8. stanbul Sempozyumu: TRKYEDE PEDYATRK KALP CERRAHS, CPB & ECLS

SSTEMLERNN GELTRLMES VE KOMPLKASYON

ORANLARININ DRLMES CN NERLER

Medipol niversitesi Hastanesi 10 Ocak 2015, Cumartesi, 9:00-18:00

Katlm cretsizdir. Katlmclarn Yrd. Do. Dr. Tijen Alkan-Bozkaya ya (dr.tijenalkan@gmail.com) e-mail gndermesini rica ediyoruz.

Sempozyum Bakanlar Prof. Dr. Atf Akevin, Yrd. Do. Dr. Tijen Alkan-Bozkaya, Prof. Dr. Halil Trkolu, Prof. Dr. Akif ndar

Davetli Konumaclar Prof. Dr. Atf Akevin Yrd. Do. Dr. Tijen Alkan-Bozkaya Perf. Sabr Alkan Perf. Sibel Aydn Prof. Dr. Hakan Ceyran

Perf. Halime Erkan Do. Dr. Ali Can Hatemi Do. Dr. Serta Haydn Prof.Dr.Gkhan pek Perf. Aydn Kahraman

Dr. Arda zyksel Do.Dr. Kerem Pekkan Do. Dr. Ece Saliholu Bio.Perf. Alper Sava Dr. Murat Tanyldz

Prof. Dr. Halil Trkolu Prof. Dr. Ayda Trkz Prof. Dr. Rza Trkz Prof. Dr. Akif ndar

TRKYEDE PEDYATRK KALP CERRAHS, CPB & ECLS SSTEMLERNN GELTRLMES VE KOMPLKASYON

ORANLARININ DRLMES CN NERLER

09.30-09.40 HOGELDNZ Prof. Dr. Atf Akevin ve Prof. Dr. Halil Trkolu

09.40-10.10 Bilimsel Aratrmalarn Temel Prensipleri ve Istanbul Sempozyumlarnn Bilime Katks Prof. Dr. Akif ndar

10.10-12.15

PANEL : Trkiyedeki yaam destek sistemleri ve 2015 ylndaki son durum

Moderatrler: Prof. Dr. Atf Akevin, Prof. Dr. Halil Trkolu ve Prof. Dr. Akif ndar

10.10-10.25 GENEL DEERLENDRME - LKEMZDEK SON GELMELER Prof. Dr. Atf Akevin

10.25-10.50 IMAEH Pediyatrik ECMO Deneyimleri Do. Dr. Serta Haydn

10.50-11.10 Pediyatrik ileri yaam destek modaliteleri ve sonularmz Prof. Dr. Gkhan pek

11:10 11:30 Kahve aras ve Posterler (Moderatr: Yrd. Do. Dr. Tijen Alkan-Bozkaya)

11:30 11:45 nfantlarda ekstrakorporeal membran oksijenasyonda membran oksijenatrlerinin ekonomik olarak etkin kullanm Dr. Arda zyksel - Dr. Tijen Alkan-Bozkaya

11.45-12.00 ECMO'da Hacettepe ocuk Youn Bakm Deneyimleri Dr. Murat Tanyldz

12.00-12.15 Pediyatrik kardiyak hastada ECMO uygulamasnda optimum ventilatr stratejisi Prof. Dr. Ayda Trkz

12.15-13.00 gle yemei ve Posterler (Moderatr: Yrd. Do. Dr. Tijen Alkan-Bozkaya)

13.00-15.30

PANEL: TRKIYEDEKI PEDIYATRIK KALP CERRAHISINE VE CPB SISTEMLERINE GENEL BAKI

Moderatrler: Prof. Dr. Halil Trkolu, Prof. Dr. Gkhan pek, Prof. Dr. Hakan Ceyran

13.00-13.15 GENEL DEERLENDRME - LKEMZDEK SON GELMELER Prof. Dr. Halil Trkolu

13.15-13.30

Hibir vakadan asla vazgeme! yi bir preoperatif cerrahi planlama stratejisi ile kompleks konjenital olgularda yksek baar mmkn m? Do. Dr. Kerem Pekkan Ko niversitesi

13.30-13.45 Myokardial korumada son gelimeler Do. Dr. Ece Saliholu

13.45-14.00 Sistemik nflamasyon Do. Dr. Ali Can Hatemi

14.00-14.15 Pediatrik Kalp Cerrahisi'nde biomarker'lar Yrd. Do. Dr. Tijen Alkan-Bozkaya

PANEL: CPB VE ECMODA PERFZYONISTLERIN ROL VE

KATKILARI Moderatr: Prof. Dr. Riza Trkz ve Perf. Aydn Kahraman

14:30 14:45 CPB Stratejileri ve Temel Prensibler Perf. Halime Erkan

14:45 15:00 Pediyatrik ECMOda sorunlar ve zm nerileri Perf. Aydn Kahraman

15:00 15:15 Kartal Kouyolu Yksek htisas Eitim ve Aratrma Hastanesi ECMO Deneyimi Perf. Sibel Aydn

15:15 15:30 VV - ECMO Deneyimimiz Perf. Sabr Alkan

15:30 16:00 Kahve Arasi ve Posterler (Moderatr: Yrd. Do. Dr. Tijen Alkan-Bozkaya)

16:00-18.00 Wet-Labs: Neonatal CPB ve ECLS devreleri ile uygulamal deneyler Moderatrler: Aydn Kahraman ve Alper Sava

Neonatal CPB devresinin prime edilmesi ve zellikleri Perf. Aydn Kahraman

Neonatal / Pediatric ECLS devresinin prime edilmesi ve zellikleri Bio. Perf. Alper Sava

18.00 KAPANI - Atf Akevin

Invited Editorial

A Multidisciplinary Approach to Expand the Use ofPediatric ECLS Systems in Turkey

Extracorporeal life support (ECLS) systems wereinitially used in children after open heart surgery in1972 and in neonates after meconium aspiration in1975 (1,2). During the following years, this technol-ogy significantly improved, and the use of thesesystems rapidly increased worldwide. VenoarterialECLS has been frequently used after open cardiacsurgery, whereas venovenous ECLS is widely used inpediatric intensive care units (ICUs) (3). Less com-monly, arteriovenous ECLS systems are used for theclearance of carbon dioxide from blood, and their usehas been reported in Turkey (4). In the USA, it hasbeen suggested that 2800 newborn patients benefitfrom ECLS systems in a year. Statistically, this rep-resents 1/1309 of live births (5). The use of ECLSsystems requires a multidisciplinary team approachwith standard clinical programs to provide qualifiedand satisfactory patient care, rather than an indi-vidual effort (5,6).

Although pediatric ECLS technology has signifi-cantly improved and the use of these systems israpidly increasing worldwide, similar improvementsin pediatric ECLS systems have been observed inTurkey. The use of ECLS systems has significantlyincreased in the pediatric ICUs along with thenumber of pediatric cardiac ICUs to manage postop-erative congenital heart surgeries. In addition tothese developments, the Sixth Istanbul Symposiumwas organized at the Dr. Siyami Ersek Thoracic andCardiovascular Surgery Training and Research Hos-pital on June 22, 2013, with significant multidisci-plinary attendance from around the country. Duringthe past five Istanbul Symposiums, the main objec-tive was to share the latest techniques and ECLS

devices that were evaluated at the Penn StateHershey Pediatric Cardiovascular Research Centerwith pediatric heart surgeons and perfusionists. Atthe Sixth Istanbul Symposium, pediatric intensivistsfrom all over Turkey also participated. In addition tothe neonatal and pediatric intensivists, pediatricanesthesiologists, pediatric cardiac surgeons, pediat-ric cardiologists, pediatric ICU nurses, perfusionists,biomedical engineers, along with a pediatric perfu-sionist from Germany and a scientist from the USAwere in attendance. In addition to lectures frominvited speakers, there was a discussion session by allparticipants for establishing a plan for future devel-opments in ECLS along with ECLS wet labs. Themost recent results regarding the ECLS outcomesfrom pediatric cardiac centers and pediatric ICUs arealso included in this article. The objectives of thiseditorial are: (i) to expand the use of ECLS systemsas rapidly as possible; and (ii) to make suggestions forimproving the outcomes after ECLS in the pediatricpopulation all around the country.

CURRENT STATUS

Across the globe, ECLS has been widely and suc-cessfully performed by the use of well-described sys-tems and protocols (7,8). The algorithm of the man-agement of ECLS can be analyzed from two aspects.

Management and system protocols: Although theseprotocols vary between ECLS centers, the generalprinciples are defined by Extra Corporeal LifeSupport Organization (ELSO) and have beenaccepted widely (5,6). The information is updatedand shared with regular symposiums, the ELSOred book, and database entries from multiplecenters registered to ELSO (3). The ELSO datahave been accepted as a reference for clinicalinvestigations by the Food and Drug Administra-tion in the USA. Therefore, a newly designedECLS instrument or protocol should make controlstudies with respect to the ELSO database.

doi:10.1111/aor.12374

Address correspondence and reprint requests to Dr. Akifndar, Department of PediatricsH085, Penn State HersheyCollege of Medicine, 500 University Drive, P.O. Box 850, Hershey,PA 17033-0850, USA. E-mail: aundar@psu.edu

This manuscript was presented in part at the 10th InternationalConference on Pediatric MCS and Pediatric CPB in Philadelphia,PA, USA, May 2831, 2014.

Copyright 2014 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Artificial Organs 2015, 39(1). In press

mailto:aundar@psu.edu

The choice of ECLS equipment: The instruments orprotocols for ECLS should be chosen according toclinical experience of centers and with respect tothe current data of the research centers on ECLS.The Penn State Hersey Pediatric CardiovascularResearch Center provides a forum for testing allcardiopulmonary support devices and equipment.It is a leading research center and presents itsreports as Translational Research (911). Animportant characteristic of this center is that morethan 600 staff members have been trained from theUSA (approximately 25 centers and more than 200staff members) and from Turkey (approximately 40centers and more than 400 staff members) by thisresearch center in terms of pediatric ECLS andcardiopulmonary bypass (CPB) (7,1215). Theselection of equipment should be chosen in accor-dance with current scientific data (1619). Other-wise, it has been proven that increased expenses willbe lost from the economic sources of countries(20,21).

THE USE OF ECLS SYSTEMS IN TURKEY

The outcomes of ECLS use in cardiac surgerycenters (Istanbul Mehmet Akif Ersoy Thoracic andCardiovascular Surgery Education and TrainingHospital; Kosuyolu Yuksek Ihtisas Kalp Hastanesi,Istanbul; Ege University, Faculty of Medicine,Department of Pediatric Cardiovascular Surgery,Izmir; Dr.Siyami Ersek Cardiovascular Surgery Hos-pital, Istanbul; Istanbul Medipol University, Istan-bul) and ICUs (Ege University, Department ofPediatric Intensive Care Unit, Izmir; Marmara Uni-versity, Faculty of Medicine, Pendik Education andTraining Hospital, Department of Pediatric IntensiveCare Unit, Istanbul [22]; Bezmilem Vakf Univer-sity, Department of Pediatric Intensive Care Unit,Istanbul; ukurova niversitesi, Department ofPediatric Intensive Care Unit, Adana; Dokuz EyllUniversity, Department of Pediatric Intensive CareUnit, Izmir; Gazi University, Faculty of Medicine,Department of Pediatric Intensive Care Unit,Ankara) that made contributions to the Sixth Istan-bul Symposium are presented in Tables 1 and 2. Thedata including ECLS numbers, ECLS type, age ofpatients, etiologies, ECLS durations, weaning rates,and survival rates are presented.

