Case

Conferenc
e

Amr Ali
PGY-5
Pediatric Critical Care Medicine
Agenda

• Case presentation
• Definition & Diagnosis of PARDS
• Management of PARDS
• ECMO management
• Troubleshooting and Common
problems on ECMO.
Case Presentation
•Chief Complaint: PMET for Respiratory distress, Lethargy

•HPI:

•23-month-old ex-24-week pre-term.

•Recently , s/p circumcision, laparotomy with lysis of adhesions, right ureterostomy takedown,
and right ureteral reimplantation & right ureteral stent placement on May 3, 2024.

•POD 1 ( May 4 ): developed tachypnea, respiratory distress, desaturation, worsening abdominal

distention & emesis.

•PMET Called.
Past Medical History:

•Rt. Hydronephrosis due to ureteral stricture.

•Hypertension

•Peritonitis

•Premature infant of 24 weeks gestation

•Retinopathy of prematurity

•History of non-occlusive portal vein and IVC thromboses, LLE femoral DVT, and right superficial femoral vein thrombosis.
Treated with heparin and lovenox, discontinued with no new thromboses since neonatal period.

Past Surgical History:

•Ureterostomy (Jan 2023)

•Laparotomy, peritoneal drain insertion

Review of Systems

• Positive:
• General: Decreased activity
• Neuro: Lethargy
• Respiratory: Difficulty breathing
• Gastro: Abdominal pain, vomiting, abdominal distention
• GU: Hematuria ( urinary catheter in place )
• Negative:
• Neuro: No Seizures
• Eyes: Pain, redness, discharge
• ENT: Nasal congestion, rhinorrhea, sore throat
• Respiratory: Wheezing, cough, apnea
• Cardiovascular: Cyanosis, cool extremities, diaphoresis, fatigue with feeding
• Musculoskeletal: Limitation of movement, muscle weakness
 Physical Examination

• General: well-hydrated, well-perfused

• Neuro: Awake but lethargic, pupils equal/reactive, normal tone, strength 5/5
• HEENT: Normocephalic, no conjunctival injection, sclerae anicteric, neck supple
• Cardiac: Regular rate/rhythm, sinus tachycardia, normal S1/S2, strong peripheral pulses
• Respiratory: Distress, labored breathing, tachypnea, subcostal retractions, symmetric chest rise,
clear lungs
• Abdomen: Slightly firm, distended, tender, no hepatosplenomegaly
• Extremities: No swelling, normal ROM, no clubbing, brisk capillary refill
• Skin: No rash, petechiae, or purpura

• Vital Signs:
• Temp 37.3 °C (99.1 °F), Pulse 170, Resp 60, SpO2 97%, BP 134/86 ( on 4 LPM nasal Canula)
 Initial management
• NS bolus 20ml/kg

• Broad-spectrum antibiotics (Zosyn)

• Blood cultures: -ve Cx,

• RVP: Rhin/Enterovirus & parainfluenza virus 3.

• SGY : NGT LIWS (dark green drainage ) NPO ,NO surgical intervention.

• Transferred to PICU for further monitoring and management.

• High-flow nasal cannula ( on HFNC 1.5/Kg 70 % ) >>>> BiPAP

• Intubated in less than 24 hours of PICU admission.

 Interval Events Leading to
ECMO Cannulation (May 7)

• Progressive hypoxemia

• Escalated conventional MV
settings: SIMV PC : PIP 32 PEEP 13
FiO2 100%

• iNO started

• High-frequency oscillatory
ventilation (HFOV), but refractory
hypoxemia persisted with OI > 55
e
 ECMO Cannulation

• 15 French Crescent
RA Venovenous ECMO
cannula via
percutaneous
approach.

