edema and ultrafiltration in ecls patients€¦ · 3/5/2019 · 1) edema (adults) averages +14% of...

Edema and Ultrafiltration in ECLS Patients

THE MISSOURI PERFUSION SOCIETY 23rd Annual Scientific Meeting Embassy Suites Country Club Plaza Kansas City,

Missouri June 1 & 2, 2018

Gary Grist RN CCP Emeritus

No disclosures

Grist 2

Hemoconcentrators

Grist 3

RESIDUAL OXYGENATOR BLOOD VOLUME:THEN AND NOW

BUBBLE OXYGENATOR WITHOUT

ULTRAFILTRATION: RESIDUAL

VOLUME ~ 1000 MLS

HOLLOW FIBER MEMBRANE

OXYGENATOR WITH

ULTRAFILTRATION: RESIDUAL

VOLUME ~ 10 MLS

4

Likely causes, frequent consequences and preventative treatments for edema in ECLS patients

Likely Causes

Frequent Consequences

Preventative Treatments

1. Congestive heart failure 2. Preoperative fluid resuscitation

3. Crystalloid hemodilution

4. Hypothermia

5. Altered blood flow

6. Vascular tone changes

7. Pediatrics

a. low body weight

b. immaturity

8. Systemic Inflammatory response

syndrome

a. increased foreign

surface exposure b. increased CPB time

c. increased capillary

permeability

1) Edema (adults) averages +14% of

body weight

2) Edema (neonates)

37-54% incidence

a) delayed chest

closure

3) Increased blood

transfusion

4) Increased length of

stay

5) Impaired tissue

oxygenation 6) Prolonged ventilation

7) Need for circulatory

support

8) Myocardial edema

9) Pulmonary edema

10) Organ dysfunction

11) Acute respiratory

distress syndrome

1) Reduce prime volume a) retrograde autologous

priming

b) mini circuits

2) Increase the oncotic/osmotic

pressure in the blood

a) mannitol

b) albumin

c) plasma protein fraction

d) fresh frozen plasma

e) dextran

f) hydroxyethyl starch

g) hypertonic saline 3) Steroids to reduce

inflammatory response

a) dexamethasone

b) methylprednisolone

4) Continuous ultrafiltration

5) Modified ultrafiltration

6) Vasopressors

7) Diuretics

Information derived from Hirleman and Larson, 2008

Perioperative Fluid BalanceAnd Survival

D. Chappell et al. Anesthesiology, V 109, No 4, Oct 2008

A. Lowell et al. Crit Care Med. 1990 Jul;18(7):728-33

n = 48 surgical ICU patients

• Native Reservoir

• Adult TBW 58%

– 19% ECW

• 4% intravascular (plasma)

• 15% interstitial.

• Neonates TBW 79%– 44% ECW

• 6% intravascular (plasma)

• 38% interstitial

• Interstitial fluid protects against dehydration/acute blood loss

• Loss of native reservoir fluid > hypotension/organ failure.– Heat stroke

• Ready Reservoir

• 33% of all peds cardiac pts have CHF

• Many adult pts coming to surgery have excess fluid from CHF.

• All pts coming to OR receive IV rehydration after fasting.

• A few pts have received IV resuscitation prior to surgery.

• Safe to remove ready reservoir fluids to prevent edema.

SYSTEMIC CAPILLARY EDEMA FORMATION DURING RESUSITATION, CPB OR ECMO:

FLUID SETTLES IN THE ORGANS AND PERIPHERY

Angioedema

PULMONARY CAPILLARY EDEMA FORMATION DURING RESUSITATION, CPB OR ECMO: FLUID SETTLES IN THE LUNGS

INTERSTITIAL EDEMA

PVR

RV FILLING PRESSURE

LV PRELOAD

MAP

aADO2

AIRWAY RESISTANCE

PULMONARY COMPLIANCE

ALVEOLAR

CAPILLARY

PLEXUS

ALVEOLAR

CAPILLARY

PLEXUS

Capillary Targets:Continuous ultrafiltration (CUF) during CPB or VA ECMO

Modified ultrafiltration (MUF) after CPB or VV ECMO

9

200 50 50 50

200 -150 800 0

500 800 1200

300 350

500

1500 1000 800 1200

500 -400

100

CPB Fluid Additions Vol (ml) CPB Fluid Deductions Vol (ml)

