2025 Pediatric Surgery Update Course - Updates in ECMO & eCPR Use

What are we doing here? A lot of things that a lot of people don't do. So we know internationally that we've talked about not doing ECPR because majority hospitals don't do it. A lot of people don't get into heavy oncology which is coming up. A lot of people don't do thyroid. So we're doing, we decided this time to do things that aren't necessarily the most common because we work through it every so often. So I think this is a great topic. You want to, are you might be introducing or you want to just let them go? Just let them go. We have doctors, Guruya and Rostin to do our next session on ECPR and ECMO cannulation. So we're going to talk mostly about ECPR or solely about ECPR. So, Rostin, who those ECPR and your institution, extra corporeal? Who enjoys it? Alright, we have like eight people in the room. Alright, so... Are you going to explain where ECPR is? Yeah, well, yeah, yeah. Maybe we'll just go next slide. So we have no disclosures. Okay. We did say, we did chat with each other a bunch, but we didn't use chat GPT and we maybe we should have a little find out in two more sessions, right? So what we wanted to talk about is ECPR. So what is ECPR? It's extra corporeal cardiopulmonary recitation, which is different from conventional. And it's the idea of adding ECMO or extra corporeal life support member in oxygenation to a conventional run of ECPR to increase your outcomes. And what is success? So we can define success as survival, probably better to determine sort of neurologic favorable neurologic outcomes. I'll leave it intentionally, think. There's lots of things to consider that both the technical aspects, the preparation, the ethical and emotional costs. And we decided that ECPR can stand for a lot of things. We won't have an uptime, of course, to talk about the ethics. We talk about ethics of why to go on, what are the disclosures to families? Are there equitable use of resources? Quite tearier, very important. Who should be considered for ECPR, rather, how to prepare team preparations? It's really, really critical. And if we have time, which is mentioned, revisiting, which is a long-term follow-up. I wanted to put up four or five scenarios just to get that mind going. Imagine you're the uncall provider and you're asked to put these kind of patients on a life-support circuit if conventional CPRs aren't working. Here's a patient with a hopefully affixable problem. Here is a patient with probably a treatable disease. You don't know why they've arrested, but they probably could be fixed, at least that's the mentality perhaps. Here's a patient with a terrible disease and a bad complication. And now, day 15 without much prognosis, is that change your attitude or should we be providing the best care for everybody not worried about why they are in the state where they are? This is at a common scenario where out of hospital cardiac arrest and kids is not often performed and probably has bad outcomes if you look at adult literature. This is different perhaps. We have the same scenario of drowning, but now we have immediate response, immediate compressions, and return of circulation at least temporarily. First poll is, who qualifies for ECPR? So we can take a polling section here. Anybody in hospital only based on underlying illness or other? Looks like in hospital only. Does anybody hear the out of hospital arrest CPR? ECPR, I'm sorry, ECPR. Yes, you tell. You tell. I'm not out of hospital. Outside of hospital arrest ECPR. We do. We have a pretty robust program for cold water drowning because we have so much cold water, especially with the spring runoff. Now that said, after reviewing it, our outcomes are as you would expect. They're pretty low. Like to Russell is from Utah for the people online. Yeah, but then we also do ECPR for other reasons for out of hospital arrest. Okay, big challenge for institution and CD, right? So one of our questions here is, do we give an ECPR, offer ECPR for everybody as a sort of equity issue or a moral issue? Or do we actually refine the indications? And it's not just similar to anything. Do you do a code? Do you run a code on anybody? So those are, I feel it's not going to be big, big questions, and we can't explain, of course. We talked about the here we had a fun. So we want to add one little layer. So not all drownings are not all out of hospital arrest are the same. Somebody might come to you after a kind of a dismal presentation, but they have very reasonable numbers. We're reflecting some sort of circulation. And you may have somebody who's got great response, community response, and had terrible numbers. So this adds to the products. You want to say something? Yeah, one other number that we pay attention to is the potassium. And just, you know, the idea is especially with avalanche victims, and then also these cold water drownings, are do they get cold first, or do they get hypoxic first? I think the potassium is, if I like the number, I use it, if I don't like the number, I make an excuse for it. We have a cut off at eight. Would anybody put on a gmal a baby in house arrest with a pH of less