• Using seldinger
technique accessing
through an existing
RIJ central venous
line.
 Management

• Initial Vent setting:

• SIMV PC: PEEP 10, PC of 10, rate of 10. FiO2 40 %. VTE 13 ml.
• SpO2 mostly 90-93%
• PaO2 high 50s.
• VV ECMO:
• Flow 110ml/kg/min
• RPM 3280
• Sweep 2.5L/min
• Inlet pressure: -48
• FiO2 100%
• Sedated, on neuromuscular blockade, Bumetanide infusion
started
Key Concepts in
PARDS & ECMO
management.
PALICC – 2
Guidelines
Monitorin
g in
PARDS
 Criteria for initiation ECMO in
PARDS
• Consider ECMO in Sever PARDS after failed lung protective strategies.

• No strict criteria for selecting patients who will benefit from ECMO in PARDS.

• No RCTs comparing ECMO vs. invasive mechanical ventilation (MV) without

ECMO support in PARDS.

• ECMO may prevent ventilator-induced lung injury, irreversible lung damage,

and secondary organ failure.

• ECMO can serve as a bridge to lung transplantation.

Historical Trials, Thresholds, and Benefits of
ECMO in PARDS

• U.K. neonatal ECMO trial (1993-1995): Lower relative risk of

death in ECMO group (0.55; 95% CI, 0.39-0.77, p = 0.0005).
• U.K. neonatal ECMO trial: OI ≥ 40 or Paco2 ≥ 90 mm Hg for
≥ 3 hours.
• ELSO Registry study: No specific OI threshold identified for
ECMO initiation, but higher OI correlated with increased
mortality.
 Lung protective ventilation
bundle
• A set of strategies aimed at minimizing ventilator-induced lung injury and optimizing outcomes in
PARDS.

• Tidal Volume:
• Use physiologic tidal volumes between 6 and 8 mL/kg.
• Use lower volumes if needed to stay below suggested plateau and driving pressure limits.

• Ventilation Pressure:
• inspiratory plateau pressure to ≤ 28 cm H2O.
• Driving pressure to ≤ 15 cm H2O (measured under static conditions).

• Positive End-Expiratory Pressure (PEEP):

• Titrate PEEP to optimize oxygenation, oxygen delivery, hemodynamics, and compliance.
• Maintain PEEP levels typically at or above the lower PEEP/higher FiO2 table from the ARDS
Network protocol.

• SpO2 Targets:
• For mild/moderate PARDS: Maintain SpO2 between 92% and 97%.
• For severe PARDS: Accept SpO2 < 92% with optimized PEEP.
• Avoid prolonged exposure to SpO2 < 88% or > 97%.

• pH Management:
• Permissive hypercapnia (lower limit pH of 7.20) to remain within recommended pressure and
tidal volume ranges.
• Consider bicarbonate supplementation in severe metabolic acidosis or pulmonary
hypertension affecting cardiac function or hemodynamic stability.
ECMO
 Patient Management
• A. Blood Flow
• V-V ECMO:
• Oxygenated blood mixes with deoxygenated blood from systemic venous return.
• Systemic arterial saturation typically 75%-85%.
• Systemic arterial saturation increases as native lung function improves.
• V-A ECMO:
• Higher proportion of infused oxygenated blood to native aortic blood.
• Normal systemic arterial saturation but potential for differential hypoxia due to uneven distribution.
• B. Gas Exchange

• Carbon Dioxide Clearance:

• Dependent on sweep gas flow.
• Correct slowly over 4-8 hours to avoid rapid cerebral perfusion changes.

• Oxygenation:
• Determined by circuit blood flow rate, total cardiac output, and hemoglobin levels.
• Venovenous (V-V) ECMO
Hemodynamics

• Does not provide direct hemodynamic support.

• Improves conditions for ventricular function by providing well-oxygenated coronary artery blood flow.

• Hypertension:
• Frequent due to venous blood diversion into the ECMO circuit resulting in low cardiac filling pressures.

• Cardiac Arrest:
• V-V circuit should continue running.
• Initiate V-A ECMO support as soon as possible.

