Pediatricke ECMO pro koho kdy a jak Ann

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Pediatricke ECMO (pro koho, kdy a jak) Ann Karimova Great Ormond Street Hospital for

Pediatricke ECMO (pro koho, kdy a jak) Ann Karimova Great Ormond Street Hospital for Children, London

pediatricke ECMO - pro koho, kdy a jak Novorozenecke ECMO Pediatricke ECMO (respiracni) respiracni

pediatricke ECMO - pro koho, kdy a jak Novorozenecke ECMO Pediatricke ECMO (respiracni) respiracni (MAS, CDH, PPHN) Kardiologicke “ECMO” (kardiochirurgicke myokarditidy kardiomyopatie arytmie…)

pediatricke ECMO - pro koho, kdy a jak Novorozenecke ECMO respiracni (MAS, CDH, PPHN)

pediatricke ECMO - pro koho, kdy a jak Novorozenecke ECMO respiracni (MAS, CDH, PPHN) Pediatricke ECMO (respiracni)

pediatricke ECMO - pro koho, kdy a jak Pediatricke ECMO (respiracni)

pediatricke ECMO - pro koho, kdy a jak Pediatricke ECMO (respiracni)

pediatricke ECMO - pro koho, kdy a jak Pediatricke ECMO (respiracni)

pediatricke ECMO - pro koho, kdy a jak Pediatricke ECMO (respiracni)

600 -800/ year (decreasing) 200 -250/ year

600 -800/ year (decreasing) 200 -250/ year

pediatricke ECMO - pro koho a kdy Indications: • severe AHRF refractory to conventional

pediatricke ECMO - pro koho a kdy Indications: • severe AHRF refractory to conventional treatment (? ? ? ) (? how severe is severe enough? - patient likely to die) • reversible cause of respiratory failure. • less than (7) 10 (14) days invasive ventilation (? ? ? ) ? ? ? inclusion exclusion criteria for pediatric ECMO BMC Health Serv Res. 2006

pediatricke ECMO - pro koho a kdy Exclusion criteria • irreversible lung pathology such

pediatricke ECMO - pro koho a kdy Exclusion criteria • irreversible lung pathology such as fibrosis, pulmonary hypertension, … (? ? ? ) • contraindication to heparinisation (low patelets !!!) • evidence of severe neurological injury • established multi-organ dysfunction of 4 or more organs ? ? ? not so easy to evaluate on admisssion !!!

pediatricke ECMO - pro koho a kdy Exclusion criteria – cont. • ? ?

pediatricke ECMO - pro koho a kdy Exclusion criteria – cont. • ? ? ? approach to co-morbidity (pre-existing co-morbid condition is acceptable if treatable and compatible with good quality of life) • prolonged cardiac arrest (? how long is too long? 20 to 40 mins? ) ECMO as “ECPR” …ECMO rescued 1/3 of patients in whom death was otherwise certain…

ECMO as “ECPR” pediatricke ECMO - pro koho a kdy ECMO as “ECPR”

ECMO as “ECPR” pediatricke ECMO - pro koho a kdy ECMO as “ECPR”

pediatricke ECMO - jak overal survival in pediatric ECMO is 50 -60%

pediatricke ECMO - jak overal survival in pediatric ECMO is 50 -60%

pediatricke ECMO - pro koho, kdy a jak United Kingdom population 60 million 4

pediatricke ECMO - pro koho, kdy a jak United Kingdom population 60 million 4 ECMO centers total ECMO around 200 runs/ year Great Ormond Street Hospital Cardio-thoracic and ECMO unit • 500 -600 admission per year • around 40 -50 ECMO runs per year

pediatricke ECMO - pro koho, kdy a jak Retrospective review of all paediatric ECMO

pediatricke ECMO - pro koho, kdy a jak Retrospective review of all paediatric ECMO cases ( age 28 days to 18 years) at Great Ormond Street Hospital for Children between 1992 – 2005 (primary cardiac patients excluded) • total 124 paediatric respiratory ECMO cases were supported (range 7 -15 cases per year) • median age was 10. 1 months and a median weight of 8 kg • median number of pre-ECMO ventilation days was 2 • median worst pre-ECMO OI was 39. 1 • median duration of ECMO support was 9 days 2008 Brown et al. : GOSH ECMO data

pediatricke ECMO - pro koho, kdy a jak overall 1 year survival 59% viral

pediatricke ECMO - pro koho, kdy a jak overall 1 year survival 59% viral infections 58 patients, survival 66% pertussis 9 patients, survival 55% bacterial pneumonia 14 patients, survival 52% sepsis/ septic shock 17 patients, survival 53% aspiration 3 patients, all survived hemo-oncol 2(+1) patients, all died 1 year survival in % 2008 Brown et al. : GOSH ECMO data

pediatricke ECMO - jak VA 63% of patients (46% mortality), VV 27% (24% mortality)

pediatricke ECMO - jak VA 63% of patients (46% mortality), VV 27% (24% mortality) conversion VV to VA 10% (50% mortality). GOSH VV versus VA ELSO registry data 2008 Brown et al. : GOSH ECMO data

pediatricke ECMO - jak

pediatricke ECMO - jak

pediatricke ECMO - pro koho, kdy a jak RISK FACTORS for DEATH 1. septic

pediatricke ECMO - pro koho, kdy a jak RISK FACTORS for DEATH 1. septic shock (P=0. 01) 2. oxygenation index (P=0. 05) 3. pre-ECMO ventilation (P=0. 08) 4. end-organ dysfunction (P=0. 09) For each 5 points increment in OI the risk of death increased by 9% Pre-ECMO OI 2008 Brown et al. : GOSH ECMO data

pediatricke ECMO - pro koho, kdy a jak 53% children had pre-existing co-morbidity …pre-existing

pediatricke ECMO - pro koho, kdy a jak 53% children had pre-existing co-morbidity …pre-existing co-morbidities may predispose children to develop severe AHRF but do not reduce survival 2008 Brown et al. : GOSH ECMO data

pediatricke ECMO - pro koho, kdy a jak CONCLUSIONS: … ECMO should be considered

pediatricke ECMO - pro koho, kdy a jak CONCLUSIONS: … ECMO should be considered promptly in the deteriorating child who does not respond to conventional treatment… 2008 Brown et al. : GOSH ECMO data

pediatricke ECMO - pro koho, kdy a jak CONCLUSIONS: … ECMO should be considered

pediatricke ECMO - pro koho, kdy a jak CONCLUSIONS: … ECMO should be considered promptly in the deteriorating child who does not respond to conventional treatment… 2008 Brown et al. : GOSH ECMO data

pediatricke ECMO - pro koho, kdy a jak long term follow up: CONCLUSIONS: ECLS

pediatricke ECMO - pro koho, kdy a jak long term follow up: CONCLUSIONS: ECLS is a complex therapy which has been used in Australian children for 18 years; a third of children survived long term, and 96% of these had a favourable outcome

pediatricke ECMO - pro koho, kdy a jak long term follow up: CONCLUSIONS: ECLS

pediatricke ECMO - pro koho, kdy a jak long term follow up: CONCLUSIONS: ECLS is a complex therapy which has been used in Australian children for 18 years; a third of children survived long term, and 96% of these had a favourable outcome