than seven? Sure. Pants? Yes? Two pants. Wow. Okay, before I turn it over to one, so we thought maybe one way to look at it is if you look at physiology and lab parameters versus the duration of downtime, which in mentally seems like they're long, so they're on, if they're getting CPR for really long time, maybe they've had a candidate. So this box and the right, lower size of the best, right? They've got great numbers, they've not been getting CPR for much time. But maybe great numbers are more important than downtime? I don't know, there's some suggestions, but, and probably the worst, of course, you've long, long downtime and terrible numbers. Upper-biting close to here. Excellent. Oh, they've been very close. Yes. Oh, great. So who are these candidates? And it's really hard to say, like, oh, you're going to be a candidate or not, right? And, you know, we need to make sure it's a witness arrest. Of course, specifically for the out of hospital, right? Like, there's only maybe one or two institutions out there doing out of hospital arrest, CCPR, which is very tricky vote for the institution and the city. You need a lot of resources for that, and the community has to buy in on this. But in hospital arrests, right? You need to have a reversible pathology. Eggmo, remember, it's not a destination. It's a bridge to try to give or gain more time. You're not fixing anything while you're an eggmo. So, for example, since any children who have all the, and this is a big short out to our PQ team, whoever gets to the PQ, humanically, not normal, they get a candidacy, yes or no, before anything can happen to them. So, by the time, if there's, unfortunately, a cardiac arrest, the team already decided whether there's going to be a candidate. So, that's huge. When you run out there, you're not struggling to find out. They've already talked to the family in the case of this arrest, right? The question mark, or the asked us, they're like active leading. Would anybody put a patient on an eggmo with a pulmonary bleeding? Not dying pulmonary bleeding, but there's some blood in the 82. ARDS. Yes? No? Hell no. Hell no is good. They are candidates. We have a lot of new things now. We have inhaled TXA. We have a peniferent through the tube. Brunk, you can go in, ENT docs and pulmonologies are great for this. So, they are candidates. So, plan ahead early in the cardiac arrest, of course. In our hospital, after the second dose of a peniferent, they activate ECPR. So, all the teams mobilized, and then you have it available. This is great in all that, and a lot of people are candidates. But you're talking to a group of people that will struggle through this to get a kid to survive, to try to get a kid on ECMO. And I'm like, I'm on the ELSO Registry website right now talking about survived to DC or transfer. But my point is, if you don't get real hardcore outcome data back to the world, that not only are you going to have people that will make it not to transfer, but to discharge, but that it's a survivable outcome that anybody would want. That's the argument that I think needs to be made a little bit clearer. And we got an answer here, sir. There are some of the data, what tells us the main things work? Reduce flow of direction? You're going to get a lot of people counting your time off. Reduce pre-eckment time. Simulation has been shown to, I think, have better outcomes, at least in terms of teen dynamics and patient selection. I think you mentioned that, I think it's a critical point, is that ICU teams need to really think every day about ECLS candidates, electively and in the crunch. So it's not a 2 a.m. moral distressing decision, say, hey, this person should go on, and nobody really knows why or anything about the patient. I'll breathe through this really briefly. In adults, of course, very different, but much more robust data. There's no randomized trials in kids. In adults, there are some randomized trials that suggest that robustness and that can improve neurologically appropriate outcomes to survival over a conventional CPR. But remember, it's a very different physiology, usually cardiac lesions. There have been three adult RCTs for out of hospital cardiac arrests. And just, I don't want to point out that there's three different answers. One, it's better, one is worse, and one is no different. So a lot more data needs to be done in adults, little lonely kids, and the, also data, I think, 3% of ECPRs were for out of hospital cardiac arrests. I think there's a slight coming up. So, we ask, what are the outcomes of ECPR to answer, or to address Nelson's question, how does ECPR compare to CCPR, and what predicts success? Here's some stuff. Yeah, so talking about the LCA outcomes, right? Like, if you look at, obviously, neonatal pulmonary has the best outcomes, right? We all know, but look at ECPR, right? Survival ETLS, 70%, 60%, survived this charge to this charge, 40%, in both pediatric and neonatal. It's key, very close to our other indications for ECMO, right? So ECPR provides these numbers, so that's your answer. You wouldn't make that patient a candidate. We have 58%, 70%, 50% discharge to that. But it's not. It's survival