ECMO Specialist Crouse Adult 2015 Flashcards by JR Gallegos

Q

During VA ECMO what should we expect in regard to the pulse pressure?

A

Dampened Arterial Waveform

- Pulse Pressure 10 mmHg

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Q

Anything that changes the volume status of the patient will change the ratio of pump to heart flow, such as ?

A

IV
Urine
Edema
Hemoconcentrator

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Q

CVP (bladder pressure) =

A

Preload to the pump

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Q

How does the mixing cloud happen?

Mixed Arterial Blood Gas

A

Blood flow from the heart crashes with Blood from from the arterial cannula.

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Q

Minor cardiac contribution with High flow rate through femoral cannulation would result in a mixing cloud at what region ?

A

Ascending Aorta

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Q

Moderate cardiac contribution with Moderate Flow Rate through femoral cannulation would result in a mixing cloud at what region ?

A

Aortic Arch

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Q

Large cardiac contribution with minimal Flow Rate through femoral cannulation would result in a mixing cloud at what region ?

A

Abdominal Aorta

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Q

To change the PaO2 what knob would you adjust ?

A

FiO2

more true for VA than VV

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Q

To change the PCO2 what knob would you adjust ?

A

Sweep gas rate

more true for VA than VV

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Q

To change the SVO2 what knob would you adjust ?

A

Pump Flow

more true for VA than VV

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Q

How would you evaluate adequacy of perfusion with a blood gas?

A

Compare PreOxygenator with Patient ABG

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Q

How would you evaluate Oxygenator Function with a blood gas?

A

Compare PreOxygenator with Post Oxygenator

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Q

How would you evaluate Pulmonary contribution with a blood gas?

A

Compare PostOxygenator with Patient ABG

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Q

Evaluate Oxygenator
Function:

Pre  = PCO2 50   PO2 45
Post = PCO2 49  PO2 350

A

Increase Sweep

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Q

Evaluate Oxygenator
Function:

Pre  = PCO2 50   PO2 35
Post = PCO2 20  PO2 350

A

Decrease Sweep

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Q

Evaluate Oxygenator
Function:

Pre  = PCO2 50   PO2 35
Post = PCO2 20  PO2  90

Study These Flashcards

A

Increase FiO2

Q

Evaluate Adequacy of Perfusion:

Pre=   PCO2 50 PO2 35 SAT 65%
Post= PCO2 40 PO2 100 SAT 100%

Study These Flashcards

A

Perfect

Q

Evaluate Adequacy of Perfusion:

Pre=   PCO2 45 PO2 35 SAT 65%
Post= PCO2 60 PO2 100 SAT 100%

Study These Flashcards

A

More Ventilation

Increase Sweep

Q

Evaluate Adequacy of Perfusion:

Pre=   PCO2 35 PO2 35 SAT 65%
Post= PCO2 25 PO2 100 SAT 100%

Study These Flashcards

A

Less Ventilation

Decrease Sweep

Q

Evaluate Adequacy of Perfusion:

Pre=   PCO2 45 PO2 30 SAT 60%
Post= PCO2 35 PO2 60 SAT  85%

Study These Flashcards

A

More Oxygenation

Increase FiO2

Q

Evaluate Adequacy of Perfusion:

Pre= PCO2 55 PO2 28
Pt ABG = PCO2 35 PO2 100

Study These Flashcards

A

More Blood Flow

Q

What is the measure of adequacy of perfusion ?

Study These Flashcards

A

Mixed Venous Saturation (SVO2)

Q

Under what circumstances is the SpreO2 NOT a true SVO2 ?

Study These Flashcards

A

VV Recirculation
AV Shunts
Circuit Shunts (Hemoncentrator in circuit)
Patient Shunts (LV Vent)

Q

To initiate cannulation what 3 things must be accomplished ?

Study These Flashcards

A

Anesthetize
Paralyze
Heparinize

What is the patient Heparin loading dose?

100 u / Kg

Target metric for Heparin dosing ?

PTT 1.5 - 2 greater than normal | ACT 160 - 240 sec

ACT targets are based on patient acuity and blood flow in the circuit. ACT for Bleeding or high flows = ACT for Not bleeding or low flows =

ACT for Bleeding or high flows = (160 - 200) ACT for Not bleeding or low flows =(200 - 240)

what are the 4 Heparin dosing steps ?

1.) Check ACT before initiation 2.) Turn Heparin GTT ON once heparin falls into range. 3.) Start GTT at 35-50 u/kg/hr 4.) Titrate GTT to maintain target ACT.

In order to provide flow to the pump, the CVP must stay positive normally above what?

8 - 12

VLP =

CVP + Height of the table | before flow starts

If the VLP is dropping quickly . . . . . . . What is going to happend ?

The pump is about to stop pumping.

What will indicate if the RA collapses onto the cannula and blood flow stops?

Chatter in the venous line

ALP =

ABP + 200 mmHg

What 4 factors dictate ALP ?

- Cannula size - Cannula position - Patients BP - Pump Flow

What is the target Pump Flows?

2.0 -3.0 CI ( 3.5 - 5.0 LPM)

My patients PaO2 is 69%, we are failing to Oxygenate. What are the 3 Hallmarks of a failing oxygenator?

1.) Widening pre-post pressures (consider flow & SVR variations) 2.) Decreased CO2 clearence (consider sweep gas flow variations) 3.) Decreased Oxygenaion (consider FiO2 variations)

What is happening if i notice the water in the water bath is colored ? What will happen i f water pressure exceeds blood pressure?

-Blood to water leak Turn off the water bath to reduce water pressure. Water will leak into the blood = hemolysis & sepsis

VA ECMO trial Off sequence ?

1. ) Increase Vent settings 2. ) Turn off oxygenator sweep gas 3. ) Clamp cannulas, flow through bridge 4. ) Check Pt & circuit ACT Q 20 min 5. ) Flash cannulas Q 20 min 6. ) Check SVO2 to assess pt during flash

VV ECMO trial Off sequence ?

1. ) Increase Vent settings 2. ) Turn off oxygenator sweep gas 3. ) Check ACT Q 60 min 4. ) Check SVO2 to assess pt continuously