Starting Level Ending Level Starting Level

PERFUSION INTAKE & OUTPUT (I & O)

MUF Fluid Additions Vol (ml) MUF Fluid Deductions Vol (ml)

Ending Level

Cardioplegia crystalloid Circuit volume bal Crystalloid Circuit volume bal

Crystalloid Ultrafiltration Ultrafiltration

Blood Urine

Estimated irrigation

Total Additions = Total Deductions = Total Additions = Total Deductions =

Additions less deductions during CPB = Additions less deductions during MUF =

( 'PERFUSION I & O' DOES NOT QUANTIFY PERIOPERATIVE PATIENT FLUID BALANCE ) PERFUSION I & O =

R#: Allergy: Date: Case#

ACCT#: MR#: SEX: Age: 0.0 DAYS Ht(cm): Wt(kg): BSA (M2): 0.00

PATIENT NAME Admit Date: WBC: H/H: Platelets: PT/APTT: Sodium:

INSURANCE: DOB: Potassium: Anion gap: Glucose: BUN: Creatinine: Calcium:

PCP: Age(YR): -

REFERRING: Age(MO): -

Age(DAYS): -

0 0 Time Product Type Unit No. Vol (ml)

200 50 50 50

200 -150 800 0

500 800 1200

300 350

Time Unit No. Vol (ml) 500

Vol (ml) n/a 1500 1000 800 1200

n/a 500 -400

0:00 100

Total = 0:00 Start *Temp º C End *Temp º C Time Vol (ml) ml/min mmHg Temp º C

On 1000 Time Amount Time Amount Time Amount Time Amount Time Amount Time Amount

Off

On

Off 0:00

On Start *Temp º C End *Temp º C

Off Total = 1000 200

On Time

Off # Total = 0 Total = 0 Total = 0 Total = 0 Total = 0

Line Arterial CVP L/min FiO2 cc/min mmHg H2O Arterial Venous pH pCO2 pO2 BE Hct % O2 Sat K+

iCa++ Glucose ACT

Comments:

Date: Date:

Legend: ACT: activated clotting time measured in seconds, CPB: cardiopulmonary bypass, H/E: heat exchanger, MUF: modified ultrafiltration, PAN03 or PAN06: model number for ultrafiltrator.

Protamine admin time

HYPOTHERMIC ARREST TIME =

* See EVENTS & STATUS: TEMPERATURES

for site of patient temperature monitoring

Flow

ml/min

SWEEP GAS

s/p protamine ACT

Perfusion Assistant Signature:

Time Event

Prime Drug Addtions Amount

PRIME COMMPONENTS

Calc. Heparin units =

Perfusionist#2:

Perfusion Assist. #2Perfusion Assist. #1

Preop Lab Date:

Cath/ECHO/Dx:

Product

BLOOD PRODUCTS ADDED TO PUMP

CPB Fluid Additions Vol (ml) CPB Fluid Deductions Vol (ml)

PATIENT ANTICOAGULATION

Protamine (mg) dose

Heparin admin time

Heparin (units) dose

Final s/p heparin ACT

s/p heparin ACT @ CPB

Prime Fluid Additions Vol (ml) Starting Level

CO2 GAS

BLOOD DRAWN FROM PATIENT OR PUMPCANNULAE

Albumin 25%

Blood

Perfusionist Signature:

CPB/Perfusion Record 7169-006 MR 09/03

CPB TIME

Drug volume

Fluid removed

from prime

Sodium bicarbonate (mEq)

Heparin (units)Crystalloid

Total Prime (ml) =

Procedure:

Ending Level

Single Dose Given

Starting Level

PERFUSION INTAKE & OUTPUT (I & O)

MUF Fluid Additions Vol (ml) MUF Fluid Deductions Vol (ml)

Patients's Blood Type:

Surgeon:

Anesthesiologist:

Pump Flow (ml/min): 0

Perfusionist#1:

In-line

%SVO2

TEMPERATURES ºCPRESSURES mmHg

CIRCUIT COMPONENTS

CROSS CLAMP TIME =

DEFIB

CARDIOPLEGIA ( Temp °C =cardioplegia temperature)

