Extracorporeal membran oxygenering. ECMO ved akut lungesvigt (ARDS)

Transkript

1 Extracorporeal membran oxygenering ECMO ved akut lungesvigt (ARDS) Christian Lindskov Anæstesiologisk-Intensiv afd. I Aarhus Universitetshospital, Skejby FSAIO landsmøde sept. 2011

2 Plan Normal værdier for ilttransport Acute Lung Injury (ALI) og Acute Respiratory Distress Syndrome (ARDS) Ventilator Induced Lung Injury (VILI) Behandlingsstrategi ved ARDS Langtids resultater efter ARDS/ECMO

3 Normal physiology

4 Normal relationship: DO2 and VO2

5 DVO2/VO2 and Sv02

6 Acute Lung Injury (ALI) og Acute Respiratory Distress Syndrome (ARDS)

7 Acute respiratory distress syndrome Acute lung injury ARDS definition Acute onset respiratory distress Bilateral infiltrates on chest x-ray Pcwp < 18 mmhg PaO 2 /FiO 2 < 200 mmhg (26.7 kpa) ALI definition Acute onset respiratory distress Bilateral infiltrates on chest x-ray Pcwp < 18 mmhg PaO 2 /FiO 2 < 300 mmhg (40 kpa)

8 ALI >2 ; ARDS > 3

9 Gattioni et al. Am J Respir Crit Care Medicine 2001; 164:1701

10 Pathophysiology of ARDS Ware and Matthay. N Engl J Med 2000; 342:1334

11 Ventilator induced lung injury (VILI) High FiO 2 High inspiratory plateau pressure High tidal volume Cyclic opening/ closing atelectatic alveoli Barotraume

12 VILI/ARDS og SIRS

13 Protective ventilation Reduced mortality with: Low tidal volume; 6-8 ml/kg ideal BW Low plateau pressure; < 30 cm H 2 O Outcome: Mortality reduced to 31% against 40% in conventional treatment group N Engl J Med 2000; 342:1301

14 ARDS Treatment Strategies I Lungprotective ventilation Peep Recruitment Prone position Conservative fluid management Corticosteroid therapy Esan A et al. Severe hypoxemic respiratory failure. Chest 2010;137:

15 ARDS treatment Strategies II NO- doners High Frequency Oscillatory Ventilation Extracorporeal Membrane Oxygenation

16 Nitric-oxide donors ved ARDS ino Prostacyclin analoger

17 NO

18 ARDS NO/PGI 2 German P et al.: Inhaled nitric oxide therapy in adults: European expert recommendations. Int. Care Med (2005) 31: NO-inhal. bør anvendes som rescue-terapi hos ARDS-ptt. med svært refraktær hypoxæmi : NO-inhal. medfører stigning i PaO2 hos % af ARDS-ptt., anvendt som rescue-terapi Klinisk effekt (mortalitet, resp.dage m.m.) af NO-inhal. anvendt som rescue-terapi er ikke afklaret ved foreliggende studier.

19 HFOV High Frequency Oscillatory Ventilation

20 HFOV in-/expir

21 PCV vs. HFOV

22

23 Quick comparison! HFOV Conventional ventilation Mean airway pressure Peak airway pressure Respiratory rate/ min 5-20 Hz ( ) 10-25

24 Evidence from RCTs P=0.10 P=0.14 Derdak et al. Am J Resp Crit Care Medicine 2002;166:801

25 Evidence from RCTs OSCAR Trial ongoing study

26 HFOV and ino

27 HFOV and ino

28 HFOV HFOV and ino

29 HFOV and ECMO day - 3

30 HFOV and ECMO day 0

31 HFOV and ECMO day +3

32 HFOV and ECMO day +7

33 Extracorporeal membran oxygenering ECMO Aarhus Universitetshospital, Skejby

34 Robert H Bartlett

35 Historik Modificeret hjete-lungemaskine 1972: Hill JD et al. ECOM behandling akut respirations insufficiens. 1979: Zapol WM et al. Randomiseret studie, ECMO/konventionel behandling af ARDS patienter. 10% overlevelse 1986: Gattinoni L et al:. ECCO 2 R, 40 % overlevelse. 1994: Morris AH et al. Randomiseret studie; 35/41 % overlevelse, PC ventilation I:E ratio forlænget. 1996: UK ECMO Trial Group: Randomiseret studie på neonatale 1996 til Mange reporter om ECMO behandlings serier. 2009: Peek GJ. CESAR-studiet i UK 2009 : H1N1-pandemi

36

37 ELSO centers

38 Adult Respiratory Runs 2011

39 ELSO Report July 2011

40 Formål med ECMO behandling At tilføre kroppens væv tilstrækkelig O 2 til at der ikke opstår yderligere organsvigt. Vinde tid til kausal behandling virker og lunger restitueres. Gøre det muligt at gennemføre lung protective ventilation og dermed undgå yderligere lungeskader

41 2 p.m

42 5 p.m.

43 7 p.m.

44 11 p.m.