to transfer or discharge, and I would argue that that is a completely useless outcome metric. To discharge? Yeah, what's the survival to discharge? Take that transfer out of there. That's like a dirty number. So clean that up. So ECPR improves survival to hospital discharge in pediatric cardiac arrests, if you compare to conventional CPR, survival to these are 40%, favorable neurologic outcome, 30%. Here is. So you wouldn't give that patient a third of a chance. You would. There you go. Okay. And also, there's going to be substratification. So, for example, for meningococcal sepsis, I think the outcomes are in the single digits, no matter what you're doing, whereas for cardiac primary ECPR as a. So it had you have to think about which patients are not saying we're not saying offered to everybody. This is a study that looked at strongest predictors or mortality sort of both pre and post. This is a survival to hospital discharge was 44% sort of in line with the ulcer data before things we mentioned before after. Polymerist, it occurs after neurologic complications, including stroke as seizures and then renal failure are all predictors of post ECPR mortality. So should we offer CPR? So one of the questions we asked is where are the complications, whether cervical approach with stroke risk or femoral approach with with limb complications or other bleeding complications? And how can one way the complications of ECPR against CPR remembering we were activating ECPR really early in the run and you may be asked to put patients on who might survive with conventional CPR and those questions are really unanswered yet in the pediatric literature. And decision on these I commend to everybody this paper out of Colorado by Pepe Diaz Morone who did some really in depth into interviews with people talking about the just. Distress sounds kind of soft, but it's really important to think about what goes to teams when they're asked to put somebody on CPR, how to fix families, how to fix providers and the ICS, how to fix us. We'll go back to our clinical scenarios. This is actually a patient we had recently in our hospital, a gal. She did have a plastic anemia. She was heavy set. She had basically four years gangrene and needed ECMO. And the request wasn't for BA, but a poll question with this patient here with extensive perinol debridement and terrible disease, a terrible complication disease. Let's say you decide to go on a ECLS, how would you approach this by femoral finding some ways, corroded in a 17 year old central for sepsis or other. So colorectal team together is a colorectal problem. Trans rectal. So two thirds going through the corroded a small minor and a small part by femoral or central. Do you want to make any comments on central for septic? I think this is a key thing, right? We all know that septic patients require a massive amount of volume to support them through ECMO. And most of the times you need central support to be able to drain that much out of the venous system. But in terms of when there's CPR ongoing, you can always put them on the neck and then transition to central. Once you're flowing and you're oxygenating better, you have to jump on central and every septic patient. Now I will put this patient through the neck. It was me. We're going to go stroke rate. But then you can always transition to central. So we learned something about each other's institutions. In Seattle we've been pushing more femoral because it stays out of the way of CPR. In bigger cases you have size. But there are definitely considerations for femoral and vessel injury and limb loss. I learned that one's institution does exclusively or almost exclusively neck. And so we looked into a little bit about what can we answer for stroke rate. These data has been going back and forth in the last 20 years. It's huge, the risk of stroke. Don't do it in other lessons. 15 kills go to the lags, the femoral vessels. Below that it's not enough flow. Then the transition to no, no, we were wrong. The risk is really low. Current data, 10% from 2.2 to 10.4% of stroke rate. However, in a smaller kid that your femoral outfit is not going to be enough, 10%, I think, it's a reasonable number. It is not insignificant the risk of stroke in older kids and adolescents when you go in the neck, especially if there's not a complete circle of will. You do not know by then. But it's something to think about. Does anybody do here femoral approach? You tell those. We used to do that in Phoenix. When I was in Phoenix, you do need a distal profusion can in our make a chimney preferably. But you need to think about this stroke rate of 10% on current data. Something to think about. If you're just somewhat summarize, I think it's important to get on however you can get on. And it's regional practices or regional practices. Some people go femoral somewhere neck. You can take your time getting off. You can involve ask a surgery if you like, or some partners have a really good controlled particularly in the groin. This is a debate we want to have a time to talk about completely. But as we know, there's groups that lagate the carotid after removal. And those who