TỔN THƯƠNG THẦN KINH Ở BỆNH NHÂN ECMO BS Huỳnh Quang Đại Bộ môn Hồi sức Cắp cứu Chống độc UNIVERSITY OF MEDICINE AND PHARMACY, HO CHI MINH CITY ECMO techniques Overall Patient Outcomes Total Runs Survived ECLS Adult Pulmonary Cardiac ECPR Pediatric Pulmonary Cardiac ECPR Neonatal Pulmonary Cardiac ECPR Total Survived to DC 50,112 47,130 14,509 33,299 28,465 6,179 66% 60% 42% 29,366 21,754 4463 58% 46% 30% 12,784 16,471 6,729 9,353 12,043 3,924 73% 73% 58% 7,879 9,091 2,821 61% 55% 42% 34,952 10,802 2,619 30,544 7,491 1,828 87% 69% 69% 25,496 4,855 1,131 72% 44% 43% 196,108 133,126 67% 106,856 54% ELSO Registry Data Through December 31, 2022 Overall Outcomes from 2018 Total Runs Survived ECLS Adult Pulmonary Cardiac ECPR Pediatric Pulmonary Cardiac ECPR Neonatal Pulmonary Cardiac ECPR Total Survived to DC 32,803 30,021 9,327 21,359 18,268 4,018 65% 60% 43% 19,175 14,508 2967 58% 48% 31% 3,798 5,691 2,707 2,933 4,337 1,479 77% 76% 54% 2,637 3,455 1,103 69% 60% 40% 3,842 2,869 864 3,158 2,052 590 82% 71% 68% 2,716 1,506 413 70% 52% 47% 91,922 58,194 63% 48,480 52% ELSO Registry Data Through December 31, 2022 ECMO & Complications Garg et al IntechOpen; 2023 http://dx.doi.org/10.5772/intechopen.105838 Tổn thương thần kinh bệnh nhân ECMO •Khơng gặp!!! •Tần suất theo tuổi •Người lớn: 7-18% •Trẻ em: 13% •Sơ sinh: 20% •Thường gặp •VA > VV ECMO •eCPR > khác •Bệnh nặng trước ECMO ELSO Slide •Tổn thương thần kinh trung ương xảy trước ECMO •Tần suất thay đổi với phương tiện chẩn đốn: MRI > CT/US •Tổn thương TKTƯ tồn mà khơng phát hình ảnh học •Tử vong cao >75% Các thể tổn thương TKTƯ bn ECMO ELSO Slide Các thể tổn thương TKTƯ bn ECMO ELSO Slide Neurologic complications in VV ECMO ELSO Registry Neurologic complications in VV ECMO 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Brain death Seizures: Clinical Seizures: EEG CNS infarction CNS hemorrhage Intraventricular Intra/extra (US/CT/MRI) by US/CT CNS hemorrhage parenchymal CNS hemorrhage Adult Pediatric Neonatal CNS diffuse ischemia (CT/MRI) Neurosurgical intervention Neurologic complications in VA ECMO ELSO Registry Neurologic complications in VA ECMO 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Brain death Seizures: Clinical Seizures: EEG CNS infarction CNS hemorrhage Intraventricular Intra/extra (US/CT/MRI) by US/CT CNS hemorrhage parenchymal CNS hemorrhage Adult Pediatric Neonatal CNS diffuse ischemia (CT/MRI) Neurosurgical intervention ECMO & ∆PaCO2 Pathogenesis of neurological injury Am J Respir Crit Care Med 2020 Jun 15;201(12):1525-1535 Sinh lý bệnh học Risk factors for neurological injuries on ECMO •Pre-ECMO factors •ECMO factors •Hypoxia •Anticoagulation •Acidemia •Alterations in intrinsic coagulation •Hypoperfusion •Inflammation •Microthrombi •Loss of pulsatile flow •Changes in cerebral blood flow and drainage Who is at risk of neurological injuries on ECMO? •Certain patient populations •eCPR •Pre-ECMO cardiac arrest •Otherwise remains a conundrum •Anticoagulation •Rapid changes in CO2 •Rapid changes in hemodynamics •Hyperoxia Cerebral hemodynamics on ECMO Neurological monitoring & Neuroprotective strategies during ECMO Neurological monitoring •Clinical exam •Serial head ultrasound •EEG if clinical indicated •Cerebral oximetry •CT scan if clinical indicated Cerebral oximetry •Adult studies (Kim et al, 2019) •Survival had higher rSO2 and lower lactate •Optical cutoff value for mortality was rSO2 value of 58% •Pediatric study (Tsou et al, 2020) •Mean rSO2 was lower in patients with unfavorable outcome •rSO2 of >20% decline in patients with unfavorable outcome Minimize risk factors Avoid secondary injuries: CO2 Crit Care Med 2020 Jul;48(7):977-984 Avoid secondary injuries: CO2 Crit Care Med 2020 Jul;48(7):977-984 Avoid secondary injuries: O2 Crit Care Med 2017; 45:1997–2005 Optimizing PO2 during peripheral VA ECMO •Oxygen: •Excessive hypo- and hyperoxemia should be avoided • Target slight hyperoxemia after the oxygenator (150 mmHg) • PPOSTO2 should probably not be lower than 70 mmHg •Targeting a patient SaO2 of 92–97% ECMO and other means of neuroprotection after cardiac arrest • Appropriately regulating ECMO ventilation/flow mode • Changing VA-ECMO to VAV-ECMO mode • PaO2 ~ 100 mmHg (