ANTICOAGULATION

During ECLS, there is continuous contact betweencirculating blood and the foreign surfaces of theextracorporeal circuit. The risk of clot formationwithin ECLS systems is increased when blood con-

tacts the inner surfaces of cannulas, oxygenators, orhemofilters, turbulence or stasis regions of blood inthe system, during low-flow periods such as weaning,or when inadequate anticoagulation occurs. To avoidclot formation in ECLS, biocompatible materialsurfaces (bioactive and biopassive) mimicking abioactive endothelial surface have been developed.These biocompatible surfaces have been adapted tothe system. Heparin, hirudin, and nitric oxide-releasing bioactive circuits activate antithrombin IIIto bind to the thrombin and inhibit thrombosis.Biopassive circuits are coated with different agentssuch as hydrophilic polymers, albumin- orphospholipid-reducing thrombus formation byreducing fibrinogen binding to surfaces, and plateletadhesion and activation (23). Both types of thesecircuits can be found in different brands. Properanticoagulation must strike a delicate balance forpatient well-being. On one hand, increased thrombinproduction and decreased thrombin suppression inan ECMO patient increases the tendency of clotting.However, heparin administration, dilution or con-sumption of coagulating factors, decrease of plateletnumber and function may result in bleeding (24).

The most widely used antithrombotic therapyin ECLS is unfractionated heparin (UNFH), ofwhich prolonged use reduces its own activity. UNFHcan also induce platelet dysfunction, generationof heparin-PF4 antibodies, and heparin-inducedthrombocytopenia (25). Monitoring methods ofanticoagulation on ECMO include periodic assess-ment of activated clotting time (ACT), anti-Xa levels,activated partial thromboplastin time (aPTT),heparin concentration, antithrombin (AT) level, andthromboelastography (TEG) (26). Anti-Xa assay isthe gold standard measure of heparin anticoagu-lation. aPTT is more reliable than ACT at delineatinglow and moderate levels of anticoagulation on UNFH(27). TEG monitoring is a sensitive technique for thedetection of hypercoagulability, but it is an expensivemethod. UNFH monitoring criteria for the manage-ment of anticoagulation during ECMO are summa-rized in Table 3 (24).

SUGGESTIONS TO EXPAND THE USE OFECLS SYSTEMS IN OUR COUNTRY

The primary rationale for establishment andexpansion of the use of ECLS systems in Turkeyis to define necessary clinical guidelines and sup-port programs. Guidelines address technology andpatient management during ECLS. In addition,several important steps such as personnel, training,credentialing, resources, follow-up, reporting, and

INVITED EDITORIAL2

Artif Organs, Vol. 39, No. 1, 2015

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INVITED EDITORIAL 3

Artif Organs, Vol. 39, No. 1, 2015

quality assurance are necessary (28). The main pointthat all these steps show is EDUCATION. Allmembers of an ECLS team should have satisfactoryeducation in terms of theoretic background and clini-cal experience.

In Turkey, previous educational activities andcourses for ECLS education are presented below:

Since 2011, wet laboratory activities have beenorganized regularly in Istanbul.

The videos recorded for education of pediatricintensive care nurses in the animal laboratory ofPenn State Hershey Medical Faculty during ECLSseminars were delivered to all attendants of theSixth Istanbul Symposium.

During the sixth symposium, one of the most recentECLS systems was presented and described by aninvited clinical pediatric perfusionist, and this was

recorded. This video was also presented to all par-ticipants of the Seventh Istanbul Symposium.

The collaboration of pediatric and neonatal inten-sive care specialists has been aimed to increase theuse and efficacy of ECLS.

MULTIDISCIPLINARY APPROACH

The ECLS teams should have a multidisciplinaryapproach, and each individual discipline should havean experience in the clinical care of critical patients(28,29). The clinical presentations and conditions ofpatients who are admitted to the ICUs have becomemore complex with multiple comorbidities. The pres-ence of complex medical presentation requires clini-cians to apply conventional or nonconventionaltechniques of ventilation, indications for ECLS, anda systematic approach to clinical conditions of criticalpatients. In addition to ventilation, the managementof hemodynamics, systemic infections, pain, sedation,anticoagulation, feeding and, if necessary, renal orneurologic status requires considerable clinical expe-rience and prompt decision making for treatment ofpatients. Therefore, the care and follow-up of pedi-atric patients in ECLS centers should be supervisedby pediatric or neonatal care specialists.

The ICU staff should have in-depth education andexperience about the outcomes of ECLS support.They should believe that this treatment option mayhave favorable results and may even be a life-savingintervention in a considerable amount of patients.

TABLE 2. Outcomes of ECLS patients from pediatric intensive care centers in Turkey

Center N TypeAge

(years) EtiologyDuration

(day) Weaning Survival

Ege University 6 c4 VV1 VA1 ECCO2

(Novalung)

2 Sepsis, ARDS 1/24 33% (2/6) 16% (1/6)4 Dilated cardiomyopathy 1

14 ALL, sepsis, ARDS 1517 Hydrocarbon aspiration 12

5 ARDS 2913 Lung transplantation, rejection 15

Marmara University 6 4 VV2 VA

4/12 ARDS 14 50% (3/6) 16% (1/6)5/12 ARDS 74 IPEX syndrome, ARDS 151,5 ALL, ARDS, sepsis 184/12 Tetralogy of Fallot, LCO 195/365 Postcardiotomy LCO 1/24

Bezmialem University 2 VV 13/12 Acute hypoxic respiratory insufficiency 28 50% (1/2) -2/365 14

ukurova University 2 VA 16 Refractory hypotension 7 50% (1/2) 50% (1/2)2 3

Dokuz Eyll University 2 VA 10 Cardiomyopathy 7 - -13 Myocarditis 13

Gazi University 2 VA 8 Septic shock 1/24 50% (1/2) 50% (1/2)3 Cardiac surgery 7

ALL, acute lymphoblastic leukemia; ARDS, acute respiratory distress syndrome; ECCO2, extracorporeal CO2 clearance; IPEX, immunedysregulation, polyendocrinopathy, X-linked syndrome; LCO, low cardiac output; VA, venoarterial; VV, venovenous.

TABLE 3. Anticoagulation Criteria for ECLS

Parameters Follow-up period (hour) Target range

ACT 12 180220 saPTT 6 5080Anti-Xa level 612 0.30.6 u/mLAT level 24 >0.5 u/mLFibrinogen level 1224 250300 mg/dLHtc 612 >35%INR 612 80 000

ACT, activated clotting time; aPTT, activated partialthromboplastin time; AT, antithrombin level; Htc, hematocrit;INR, international normalized ratio.

INVITED EDITORIAL4

Artif Organs, Vol. 39, No. 1, 2015

In high-risk patients, the best time to use ECLScan be determined with collaboration of medicalspecialists. In Turkey, ECLS systems are mostlyused following low cardiac output syndrome, cardio-pulmonary arrest and resuscitation, failed weaningfrom CPB following cardiac surgery, and hypoxemiaresistant to assisted ventilation. Each center shouldprovide information on patients including theprimary reason for ECLS, modality used, complica-tions, and outcomes. All these experiences shouldbe shared between medical centers through acomputer-based database system and a nationaldatabank. Because ECLS treatment is financiallysupported by the government, we believe that it canbe beneficial if the government supports the centersfollowing the entry of medical information and out-comes into the database system. Moreover, the cer-tification of some centers may contribute toqualifying other centers for ECLS. Regular semi-nars and courses by such centers should be sup-ported. In addition, we believe that the set-up ofanimal laboratories can be beneficial to increase theexperience and information available on ECLS,increasing quality of care.

The general consensus on complications of ECLSand their management can be established usingstandard protocols. The most important problemfollowing cardiotomy is bleeding. Anticoagulation ismost frequently followed using ACT levels and thetarget levels of ACT can be reached by increasingthe dose of unfractioned heparin; this may increasethe risk of bleeding. Nevertheless, the level ofanticoagulation or coagulation activity is generallyaffected by CPB and therefore follow-up of onlyACT levels may be inappropriate. In ECLS cases,the management of anticoagulation should includeregular follow-up of aPTT, anti-Xa, AT-III, andfibrinogen levels. Additionally, some procoagulantagents such as factor VII, cryoprecipitate, orapheresis thrombocyte should be available in ECLScenters to decrease the bleeding risk if necessary.

In newer ECLS centers, perfusionists set up theECLS system, and intensive care nurses manage thecare of the patients and ECLS system with routineclinical follow-up. This allows integration andadaption of intensive care nurses to ECLS care andpotential complication of the system during mainte-nance and weaning periods. In our country, thenumber of experienced cardiac perfusionists inECLS is limited. Education of other perfusionists aswell as intensive care nurses allows more ECLScenters to be qualified. Additionally, the number ofpediatric intensive care specialists is also inadequate.Therefore, qualified nurses in the ICU play an

important role in staffing the maintenance andfollow-up of ECLS cases.

ECLS IN PEDIATRIC CARDIOLOGY ANDPEDIATRIC INTENSIVE CARE EDUCATION

Most pediatric cardiologists in our country do nothave a chance to experience the follow-up of patientsafter cardiac surgery in the ICU. This also leads tolimited experience about the timing of ECLS inpostcardiotomy patients. Therefore, we suggest thatthe education of pediatric cardiologists should bedeveloped in centers that have a cardiac surgery teamas well as pediatric cardiac surgery and pediatric car-diology ICUs. Of those pediatric cardiologists whowere educated about ECLS, some may be specializedin the ICU of pediatric cardiology. The governmentshould increase the number of those clinicians toexpand the use of ECLS in pediatric or neonatalICUs.

In pediatric cardiology, ECLS systems can be usedin high mortality interventions including neonatalaortic stenosis, pulmonary hypertension, hybrid pro-cedures for hypoplastic left heart syndrome, and per-foration or reconstruction procedures. In such cases,ECLS systems should be available and immediatelyapplied to patients in case of life-threatening events.In addition, education on an advanced stage of car-diopulmonary resuscitation under ECLS (ECLS-CPR) should be provided, in order to establishgreater chance of survival for patients. ECLS can beused in patients with congenital heart disease duringcardiac catheterization and interventions. In particu-lar, for patients who develop pulmonary hyperten-sive crisis in the catheter laboratory or ICU, the useof ECLS will be lifesaving.

Similarly, ECLS education is provided duringthe training of pediatricians in pediatric ICUs.However, pediatric clinicians should play a moreactive role on the management of ECLS in pediatriccases with congenital heart anomalies as well as inpatients who develop low cardiac output due topostcardiotomy syndrome. Pediatric intensivistswho are interested in cardiac anomalies and theircare can be encouraged to be educated on pediatriccardiology.

FINANCIAL STATUS

In Turkey, necessary equipment for ECLS is avail-able as an ECMO set, which includes an ECLSoxygenator, a centrifugal pump, and a tubing set.This set is provided primarily by two companies:Maquet (Maquet Quadrox PLS, MAQUET Cardio-pulmonary AG, Hirrlingen, Germany) and Medos

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Artif Organs, Vol. 39, No. 1, 2015

DP3 (Medos AG, Stolberg, Germany). The prices forthese disposable sets are very similar to each other,about $6000 (USD). The government financially sup-ports the cost of disposables for hospitals.