will reconstruct their pros and cons to both. I wanted to make a pitch for long term surveillance no matter what. Even if you have lagate because we're finding out more and more. We've done a study at Seattle Children's where we found. Most of the studies they publish are mostly sort of sort of. Bynomial outcomes. There is either a complication of the neck reconstruction with some narrowing or occlusion. Or it's open. And I think there's more subtlety to that. And I think that the problem is that we're finding a lot of the problems that we're finding. Dilation narrowing of different percentages even in small flaps. And so I think it's really important to. So the other is. Yeah. So over half of our group has in the seven years media and follow up has had some. Perhaps actionable into adulthood. So we're just make a pitch for long term surveillance rather than one and done. Lastly to say that. Vime experience and preparation really matter. And patients like this critical some people even argue she's going to E.C.L.S. Before becomes E.C.F.Y.R. Again not enough time to debate that. And to summarize. Yeah, I mean the other thing like. You know we used to see like our oncology patients not candidates and try and I'm bleeding not candidates. We're putting more and more patients on neckman out of this everybody goes on right. Everybody's candidate like oncology always goes back like no we can treat this right. So put them on right. Those BMT yes or no. Agno. Depends on how long they've been from in graph. Exactly. In graph. It's key right patients like some that's why you need to preventively talk to the peak you like is is a candidate talk to college talk to BMT. But we need to think about we're doing the right thing and I'm a huge egg. No supporter but we need to make sure that we're putting secret secret patients on agno and we're patients secret patients are surviving. Nowadays are we doing the correct things real quick. Real quick I know you guys are out of time but because this is the update course and there's that that 2025 article on minimizing pauses during ECPR. What's the secret there because like I agree with you it's right to do this but it's painful to do this so talk to me about that. I mean you've seen in in our center right that the CPR coaches are key right. Showing your outcome through your cardiac output. Entitle coaching right your voice you will always have it in I don't know if you've seen it in the PQ the team is constantly circulating through that patient changing compressors showing live versions I don't know who has the these monitors in your institution or not but you can see the entitled you can see the oxygenation you can see the cardiac index from those compressions. I think that's key. Minimizing pauses the earlier you can get to roast the better if you cannot the earlier you jump on ECMO has the best outcomes. I have a question for you guys I've asked this before to you guys who do more. I've only done one and it was a nightmare because I couldn't see the anatomy as well because there was no pulsating vessels. Is there a way to teach this technique so you're not doing it for the first time on a CPR patient. Has someone come up with a way of teaching in a non-pulsatile patient identifying the anatomy in a systematic way. There's a lot of simulation going on through the nation. In our center we do with manicies like literally dissection, cannulation, the entire code, rons, nothing like the live version of course. I think having people's crubbing with you at the moment is nothing like that right. Knowing your anatomy is key of course if you've done it in a semi-elective ECMO situation is better because you can know your anatomy and your landmarks and the way you should dissect down the younger the patient the easier it's to get into these vessels. Right. To attend this key for ECPR we do that in our center. We think is better at least for our institution is if you are to attend this one I think that provides the argument. You know when in these situations it's scales right and everybody is like running around and people are pushing you from behind you need to pause compressions to see you need to pause compressions to kind of lead to make your outer your anatomy. So it's tricky however if 50% are going to make the 30% good neurologic outcome. Yeah. I'd say we can learn we can learn from adults again different disease but people are putting adults on perk bilateral groins straight to the cathula. We don't need to go to cathula but the perk approach keeps you out of the way from the chest and it can be faster in the right hands Vera. No I just was going to add on to one point about the two attending. I think the other part of the two attendants sometimes you get a scrub who hasn't done any CTR case before and so that second attending can check the circuit make sure you have the right cannulas. Tell the scrub know what they're supposed to need. You know all of those things in order that the person who's actually doing the cannulation doesn't have to be paying attention to that stuff but I think that helps a lot. Excellent point. Thank you so much. This was a great session. Thank you.