• Venoarterial (V-A) ECMO

• Hemodynamic Support:
• Depends on cannula size, native cardiac output, and systemic vascular resistance.
• Systemic perfusion usually adequate despite lower pulse pressure and mean arterial pressure.
• Wean inotropes and vasopressors as perfusion improves.

• End-Organ Oxygen Delivery:

• Assessed by mixed venous blood saturation, lactate, urine output, NIRS, and peripheral perfusion.
• Increase pump flows if systemic oxygen delivery is inadequate.

• Hypertension:
• May reflect fluid overload, pain, or agitation.
• Treated with systemic vasodilators, diuretics, or sedation depending on the cause
Recirculation
•Occurs exclusively in venovenous ECMO.

•Reinfused oxygenated blood is withdrawn through the

drainage cannula without passing through systemic
circulation.

•Decreases ECMO efficiency in providing oxygenation.

•Clinical Significance:

•Depends on the patient's dependency on ECMO for

oxygenation.
•Whether intervention is needed varies based on the
degree of dependency.
• Increased by higher circuit flow and
lower cardiac output.
• Affects SvO2 reliability.
 Factors Affecting Recirculation:

Cannula Configuration and Positioning:

• Two-site venovenous ECMO with femoral and internal jugular
cannulation.

• Closer proximity of drainage and reinfusion cannulae leads to

higher recirculation.

Pump Speed, Cannula Size, and Blood Flow:

• Increases correlate with higher recirculation.

• Larger cannulae may mitigate recirculation by allowing for

higher blood flow rates

Changes in Pressures:

• Intra-thoracic and Intra-cardiac Pressures:

• Pneumothorax, pericardial tamponade.

• Impede venous return to the heart, increasing recirculation.

Identifying and quantifying the
amount of recirculation

• Recirculation (%) = (SpreO2 –

SvO2)/(SpostO2 – SvO2) x100

• None of these methods has been definitively

shown to accurately measure the percent
recirculation, though trends in each of these
values, in conjunction with assessments in
SaO2, may be useful in identifying changes in
the amount of recirculation and, therefore,
efficiency of the ECMO circuit over time.
 Interventions to reduce recirculation
• Increasing Distance Between Cannulae
• In two-site venovenous ECMO.
• Withdraw one or both cannulae.
• No standard distance defined; assessment via chest radiography or ultrasonography.

• Monitoring:
• Close observation of SpreO2, blood flow, and negative venous pressure during manipulation.

• Alterations in ECMO Circuit Configuration

• Bicaval Dual-Lumen Cannula:
• Single venous access site with drainage ports in SVC and IVC; reinfusion directed toward tricuspid
valve.
• Low recirculation (<2%) with proper positioning.
• Additional Drainage Cannula:
• Permits comparable blood flow rates at lower pump speeds and negative pressure.
• Monitoring and adjusting pump speed.
• Manipulation of Reinfusion Cannula:
• Attempts to direct reinfusion jet toward tricuspid valve; limited data and not generally
recommended.
• Careful consideration of patient positioning.
Ventilator
Manageme
nt on ECMO
 Ventilation on ECMO : Lung rest
Settings

• Goals:
• Reduce barotrauma/volutrauma.
• Minimize oxygen toxicity.
• Ventilator Settings:
• PIP: <25 cm H2O.
• FiO2: <50%.
• PEEP: 5-15 cm H2O.
• Titrated for lung recruitment and airway distention.
• Respiratory Rates: Low or none.
• Spontaneous Breathing:
• Enhances recovery and lung rehabilitation.
• Risk of patient self-inflicted lung injury (P-SILI) with strong spontaneous breathing.
• Sweep Gas Adjustment:
• Maintain blood PaCO2 at 40-45 mm Hg.
• Permissively higher PaCO2 in chronic lung disease patients.
•Pneumothorax Management:
•Reduce ventilator settings, risk of atelectasis.
•Consider CPAP or no positive pressure.
•Chest tube placement only with hemodynamic compromise due to bleeding risk.