RECOMMENDATIONS

1 The general principles of ECLS can be foundin the web page of the ELSO registry. Thedata after 40 years of experience should beimmediately translated to the Turkish languagefrom the Internet address, http://www.elso.med.umich.edu, and this literature should be placed inthe web pages of national societies.

2 Collaboration in experience and informationshould be increased to the highest level. The sym-posiums that we organized in Istanbul after 2011should be continued regularly within the nextseveral years. The latest technology and news thuscan be shared with our colleagues in Turkey. It isan obligation to organize ECLS courses, in whichECLS certifications will be given.

3 ECLS education videos can be inserted to the webpages of related national societies.

4 As seen in Tables 1 and 2, the number of ECLScenters are limited, as well as the number of ECLScases performed in these centers. Therefore, it isvery important to organize symposiums and asso-ciated courses by these centers for education ofother centers in the future to share their experi-ence and to expand the use of ECLS. Simulationcenters should be designed and opened.

5 The national database for ECLS cases should beopened and the data of all cases should be sharedwith active contribution of each ECLS center.

6 A mandatory ECLS registry should be organizedby the government.

7 Anticoagulation for ECLS should be managedmore precisely by increasing the number offollow-up parameters. Special blood products suchas factor VII or cryoprecipitate should be availablein hospitals and immediately used, if necessary.The price of these products should be regulated bythe government and medical centers.

8 To expand the use of ECLS, animal laboratoriesshould be opened. This increases the experience ofECLS staff, quality of patient care and survival ofpatients.

9 Each member of an ECLS team should be sup-ported to follow every international congress orsymposium on ECLS and the newest technology.The clinicians should follow and attend the offer-ings of the leading ECLS centers in order toincrease their knowledge and experience.

CONCLUSIONS

An increasing number of patients return to theirnormal life by routine use of ECLS in developedcountries every year. Especially, ECLS systems havebeen improved significantly, and the use of thesesystems has been widely expanded and simplifiedduring the last few years, in comparison with previ-ous life support systems (710,3032). In Turkey, astandard quality of ECLS is provided in a relativelylimited number of centers. Therefore, there is a needfor an urgent planning as rapidly as possible toexpand the use of ECLS systems and to give a satis-factory education for all team members. The mostimportant principle that should be remembered forthe success of ECLS all around the country is thecollaboration of all related departments of special-ized medicals centers, Ministry of Health, and for-profit and nonprofit companies.

Ismihan Selen Onan, *Serta Haydin,****Akif ndar, M. Nilfer Yalndag-ztrk,

Demet Demirkol, Gkhan Kalkan,Hakan Ceyran, Yksel Atay,

**Ahmet Sasmazel, **Ali Rza Karac,Esra Sevketoglu, ***Tolga Kroglu,

*Hsn Frat Altn, Pnar Yazc,Diner Yldzdas, Ali Ekber icek,

*Ender demis, Atf Akevin, and *Ihsan Bakr*Department of Cardiovascular Surgery, Pediatric

Cardiac Surgery Division, Istanbul Mehmet AkifErsoy Thoracic and Cardiovascular Surgery

Education and Training Hospital; Faculty ofMedicine, Pendik Education and Training Hospital,

Department of Pediatric Intensive Care Unit,Marmara University; Department of Pediatric

Intensive Care Unit, Bezmilem Vakf University;Department of Pediatric Cardiac Surgery,

Kosuyolu Yksek Ihtisas Hospital; **Dr. SiyamiErsek Cardiovascular Surgery Hospital; Pediatric

Intensive Care Unit, Bakrkoy Dr. Sadi KonukEducation and Training Hospital; Department of

Cardiovascular Surgery, Istanbul MedipolUniversity, Istanbul; Faculty of Medicine,

Department of Pediatric Cardiovascular Surgery,Ege University; ***Department of Pediatric

Intensive Care Unit, Dokuz Eyll University;Department of Pediatric Intensive Care Unit, Ege

University, Izmir; Faculty of Medicine,Department of Pediatric Intensive Care Unit, Gazi

University, Ankara; Department of PediatricIntensive Care Unit, ukurova niversitesi, Adana,Turkey; ****Department of Pediatrics, Surgery and

Bioengineering, Penn State Milton S. Hershey

INVITED EDITORIAL6

Artif Organs, Vol. 39, No. 1, 2015

http://www.elso.med.umich.edu,http://www.elso.med.umich.edu,

Medical Center, Penn State Hershey College ofMedicine, Pennsylvania, PA, USA

REFERENCES

1. Bartlett RH, Gazzaniga AB, Fong SW, Jefferies MR, RoohkHV, Haiduc N. Extracorporeal membrane oxygenator supportfor cardiopulmonary failure. Experience in 28 cases. J ThoracCardiovasc Surg 1977;73:37586.

2. Bartlett RH. Artificial organs: basic science meets critical care.J Am Coll Surg 2003;196:1719.

3. Extracorporeal Life Support Organization. ECLS RegistryReport International Summary. Ann Arbor, MI: Extracor-poreal Life Support Organization, 2014, 126.

4. Yalndag-ztrk N, Vuran C, Karako F, Ersu R. Use ofpumpless extracorporeal lung assist as a rescue therapy in anadolescent with cystic fibrosis. Pediatr Int 2013;55:e835.

5. Extracorporeal Life Support Organization. ELSO Guidelinesfor ECMO Centers. version 1.7, February 1, 2010. Availableat: http://www.elso.med.umich.edu. html. Accessed August 1,2013.

6. Haydin S, ndar A. Updates on extracorporeal life support inthe world and challenges in Turkey. Anadolu Kardiyol Derg2013;13:5808 (Turkish).

7. McCoach R, Weaver B, Carney E, et al. Pediatricextracorporeal life support systems: education and training atPenn State Hershey Childrens Hospital. Artif Organs 2010;34:10236.

8. Palanzo D, Qiu F, Baer L, Clark JB, Myers JL, ndar A.Evolution of the extracorporeal life support circuitry. ArtifOrgans 2010;34:86973.

9. ndar A. Penn State Hershey Pediatric CardiovascularResearch Center: 2011 update [Invited Editorial]. ArtifOrgans 2011;35:35860.

10. Qiu F, Talor J, Zahn J, et al. Translational research in pediat-ric extracorporeal life support systems and cardiopulmonarybypass procedures: 2011 update. World J Pediatr CongenitHeart Surg 2011;2:47681.

11. Vasavada R, Qiu F, ndar A. Current status of pediatric/neonatal extracorporeal life support: clinical outcomes, circuitevolution, and translational research. Perfusion 2011;26:294301.

12. ndar A, Haydin S, Erek E, et al. Recommendations for theselection of techniques and components used in congenitalheart surgery in Turkey. Turk Gogus Kalp Dama 2012;20:399405 (Turkish).

13. ndar A, Haydin S, Yivli P, et al. Istanbul symposiums onpediatric extracorporeal life support systems. Artif Organs2011;35:9838.

14. ndar A, Bakr I, Haydin S, et al. Congenital heart surgery inTurkey; today and tomorrow. Turk Gogus Kalp Dama 2012;20:1815 (Turkish).

15. ndar A, Alkan-Bozkaya T, Palanzo D, et al. Istanbul sym-posium on neonatal and pediatric cardiopulmonary bypassprocedures [Guest Editorial]. Artif Organs 2012;36:4636.

16. Khan S, Vasavada R, Qiu F, Kunselman A, ndar A.Extracorporeal life support systems: alternative vs. conven-tional circuits. Perfusion 2011;26:1918.

17. Qiu F, Khan S, Talor J, Kunselman A, ndar A. Evaluation oftwo pediatric polymethyl pentene membrane oxygenatorswith pulsatile and nonpulsatile perfusion. Perfusion 2011;26:22938.

18. Qiu F, Clark JB, Kunselman AR, ndar A, Myers JL.Hemodynamic evaluation of arterial and venous cannulaein a simulated neonatal ECLS circuit. Perfusion 2011;26:27683.

19. Qiu F, Lu CK, Palanzo D, Baer L, Myers JL, ndar A.Hemodynamic evaluation of the Avalon Elite bi-caval lumencannulae. Artif Organs 2011;35:104851.

20. Guan Y, Su X, McCoach R, Kunselman A, El-Banayosy A,Undar A. Mechanical performance comparison betweenRotaFlow and CentriMag centrifugal pumps in an adult ECLSmodel. Perfusion 2010;25:716.

21. Palanzo DA, El-Banayosy A, Stephenson E, Brehm C,Kunselman AR, Pae WA. Comparison of hemolysisbetween centrimag and rotaflow rotary blood pumps duringextracorporeal membrane oxygenation. Artif Organs 2013;37:E1626.

22. Yalindag-ztrk N, Ak K, Besci T, et al. VV ECLS for aninfant with ARDS and airleaks: first success by a newlyfounded program in Turkey. Int J Art Organs 2013;36:293.

23. Downard CD, Betit P, Chang RW, Garza JJ, Arnold JH,Wilson JM. Impact of AMICAR on hemorrhagic complica-tions of ECMO: a ten-year review. J Pediatr Surg 2003;38:12126.

24. Muntean W. Coagulation and anticoagulation in extracor-poreal membrane oxygenation. Artif Organs 1999;23:97983.

25. Oliver WC. Anticoagulation and coagulation managementfor ECMO. Semin Cardiothorac Vasc Anesth 2009;13:15475.

26. ONeill AI, McAllister C, Corke CF, Parkin JD. A comparisonof five devices for the bedside monitoring of heparin therapy.Anaesth Intensive Care 1991;19:5926.

27. Hirsh J, Raschke R. Heparin and low-molecular-weightheparin. Chest 2004;126:188203.

28. Guerguerian AM, Ogino MT, Dalton HJ, Shekerdemian LS.Setup and maintenance of extracorporeal life support pro-grams. Pediatr Crit Care Med 2013;14:8493.

29. Connelly JT, Weaver B, Seelhorst A, et al. Challenges at thebedside with ECMO and VAD. World J Pediatr CongenitHeart Surg 2012;3:6771.

30. Wang S, ndar A. Current devices for pediatricextracorporeal life support and mechanical circulatory supportsystems in the United States [Invited Review]. Biomed MaterEng 2013;23:5762.

31. Krawiec C, Wang S, Kunselman AR, ndar A. Impact ofpulsatile flow on hemodynamic energy in a MedosDeltastream DP3 pediatric extracorporeal life support system.Artif Organs 2014;38:1927.

32. Durandy Y, Wang S, ndar A. An original versatile non-occlusive pressure regulated blood roller pump forextracorporeal perfusion. Artif Organs 2014;38:46973.

INVITED EDITORIAL 7

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Perfusion 1 4

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Introduction

The number of clinical applications of extracorporeal membrane oxygenation (ECMO) has progressively increased, with a total of over 50,000 patients as of January 2013, more than half of whom are neonates with an overall mortality rate of over 50%.1 Obviously, such interventions are related to long hospitalization periods with high costs. Although the poly-methylpentene (PMP) oxygenators have significant advantages in ECMO implementation, their usage may be limited in some situations, which may be related to economic con-straints or legal issues regarding to cessation of the unprecedented PMP oxygenators in the market.1 Shipment of the Quadrox iD, (Maquet Cardiopulmonary AG, Hirrlingen, Germany), which had been the only available PMP oxygenator for ECMO implementation in the U.S., had been blocked by FDA for several weeks for safety concerns, which led the ECMO Centers to find a rapid solution, such as using a hollow-fiber oxygenator in the ECMO setup.

