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ECMO and Acute Lung Injury: Is There An Indication

Background. ARDS200,000 US cases per year30-80% mortalityTrials with a mortality benefit:6 ml/kg vs 12 ml/kgARDSnet, NEJM 1998Trials without a mortality benefit:HFOVWunsch, Cochrane Database 2004INOGriffiths, NEJM 2005Prone positioningGattinoni, NEJM 2001Liquid ventilationHirschl, Am J

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ECMO and Acute Lung Injury: Is There An Indication

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    1. ECMO and Acute Lung Injury: Is There An Indication? Kristen C. Sihler, MD, MS

    8. Trial Design Randomized controlled clinical trial ECMO versus “conventional therapy” ECMO conducted at Glenfield Hospital, Leicester, England Only adult ECMO center in Great Britain “Conventional therapy” at select Conventional Treatment Centers (CTC) High volume hospitals

    17. Results

    18. Results

    19. Results Reasons for not receiving ECMO 16 improved 3 late deaths 2 Died before transfer 3 died in transport 1 required amputation 13/22 (59%) patients randomized to ECMO but did not receive ECMO survived

    20. Results

    21. Results

    23. Results Subgroup analysis: no differences in outcomes Age group Requirement for transport Duration of high pressure/FiO2 >48 hrs Pneumonia vs ARDS vs trauma No. of organs failed

    24. Conclusions ECMO improves survival in adult patients with early, severe, and potentially reversible respiratory failure One additional survivor for every six patient treated

    25. Strengths No crossover Conventional treatment could not get ECMO Limited selection bias ECMO not available outside of clinical trial “Pragmatic” trial design “Conventional treatment” reflects current practice Similar design to neonatal ECMO trial

    26. Limitations Small size Initially intended to include 240 patients Halted by DSMB at 180 patients No standard protocol for “conventional therapy” Every intensivist thinks their own protocol would be superior Many patients randomized to ECMO did not receive ECMO Perhaps outcome advantage is related to transfer to better hospital rather than ECMO itself

    31. Overall Patient Outcomes

    32. Adult Respiratory Cases

    36. ECMO and Influenza 1990-2009 196 patients, 200 runs between 1990 and 2009 Age: mean 8.5 + 12, median 2.6 years range 1h to 68.5 years Gender 53% female 47% male Indication pulmonary 80% cardiac 16% ECPR 4% Mode: VV or VVDL 34% VA 53% VAV, other 13% Pre ECMO 4.5 + 9 d, med 1.9 (0- Run Times: mean 263 + 202 h, median 210 range 1h to 954 hours Overall Survival: 103/196 =52.6%

    37. ECMO and Influenza 1990-2009

    38. ECMO and Influenza 1990-2009

    39. ECMO and Influenza 1990-2009 Overall survival 52.6% Pediatric ECMO for influenza Total number of reported patients to date 174 54.0% survival Adult ECMO for influenza not reported to ELSO until 2000 Total number of reported patients to date 22 40.9% survival

    40. Australia/New Zealand Approximately 340,000 cases, >750 ICU admits 68 on ECMO VV 63 VA 4 Central 1 Many young adults, 3 children, 4 adolescents Transports Almost 3/4 transferred in to ECMO center 79% (38/49) cannulated at referral hospital for transport Mortality 21%

    41. ELSO February 16, 2010 H1N1 Registry 227 Cases Age 23.9 years, median 23 Gender 51% female 49% male BMI mean approx 30 Mode VV 145, VA 37, other 28

    42. ELSO February 16, 2009 H1N1 Registry Traditional Risk Factors reported in 203 patients

    43. ELSO February 16, 2009 H1N1 Registry

    44. Risk Factors 27% women reported in sample pregnant ELSO February 16, 2009 H1N1 Registry

    45. ELSO February 16, 2009 H1N1 Registry Intubation to Time on ECMO Mean 5.6 days, median 3.6 (0 – 41.7) Longest with survivor to date, 7 yo, 29 days Run times Mean 280 hours, median 211 (0 – 1438) Longest with survivor to date, 22 yo, 50 days Outcome known in 195 cases Survival 61% (119/195)

    46. ELSO February 16, 2009 H1N1 Registry

    47. Preliminary Summary 2/16/10 Australia/ELSO H1N1data At least 300 cases worldwide to date **Kudos to Australia/New Zealand** Patients requiring ICU admission appear to be minority of H1N1 patients, however respiratory failure can be severe Many Young Adults Few prior traditional influenza risk factors Overall survival to date: range 60-80%

    48. ECMO is a Bridge

    49. Make sure it isn’t a bridge to nowhere Make sure it isn’t a bridge to nowhere

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