45 Transudation

46 V-A ECMO,V-V ECMO, A-V ila Veno-arteriel ECMO Kan bruges både ved hjertesvigt og lungesvigt, da det både støtter kredsløbet og lungen. Rsiko: blødning og emboli Veno-venøs ECMO Kun ved lungesvigt Subnormal oxygenering Arterie-venøs interventional lung assist Kun ved CO2 retention Minimal oxygenering

47

48 V-A ECMO,V-V ECMO, A-V ila Veno-arteriel ECMO Kan bruges både ved hjertesvigt og lungesvigt, da det både støtter kredsløbet og lungen. Rsiko: blødning og emboli Veno-venøs ECMO Kun ved lungesvigt Subnormal oxygenering Arterie-venøs interventional lung assist Kun ved CO2 retention Minimal oxygenering

49

50 V-A ECMO,V-V ECMO, A-V ila Veno-arteriel ECMO Kan bruges både ved hjertesvigt og lungesvigt, da det både støtter kredsløbet og lungen. Rsiko: blødning og emboli Veno-venøs ECMO Kun ved lungesvigt Subnormal oxygenering Arterie-venøs interventional lung assist Kun ved CO2 retention Minimal oxygenering

51 Pumpless extracorporeal lung assist (ila/novalung)

52 ECMO venous access

53 ECMO venous access

54 AVALON dobbelt lumen kateter

55 Adult ECMO Set-up SKS

56 ECMO Rota flow pumphead

57 Clot Formation

58 Oxygenator

59 Plasma Leak

60 oxygenator

61 Present Set-Up

62 Outcome ECMO (n=93) CM (n=92) Death before discharge 28 (30%) 54 (59%) Know death before age 1 year 30 (32%) 54 (59%) Lancet 1996: 348: 75-82

63 The CESAR study Conventional Ventilation or ECMO for Severe Adult Respiratory Failure Inclusion Exclusion 180 Adult (18-65 years) Duration of high pressure and high Severe but FiO potentially reversible 2 ventilation > 7 days respiratory failure. Murray score > 3,0 or uncompensated hypercapnoea with a ph < 7,20 Intracranial bleeding Contra-indication for limited anticoagulation Moribund or any contraindication to active treatment

64 The CESAR study Conventional Ventilation or ECMO for Severe Adult Respiratory Failure CON group: n = 90 from 68 centers ECMO group: n = 90; all treated at Glenfield, Leicester 22 did not receive ECMO.

65 The CESAR study Conventional Ventilation or ECMO for Severe Adult Respiratory Failure Survival and absence of severe disability at 6 months ECMO: 57/90 CON: 41/87 p< in the ECMO group had CON therapy intension to treat The Lance vol 374, oct 17, 2009

66 SKS protokol

67 Former Indications Acute potentially reversible life threatening respiratory failure PaO 2 <6.7 kpa for more than 2 h with FiO 2 = 1.0 and Peep >12 cm H 2 O Pulmonary compliance < 25 ml/cm H 2 O

68 Former Indications slow entry maximal medical therapy in > 24 hours PaO2 < 6.7 kpa with FiO2 > 0.6 and Peep > 12 cm H2O Intrapulmonary shunt > 30% Pulmonary compliance < 25 ml/cm H 2 O

69 Exclusion Criteria Mechanical ventilator therapy Paediatric > 7 days and FiO > 3 days Adults > 7 days and FiO > 3 days Paediatric: 4 weeks - 15 y adults > 15 y Cancer Non-reversible CNS injury ECMO 02/9

70 Relative contraindications Chronic disease with short life expectancy Profound uncontrollable sepsis Advanced multiorgan dysfunction Cardiac failure not caused by the acute disease Bleeding diathesis Age > 65 years (increasing age limits) ECMO 02/09

71 ELSO indications 1. In hypoxic respiratory failure due to any cause (primary or secondary) ECLS should be considered when the risk of mortality is 50% or greater, and is indicated when the risk of 80% or greater. a. 50% mortality risk can be identified by a PaO2/FiO2 < 150 on FiO2 > 90% and/or Murray score 2-3 b. 80% mortality risk can be identified by a PaO2/FiO2 < 80 on FiO2 > 90% and Murray score CO2 retention due to asthma or permissive hypercapnia with a PaCO2 > 80 or inability to achieve safe inflation pressures (Pplat 30 cm HO) is an indication for ECLS. 3. Severe air leak syndromes

72 Contraindications Contraindications There are no absolute contraindications to ECLS, as each patient is considered individually with respect to risks and benefits. There are conditions, however, that are known to be associated with a poor outcome despite ECLS, and can be considered as relative contraindications. 1. Mechanical ventilation at high settings (FiO2 > 0.9, P-plat > 30) for 7 days or more 2. Major pharmacologic immunosuppression (absolute neutrophil count <400/ml 3 3. CNS hemorrhage that is recent or expanding