In this report, we aimed to share our initial clinical experience about the mandatory usage of a hollow-fiber membrane oxygenator, due to limited funds, in the

ECMO circuit, which provides a cost-effective solution for the treatment of patients during the neonatal period.

Patients and Methods

A retrospective analysis of the cardiac surgery database was performed in order to identify patients for whom the ECMO intervention was performed between the years 2012 and 2013. The patient characteristics, indications for the ECMO usage, perioperative course and details about the system setup were obtained for this analysis. The

Cost-effective usage of membrane oxygenators in extracorporeal membrane oxygenation in infants

A zyksel, C Ersoy, A Akevin, H Trkolu, A E iek, A Kahraman, B Kayhan and E Cantrk

AbstractAlthough the poly-methylpentene (PMP) oxygenators have significant advantages in ECMO implementation, their usage may be limited in some situations, which may be related to economic constraints. In this report, we aimed to emphasize our cost-effective usage of a membrane oxygenator at the ECMO setup. We implemented ECMO with eight Capiox FX05 or Baby RX05 hollow-fiber membrane oxygenators in five neonatal patients. The average ECMO duration was 121 hours (ranging from 41 to 272 hours). Following the termination of the ECMO, the system was broken down into its components for macroscopic analysis. Neither gross blood clots nor plasma leakage were observed in any of the components. The integration of a centrifugal pump and a separate hollow-fiber oxygenator may provide a cost-effective ECMO implementation setup with no adverse effects which may be an encouraging alternative for the low cost usage of ECMO in neonates.

Keywordsextracorporeal membrane oxygenation; oxygenator; congenital heart defect; infant; centrifugal pump

Department of Cardiovascular Surgery, Medipol University, Istanbul, Turkey

Corresponding author:Arda zyksel, MDMedipol UniversityTEM Otoyolu Gztepe kNo: 1, Baclarstanbul Turkey Email: ozyukselarda@yahoo.com

540024 PRF0010.1177/0267659114540025PerfusionOzyukselresearch-article2014

Original paper

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2 Perfusion

ECMO system consisted of a centrifugal pump, RotaFlow (Maquet Cardiopulmonary AG, Hirrlingen, Germany) and a hollow-fiber oxygenator, Capiox FX05 or Capiox Baby RX05 (Terumo Corporation, Tokyo, Japan) (Figure 1). After the initial de-airing with the multiple electrolyte solution Isolyte-S, (Eczacba-Baxter, Istanbul, Turkey), the ECMO system was primed with fresh frozen plasma (FFP) and erythrocyte suspension (ES). Neither heparin nor any other additive was used at the prime solution. The total time needed for the priming of the system was 3 minutes. Mediastinal access was preferred for the venous drainage and arterial return. The venous drainage was performed by the DLP Single Stage Venous Cannula (Medtronic Inc., Minneapolis, MN) with the cannula sizes between 12-20 French. The arterial return cannula, DLP Pediatric One Piece Arterial Cannula (Medtronic Inc., Minneapolis, MN) at the sizes between 8-12 French was inserted into the ascending aorta.

Results

A total of 5 patients (2 males, 3 females) had ECMO implementation. The average age was 7 months (ranging from 8 days to 12 months), the average weight was 6.240 grams (ranging from 2.400 grams to 10 kg) and the aver-age body surface area was 0.31 m2 (ranging from 0.17 m2 to 0.45 m2). The operative characteristics of the patients are summarized in Table 1. The primary indication for

ECMO implementation was post-pericardiotomy low car-diac output status and the associated respiratory compli-cations. All implementations were performed with sternotomy, followed by cannulation using the venoarte-rial route; the venous cannula at the right atrium and the arterial cannula at the ascending aorta. All of the ECMO implementations were at the early postoperative period except for patient no.5, who could not be weaned from cardiopulmonary bypass (CPB) and, therefore, the ECMO implementation had to start in the operating room. Two of the ECMO implementations (patients no.1 and 2) were initiated following cardiopulmonary arrest. All the patients received moderate doses of inotropic infusions and peritoneal dialysis. Initial ECMO settings were aimed to bypass >75% of the cardiac output, with maintenance of adequate oxygenation, mean arterial pressure and acid-base status. All the ECMO support was conducted under normothermia. The patients who had cardiac arrest before ECMO initiation were passively cooled down to a body temperature of 34C. Activated clotting time (ACT) count and arterial blood gas analysis were performed at two hour intervals unless more frequent studies were needed. The goal was to achieve an ACT value between 150 and 200 seconds by means of continuous intravenous heparin administration. Platelet, ES and FFP transfusions were held on a routine basis in order to provide a hematocrit level of 35% and platelet count of 100,000/mm3. The mechanical ventilation support was set at 6-8 breaths/min,

Figure 1. Schematic presentation of the extracorporeal membrane oxygenation system with separate membrane oxygenator.

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Ozyuksel 3

positive end expiratory pressure (PEEP) at 5-8 cmH2O and FiO2 at 0.50-0.60, respectively. The average ECMO duration was 121 hours (ranging from 41 to 272 hours).

A total number of eight oxygenators (3 Capiox Baby RX05, 5 Capiox FX05) were used in five patients. The criteria to replace the membrane oxygenator during ECMO implementation was a drop in partial blood oxy-gen pressure below 70mmHg in arterial gas analysis. The membrane oxygenator was replaced at the 92nd hour, 173rd hour (after 81 hours of usage) and 272nd hour (after 99 hours of usage) on patient no.1 and at the 90th hour and 166th hour (after 76 hours of usage) on patient no.2 during the ECMO period, where the final replacements indicate ECMO termination. The analysis of the ECMO implementation is summarized in Table 2. Following the termination of ECMO, the system was broken down into its components for macroscopic anal-ysis. Neither gross blood clots nor plasma leakage were observed in any of the ECMO systems. Three patients could not be weaned from the ECMO intervention. The reasons for mortality in patients no.1, 2 and 3 were necrotizing fulminant pneumonia, intracranial hemor-rhage with disseminated intravascular coagulation and sepsis with multiorgan failure, respectively. Patients no.4 and no.5 were successfully weaned and discharged without any complication at the 48th and 20th days after the termination of ECMO, respectively.

Discussion

Many clinical indications leading to cardiac and/or respiratory complications have been successfully treated with ECMO implementation today. The usage of ECMO

represents a wide spectrum of patients, more than 13,000 of whom have been treated with survival to dis-charge rates of 40%, 49% and 39% for neonates, pediat-ric and adults, respectively.2 As well as in primary cardiac etiologies, initiation of a rapid ECMO therapy before the circulatory collapse comes into consideration and is an important strategy in such patients.3,4 Since the primary purpose of the hollow-fiber oxygenator design is to be used in a CPB setup, the data about its clinical usage in ECMO systems is limited.5 In our patients, we observed that it provides a cost-effective alternative without adverse effects when it has been integrated in the ECMO system. The low prime volume and wide blood flow range enables the safe clinical usage in patients especially under the weight of 10 kg.

Plasma leakage, which seems to be a major problem when a hollow-fiber oxygenator is used in a prolonged implementation, was not encountered in our patients, but could have necessitate the earlier replacement of the oxy-genator than expected. We also did not encounter any significant hemolysis over the physiological range of the newborns. Routine blood parameters (direct-indirect bilirubin, free plasma hemoglobin) for hemolysis were continuously monitored in order to determine an early finding of hemolysis at a level more than the physiologi-cal jaundice of the newborn. Oxygenator types, mean venous inlet pressure and mean pump speed are related with the risk of hemolysis in ECMO.6

We would like to clarify one important point about our setup. The cost of one Capiox series oxygenator is about $500 (USD) whereas a typical ECMO oxygenator is about $6000 (USD) in our country. We had to use a cheaper CPB oxygenator instead of a routine use of PMP

Table 1. The operative characteristics of the patients.

Pt. No Age Body Weight (kg) BSA (m2) Primary Diagnosis Type of Operation

1 6 months 7 0.32 TA, VSD, RV hipoplasia Glenn Shunt2 1 month 2.4 0.17 truncus arteriosus Rastelli Procedure3 8 days 2.8 0.19 TGA, VSD ASO4 12 months 9 0.42 TOF Total repair5 10 months 10 0.45 TOF Total repair

TA: Tricuspid atresia; VSD: Ventricular septal defect; RV: Right ventricle; TGA: Transposition of the great arteries; TOF: Tetralogy of Fallot; ASO: Arterial switch operation.

Table 2. The analysis of the ECMO duration.

Pt. No ECMO implementation time

ECMO on CPR

Aortic Cannula (Fr)

Flow (Lt/min/m2)

ECMO duration (hours)

Mortality

1 po. 5. day Yes 12 768 272 +2 po. 6. day Yes 8 408 66 +3 po. 3. day No 8 455 41 +4 po.12. hour No 12 1008 63 5 early after CPB No 12 1080 166

PO: Postoperative; CPB: Cardiopulmonary bypass; CPR: Cardiopulmonary resuscitation.

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4 Perfusion

ECMO oxygenator because of limited funds and reim-bursements. We do not recommend replacing the rou-tine use of CPB oxygenators with PMP ECMO oxygenators. When funds are limited, then we recom-mend the use of hollow-fiber CPB oxygenators instead of PMP ones in neonatal ECMO patients, in whom even multiple replacements are more cost effective than using PMP ECMO oxygenators.

Although this report includes a limited number of patients, we wanted to share our experience with this setup. The safe period of the membrane oxygenators is obviously shorter than the spiral coil silicone mem-branes and PMP oxygenators which were originally invented for prolonged usages.7 We do not find it neces-sary to conduct a clinical trial in order to compare PMP ECMO oxygenators with hollow-fiber CPB oxygenat-ors, since our only thought was to create a solution in patients in this limited number of our patients where the funds were limited.

Conclusion

A centrifugal pump and a separate hollow-fiber oxy-genator may provide a cost-effective ECMO setup without plasma leakage, hemolysis and thromboem-bolic complications. This simple and low cost setup may encourage the usage of ECMO with extended indi-cations in the neonatal period, in particular, when the funds are limited.

Author NotePresented at the 7th Symposium on Pediatric Extracorporeal Life Support Systems, September 28th, 2013; Istanbul, Turkey

Declaration of Conflicting Interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References1. Undar A, Wang S, Palanzo D. Impact of polymethylpen-

tene oxygenators on outcomes of all extracorporeal life support patients in the United States. Artif Organs 2013; 37: 10801081.

2. Extracorporeal Life Support Organization (ELSO). Extracorporeal Life Support Registry Report International Summary. Ann Arbor, MI: ELSO; 2013.

3. Yerebakan C, Ozyuksel A, Yildirim O etal. Extracorporeal membrane oxygenation for the treatment of acute res-piratory failure due to respiratory syncytial virus after congenital heart surgery. Wien Med Wochenschr 2013; 429431.

4. Bryner BS, West BT, Hirschi RB et al. Congenital dia-phragmatic hernia requiring extracorporeal membrane oxygenation: dose timing of repair matter? J Pediatr Surg 2009; 44; 11651171.