Crystalloid only =

Isoflurane (%)

Ending Level

Cardioplegia crystalloid Circuit volume bal Crystalloid Circuit volume bal

Crystalloid Ultrafiltration Ultrafiltration

Blood Urine

Estimated irrigation

Total Additions = Total Deductions = Total Additions = Total Deductions =

Additions less deductions during CPB = Additions less deductions during MUF =

( 'PERFUSION I & O' DOES NOT QUANTIFY PERIOPERATIVE PATIENT FLUID BALANCE ) PERFUSION I & O =

DRUG ADDITIONS

Single Dose Given

LAB VALUES & RANGES

EVENTS & STATUS

MUF FLUID BALANCE VS.

HEMATOCRIT INCREASE

0

2

4

6

8

10

-70 -60 -50 -40 -30 -20 -10 0

NET FLUID BALANCE MLS/KG

% H

EM

AT

OC

RIT

IN

CR

EA

SE

ULTRAFILTRATION OR DIURESIS REVERSES EDEMATO IMPROVE TISSUE OXYGENATION: SYSTEMIC CAPILLARIES

12

FLUID FROM CHF, IV

CRYSTALLOID & PUMP

PRIME SETTLES IN LUNG

DURING CPB OR ECMO,

DECREASING PCD

FLUID REMOVED FROM LUNG

DURING MUF OR SCUF

INCREASES PCD

Net fluid balance after

CPB/MUF = - 32 ± 55 ml/kg

PULMONARY EDEMA

PVR

RV FILLING PRESSURE

LV PRELOAD

PULMONARY EDEMA

PVR

RV FILLING PRESSURE

LV PRELOAD

aADO2

AIRWAY RESISTANCE


CVP = 16, MAP = 40

aADO2

AIRWAY RESISTANCE


CVP = 8, MAP = 80

ALVEOLAR

CAPILLARY

PLEXUS

ALVEOLAR

CAPILLARY

PLEXUS

Pulmonary Edema Reversal by MUF or SCUFEdema Formation Impairs Heart & Lung Function

Oncotic vs. Osmotic Pressure

• Oncotic (colloid osmotic pressure, COP)

• Pressure exerted by larger molecules (proteins) in plasma

• Osmotic

• Pressure exerted by smaller molecules (glucose, ions) in plasma

Hemodilution AndColloid Oncotic Pressure (COP)

• Hemodilution decreases COP unless albumin or colloid-based volume expanders are added to the prime– Normal COP = 20-30 mmHg– Normal albumin 3-5 gm/dL

• COP causes fluid to move from blood into the extravascular space

• COP causes fluid to move from extravascular space into the blood

• SIRS causes capillary protein leak > edema

Hemodilution AndOsmotic Pressure (Osmolarity)

• Hemodilution does not effect osmolarity– Nml = 275-299 mosmols/L

• Low blood osmolarity moves fluid from blood to extravascular space– LR = 275 mosmols/L– 0.45%NS = 154 mosmols/L– D5W = 250 mosmols/L

• Becomes free water

• High blood osmolarity moves fluid from extravascular space to blood– 0.9%NS = 308 mosmols/L– Plasmalyte 310 mosmols/L

• 2/3 of crystalloid solutions move across capillary > edema

INFANT MUF

PULMONARY

PHYSIOLOGY

Blood proteins in residual

circuit volume are

concentrated and directed

into lungs

ADULT MUF

PULMONARY

PHYSIOLOGY

Mannitol 2 gm/L or

50 mEg/L NaHCO3

into residual circuit

volume and directed

into lungs

FLUID BALANCE VS. MORTALITY80% NEGATIVE BALANCE, 20% POSITIVE BALANCE [n = 1540]

Grist G, Whittaker C, Merrigan K, Fenton J, Worrall E, O'Brien J, Lofland G.The Correlation Of Fluid Balance Changes On Cardiopulmonary Bypass To Mortality In Pediatric And

Congenital Heart Surgery Patients. J Extra Corpor Technol, Dec, 2011;43(4):215–226

