Study Guide Flashcards
(270 cards)
1
Q
What anticoagulant is used for neonatal/peds patients?
A
Heparin
Neonate loading dose 100 units/kg
2
Q
What anticoagulant is a direct thrombin inhibitor?
A
Bivalrudin
3
Q
What is the desired range for ACT?
A
ACT in bleeding = 160-180 sec
4
Q
What is the desired range for AntiXa
A
Normal 0.3-0.7
Bleeding 0-2-0.25
5
Q
What factors affect how this range is determined?
A
Bolus dose of Heparin in Neonate with ACT >300.
Maintenance dose 180-220 sec.
6
Q
What elements are required for heparin to work?
A
ATIII
7
Q
What test measures the effectiveness of bivalirudin?
A
PTT, ACT, TEG
8
Q
What does PTT measure?
A
How long it takes for a clot to form.
9
Q
What is normal PTT?
A
25-35 sec
10
Q
What is the normal range of PTT while on ECMO?
A
60-80 sec.
If stranding/clots seen will increase range.
11
Q
What are the 2 pathways in the coagulation cascade?
A
Extrinsic and Intrinsic
12
Q
How is each pathway activated?
A
Extrinsic = tissue injury (Factor 3 to Factor 7)
Intrinsic= foreign body and inflammation (TF 12)
They both lead into the common pathway at Factor 10.
13
Q
What are the tests used to evaluate anticoagulation in the neonate?
A
ACT & TEG initially then AntiXa & PTT.
14
Q
What is the bolus dose of heparin given to a large ped/adult ?
A
10,000 IU/KG
15
Q
What is the bolus dose of heparin given to an infant or small child?
A
100 IU/KG
16
Q
Which drug with CRRT affect?
A
Heparin
17
Q
Why will heparin affect CRRT?
A
it pulls across the membrane and clear it out
18
Q
What is the reversal agent or antidote for heparin?
A
Protamine
19
Q
What is the reversal agent or antidote for Bivalrudin?
A
NONE
20
Q
Calculate the bolus dose of heparin for 4Kg patient? The concentration of heparin = 1,000 units/1ml
A
4 KG x 100 IU/kg= 400 IU
400 % 1000= .4ml
(bolus dose =100)
21
Q
Calculate the infusion rate of heparin with the following:
Concentration = 100 units/ml
Dose = 30 units/kg/hr (infusion)
Pt weight = 4KG. If the ACT came back with level of 240 s what would I do?
A
Decrease the dose per protocol. Could do nothing and wean per AntiXa NOT ACT.
22
Q
What is ACT?
A
Activating Clotting Time
23
Q
What does ACT measure?
A
Measures the entire time it takes for a clot to form from whole blood.
24
Q
What are the unit of measure for ACT?
A
Seconds.
25
What bedside test device(s) are used to run the ACT?
POC Hemochron
Signature Elite
26
Why is the ACT elevated in the prime?
Only PRBC's are used in the prime then there are no clotting factors.
27
What anticoagulant does the ACT measure best?
Heparin
A Kaolin activated ACT will give a false high measurement for Bivalrudin.
28
Is the ACT an exact measurement?
No, has a +/- 20 % error
29
What are the factors that affect anticoagulation?
Platelet function, temp, ATIII deficiency, Hypotn, Sepsis, Liver Dysfunction, DIC, Body habitus.
30
What is the dose of Heparin goes into the adult circuit?
NONE.. bolus is given to the patient.
31
What is the dose of Heparin for the neonatal circuit?
0.2 mls (20 units)
32
What are PRBC?
Packed Red Blood Cells
33
When is PRBC given?
Adults <7
Neonates <10
34
Why is PRBC given?
To increase O2 carrying capacity
35
What is Cryoprecipitate ?
Small volume is rich in fibrinogen
36
When is Cryoprecipitate given?
Good to give to peds because it is low volume dosage with high yield.
37
Why is Cryoprecipitate used?
Fibrinogen helps stabilize bleeding, its ideal to use in neonates who commonly bleed from cannulation sites
38
What is FFP?
Fresh Frozen Plasma
39
When is FFP given?
INR > 1.5
40
Why is FFP given?
To give clotting factors to a bleeding patient.
41
What are platelets?
Manufactured by whole blood and binds to fibrinogen
42
When are platelets given?
Adults don't get platelets transfused unless bleeding.
Adult platelet count <15,000.
Peds/neo platelet count < 80,000. Pt dependent
43
How are platelets given to adult ECMO patients?
Peripherally via nurse
44
What are the blood components given into the neonatal circuit?
PRBC, FFP, Platelets
45
Where are the ports used to give blood products on neonatal circuit?
PRBC= one of the venous pigtails, manifold on venous side ran on a syringe pump.
FFP= one of the venous pigtails, manifold on venous side. Ran on syringe pump.
Platelets= Arterial side of the bridge. Pushed manually , 5cc every 5 min, after giving full amount, flush line with saline to clear.
46
What is the usual dose or volume of PRBC, FFP, platelets for a 4 KG child?
10-15 cc/kg (if the patient is exsanguinating then 20 cc/kg)
47
What does it mean to use emergency release blood?
Not crossed-matched
O (-) blood
48
What does blood type mean?
Blood types are determined by the presence or absence of certain antigens.
49
What blood type is the universal donor?
O negative
50
What blood type is the universal recipient?