5. Talor J, Yee S, Rider A et al. Comparison of perfusion quality in hollow-fiber membrane oxygenators for neo-natal extracorporeal life support. Artif Organs 2010; 34: E110116. doi: 10.1111/j.15251594.2009.00971.x.

6. Lou S, Maclaren G, Best D et al. Hemolysis in pediat-ric patients receiving centrifugal-pump extracorporeal membrane oxygenation: prevalence, risk factors, and outcomes. Crit Care Med. 2014; 42: 12131220.

7. Yu K, Long C, Hei F etal. Clinical evaluation of two dif-ferent extracorporeal membrane oxygenation systems: a single center report. Artif Organs 2011; 35: 733737.

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Yaam destek sistemlerinin Dnya'daki gelimeleri ve Trkiyedeki son durum

Updates on extracorporeal life support in the world and challenges in Turkey

Yazma Adresi/Address for Correspondence: Dr. Serta Haydin, stanbul Mehmet Akif Ersoy Gs Kalp ve Damar Cerrahisi Eitim ve Aratrma Hastanesi, ocuk Kalp Damar Cerrahisi, stanbul-Trkiye Tel: +90 532 242 69 86 Faks: +90 212 471 94 94 E-posta: sehaydin@hotmail.com

Kabul Tarihi/Accepted Date: 15.03.2013 evrimii Yayn Tarihi/Available Online Date: 24.07.2013Telif Hakk 2013 AVES Yaynclk Ltd. ti. - Makale metnine www.anakarder.com web sayfasndan ulalabilir.

Copyright 2013 by AVES Yaynclk Ltd. - Available on-line at www.anakarder.comdoi:10.5152/akd.2013.182

Serta Haydin, Akif ndar1

stanbul Mehmet Akif Ersoy Gs ve Kalp Damar Cerrahisi Eitim ve Aratrma Hastanesi, Kalp Damar Klinii, stanbul-Trkiye1Department of Pediatrics, Surgery and Bioengineering, Penn State Hershey Pediatric Cardiovascular Research Center, Penn State Hershey

College of Medicine, Hershey-USA

Derleme Review580

ZETEkstrakorporal yaam destei (ECLS) medikal tedaviye yant vermeyen, yaamsal fonksiyonlarn zayflad durumda uygulanan bir tedavi yntemidir. Gelimi lkelerde uzun yllardr belli endikasyonlar iin kullanlmaktadr. lkemizde ise ok yakn bir zamanda, baz merkezlerde tarif edildii ekilde kullanlmaya balanmtr. Ancak bu kullanmn byk ounluu postkardiyotomi uygulamalardr. Oysa ki bu tedavi eklinin ortaya k sebebi de dahil olmak zere dnyadaki uygulama endikasyonlar daha genitir. Gelien teknoloji ile sistemin hemen tm ekipmanlar deiime uramaktadr. Bu makaleyi yazmamzdaki ama, bu ileri tedavi yntemine dikkat ekmek, ekipmanlar tantmak, organizasyon ve sistem ynetimi hakknda bilgiler vererek bu tedavinin lkemize doru ve etkin ekilde girmesi iin nerilerde bulunmaktr. (Anadolu Kardiyol Derg 2013; 13: 580-8)Anahtar kelimeler: Ekstrakorporeal yaam destei, ekstrakorporeal membran oksijenasyonu, ekstrakorporeal yaam destei organizasyonu, perfzyon, ocuk kalp cerrahisi, ekstrakorporeal membran oksijenasyonu kanlleri

ABSTRACTExtracorporeal life support (ECLS) is instituted for the management of life threatening pulmonary or cardiac failure (or both), when no other form of treatment has been or is likely to be successful. It has being used in developed countries for many years. ECLS has come into practice for a while in Turkey, in order to ECLS recommendations. However, most of them are postcardiotomy cases. However, this therapeutic option has more indications including its reason that brought it into practice. All equipment of the system has being changed with the developing technol-ogy. The aim of this paper is to point out this modality, to introduce equipment, and to give information about organization and management to bring this therapeutic option in Turkey in order. (Anadolu Kardiyol Derg 2013; 13: 580-8)Key words: Extracorporeal life support, extracorporeal membrane oxygenation, extracorporeal life support organisation, perfusion, pediatric cardiac surgery, extracorporeal membrane oxygenation cannulei

Giri

Ekstrakorporal Yaam Destei (ECLS) ocuklarda ilk kez 1972 ylnda Byk Damar Transpozisyonu nedeni ile yaplan Mustard Operasyonu sonras gelien kalp yetersizlii iin ve yenidoan-larda ilk kez 1975 ylnda mekonyum aspirasyonu nedeni ile geli-en pnmoni ve pulmoner hipertansiyon (PH) iin Dr. Robert H. Bartlett tarafndan kullanlmtr (1-3). Gnmzde, maksimum tbbi tedaviye yant vermeyen solunum ve/veya kalp yetmezlii bulunan yenidoan, ocuk ve erikin hastalarda kullanlan bir tedavi yntemidir. Amerikada ylda, 2800 yenidoan hastann ECLSden fayda grd tahmin edilmektedir ki, bu say 1/1309 canl douma denk gelmektedir (4).

ECLSdeki son teknolojik gelimelerden nce ECLS ynetimi-nin son durumunu tespit etmek gereklidir. Extra Corporeal Life Support Organisation (ELSO) bu durum tespitini yapm ve herkes tarafndan kabul edilen ynergeler yaynlamtr (4). Ayrca ELSO verileri Amerikada Food and Drug Administration (FDA) tarafn-dan klinik aratrmalar iin referans verileri olarak kabul edilmi-tir. Yeni aratrlan bir ECLS aleti veya protokol iin ELSO verileri referans olarak kullanlabilir, kontrol grubuna ihtiya yoktur.

lkemizde de ECLS kullanlmakta olup vakalarn byk ounluu post-kardiyotomi hastalardr. Bu uygulamalar da tamamen kiisel tecrbelerle olup bir ECLS ynetimi tanmlan-mamtr. ECLSnin esas kullanm alan olan postkardiyotomi dndaki hastalarda son zamanlardaki birka mnferit vaka

dnda kullanm yoktur. leride de tarif edilecei zere bu yne-tim bir ekip iidir. Farkl disiplinlerin bir arada alarak ortaya koyduu bir tedavi eklidir. ECLSnin kardiyopulmoner baypasstan farkl olduunun bilinmesi gereklidir.

Bu yazy yazmamzdaki ama, yaklak 40 yldr kullanlan ve artk tm gelimi lkelerde bir tedavi metodu olarak kabul edi-len, binlerce hastann hayatlarnn kurtarld ve ana hatlar ile detayl bir ekilde tanmlanm olan ancak maalesef henz lke-mizde neredeyse tanmland ekilde kullanlmayan bu ileri tedavi yntemine dikkat ekmek, mevcut tanmlardan yola ka-rak bu tedavinin lkemize doru ekilde girmesi iin nerilerde bulunmaktr.

ECLS, hastaln kritik dneminde yaamsal fonksiyonlarn devam ettirilemedii durumda, uygun endikasyonlar altnda uygulanan ve hastay hayatta tutmay salayan bir tedavi ynte-midir. Veno-arteryel (VA) ve veno-venz (VV) olmak zere 2 uygulama yntemi ile yaplmaktadr. Hastadan gelen sistemik venz kann vcut darsna alnarak yapay bir akcier olan oksijenatr vastas ile kandan karbondioksitin (CO2) uzaklatrl-mas ve oksijenin (O2) verilmesi, yine yapay bir kalp grevi gren pompa yolu ile de kann vcuda gnderilmesi prensibi ile alr. Kalp ve akcier yetmezlii durumlarnda VA, sadece akcier yetmezlii durumunda VV yntemi uygulanr (ekil 1). Yenidoan, ocuk ve erikin hastalarda kullanm alanlar vardr. Kardiyak veya non-kardiyak sebeplerle uygulanr. ECLS lkemizde daha sklkla kardiyotomi sonras gelien akut kalp yetersizlii iin kullanlmaktadr.

ECLS kullanm alanlarPediyatrik ECLS uygulamas mekonyum aspirasyonu sonras

gelien pnmoni ve PH sebebi ile pediyatrik kullanma girmi, ardndan konjenital diyafram hernisi onarm ncesi ve sonras destek iin byk bir baar ile kullanlmtr. Bunu takiben post-kardiyotomi de dahil olmak zere kullanm alanlar genilemi ve gnmzde daha yeni endikasyonlarla geni bir hasta kitlesinde uygulanr hale gelmitir.

ECLS ile tedavi edilebilen hastalklar Persistan Pulmoner Hipertansiyon (PPH) Mekonyum Aspirasyon Sendromu (MAS) Respiratuvar Distres Sendromu (RDS) Konjenital Diyafragmatik Herni (KDH) Pnmoni Post-operatif konjenital kalp hastalklar/kalp transplantas-

yonu Kardiyomiyopati/miyokardit/Kontrol edilemeyen aritmiler Aspirasyon pnmonisi Pulmoner embolizm

Bu hastalklar arasnda ECLS tedavisi sonras ELSO verileri-ne gre KDHde %51, MASta %94e varan baar elde edilmek-tedir. ECLS imkan olmayan bir lkede zellikle KDH hayatta kalm yzdesi ok dktr. Bu iki hastalk ile birlikte PPH yeni-doan ECLS uygulamalarnn %75ini oluturmaktadr ve ne yazk ki lkemizde bu endikasyonlar ile ECLS uygulamas yaplm bir hasta bildirilmemitir.

ECLS ile tedavi edilebilen hastalklar-yeni yaklamlarAada sralananlar ECLSnin yeni kullanm alanlar olup

giderek daha fazla hasta bu tedaviden yararlanmaktadr. Eski kontrendikasyonlarn bir ksm gnmzde endikasyonlar ierisi-ne girmitir.

Sepsis Travma hastalarnn kurtarlmas: Sava durumunda, vbGebelik komplikasyonlarndaKardiyolojik giriimler esnasndaGiriimsel akcier destei ve koruyucu ventilasyon Hastane ii/d kardiyak arrest: E-CPR Pre-operatif stabilizasyonTrakeomalazi cerrahi tedavisiOrgan alnmasnda

Sava alannda yaralanan gerek solunumsal yetmezlik [yanklar, erikin respiratuvar distres sendromu (ARDS)] gerekse kardiyak yetersizlik hastalarnda baar ile kullanm rnekleri vardr. Kliniimizde, Blalock-Taussing (BT) ant tkal bir halde acil olarak kateterizasyon ile antn ald bir hastada ilem srasnda baar ile kullanlmtr. Solunum yetmezlii durumla-rnda akcierin fonksiyonunu yeniden kazanmas iin geen srede veno-venz ECLS iyi bir destek salamaktadr. Hastane ii kardiyak arrestlerde CPR (kardiyopulmoner canlandrma) yant alnamyorsa ECLS tedavisi uygulanabilir. Hastane d kardiyak arrestlerde, ok yaygn kullanlmamakla birlikte, hastay arrest olduu yerde ECLSye balayarak merkeze tama baar ile uygulanmaktadr. Bu her iki durum E-CPR (Ekstrakorporeal-CPR) adn almtr. Hastanemizde de zellikle pediyatrik vakalar-da E-CPR uygulamas yaplmaktadr. Son zamanlarda baz organ transplantasyon merkezleri donrleri ECLSye balayarak organ mrn uzatmakta ve transplantasyon baarsn arttrmaktadr.

ekil 1. Veno-arteryel (VA) ECLS emas (A), Veno-venz (VV) ECLS emas (B)ECLS - ekstrakorporeal yaam destei

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ECLS ynetimine genel bak ve ELSOELSO, ECLS tedavi yntemi hakknda merkez standartlar,

fiziki artlar ve techizat, hasta ynetimi, eitim ve takip iin her trl detay tanmlam, talimatnameleri yaynlamtr (4). Bu talimatnamelerin bir ksm Ekstra Korporeal Yaam Destei (ECMO) merkezleri, bir ksm da ECMO merkezi olmayp ihtiya durumunda ECMO yapan merkezler iin tanmlanmtr. ocuk ve erikin ECMO talimatnamelerinin bir ana hatlar rtmekle beraber zellikle merkez ve techizat bakmndan farkllklar var-dr. Tanmlamalarmz ocuk vakalar arlkl olacaktr.

