Ecmo 3

Question 1

What should CRRT circuits be plugged into?

Answer 1

Red outlet. Not a power strip.

Question 2

Cardio help: what does alarm “pump disposable error” mean?

Answer 2

Pump was dislodged, reseat it and then go to deep zero.

Question 3

On Nautilis oxygenator- set alarms to what?

Answer 3

0-290- not less then zero. And X will show.

Question 4

What kg gets a femoral cannulation?

Answer 4

20kg, usually 2y.o. Whose been walking

Question 5

When cannulating or circuit change- when should you send down your VBG instead of doing an istat?

Answer 5

When your on iNO

Question 6

What surgeon gets paged in a cardiac blast page?

Answer 6

Both CV and general

Question 7

Does an isolet have fleuro?

Answer 7

No

Question 8

When water accumulates and you need to sigh, what do you see first?

Answer 8

Decreased ability to remove CO2(page 8), it rarely affects oxygenation. But then page 29 says you see lower post oxy pO2 and rising gas pressure. Page 42 says both

Question 9

What meds cause an interference with the gas exchange of the oxygenators?

Answer 9

Protocol & lipids

Question 10

What is the limiting factor for getting faster flow?

Answer 10

The venous cannula size

Question 11

What is the usual max flow rates needed for just cardiac failure in neo/peds/adults?

Answer 11

100ml/kg/min neo
80ml/kg/min peds
60ml/jg/min adults

Question 12

When the LV function is minimal & there is lung dysfunction- what’s going on with the coronaries? On ecmo

Answer 12

The LV diastolic pressure rises which causes reduction in coronary perfusion. And if you have some cardiac function; but bad lungs the blood getting to the coronaries is less oxygenated since the heart is perfusing the coronaries not the Ecmo pump. As long as the aortic valve is opening the primary source of coronary blood flow is from the heart.

Question 13

What happens when the LV is distended?

Answer 13

Pulmonary edema & hemorrhage. And worsens LV dysfunction. And a clot can form in LV

Question 14

Roughly what amount of femoral cannulations need a reprofusion cannula?

Answer 14

1/3- so if femorally cannulated watch the perfusion closely!

Question 15

Signs of North south syndrome

Answer 15

Low cerebral NIRS, low sats on one/both arms, bad ABG on radial gasses. Fix with arterial catheter to RIJ

Question 16

To improve oxygenation in VA ECMO with no native lung function:

Answer 16

More hgb, flow, FIO2, improve CO, sedate/paralyze. If lung function can try vent setting changes

Question 17

Why are VV goal sats 80-95 if no lung function?

Answer 17

ECMO blood with always mix with patients venous blood, so it’s always mixed

Question 18

When we say to increase Ecmo flow when initiating Ecmo at a 1:1 ration- what does that mean

Answer 18

If the patient is on 100mls/kg/min sweep is 1.

Question 19

What do you do if your VV Ecmo patient isn’t achieving adequate oxygenation? (You already have good placement, flow, hgb…)

Answer 19

Add another venous drainage cannula so you can get more more Ecmo flow.

Question 20

What is the main contributor to oxygen delivery?

Answer 20

Ecmo flow. Check SVO2 to judge adequate oxygen delivery to tissue. Flow is also the primary way to affect patient sats.

Question 21

Why won’t FIO2 adjustments help increase the SVO2 much?

Answer 21

Because all of the blood is usually 100% saturated leaving the oxygenator

Question 22

How is the SVO2 on VV Ecmo?

Answer 22

Inaccurate, recirculation

Question 23

Raising the FiO2 on the sweep above what is needed to fully saturate blood leaving the oxygenator….

Answer 23

Adds very little to oxygenation. You need more flow or hemoglobin

Question 24

On a cardiohelp, the main limiting factor to flow is cannula size, so at some point increasing RPMs…

Answer 24

Doesn’t increase flow and only causes a more negative bladder pressure and hemolysis

Question 25

If a circuit is primed, but then not used, how long till we have to monitor the gas/lytes?