73 Fremtidige indikationer for ECMO PaO 2 8kPa og Murray Score/ALI score : 3-4 CO 2 retention med ph < 7.25 forårsaget af astma eller permissive hypercapni med respirator plateau tryk cmh 2 0 Svær pneumothorax eller mediastinal emfysem under overtryksventilation alder 65 år

74 Treatment Dormicum Fentanyl Initialt muskel relaksation Heparin infusion (aptt: sec) Enteral ernæring Diagnostik protocol ECMO 3/01

75 Respirator terapi PIP < 30 cm H 2 O (så lavt som muligt) frekvens 10-15, tidalvol < 6 ml/kg FiO 2 = 0.4 PIP - Peep = cm H 2 O Recruitment: initialt, senere??? MÅL: SaO 2 > 85 %, PaO2 > 7 kpa ECMO 3/01

76 Dagnosis Primary and secondary ARDS adult outcome Number and gender F/M Mean age (range) Survival to discharge (%) Primary lung injury 66/791 (72.5) Pneumonia Bacterial 54 28/26 48 (17-63) 40/54 (74.1) Viral 25 8/ (18-65) 17/25 (68.0) Aspiration 8 3/ (27-67) 6/8 (75) Vasculitis 4 0/ (18-59) 3/4 (75.0) Secondary lung injury 18/29 (62.1) Trauma 18 3/15 3o.2 (20-59) 13/18 (72.2) Sepsis 15 6/ (16-67) 9/15 (60.0) Total / (16-67) 88/124 (71.7)

77 Antal ECMO per år - voksne

78 ECMO Retrieval Start 1998 Transport hold: 2 perfusionister 1 thorax kirurg 1 thorax anæstesiolog 106 transporter af patienter på ECMO (86%). 3 døde inden afgang. Ingen komplikationer undervejs.

79 Antal ECMO patienter overflyttet fra: Norge 1 Irland 1 14 Sverige

80

81

82

83 Dødsårsager n:34 Ikke mulig at aftrappe respirator 7 Fatale cerebrale komplikationer 11 Ukontrollabel sepsis 6 Splanchnicus iskæmi 3 Blødning 3 Andet 4

84 Udskrivelses fraktion og MURRAY score 1 a 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0, ,25 3,5 3,75 4

85 Udskrivelses fraktion og SAPSII score (Simplified Acute Physiology Score) 1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,

86 Langtids resultater efter ARDS/ECMO

87 3 months after

88 Long-term survival plot: 41 ECMO patients; 4100 controls

89 Præmorbide status: Alder, grundsygdomme, psyke,, cerebrale status, sociale netværk Smerte, sensorium Indlæggelse, intensiv Respirator tid Steroid Neuroendokrine stress ARDS og behandlingen delerium Hypoxi Sedation, medicinering Seminars Resp Crit Care Med 2010;31(1):55-63 Immobilitet

90 Healt Related Quality of Life: HRQoL Pleje afhængig Økonomiske problemer Cognitiv dysfunktion HRQoL SF 36 Arbejds evne PTSD, Depression l Seminars Resp Crit Care Med 2010;31(1):55-63 Fysisk handicap

91 Isotop udvaskning ECMO in ARDS: a long term follow up study regarding pulmonary morphology and function and health related quality of life Acta Anaesthesiologica Scandinavica Volume 53, Issue 4, pages , 18 FEB 2009 DOI: /j x

92 Fysiske ændringer: vægt N Eng J Med 2003;348:687

93 Påvirkning af lunge funktionen N Eng J Med 2003;348:688

94 Healt Related Quality of Life: HRQoL N Eng J Med 2003;348:689

95 Prospectiv stuie af 109 ARDS patienter som overlevede til udskrivelse fra ICU. Fulgt årligt i 5 år. N Eng J Med 2011;364(14):

96

97 62 månder, 37 voksne ECMO patienter 26 (70%) overlevede til udskrivelse 21 undersøgt efter 12 måneder

98 Lungefunktion ECMO in ARDS: a long term follow up study regarding pulmonary morphology and function and health related quality of life Acta Anaesthesiologica Scandinavica Volume 53, Issue 4, pages , 18 FEB 2009 DOI: /j x

99 Sct Georges Respiratory Questionnaire ECMO in ARDS: a long term follow up study regarding pulmonary morphology and function and health related quality of life Acta Anaesthesiologica Scandinavica Volume 53, Issue 4, pages , 18 FEB 2009 DOI: /j x

100 Conclusion Seminars Resp Crit Care Med 2010;31(1):55-63 These patients experince several physical, mental and phychological morbidities that significantly impair their HRQoL. Persistent for years after hospital discharge, decrements in functional and neurophsycological outcome results in lost savings, employment reduction, and HRQoL among survivors and their caregivers.

101 Tak for jeres opmærksomhed

102 Mortality rates in ARDS patients after 24h ventilator treatment (PEEP 10 ) 9% had P a O 2 /FiO 2 > 300 mmhg : 6% 35% < : 20% The rest - - < : 45% Vilar J et al. Am J Respir Crit Care Med 2007;176(8):