ECMO merkezleri iin ELSO ynetmelikleriECMO tedavisinin tersiyer merkezlerde yaplabilecei; bu

merkezlerde yenidoan ve ocuk youn bakm nitelerinin olma-s gerektii, multi-disipliner ECMO ekibinin varolmas gerektii tanmlanmtr. Yllk vaka says 6 veya zerinde olmaldr.

ECMO ekibinin ynetim emas1. ECMO program yneticisi: Neonatalog, youn bakm uzma-

n, pediyatrist, kardiyovaskler cerrah, travma cerrah olabilir. ECMO eitimli olmas gerekmektedir.

2. ECMO koordinatr: Yenidoan veya pediyatrik youn bakm hemiresi, solunum terapisti (youn bakm tecrbeli) veya klinik perfzyonist (ECMO tecrbeli) olabilir.

3. ECMO doktoru: Neonatalog veya pediyatrist olabilir. ECMO eitimli olmas gerekmektedir.

4. ECMO spesiyalisti: Hemire, solunum terapisti, perfzyo-nist, biyomedikal teknisyeni veya salk teknisyeni olabilir. ECMO eitimli olmas gerekmektedir.

ECMO merkezinde bulunmas gereken disiplinlerocuk kardiyolojisi ocuk kalp damar cerrahisi Genel cerrahiocuk anesteziyolojisiocuk beyin cerrahisi ocuk radyolojisiocuk kardiyovaskler perfzyon blm GenetikSolunum terapisi (youn bakm tecrbeli)Biyomedikal mhendisiocuk nrolojisiocuk nefrolojisiFizik tedaviGeliim ve rehabilitasyon uzman

ECMO transport ekibi ocuk kalp damar cerrah ocuk youn bakmcs Perfzyonist 2 Hemire (ECMO eitimli, pediyatrik kardiyak youn bakm

hemiresi)

Bu ekip tam techizatl, eitimli ve 24/7 greve hazr olmaldr.

ECMO merkezinde fiziki artlar ve techizatn salanmas ECMO sistemi: Pompa (servo reglatrl) Servo reglatr (pompada bu zellik yoksa): Santrifugal pompann hzn (RPM) (akmn) anlk kan basncna gre dzenler. Istc-soutucu Antikoaglasyon lm cihaz (hasta ba) Uygun aydnlatma (cerrahi prosedrler iin) Cerrahi ekipman (kanlasyon, revizyon) Tm ekipmann yedei

Tm ECLS hastalar iin genel talimatnamelerELSOnun internet sitesinde (http://www.elso.med.umich.

edu/ ve http://www.elsonet.org), ve ECMO-Extracorporeal Cardiopulmonary Support in Critical Care, 4th Edition isimli ELSO yaynnda detayl bir ekilde tanmlanmtr.

ECMO spesiyalistinin eitimi ve eitim devamll iin ELSO talimatnameleriHer ECMO merkezinin personelinin eitimi, sertifikasyonu

ve re-sertifikasyonu iin iyi tanmlanm bir program olmaldr. aydan daha uzun sre ECMO kullanmayan personelin

ECMO programnca tanmlanan re-sertifikasyon ilemine tabi tutulmas gereklidir.

Ayrca http://ecmojo.sourceforge.net/ isimli internet sitesin-den de eitim alnabilir.

ECMO hastalarnn uzun dnem takibi iin ELSO talimatnameleri Taburcu ncesi deerlendirme 4-6 aylk deerlendirme 1, 2, 3, 5 yllk deerlendirmeler

Perfzyonistlerin ECMO programnda yerleriKuzey Amerika ktas perfzyonistleri arasnda yaplan 2005

survey sonularna gre perfzyonistler ECMO program balan-gcnda yer almyorlar (5). Postkardiyotomi ECMOsunda katklar daha fazla. Gelimi lkelerde perfzyonistlere den grev devreyi kurmak ve hastay stabilize etmektir. Bundan sonra, hasta ECMO hemiresine devredilir. Bu gven, son yllarda non-oklsif santrifugal pompalarn yaygn kullanm sonucu ortaya kmtr. Hastann ECLS knda perfzyonistler yeniden grev alrlar. Hasta banda 24/7 beklemek sorumluluklar deildir. Ancak lkemizde rneklerine rastland gibi ak sistemle veya prensiplerine uymadan yaplan ECLS benzeri uygulamalar sra-snda bir perfzyonist hasta banda bekletilmekte ve gereksiz bir i kayb ortaya kmaktadr.

Maalesef ki, lkemizde de son stanbul Sempozyumunda sunulan bir anket almasna gre, ankete katlan perfzyonist-lerin %85inin bugne kadar ECLS uygulamas yapmad grl-mtr (6).

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http://www.elso.med.umich.edu/http://www.elso.med.umich.edu/http://ecmojo.sourceforge.net/

ECMO sisteminin ekipmanlarnn tantm

PompalarPompalar roller ve santifugal olmak zere 2 eittir.

Standart alldk kardiyopulmoner baypasta roller pompalar daha arlkldr ki uzun zamandr Kuzey Amerika Ktasnda erikin has-talarda santrifugal pompalar kullanlmaktadr. Bu uygulama son yllarda standart hale gelmitir. ocuk hastalarda da santrifugal pompalar giderek sk kullanlmaya balanmtr. ECMO sistemleri iin ise santrifugal pompalar standart hale gelmi gibidir.

Santrifugal pompalar n yk baml olan, oklzif olmayan pompalardr. Dk primer hacmi ile beraber temas yzeyinin de azalmasna sebep olurlar. Hastadaki basnca gre pompa ota-matik olarak debisini indirebilir ve kartabilir. Eer bir servo reglatr ile beraber kullanlyor ise akm azalmas da otomatik olarak gerekleir. Yksek basn gradyan mmkn olmad iin nemli emboliye veya tp yrtlmasna neden olmazlar. Tanmalar kolaydr.

Son jenerasyon santrifugal pompalar arasnda CentriMag (Levitronix LLC, Waltham, MA, USA), PediMag (Levitronix LLC, Waltham, MA, USA), Medos Deltastream DP3 (Medos AG, Stolberg, Germany), Maquet Rotaflow (MAQUET Cardiopulmonary AG, Hirrlingen, Germany) ve Medtronic Affinity CP (Medtronic Inc, Minneapolis, MN, USA) yer alr (ekil 2). Levitronix FDAdan RVAD olarak 30 gne kadar kullanma onayldr ancak ok paha-ldr. Ayrca bu pompadan elde edilen verimin ok daha ucuz pompalarla da elde edilebilecei gsterilmitir (7).

Son olarak da Maquet Rotassist VAD 2,8i retmitir. Entegre basn sensr vardr ve 30 gne kadar kullanma onayldr.

Santrifugal pompa kafa fiyatlar Rotaflowda olduu gibi $400 ile Levitronix Centrimagde olduu gibi $9.000 arasnda dei-mektedir.

Biomedicus sistemi uzun yllarca kullanlm ve binlerce has-tann hayatlarnn kurtarlmasn salamtr. Fakat mhendislik olarak yllarca pompada hi bir deiiklik yaplmamtr. Rotaflow ve Medos DP3 gibi yeni pompalar Biomedicus pompasnn (Medtronic Inc, Minneapolis, MN, USA) yerini almlardr.

Bladder bag giri (inlet) emiini kontrol eden ve len kollabe olabilen bir tp set parasdr. Yksek emi gcne sahip roller pompalar ile beraber kullanm da gerekmektedir. Santrifugal pompa ile birlikte kullanm da vardr ve kliniimizde uygulanmaktadr.

OksijenatrlerECMO sisteminin en nemli paras olan oksijenatrler ilk

olarak Silikon Membran olarak retilmitir. Bir sre sonra yerle-rini 2. jenerasyon olan Hollow Fiber (Heparine coated micropo-reus polypropylene) oksijenatrlere brakmlardr (ekil 3A). Ancak plazma sznts da bu oksijenatrlerin verimli kullanlma-sna msaade etmemi ve yerlerine 3. jenerasyon PMP (Poly Methyl Penthene) kapl hollow fiber oksijenatrler kmtr (ekil 3B). Halen verimli bir ekilde kullanlmaktadrlar. ECLS iin kullanlan oksijenatrler Tablo 1de gsterilmitir.

En bilinen ve sk kullanlan ECMO oksijenatrleri Maquet-Quadrox D, ID (MAQUET Cardiopulmonary AG, Hirrlingen, Germany) ve Medos Hilite LTdir (Medos AG, Stolberg, Germany) (ekil 4). Maquet-Quadrox ID yenidoan ve infant oksijenatr QUADROX PLS Oxygenator (Permanent Life Support) HMOD 20000 ad altnda 14 gn kullanma CE onayl olarak kullanmda bulunmaktadr. Hastanemizde de Medos Hilite 1000 ve 2400 oksi-jenatrleri ECMO iin tercih edilmektedir.

KanllerVeno-arteryel ve veno-venz ECMO iin farkl kanlasyon

teknikleri olduu gibi farkl tipte kanller de kullanlmaktadr.

ekil 2. Son teknoloji pompalar: Levitronix Centrimag (A), Levitronix Pedimag (B), Medos Deltastream DP3 (C), Maquet Rotaflow (D), Medtronic Affinity CP (E)

Oksijenatr EurosetsEcmo Novalung Sorin Dideco-Eos Lilliput 2 ECMO Maquet-QuadroxD, ID Medos Hilite LT iLA activve, iLA Ecmo 7000, 2400, 1000 membrane ventilator

zellikler Erikin Erikin, ocuk Erikin Erikin Erikin, ocuk, Erikin, ocuk, CO2 uzaklatrlmas yenidoan yenidoan

ECLS - ekstrakorporeal yaam destei

Tablo 1. ECLS iin kullanlan oksijenatrler

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Arteriyo-venz ECMO iin boyun (common carotis arter-internal jgler ven(ak/yar ak)), gs (aorta-sa atriyum) veya femoral blge (common femoral arter-femoral ven) tercih edile-bilir. Maquet HLS (15-29 Fr) (MAQUET Cardiopulmonary AG, Hirrlingen, Germany) ve Bio-Medicus (8-14Fr/pediyatrik, 15-29Fr/erikin) femoral arter ve ven kanlleri (Medtronic Inc, Minneapolis, MN, USA) en sk tercih edilenlerdir (ekil 5).

