sure we have stable hemodynamics, specialized team that's present in the unit that is dedicated to this specific initiative.  And we want to make sure we have a long-term plan for these patients. Brad very nicely delineated sort of various support strategies around this.  And our, I think, heart failure colleagues have very nice pathways for getting these patients to rehabilitate. They use temporary or durable VAT implantations  for these patients to get them to a transplant. In our respiratory population, we have various types of support strategies. So you can have patients with dual ECMO cannulas.  Obviously, those would be much more difficult. If these cannulas are placed in femoral position, movement of their lower extremities will be much more restricted than those that  are cannulated through the neck. Obviously, it's more optimal to actually use a single cannula with dual lumens, such as Avalon cannula.  That only requires a single axis intravascularly, so less to worry about. And then I'll show you guys our experience with use of Berlin cannula in mobilizing some of these patients.  Most importantly, it takes a team. I mentioned this in the beginning. You can't do it on your own. You have to have a dedicated team  to do this, physical therapy, occupational therapists, family that has to be on board with this, various consulting services. And obviously, you want to have a surgeon around.  So stepwise approach to the therapy is first make sure the medical team is on board with this. Obviously, you don't want to have people who are conflicting  with your plan for mobilization of these patients. So the whole team has to be on board and agree to it. And then PTOT has to evaluate their level of activity  and their actual plan for the therapies. In preparation, we need to secure our intravenous lines, remove any extraneous connections,  ensure hemodynamic monitoring is available to monitor for any type of stress on these patients and whether they can tolerate further therapies. We need to make sure someone inspects  the extracorporeal circuit, ensure adequate tubing slack is present to allow for safe movement. And obviously, all connections need to be tight.  We need to assess for any leaks, any thrombus within the circuit. And obviously, we have to have a team for this. Everybody has to have their responsibilities,  such as monitoring for vital signs, circuit integrity, and then assisting patient with movement. Safety 101 says, how do we secure cannulas? I'll show you a couple of pictures  of how we sort of attempted to ensure that this cannula stays stable. This depends on the location of the sutures for the ECMO cannulas.  So it depends on where the headband can actually be applied. But also, it depends on the amount of anticipated movement of the patient. So you might just start with a little bit  of passive movements in the patient. But once they progress to a mobility, you might need to have a much more secure for, much better securement of these cannulas.  We typically use a soft straps with Velcro that go over. This is mainly in the patients just that will have a passive movement or just waking up,  allows us to keep these cannulas safe. But once these patients start moving more and more, we utilize ET2 fasteners on their foreheads to give more stability to that Velcro.  And then we start taping the tube onto the headband to give it more securement when the patient actually starts getting out of bed and performing sitting exercises.  This system we utilize on our infant. So it's a ET2 fastener that's attached to the chest and then connected to the ECMO cannula through a Velcro connection.  So just to summarize the general goals of physical therapies, they're dependent on the type of cannulation and stability of the cannulas.  That will dictate your progression of therapy and any positional changes. We want to optimize positioning first to ensure neutral joint alignment,  promote tolerance to tactile stimulation. So obviously, you just don't want to wake up a patient and make them sit up in bed. They have to tolerate waking up.  They're commonly agitated and require sort of dealing with that first. And then you start progressing them to a strength, endurance, and developmental activities.  You have to make sure the family is on board and is able to sort of work with you in parallel to get these kids to actually progress, then finally, hopefully, to a motor movement.  So these have to be gauged towards each patient population. So obviously, we're not going to manage a nine-month-old trying to make them stand up in bed.  But we might have to approach a child differently than we would approach an infant. And that's based on their developmental goals.  General progress to mobility is typically supine exercises, then sitting balance, weight-bearing exercises, then standing and balance, transfers out of bed,  activities of daily living, ambulation, and then progressive rehabilitation. This just highlights one of our patients that went through all these stages of a gross motor  movements with a nice, initially, elevation of head of the bed, supported sitting positions, then sitting with legs off the bed, and then sitting out of bed.  It's really helpful to actually have some kind of skills that allows you to develop goals and actually monitor the progress of these patients  when they move through various stages of mobilization. And last but not least, I would like to highlight one case and share with you guys our experience  with this new sort of cannulation strategy. This was a 17-month-old male that initially presented with acute and chronic respiratory distress in the setting of a viral illness.  