Answer 25

1hr. It’s good for 4hrs

Question 26

If a patients SVO2 is slower than the parameters, what other things can we look at to determine if that SVO2 is okay for them?

Answer 26

Lactate, urine output, vitals. They may not want to increase flow in order to rest the stressed ventricles (don’t want LV distention)

Question 27

To increase oxygen delivery:

Answer 27

Flow, hemoglobin, FiO2…. Sedate, paralyze, use vent…

Question 28

If your LV is distended from high flow and low function, how are your coronaries feeling?

Answer 28

Not great. There is less coronary blood flow

Question 29

On VV, what flow rates are typical going to cause too much recirculation?

Answer 29

120-150mls/kg/min

Question 30

4 things that affect VV recirculation

Answer 30

Flow, position, volume, cardiac output (any tamponade?)

Question 31

On VV, is patient has poor sats or SVO2 (we think, this value will be inaccurate)- how do you improve oxygenation?

Answer 31

Potentially more cardiac output- so inotropes, increasing pump flow as long as you’re not overcirculating, more hemoglobin, increase Fso2, ventilator settings

Question 32

What happens to patients who have too much metabolic alkalosis (from diuretics and blood products?)

Answer 32

Hemoglobin doesn’t unload oxygen well, and hearing loss. Give diamox At

Question 33

Any time cannula is in RCCA you may have trouble…

Answer 33

Picking up sats in R arm

Question 34

What kind of cannula cannot be stented?

Answer 34

Femoral venous cannulas

Question 35

VV weaning recommendations

Answer 35

Flow 40, then wean sweep

Question 36

What is the preferred volume replacement for the initial capillary leak/third spacing phase?

Answer 36

FFP, to provide clotting factors

Question 37

Best way to decrease plasma hemoglobin in setting of an aging circuit?

Answer 37

Circuit change

Question 38

Considerations of PEEP when first on Ecmo?

Answer 38

Peep 12 for capillary leak unless normal lungs and cardiac dysfunction to preserve preload

Question 39

Pneumo’s on Ecmo

Answer 39

Can leave to be reabsorbed if asymptomatic. Keep vent settings low.

Question 40

Management of pulmonary hemorrhage

Answer 40

High PEEP for tamponade effect and racemic Epi for vasoconstriction. Or remove ventilation and allow lungs to collapse. Was the plum hemmorage from LV distention and a septostomy is needed?

Question 41

Things that cause hemolysis

Answer 41

Sepsis, clots (in circuit or patient), negative pressure, over heating, or dying organs.

Question 43

INR- what’s it a reflection of, what doesn’t impact it, how do we correct it ?

Answer 43

It’s a reflection of clotting factors, not affected by heparin or platelets, FFP corrects it and cryo does too

Question 44

A prolonged ACT with little heparin due to coagulopathy doesnt

Answer 44

Protect against clotting. Correct coagulopathy

Question 45

Circuit DIC signs:

Answer 45

Low platelets, fibrinogen & prolonged INR

Question 46

Emergency release blood for <4mo

Answer 46

Must be irritated, which takes 17 mins

Question 47

What type of preservative is preferred in priming & why?

Answer 47

Adsol removed, not CPDA? High K

Question 48

If you have LV stun, what band aid can you do while waiting for PFO?

Answer 48

Inotropes & after load reducers

Question 49

If you lose arterial cannula you can use the Ecmo pump as rapid blood product

Answer 49

Clamp patient off. Keep running circuit by opening bridge. Arterial side is clamped above bridge. Connect rapid infuser in bladder. Unclamp venous limb and move clamp to below bridge but before bladder. Can do similar thing with venous cannula loss, just rapid infuse and keep bridge closed and venous cannula clamped.

Question 52

Sign out of OR computer

Question 54

Who must be present to decannulate in ICU or OR?

Answer 54

Perfusion

Question 56

When can you release Ecmo blood from blood bank?

Answer 56

After cannulas are removed.

Question 57

ACTs should be run as

Answer 57

VBG (not pVBG)

Question 59

Where are Ecmo femoral sheaths found?

Answer 59

Red bag on CV and PI line carts