•Inhaled Nitric Oxide (iNO):

•Consider in severe right heart failure and pulmonary hypertension.
•Promote forward flow and ventilation/perfusion matching.

•Ventilator PEEP:
•Optimize to minimize right heart strain.
•Consider prostaglandins to maintain ductal patency in neonates.

•Extubation on ECMO:
•Decreased sedation, improved neurologic assessments, increased rehabilitation.
•Risk of inadequate secretion clearance and cannula kinking/dislodgement, especially in
young children
 Fluid Management on ECMO
•Ultimate Goal:

•Achieve target dry weight.

•Diuretics:

•Initiate once Hemodynamic Stability achieved

•Hemofiltration:

•In AKI, Continuous hemofiltration added to the extracorporeal circuit.

•Maintain fluid and electrolyte balance.

•Early Renal Support:

•Optimal nutritional and metabolic support.

•Prevent or reverse fluid overload.

 Sedation Management on ECMO
•Initial Sedation:
•Adequate sedation (based on patient’s anxiety and discomfort ) during cannulation and first 12-24 hours.
•Goals: Avoid air embolism, minimize metabolic rate, secure cannulation sites, reduce risk of bleeding.

•Paralysis:
•Rarely necessary except during cannula placement or to enhance venous drainage.

•Sedation during V-V ECMO:

•Often required to tolerate endotracheal intubation.
•Consider conversion to tracheostomy for prolonged ECMO runs to minimize sedation and immobilization.
.
•Benefits of Minimizing Sedation:
•Increased mobilization.
•Promotion of spontaneous ventilation for pulmonary recruitment and lung recovery.
•Decreased risk of withdrawal.
Neurological assessment on ECMO
• Head Ultrasounds (Neonates):
• Perform at ECMO initiation.
• Conduct daily or every other day thereafter.

• Daily Assessments:
• Conduct daily neurologic assessments for all patients on ECMO.
• Use computed tomography (CT) if there are concerns for bleeding or infarction.

• Near-Infrared Spectroscopy (NIRS):

• Utilize NIRS to monitor cerebral oxygenation, especially in sedated patients.

• Electroencephalography (EEG):
• Employ EEG for continuous neurologic function monitoring in sedated patients.
Weaning Off ECMO (V-V ECMO)
• Indications:
• Improvement in Lung Compliance ( i.e Recovery):
• Better radiographic appearance of the lungs.
• Enhanced oxygenation and ventilation without circuit or ventilator adjustments.
• May be indicated in cases of uncontrolled bleeding or other specific circumstances.

• Weaning Process
• Occurs as the patient improves while on the lowest blood flow providing adequate
support and low ventilator settings.
• Avoid Over-Sedation:
• Over-sedation can cause dyspnea and hinder weaning.
• Providers should distinguish between dyspnea without distress and dyspnea with
distress.
• Avoid removing or depressing the respiratory drive to facilitate effective weaning.
• Tolerate Higher CO2 Levels:
• Necessary for patients with residual chronic lung disease.
• Adjust sweep gas to allow higher CO2 levels before the wean.
 Trial off ECMO
• Adjust Ventilator Settings:
• Set to acceptable levels to test gas exchange independently from ECMO support.
• Maintain Blood Flow and Anticoagulation:
• Stop sweep gas and cap off the oxygenator.
• Assessment During Trial Off
• Monitor Parameters:
• Arterial blood gases.
• Oxygen saturation.
• End-tidal CO2.
• Clinical examination for tolerance.