He was actually found to have cardiomegaly on his X-ray, echo-revealed, and ASD, and actually high elevated RV pressure. So the patient was then taken to a cath lab, NSCT,  and was actually found to have severely elevated pulmonary vascular resistance of 10, as well as pulmonary vasooclusive disease. So the patient was actually transferred  to our Center for referral for lung transplant and evaluation. However, on arrival, he very rapidly progressed to a refractory hypoxic respiratory failure.  And a dean decided to offer him a ECMO support as a bridge to a potential transplantation or transplantation candidacy. Because of this patient's severely  depressed right ventricular function and severely elevated pulmonary vascular resistance, the team actually decided to cannulate the patient  with sort of quite novel approach strategy. We actually used a venous cannula in the pulmonary artery position. We utilized the Berlin cannulas.  So obviously, the patient had to have a sternotomy. And then we utilized our arterial cannula in the aortic position, which were then connected to an ECMO circuit.  So with the hopes of basically offloading the right heart, so reducing the right heart afterload, enabling the right heart recovery, but as well as providing their ability  to oxygenate and ventilate. So this is what the patient looked like before and after cannulation. So developed significant consolidation of their lungs  and significant edema in the lungs as well. We were able to actually extubate this patient within three days after the surgery and started working on the lung recovery.  He had quite a tough time sort of tolerating his respiratory distress. But eventually, with time, was able to actually nicely recruit his lungs.  And I'll show you guys a picture in a second. But what's most impressive about his actual picture of sedation is you can see the time period between those two  red lines, where a patient actually was extubated within a day or two, were able to get him off of his drip medications, and almost completely reduced his rescue doses of sedations.  The part on the right with the past the red line is actually when a patient went for transplant. So once again, escalated all the amount of sedation that he was on previously.  We did use clonidine, but that was primarily used for afterload reduction in a setting of ECMO. So therapy, he was able to progress really nicely  through his mobility therapies with gross motor skills, such as supported sitting, bench sitting, went up to a steady sitting with upper extremity,  lower extremity activities, and eventually progressed to standing and was quite active in the unit. So chest x-ray at the time of actually of his transplant  showed significant re-recruitment of the lungs, which he was all able to do on his own. And a patient was actually able to tolerate full nutrition, full mobility, and fairly  interactive with the team and the family. So in summary, early mobilization on ECMO is possible and should be considered in a right and safe environment.  Benefits of early mobilization are hard to study, but clinically evident based on the limited experience. And then mobilization of children on ECMO  requires a team and a strategic approach  to ensure minimized risk and amplified benefits. I wouldn't be able to put this talk together if not for our physical therapy team at Texas Children's, who  does a lot of work with these kids and develops the entire protocols. And obviously, it takes a village to make this possible. Thank you. Thank you.  Are there any questions for Dr. Tumay?  Very nice.  I can talk loud. Heidi Flores from the University of Michigan, actually, question for you about the tachypnea that you were alluding to.  Because we've seen that a couple of times as well, as they have significant lung disease and you're trying to wean support, if not get them off.  And they get just so distressed and dysregulated that you end up on some sedation as well. So it seems to be not so difficult to attain. How long in this one patient, for example,  did you say that it took them to get used to their physiology? Yes, it's a very good question. And I would actually ask the question whether the patient is distressed  or the medical team is distressed. I'll tell you, I cared for that patient that I presented, the last patient that I highlighted. And every hour, somebody would come around and ask  when we would reintubate the patient. And we left the patient alone. Yes, he did require bits of sedation here and there just to get him a little bit more comfortable.  He did have significant respiratory distress. These patients have poor compliance, are not able, are very air hungry in the beginning. And I think that's something that you  have to monitor very closely, whether it's affecting their circulation, number one, because all that increased work of breathing requires additional cardiac output.  So that needs to be matched with your support strategy. That's why I emphasize on making sure that you actually have an optimal support strategy on these patients.  Number two is, what do you use? Do you use positive pressure, BiPAP, any other non-invasive positive pressure modes? We tried everything on him. He wouldn't tolerate anything.  He just wanted to stay without anything on his face. He did have significant work of breathing. And yes, that's where you would use intermittent rescue doses of some sedatives.  But I think there is a component of bioreceptor reset and also tolerance for CO2. So we would actually leave him a little bit higher CO2 levels  just to decrease that drive for respiration. And eventually, with him specifically, it took around a week for him to settle down. Yeah.  We've seen it in particular in some of the older kids, too, where they actually can generate a fair amount of support. And it's also very disarming for the family.  