Veno-venz ECMO iin iki ayr kanl kullanarak boyun-femo-ral blge veya sa-sol femoral blge seimi yaplabilecei gibi, ift lmenli kanl ile sa internal jgler ven kanlasyonu da yaplabilir. Her iki seimde de resirklasyona dikkat edilmelidir. Maquet HLS (8-16 Fr), Maquet ELS (12-15 Fr), MAQUET - Avalon Elite Bi-Caval Catheter (13-31 Fr) (MAQUET Cardiopulmonary AG, Hirrlingen, Germany/Avalon Laboratories, Rancho Dominguez, Calif), OriGen Dual Lumen Catheter (12-18 Fr) (OriGen Biomedical Inc., Austin, TX, USA), ve Novaport Twin (18-24 Fr) (Novalung GmbH, Germany) en sk kullanlan ift lmenli kanl markalardr (ekil 6). lkemizde OriGen ift lmenli kanl ile tecrbeler var-dr. Bu kanln fiyat yaklak olarak $500dr. Maquet Avalon ve Novaport Twin st dzey ift lmenli kanllerdir. Birincisinin Kuzey Amerika Ktas fiyat $1700, ikincisinin Avrupa Ktas 5000 Euro civarndadr.

Ayrca damar ierisine sokulduunda genileyebilen ve daha kk damarlara girebilen self-expanding venz kanl de kulla-nma sokulmutur ancak pahaldr.

Tm ECMO sisteminde konnektrler ile beraber kanller de anti-trombojenik yzeye sahip olmayan paralardr ve trombus gelitirme riskleri vardr. Buna karlk i yzeyi kapl kanller de retilmitir (r: Carmeda Bio-Active Coating, Medtronic Inc, Minneapolis, MN, USA).

Ekokardiyografik inceleme altnda yaplan boyun kanlasyo-nu kanllerin ideal pozisyonu ve komplikasyon riskinin azalmas iin nemlidir.

KonsollarEn sk kullanlanlar Bio-Console 560 Version 1, 1.5

(Medtronic Inc, Minneapolis, MN, USA), Rotaflow konsol (MAQUET Cardiopulmonary AG, Hirrlingen, Germany), MEDOS DELTASTREAM DC ve MEDOS DELTASTREAM MDC (Medos AG, Stolberg, Germany) konsollardr (ekil 7). Konsollar zerin-den hz (RPM-rate per minute), akm, basnlar ve s takip edile-bilmektedir.

llen ve takip edilen basnlar P1, P2, P3 ve P4tr (ekil 8). Ortak kullanma gre P1 kafa ncesi basn, P2 kafa ile oksijenatr aras basn ve P3 de oksijenatr sonras basntr. P4 istee gre ilave bir basn lm iin kullanlabilinir. P1in pozitif deerde olmas ki, genellikle +10 ideal bir deerdir, sant-rifugal pompann etkili alabilmesi iin uygun bir preload dee-ridir. P2 oksijenatr ncesi basn olduu iin oksijenatrdeki basn d sebebi (pressure drop) ile P3ten 10-15 mmHg daha yksektir. Bu farkn alyor olmas oksijenatr ile ilgili bir problemin gstergesidir.

On-line monitrizasyonSystem M4 (Spectrum Medical, Fort Mill, SC, USA) ve CDI

500 (Terumo Corp., Tokyo, Japan) olmak zere 2 sistem kullanl-maktadr (ekil 9). On-line monitrizasyon ile ECMO srasnda

ekil 3. Hollow fiber (A) ve PMP oksijenatrler (B). Her iki oksijenatr aras farkn ematik grnm(C)PMP - poli-metil-penten

ekil 4. Maquet QuadroxID (A) ve Medos Hilite (B) oksijenatrler

ekil 5. Maquet HLS (A) ve Biomedicus (B) femoral kanller

ekil 6. Origen (A), Avalon (B) ve Novaport twin (C) ift lmenli veno-venz ECMO kanlleriECMO - ekstrakorporeal membran oksijenasyonu

ekil 7. Maquet rotaflow konsol (A), Medos MDC konsol (B)

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devaml olarak SaO2, SvO2, PO2, PCO2, FIO2, Hct, Hb ve K lm-leri yaplabilmektedir.

TransportECMO sistemlerinin gelimesi ve ECMO hastalarna verilen

bakmn daha iyilemesi ile beraber hasta ba ECMO uygulama-snn yan sra ECMOnun hasta transferi srasnda da kullanla-bildii grlmtr. Merkeze belirli mesafede kardiyak arrest gelien bir hastann olay mahallinde ECMOya sokularak transfer edilme ilemleri balamtr. Bunun ileri bir aamas olarak ehir-ler hatta lkeler arasnda ECMOlu hastalarn transferleri yapl-makta ve hastalar ECMO merkezlerine tanmaktadr. Bunun son bir rnei olarak yaralanan 2 NATO askeri Afganistanda ECMOya konmu, yaral transportu iin dzenlenmi C-130 ar nakliye ua ile nce Avrupadaki bir NATO n ssne getirilmi ardndan Almanyadaki ECMO merkezine ulatrlarak hayatta kalmalar salanmtr. Her iki asker de taburcu edilmitir (8).

Bu gelimeler nda ECMO sistemlerinin de tanabilir olmas gerekmektedir. Bu nedenle daha hafif sistemler gelitiril-mitir. Son olarak Maquet CARDIOHELPiyi kartmtr (ekil 10A). Arl 10 kgden dktr. zerinde HLS Module Advanced 7,0 takldr (ekil 10B). yi gelitirilmi hareketli bir ECMO sistemidir. Fiyat konvensiyonel ECMO sitemlerine gre daha fazladr. Yeni teknoloji olmasna ramen standart hasta ba kullanm iin dierlerinden farkl deildir ve maliyeti arttr-cdr.

NIRS (Near infrared spectroscopy)Nromonitrizasyon tekniklerinden birisi olan NIRS beyin

dokusu oksijenasyonunun takibinde kullanlan noninvazif, optik bir yntemdir. Youn bakm ve peroperatif birok hasta grubunun takibinde ok nemli bir yer kazanan NIRS, ECMO hasta takibin-de de hak ettii yeri almtr. Devaml serebral ve/veya somatik oksijenasyon takibi ile ECMO ile ilgili oluabilecek problemlerde anlk tan konup tadavi yaplabilmesine olanak tanr. Akm dei-iklikleri, eritrosit replasman, intravaskler dolgunluk ve zellik-le boyun kanlasyonlarnda kanllerin pozisyonunun verimlilii hakknda nemli destek bilgisi salar.

deal pediyatrik ECLS ekipman konfigrasyonuAadaki sralama en basitten balayarak en ideale doru

pediyatrik ECMO ekipmanlarnn olmas gereken konfigrasyo-nunun tanmlamaktadr.

Sentrifugal pompa+Pediyatrik ECMO oksijenatr+Kapl Tubing set

Sentrifugal pompa+Pediyatrik ECMO oksijenatr+Kapl Tubing set+Bladder bag

Sentrifugal pompa+Pediyatrik ECMO oksijenatr+Kapl Tubing set+Servo reglatr

Sentrifugal pompa+Pediyatrik ECMO oksijenatr+Kapl Tubing set+Servo reglatr+Bladder bag

Sentrifugal pompa+Pediyatrik ECMO oksijenatr+Kapl Tubing set+Entegre servo reglatr+Bladder bag

On-line monitrizasyon

Servo reglatrne ilaveten bladder bag kullanm kendi fikri-miz olup venz kompliyans oluturmas ile dolama ek bir kazan salayacan dnmekteyiz.

En sk kullanlan ve verimli ECLS sistemleriBu sistemler gerek bizim gerekse dnyadaki hem kullanm

hem de transrasyonel aratrma tecrbelerine gre en verimli ECLS sistemleridir (9-13).

Pediyatrik sistemler: Maquet QUADROX PLS&ROTAFLOW (ekil 11)

Medos DP3Erikin sistemler: Maquet Cardiohelp&ROTASSIST

VAD 2.8 Medtronic Bio-PumpBPX 80/50 II

ekil 9. Spectrum Medical System M4 (A) ve Terumo CDI 500 (B) evrimii monitrizasyon cihazlar

ekil 10. Maquet CARDIOHELPi konsolu (A), HLS Module Advanced 7.0 (B)

ekil 8. Medos MDC konsol arayz

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Pediyatrik sistemler ayn zamanda erikin iin de byk bir verimlilikle kullanlmaktadr.

Sol ventrikl (LV) dekompresyonuVA ECMO uygulamas srasnda ileri derecede LV yetmezlii

veya kardiyak arrest olan hastalarda inter atriyal balant da yoksa sol atriyum gerilmesi ve akcier demi ile sonlanabilen sol atriyum dilatasyonu bir ECMO komplikasyonudur. Bu durum iin nerilen baz yntemler de burada sunulmaktadr.

Damar ii hacmin azaltlmas ve santral venz basncn (CVP) drlmesi.

ECMO akmnn azaltlmas.Atriyal septostomi Sol atriyumun vent edilmesi Perktenz, transeptal AkSol ventrikl asist cihaz (LVAD) kullanlmas

Heparinsiz ECMO (HECMO)ECMOnun en byk komplikasyonu olan kanama durumla-

rnda, tm sistemin kapl olmas art ile, heparin infzyonu bir sre iin kesilebilir. Bir ile 28 saat arasnda heparinsiz ECMO kullanm bildirilmitir (14). Ayrca heparinin kesildii durumlarda sisteme Nitrik Oksit (NO) ve Prostasiklin verilmesi ile de trombo-sit aktivasyon, adhezyon ve agregasyonunun engellenerek hepa-rine bal kanama durana kadar sistemi phtdan koruduu da gsterilmi ve klinikte uygulanmtr (15). Japonyada hi heparin kullanmadan sistemi kaplayarak ECMOya girme ve devam etme zerine de baarl almalar vardr (16). Aktif kanamal travma hastalarnn da ECMOya girebilmesi iin bylesi bir uygulamaya da gereksinim vardr.

AutoPulse (Non-invazif kardiyak destek pompas)AutoPulse (Zoll Medical Corp., Chelmsford, MA, USA), hasta-

ne d arrestlerde, ECMOda da olduu gibi, standart CPRye alternatif olarak kullanlan mekanik bir CPR cihazdr (ekil 12). nsan tarafndan yaplan CPRye gre ok daha fazla verimlidir. Transportu kolaylatrmaktadr. Gs kompresyonlarn tm gsn evresinden yapt iin n basya gre kardiyak debi daha fazladr. Aralksz almaktadr. Otuz dakikalk pil mr vardr ve yedekleri ile kolaylkla deitirilebilmektedir. Ayrca kardiyak arrest olan transplant donrlerinde de, ECMOda oldu-u gibi, kullanlmakta ve transplant baarsn arttrmaktadr.