FIG 4. CPB PATIENTS: WEIGHT,

NEGATIVE OR POSITIVE FLUID BALANCE CHANGE , AND % MORTALITY

0

5

10

15

20

25

<6 KG n=611 6-12 KG n=476 >12 KG n=453

WEIGHT CATEGORY

% M

OR

TA

LIT

Y NEGATIVE FLUID BALANCE PATIENTS

POSITIVE FLUID BALANCE PATIENTS

p = 0.004

Exp = 2X

p = 0.069

Exp = 3X

p = 0.024

Exp = 4X

19

FLUID BALANCE VS. MORTALITY80% NEGATIVE BALANCE, 20% POSITIVE BALANCE [n = 1540]

Grist G, Whittaker C, Merrigan K, Fenton J, Worrall E, O'Brien J, Lofland G.The Correlation Of Fluid Balance Changes On Cardiopulmonary Bypass To Mortality In Pediatric And

Congenital Heart Surgery Patients. J Extra Corpor Technol, Dec, 2011;43(4):215–226

CPB PATIENTS: FLUID BALANCE CHANGE AT END OF CPB/MUF VS. MORTALITY

* Indicates Percent of Population Occurance, n = 1540

0

2

4

6

8

10

12

14

16

18

20

< -41 -40 TO -21 -20 TO 0 +1 TO +20 +21 TO +40 >+ 41

FLUID BALANCE MLS PER KG

% M

OR

TA

LIT

Y

34%*

20%* 26%*

11%*

6%*

3%*

20

Targeting the Need for CUFDo you need to ultrafiltrate?

Is The Patient Taking Diuretics (CHF)?Do you want to avoid RAP (unstable BP) ?

DRY WT.% CHF FLUID

WT. GAIN

FLUID

OVERLOADWET WT. CPB TIME

CONTINUOUS UF

FLUID REMOVAL

RATE

TOTAL FLUID

REMOVED

FLUID

REMOVED

% NET

FLUID

BALANCE

70 KG 5% 3.5 L 73.5 KG 60 MIN 20 ML/MIN 1.2 L - 17 ML/KG -1.7%

70 KG 5% 3.5 L 73.5 KG 120 MIN 20 ML/MIN 2.4 L - 34 ML/KG - 3.4%



Infant MUF vs. Adult MUF

• Blood passing through the hemoconcentrator develops a high oncotic pressure as excess fluid is removed from it.

• Infant MUF ratio = 1/5 MUF blood to venous return

– 100 cc/min MUF flow : 500 cc/min CO

• Higher oncotic blood going to the right heart and lungs

• Pulmonary water (edema) removed from the lungs

• Improved pulmonary and hemodynamic function

– Typically 5-10% hematocrit increase

– Clotting factors increased w/o increasing blood volume

23

• Blood passing through the hemoconcentrator develops a high oncotic pressure as excess fluid is removed from it.

• 1/20: MUF blood flow / venous return to the lungs– 200 cc/min MUF flow : 4000 cc/min CO

• High oncotic MUF blood diluted by the high volume of right heart blood

• Relatively low oncotic blood goes to the lungs

• No significant oncotic drag to remove water from lung tissue

• Pulmonary benefits negligible

– Typically 1- 4% hematocrit increase

– Clotting factors minimally concentrated• +/- reduced bleeding

Adult MUF

24

• After CPB, patient osmolarity = 300 mosmoles

• Residual circuit volume = 1 L @ 300 mosmoles

• Add 50 mEq/L NaHCO3 or 2 gm/L mannitol to circuit– Increases residual circuit fluid osmolarity to 400 mosmols/L

• 200 mls/min MUF blood (400 mosmols/L) + 4000 mls/min patient blood (300 mosmols/L) passing through the right heart to the lungs

• Pulmonary artery blood osmolarity increases from 300 to 305

• Osmotic drag removes 67 mls/min fluid from lung tissue

• Removes 335 mls from lungs in 5 minutes of MUF

• Also, can add 50% albumin (50-100 mls) to circuit volume.

Adult MUF:

Pulmonary effects can be improved

Circuit Configuration:Cardioplegia, CUF and MUF

Questions

edema and ultrafiltration in ecls patients€¦ · 3/5/2019 · 1) edema (adults) averages +14% of...

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