So they're also very distressed by watching their children. It is. And that's why I think these families have to be on board with this, actually  have to be prepared for this really well to make sure that they understand what their child is going through.  Thank you, Dr. Humay. Actually, one quick question for you. What is the youngest child that you've mobilized in your unit? Four months old. Four months old? Four months old, yes.  Mobilized meaning we performed active passive moving exercises. That child would not be expected to stand up, but basically awakening and passive movement exercise.  With minimal sedation? Yes. That's interesting. Thank you.  Finally, we have Dr. Ravi Thyagarajan. He is the Chief of the Division of Cardiac Critical Care at Boston Children's Hospital, as well as Professor of Pediatrics.  Thanks very much to SCCM for inviting me. Good morning, everybody. My job is to talk a little bit about functional outcomes for children who have been supported with ECMO.  Those are my two colleagues, Dr. Ravi and Dr. Thyagarajan. ECMO. Those are my conflicts of interest. So this talk will look at a few aspects of long-term survival  and functional outcomes for these patients, long-term survival, physical health, neurodevelopment, and quality of life. Sebastian alluded to this.  We are using ECMO in our intensive care units. And it's a really good rescue strategy for children who have refractory cardiorespiratory failure. This is data from the ELSA registry  to show that there are about 400 or so centers around the world doing ECMO. Outcomes for ECMO survival to hospital discharge is still challenging.  About 50% of patients who have ECMO for cardiac indications or eCPR end up dying. And therefore, the ECMO community has largely been focused on improving survival  to hospital discharge. But however, we are recognizing there are survivors. And survivors often have long-term disabilities. And those need to be evaluated and improved.  So let's talk a little bit about long-term survival. This is data from the Great Ormond Street Group, Hospital for Sick Children. They looked at 740 children that they had supported  during 1992 to 2010. 63% survived to hospital discharge. And they estimated five-year survival. And if you look at five-year survival, it actually varies by diagnosis.  Children with congenital heart disease have four or five-year survival compared to those with respiratory disease. But if you looked at patients who  had survived for more than 90 days after ECMO, then their long-term outcomes were actually quite good. 98% survival in the meconium aspiration group  and 85% survival in children with congenital heart disease. These are patients that we are sending out to the community. And they really require close follow-up.  Late death was associated with primary disease, as you can see on the slide. Comorbidities that patients acquire during their course of critical illness,  as well as during ECMO, such as neurological injury, often do reduce long-term outcomes for these patients. Sebastian alluded to this as well.  The critical illness course of patients through intensive care units, things that we do to them, such as sedation, paralysis, immobility, and their complex post-ICU recovery  often reduces health and quality of life in this population. It is especially so in ECMO patients, because they're the sickest patients in our ICUs.  So let's look at physical health in ECMO survivors. And this is a paper from the group from Washington, DC. They looked at neonatal ECMO patients who survived.  And they looked at their physical function, largely pulmonary function tests, cardiac function, as well as cardiopulmonary exercise tolerance at 10 to 15 years of age.  So this was 10 to 15 years post-ECMO. 17 neonatal ECMO survivors and 17 healthy controls. They did a bunch of pulmonary function tests, cardiac evaluation, and exercise testing.  Patients who had reduced pulmonary function tests, these were largely in the mild category, with mostly lower respiratory obstructive type of disease.  But their cardiac performance was actually good. And this was evaluation using echocardiography. And compared to controls, their cardiac function looked good.  And despite the reduced pulmonary function tests, their cardiopulmonary exercise testing was really comparable to healthy controls. So these patients are doing well,  especially if you have ECMO support for pulmonary disease. Those patients actually have good physical function and health moving forward.  One aspect of physical health to look at is sensorineural hearing loss. The incidence of deafness, sensorineural deafness, in ECMO is about 33% to 21% in ECMO survivors.  And that's pretty astounding. And this is some work that we did in our center about 15 years ago, looking at sensorineural hearing loss in our ECMO survivors.  And there were 111 ECMO survivors at that time.  26% had sensorineural hearing loss. And the important issue with sensorineural hearing loss is that may not always be present when you discharge them.  And some patients will acquire that over a period of time. And the reason why deafness may be present in ECMO patients may be related to the severity of illness.  It may be related to the medications or the toxic medicines that patients get during the critical illness. And in our study, at least, it was related to duration of ECMO.  The patients with longer duration of ECMO perhaps subject to more autotoxic medications are more likely to have sensorineural hearing loss. So this is an important aspect.  Sensorineural hearing loss delays language development in children, as well as reduces quality of life. So it's an important thing to look at.  