Tartlanlar ve Trkiyedeki durumECMO program balatmak iin kalp cerrah ve perfzyoniste

gerek var m?Btn ocuk kalp merkezlerinin 24/7 ECMO imkan olmal m?Non-kardiyak ECMO kardiyak merkezde yaplabilir mi?Deer mi? Sa kalm Hayat kalitesi Maliyet

Trkiye iin ECMO merkezleri mi, ECMO yapan merkezler mi?lkemizdeki ECMO uygulamalarnn byk ounluu kardi-

yak merkezlerde yaplan postkardiyotomi ECMO uygulamalardr. Yani, ECMOnun esas uygulama alanlar lkemizde neredeyse

ekil 11. Maquet QUADROX PLS ve ROTAFLOW, Penn State ECMO sistemiECMO - extracorporeal ekstrakorporeal membran oksijenasyonu

ekil 12. AutoPulse non-invazif kardiyak destek pompas

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ekil 13. MAEH ECMO sistem izimi (A) ve fotoraf (B)ECMO - ekstrakorporeal membran oksijenasyonu, MAEH - stanbul Mehmet Akif Ersoy Gs Kalp ve Damar Cerrahisi Eitim ve Aratrma Hastanesi

uygulama ddr. ECMO uygulamas yapan merkezler de bir ECMO merkezi olarak deil, ECMO imkan olup hastalarna bu hizmeti sunabilen merkezlerdir. ECMO tedavisi bir sistem dahilin-de deil, acil durumlarda bir son tedavi olarak uygulanmaktadr. Bu uygulamalarn mortalite ve morbiditesi de bilinmemektedir. Hangi endikasyon ile ECMO tedavisine baland da belli deil-dir. Geri dn olmayan bir sebeple gelien kardiyak arrest sonras uygulanan ECMO tedavisinin mortalitesi de %100 ola-caktr. Hastanemiz ald gnden itibaren bu tedavi ekline byk nem vermi, kendi ECMO sistemini kurmu (ekil 13), youn bakm personeline ECMO eitimini vermi ve baarl ECMO uygulamalar yapmtr. Bunun yan sra ECMO ile ilgili uluslar aras seminerler dzenlemi ve Trkiyenin drt bir yanndan perfzyonist, hemire ve ilgili klinisyenlerin eitilmesi iin ura vermitir ve vermeye de devam edecektir (17). Bu gne kadar uygulad 25 pediyatrik ECMO says ile nemli tec-rbesi olan bir merkezdir.

Konunun bandaki sorulara dndmz zaman ECMO program balatmak iin kalp cerrah ve perfzyoniste lkemizde gerek vardr. nk zaten zor olan pediyatrik vakalarda ileri bir tedavi yntemi olan ECMO uygulamalarnn hatasz yaplabilmesi iin ocuk kalp cerrahisi ameliyatlarnda benzer bir sistemi kul-lanan eitimli ve tecrbeli bir personelle bu programn balatl-mas baary arttracak ve hatay azaltacaktr. Sonrasnda dier personeller yeterli eitimi alnca cerrah ve perfzyonist dnda-ki ilgili klinisyen ve teknisyenler de ECMO uygulamas yapabile-cek hale gelecektir.

ocuk kalp merkezi olarak alan bir hastanenin 24/7 ameli-yathane ve youn bakm hizmeti zaten var olmaldr. Buna ilave-ten kendi hastalar iin ECMO imkan olmas merkezin kendi tercihidir. Ancak ECMO merkezi olarak kardiyak d hastalara 24/7 hizmet iin merkezler belirlenmesi ve bu ynde desteklen-mesi uygun olacaktr.

Non-kardiyak ECMO kardiyak merkezde yaplabilir ancak bal bana bir program gerektirir ve zaten youn olan kardiyak hasta programn etkilememesi gerekir. Yaznn banda tarif edi-len ECMO ekibi ve ilgili disiplinler eliinde kardiyak merkezlerde de bamsz bir nite olarak bulunabilir. Ayrca bu merkezlerde post kardiyotomi ECMO uygulamalar da bamsz ve profesyo-nel bir ECMO ekibinin bulunmas halinde daha baarl olabilir.

Deer mi? Tm bu verilerden sonra ECMO tedavisinin nemi ortadadr. Uygun artlar altnda yapldnda medikal tedavinin yetersiz olduu durumlarda nemi ortaya kmakta, dzelmesi mmkn bir hastalk halinde hastann hayatta kalmasn sala-maktadr. Uygulamadaki zorluklar; mutlaka profesyonel bir ekip tarafndan bir program dahilinde yaplmas gereklilii, youn emek harcanmas ve maliyettir.

ECMO eitimi, programn balatlmas ve kalitenin devamll iin nerilerECMO merkezleri youn bakm nitesi olan tersiyer merkez-

ler ierisinde olmaldr. Merkez ierisinde tek bir ECMO yerle-kesi olabilecei gibi, tm youn bakm niteleri ierisinde de

ECMO yaplabilir veya mevcut youn bakm nitesinin bir blm ECMO hastalar iin ayrlr. Acil durumlar iin ok iyi bir iletiim sistemi olmaldr. Tm ekipmann olas acil durumlar iin bir yedei bulunmaldr. Ekipmann, reticinin nerdii periyodik bakmlar yaplmaldr. The Joint Commission (TJC) dzenlemele-rine gre dkmantasyon yaplmaldr. ECMO merkezinde bulun-mas gereken disiplinler olmaldr. Hastane ii ve d ECMO transferlerinde belirlenmi kurallar izlenmelidir. ECMOdaki veya ECMOdan kan hastalarn psikososyal durumlar mutlaka gz nnde bulundurulmal ve gereken tedbirler uygun branlar ile birlikte alnmaldr. Yenidoan hastalar iin nrogeliimsel takip program oluturulmaldr. ECMO program yneticisi, ECMO koordinatr, ECMO doktoru ve ECMO spesiyalistinden oluan ECMO ynetim emas salanmal ve grev tanm yaplmaldr. Bu sistematik dnda yaplan ECMO uygulamalar bir program deil, bireysel uygulamalar eklinde olacaktr. ECMO spesiyalis-ti olan ECMO hemiresinin en az bir yllk yenidoan, ocuk, kardiyak veya erikin youn bakm tecrbesi olmal, 1:1 veya 1:2 hasta bakm vermesi salanmaldr. ECMO programnn baars ECMO spesiyalistinin baarsna baldr. Tm takm elemanlar birlik ve beraberlik ierisinde almaldr.

ECMO eitim konu balklar ve ECMO teknik uygulamalar ok ayrntl bir ekilde tanmlanmtr (18). Daha nce de belirtil-dii gibi en az 1 yl youn bakm tecrbesi olan aday bu temel eitimi devamszlk yapmadan tamamladktan sonra yazl veya szl snava girerek yeterlilik kazanr. almaya baladktan sonra da yeterlilik kontrol devam eder. Merkezin belirledii aralklarla kurslara katlr, szl veya yazl snavlara tekrar girilir ve belirlenmi bir sredeki ECMO uygulama saati doldurulur. Yllk 6 ECMO uygulamasndan az yaplrsa eitim srecinin tek-rarlanmas gereklidir.

Programn sonular deerlendirilirken baar iin yalnzca hayatta kalm deil, standart yntemlerle llen komplikasyon-lar da dikkate alnmaldr.

lkemizde de ECLS eitimi ve sreklilii hastanemiz nderli-inde ve Penn State Hershey Tp Fakltesi ibirlii ile 2011 yln-da stanbul Sempozyumlar ad altnda balatlm ve bugne kadar 4.s yaplmtr (6, 17, 19). Sunumlar ve wet-lablar ile lkenin eitli blgelerinden katlan perfzyonistlere ECLS hak-knda gncel bilgiler verilmitir.

Simlasyon ile eitimUzun yllardan beri zellikle askeriye ve hava tamaclnda

uu eitimleri iin rutin ve olas acil durumlar taklit eden simu-lasyon programlar kullanlmtr. Son yllarda cerrahi bata olmak zere tbbn deiik branlarnda da kullanlmaya balan-mtr. ECLS simulasyonlar da bu kullanm alanlar arasna gir-mitir. Hem hasta hem de ECLS sistemi asndan gereki bir ortam oluturarak eitim verilmesi amalanmaktadr. ECLS eiti-mindeki yerinin nemi yaplan almalar ile gsterilmitir (20, 21). Eitim srasnda deiik senaryolar oluturarak her trl olas komplikasyona kar nceden hazrlk yaplmaktadr. Hayvan laboratuvar ve wet-laba gre avantaj vardr nk

Haydin ve ark.Yaam destek sistemleri

Anadolu Kardiyol Derg 2013; 13: 580-8 587

eitime hastann fizyolojik parametreleri de katlmaktadr. ECMO merkezlerinin eitiminin nemli bir paras olmutur.

Sonu ve nerilerTm bu aklamalar sonucunda ECMO, dnyann gelimi

lkelerinde uygulanan, lmcl bir hastalk durumunda tbbi tedaviye yant alnamayan durumlarda hayatta kalm salayan bir tedavi eklidir. Yksek bir maliyeti olsa da akut, lmcl bir hastalktan salkl bir yaama dnmenin llebilir bir deeri yoktur. lkemizde de yeni gelimeye balayan bu yntemin temelleri salam atlmal, tarif edilmi ynergelere uyulmaldr. ECMO merkezleri mi, ECMO yapan merkezlere mi ihtiyacmz olduu tespit edilmelidir. ECMO programnn mutlak sistematii iyi anlalmal, yanl yaplanmalardan kanlmaldr. Belirtilen talimatnamelere uyulmadan yaplan ECMO giriimlerinin sonu-suz kalaca, harcanan paralarn boa gidecei unutulmamaldr. ECMO programnn baarsndaki en nemli ksm olan eitim zerinde durulmal, yurt d kurslarna katlmal, ELSO faaliyetle-ri takip edilmeli ve ELSO yelikleri yaplmaldr. Ayrca ulusal bir ECMO veri bankas oluturulmal ve tm sonular, olumlu-olum-suz, paylalmaldr. Tm dnyada halen btn ECMO komplikas-yonlar ELSO ats altnda paylalmakta ve bunlardan karlan dersler ile daha iyi ECMO uygulamalar yaplmaktadr. Alla geldik tedaviler ile karlatrldnda sa kalm olarak daha iyi sonular elde edilmektedir (22). Alla geldik tedaviler ile %50nin altnda yaam ans olan hastalara %50-90 arasnda bir ans salamakta ve %5-15 hasara neden olmaktadr. Sonular bilim-sel olarak kantlanm olan bu tedavi yntemi iin zellikle ocuk hastalardaki faydas gz ard edilmemelidir. Bir topluma verilen deer, o toplumun karakteristiklerine baldr, Robert H. Bartlett.

kar atmas: Bildirilmemitir.

"Peer-review" deerlendirilmesi: bamsz deerlendirme.

Yazarlk katklar: Fikir - S.H., A..; Tasarm - S.H.; Denetleme - S.H., A..; Kaynaklar - S.H.; Malzemeler - S.H.; Veri toplanmas ve/veya ilemesi - S.H.; Analiz ve/veya yorum - S.H., A..; Literatr taramas - S.H.; Yaz yazan - S.H.; Eletirel nceleme - S.H., A..

Kaynaklar

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15. Dando H, Gill M, Dittmer J, OShaughnessy K, Lei J, McCauley J, et al. Alternative Anticoagulation for Extracorporeal Membrane Oxygenation. Presented at 7th International Conference on Pediatric Mechanical Circulatory Support Systems & Pediatric Cardiopulmonary Perfusion; May 5-7, 2011, Philadelphia, USA

16. Mizuno T, Tatsumi E, Nishinaka T, Katagiri N, Ohikawa M, Naito H, et al. Observation of alveolar fibrosis in a goat following venoarterial bypass for up to 5 months using extracorporeal membrane oxygenation. J Artif Organs 2004; 7: 107-9. [CrossRef]

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