• Criteria for Decannulation

• Adequate Lung Function:
• If lung function is sufficient at safe ventilator settings for an hour or more, consider decannulation.
• Extended Trial for Questionable Cases: for 24-48 hours
• To ensure tolerance for patients with highly questionable trials off ECMO.
• Avoid Muscle Paralysis During Decannulation:
• Some patients may not tolerate muscle paralysis, leading to hypercarbia and failure to wean off ECMO.
 Relative Contraindications, Conditions
With Poor Prognosis

• Conditions rendering patient

unlikely to benefit from ECLS: • Conditions with worse prognosis
• Large intracranial bleed with mass effect
or need for
in respiratory ECLS:
• Neurosurgical intervention • Hepatic or renal failure
• Hypoxic cardiac arrest without adequate • Pertussis infection in infants
CPR • Fungal pneumonia
• Irreversible underlying cardiac or lung • Immunodeficiency
pathology (and not a transplant
candidate)
• Pulmonary hypertension and chronic lung • Relative contraindications:
disease
• Vessel anomalies or having previously
• Chronic multiorgan dysfunction been clipped or ligated for prior ECMO
• Incurable malignancy • Localized site infection
• Allogenic bone marrow recipients with
pulmonary infiltrates
Cannulation complications

• Cannula malposition
• Bleeding
• Vessel damage
• Adjacent organ injury
• Air embolism
• Right atrial injury
• Pericardial effusion
Surgical procedures on
ECMO.

Is it possible?
Challenges and Historical
Limitations
• Historical Challenges:
• High risk of hemorrhagic complications
• Requirement for continuous anticoagulation
• CDH Focus:
• Initially limited to CDH repair
• Essential for managing severe pulmonary hypertension in
neonates
• Timing of CDH repair debated: during ECMO vs. post-
decannulation
 Overcoming Challenges and
Common Surgical Procedures
•Technological Advancements:
•Improved ECMO machinery and anticoagulation strategies
•Reduced hemorrhagic risks

•Common Surgeries:
•Thoracotomy/thoracoscopy
•Tracheostomy: performed in <5% of cases, improves mobility and reduces sedation
•Laparotomy: occurs frequently, with a 50% incidence of bleeding not linked to increased mortality

•Abdominal Compartment Syndrome (ACS):

•Caused by fluid resuscitation and interstitial edema
•High mortality rate
•Managed with conservative measures; decompressive laparotomy if needed
•Can reduce ECMO flow rates
PICU Course Cont’d
Acute Event on ECMO ( 3rd
day )
• Acute desaturations occurred immediately after initiation of wiping his legs with CHG
wipes. On entering the room, saturations on the monitor were in the 40s,no
hemodynamic changes, ECMO settings flows and inlet pressures were same. The
SvO2 was in 50s and Sao@ was 60s.

• Increased the vent O2 from 30 to 100 and ECMO O2 from 60 to 100. Saturations
started improving within a few minutes. Vent O2 was weaned back down to 30% and
initiation of weaning the ECMO oxygen as well.
Decannulation on
5/15
Surgical Course Summary

• 5/17: Initial Surgery

• Findings: Perforated peritonitis, massive bowel necrosis and perforations, fecaloid fluid in peritoneal cavity
• Procedure: Attempted dissection of necrotic bowel; patient became unstable; temporary abdominal closure with VAC system
• Plan: Stabilize patient, return to OR in 48-72 hours, continue cefepime, metronidazole, vancomycin, initiate fluconazole

• Peritoneal Fluid Cultures

• Cultures: Gram-negative bacilli, Actinomyces, Candida glabrata
• Plan: Switch to micafungin, discontinue vancomycin, continue Zosyn, metronidazole

• 5/20: Second Surgery

• Findings: Viable stomach, duodenum, 70 cm of viable small bowel, 10 cm viable terminal ileum, viable colon
• Procedure: Resection of necrotic bowel, warm saline washout, temporary closure with VAC system

• 5/22: Third Surgery

• Procedure: Jejunum-Ileum Anastomosis
• Viable Bowel: 75 cm from LOT, 10 cm terminal ileum, ileocecal valve, large colon

• 5/26: Extubated to NC 2 LPM

Questions
Thank you.
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