What about neurodevelopmental outcomes? The majority of neurodevelopmental work in ECMO, especially in those whose ECMO was for respiratory indications, comes  from the group from Netherlands. And they've done some fantastic work following these patients forward. So let's look at some of those aspects from that group.  So the first paper looks at children who are eight years of age who are neonatal ECMO survivors. There were 135 of them in this cohort.  18% of these patients had CNS injury acquired during ECMO. And they did a battery of tests, including assessment of intelligence or IQ, concentration, hand-eye coordination,  and behavioral assessment. These patients had normal intelligence at eight years of age. So their IQ was pretty in a good spot. But if you actually looked at school performance,  only 50% of patients went to regular school. And the other patients either required increased help or needed special needs, despite having normal intelligence.  If you dig deeper, these patients had issues with concentration, working speed, and accuracy, which led on to reduced school performance in these children.  So even though they had normal intelligence, they had multiple aspects of neurodevelopment that were compromised. This group took this work.  7% of these patients had behavioral disabilities. And they largely were surrounding organization or ability to do their homework and organization around homework.  So this group took this to the next level, looking at these patients 10 years post their first evaluation. So looking at patients at 17 to 18 years of age.  Again, these were patients who received ECMO for neonatal respiratory failure. And here, they used neuropsychological assessment and included both parent and patient surveys.  Again, head ultrasound abnormalities in 9% and seizures in 29% of patients. In this cohort, intelligence was a little bit lower than the Dutch normal intelligence.  And 15% of patients needed special education. And the majority of patients who did poorly had memory deficits. And they affected memory in all aspects,  shortened long-term verbal memory, their ability to perform visual spatial tasks, and working memory. And parents in this cohort actually reported reduced executive function.  So it seems like concentration difficulty with school then translates to reduced intelligence, memory issues, and eventually reduced executive function in this population.  And these are all subtle things that you would not notice if you just examined a patient, and unless you actually did specialized neurodevelopmental testing,  these are not going to be evident.  I'm taking you to our population, the cardiac ICU population.  I work in a center that has a robust neurodevelopmental program. All children who get cardiac surgery at less than a year of age and get cardiac surgery with cardiopulmonary bypass  get neurodevelopmental assessment in our program. And we were fortunate to send our ECMO patients to this program as well. So we looked at over a 15-year period,  28 cardiac ECMO patients. One of the biggest issues with neurodevelopmental assessment is people don't want to come back for these testing. So there were 72 eligible patients,  but we could only get 28 patients to come back to have testing. Our cohort had ECMO less than three years of age, and we tested them a year to 42 months after ECMO,  and we used a number of neurodevelopmental tests that are pretty standard for this population. Most of our population had complex congenital heart disease.  They are the patients who get ECMO in our center. 29% of patients had seizures, so really quite high incidence of neurological injury in these populations.  And we noticed that cognition was reduced in a third of patients. Language development was poor in half our cohort, and motor development was reduced  in a little bit more than 60% of our population. Our patients on ECMO after cardiac surgery especially get ECMO through an open chest, so they're all sedated and paralyzed,  which might explain why they had gross motor issues.  We were interested in evaluating as to whether ECMO provided additional neurodevelopmental disability in our patients, or was that just related to cardiopulmonary bypass?  So 25 of the 28 patients had prior cardiac surgery prior to going on ECMO, and we matched them with a cohort of 70 or so patients  who had cardiopulmonary bypass-related cardiac surgery, but didn't go on ECMO. And as you can see, those are on the green bars, and the ECMO patients on the red bars.  Neurodevelopmental testing across all domains in patients who received ECMO was reduced. They're not statistically significant, but they're all reduced,  suggesting that there's perhaps an additional effect of ECMO in reducing neurodevelopment in this population.  So if you look at neurodevelopment over time, most of our ECMO, especially the ones with respiratory failure, ECMO often have normal intelligence,  but they have many areas of neurodevelopmental issues that include attention, memory, executive function, and many of our ECMO patients need special needs.  And many of these deficits may not be evident at the time you look at them up front, but these patients may grow into these deficits over time.  And the group in Rotterdam called this growing into deficits for these patients who get ECMO for respiratory failure.  Severity of illness and ECMO care in these cohorts have not been associated with poor neurodevelopmental outcomes, which is kind of disappointing,  because those would be probably opportunities for us to change. Another area that's been looked at is do neuroradiological imaging,  do they predict neurodevelopmental disability over time? And the majority of studies show that there are many things that are abnormal in children who have ECMO on their MRIs,  but they don't often correlate with neurodevelopmental issues. One area that's been increasingly looked at is hippocampal volume in the brain,  and those are really closely associated with memory loss. So if you have somebody that you have an MRI and they have reduced hippocampal volume,  then those patients perhaps may develop memory loss and should be looked upon carefully, and you could use that as a potential way of screening patients moving forward.  And then finally, this all boils down to quality of life. How do ECMO survivors and their families perceive their quality of life and well-being? So there are a number of studies  that looked at quality of life. The first one is from the group in Atlanta, published in 2015, 16 survivors of pediatric respiratory failure, and ECMO related to that.  This, again, came from a cohort of 37 patients who were eligible, so our ascertainment rate for research is actually quite poor in this population. That's a huge challenge,  learning how these patients do in the future. So they use PEDSQL, which is a standard quality  of life assessment test.  The mean age of ECMO in this population is a little bit older, two and a half years of age. They got looked at at eight years. A third of them are receiving special education.  The majority of patients here had no statistically significant difference than a normative population. But if you look at scores, they were all reduced.  For example, if you look at psychosocial functioning, 50% of patients in this cohort had psychosocial functioning less than the first one standard deviation.  So there are problems related to quality of life.  We did similar work in our population, the cardiac population, 41 ECMO survivors. We looked at them between five to 18. The instrument that we used, the Child Health Questionnaire,  works best greater than five years of age. And we found that, similar to what I showed you before in neurodevelopment, many of our patients reported poor physical function,  but they had good psychomotor function. And again, deafness, 20%. Really, it's a huge problem. We need to really focus on that for ECMO survivors.  The one good thing about our population is that our cardiac ECMO survivors reported better self-esteem than the normative U.S. population.  This was from a comparison to Dutch children. They actually reported better self-esteem. And you saw a display of that  in the opening ceremony of the SECM, where the VV ECMO survivor just, you know, did a fantastic rendition of the National Anthem. So I think people are doing well.  And this made me really happy, looking at how children who survived neonatal respiratory failure, ECMO, how they looked like at 20 years of age.  This was a multi-center study done by Dr. Engel. He looked at, he surveyed these patients using a health status survey. And patients who completed the survey  were at least 18 years of age. The survey was actually modified by these two U.S. population-based survey data. One is the Behavioral Risk Factor Surveillance System,  and the other one was the National Health Interview Survey System. So he took questions from both these surveys and administered this to ECMO patients.  And again, in this cohort, there was 1,600 eligible patients, but they were only able to reach 146 patients.  These patients had to be, you know, you had to get their addresses and really see where they lived and then send these survey to them. So one could, it was just an enormous effort.  Patients who reported in this survey, so there is selection bias in this, but however, patients who reported into this survey reported increased exercise limitation  or activity limitation. They had ADHD and many health conditions. However, they reported better satisfaction with life and general health compared to the normative data.  So very reassuring. There was higher incidence of college attendance, higher employment, and many of these patients had health insurance. Really reassuring.  So in summary, long-term survival, physical health, neurodevelopment, quality of life outcomes for ECMO patients appear reasonable,  especially if you had ECMO for respiratory failure. Outcomes for patients who had respiratory ECMO are much better than patients with cardiac ECMO,  and you can imagine patients with congenital heart disease often have repeat interventions and they are really quite sick. However, there are many subtle neurological abnormalities  that really require us to focus so that we could maximize the potential for life. And I would just make a pitch to say hearing evaluation's really important.  Many of these patients do have sensorineural hearing loss. So with that, thanks very much. Thank you.  Theogarajan?  All right, just one quick question for me. So it seems that now that we have some data on long-term survival of ECMO and that that's becoming more of a thing  now that patients are surviving longer, do you think that some of these neurodevelopmental deficits that people have been finding  should be part of the consent process when you do ECMO?  That's a really good question. I think we just don't have enough information to include that.  You're really using ECMO in patients who are looking at imminent mortality. So perhaps not at this time. But perhaps when we understand this a little bit better,  it may be not as part of the consent process but perhaps a follow-up conversation. Because there are things that we can do to intervene to improve developmental issues in children.  And therefore, I wouldn't limit ECMO based on just long-term outcomes alone.  Thank you.  That concludes our session. Thank you very much for attending.

Video Summary

The session was focused on various aspects of ECMO, including the physics of arterial and venous catheters, the benefits and limitations of percutaneous versus open cannulation, and the challenges of ECMO cannulas. It was highlighted that successful ECMO begins and ends with a cannula, and that proper cannulation is crucial for patient support. The importance of early mobilization on ECMO was emphasized, with the goal of reducing sedation, preventing muscle wasting, and optimizing neurocognition. It was noted that sedation and immobility can have negative effects on long-term outcomes, and that early mobilization can help improve physical health, neurodevelopment, and quality of life for ECMO patients. Long-term survival rates were discussed, with studies showing that survival rates vary depending on the type of ECMO and the underlying condition. It was noted that while long-term survival rates have improved, there can still be long-term disabilities and challenges for ECMO patients, such as reduced pulmonary function, sensorineural hearing loss, neurodevelopmental issues, and reduced quality of life. In conclusion, the session highlighted the importance of proper cannulation, early mobilization, and long-term support for ECMO patients. It emphasized the need for ongoing monitoring and interventions to improve outcomes for these patients.

Asset Subtitle

Procedures, Pediatrics, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Explain current strategies in cannulation and their implications on outcomes
Describe controversies and innovations in current anticoagulation strategies on extracorporeal membrane oxygenation (ECMO)
Describe practical current strategies for mobilization of patients on ECMO
Apply the current knowledge available on post-ECMO outcomes toward patient management

ECMO Cannulation Strategies: Science or Divination?

Bradley A. Kuch

Wingardium Leviosa! Mobilizing Patients on ECMO

Sebastian C. Tume

The Boy Who Lived: Updates on Functional Outcome After ECMO

Ravi R. Thiagarajan

Meta Tag

Content Type Presentation

Knowledge Area Procedures

Knowledge Area Pediatrics

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Extracorporeal Membrane Oxygenation ECMO

Tag Cardiothoracic Critical Care

Year 2020

Keywords

ECMO

cannulation

mobilization

sedation

long-term survival

pulmonary function

hearing loss

neurodevelopment

quality of life

monitoring

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