AB positive
51
What are the special requirements for infants <4 months with respect to blood?
Initial sample at birth
sample is good for 4 months due to immature liver not making anitgens.
52
What part of the blood carry antibodies?
Plasma
53
What is thrombocytopenia?
Low platelet level
54
What is given when someone has thrombocytopenia?
Platelets
55
When does RH matter?
Women of pregnancy age as well as pregnant women?
56
How long does blood stay in the unit refrigerator?
There is NO UNIT refrigerator but can stay in the coolers for 12 hours.
57
What factors may be placed in the refrigerator?
PRBC, FFP
NO PLATELETS
58
Trace the blood flow through your circuit from cannula tip to cannula tip on CardioHelp (ADULT)
CardioHelp (ADULT)
1. Venous Cannula
2. Pre-pump/Pre-oxygenator/CRRT- Return pigtail
3. Venous sat probe (hb,hct venous temp)
4. Centrifugal Pump
5. Connection for pressure monitor cable
6. Yellow de-airing cap
7. Oxygenator (7.0)
8. Post-pump/post- oxygenator/De-airing/CRRT Pull pigtail.
9. Post-pump/Post oxygenator/ABG pigtail
10. Flow probe & bubble detector
11. Arterial Cannula
59
Trace the blood flow through the circuit from cannula tip to cannula tip on CardioHelp (PEDS).
1. Venous Cannula
2. Bridge (Venous side) & CRRT Return
3. Venous Manifold Port
4. Venous Sat probe (hb, hct, venous temp)
5. CardiHelp Centrifugal Pump
6. Connection for Black Pressure Monitor Cable. Post pump/preoxygenator/ VBG pigtail
7. Yellow De-airing Cap
8. Oxygenator (5.0)
9. Postpump/post oxygenator De-airing pigtail
10. Post pump/Post oxygenator Arterial Manifold Port
11. Flow probe & bubble detector.
12. Bridge (arterial side)
13. Arterial Cannula
60
Trace the blood flow through the circuit from cannula tip to cannula tip on Rotaflow (ADULT)
1. Venous Cannula
2. Venous Spectrum Sat probe (SV02)
3. Pre-pump /pre-oxygenator/CRRT Return pigtail
4. Rotaflow Centrifugal Pump
5. Post pump/preoxygenator/ VBG pigtail.
6. Yellow De-airing Cap
7. Post-pump/Post oxygenator/de-airing/CRRT Return Pigtail
8. Post-pump/post oxygenator/ABG pigtail
9. Spectrum Arterial sat probe (hb, hct )
10. Spectrum Flow Probe
11. Arterial Cannula
61
Trace the blood flow through the circuit from cannula tip to cannula tip on neonatal circuit with Spectrum.
1. Venous Cannula
2. Venous Spectrum Sat Probe
3. Venous Manifold Port
4. Bridge (Venous side) & CRRT Return
5. Pre-pump/pre-oxygenator Venous Pressure line (DLP RED BOX
6. (2) Pre-pump/Pre-oxygenator pigtails for MED infusions
7.Rotaflow Centrifugal Pump
8. Pre-oxygenator Pressure Line (DLP RED BOX)
9. Oxygenator (5.0)
10. Yellow De-airing Cap
11. Post Oxygenator Arterial Pressure Line (DLP RED BOX) & CRRT pull access.
12. Post-pump/Post oxygenator Arterial Manifold port
13. Spectrum Arterial Sat Probe (hb,hct)
14. Bridge (Arterial side) & Platelet Infusion Access.
15. Spectrum Flow Probe
16. Arterial Cannula
62
What is the different about the neonatal circuit from the adult Rotaflow and CardioHelp?
Bridge, more venous pigtails and manifold
63
What is the function and location in the circuit of the following
Arterial and venous sat probes
CardioHelp Venous= Pre-pump on the mounted sensor
CardioHelp Arterial=Post oxygenator near the pigtail for ABG access.
Rotaflow Venous=(Spectrum Monitor)=External probe near venous cannula
Rotaflow Arterial (Spectrum Monitor) External probe near arterial cannula
Neonatal Venous= (Spectrum Monitor)=External probe placed close to the patient from the recirculation line from manifold.
64
What is the function and location in the circuit of the
Pigtail
Adult CardioHelp =
4 pigtails
1. venous line post-
pump/preoxygenator,
2. post-pump /post
3. oxygenator/de-airing/post
4. pump/post oxy/ABG
65
What is the function and location in the circuit of the
Venous Pressure
Adult /Pediatric CardioHelp
Internal reading pre-pump
Neonatal Circuit
On a red box connected to the post-pump/preoxy port (Y'd in with the preoxy pressure)
66
What is the function and location in the circuit of the
Pre oxygenator pressure
Adult/Ped CardioHelp
Internal post-pump/preoxy
Neonatal Circuit
On a red box connected to the post pump/preoxy port (Y'd in with the post oxy pressure)
67
What is the function and location in the circuit of the
Post oxygenator pressure
Adult/Peds CardioHelp
Internal near the post-pump/post oxy/ABG pigtail
Neonatal Circuit
On a red box connected to the post-pump/post oxygenator port( Y'd in with the preoxy pressure)
68
What is the function and location in the circuit of the
Oxygenator
Oxygenates the blood, removes CO2, also acts as the heat exchanger between the circuit and heater/cooler. Placed Post pump.
69
What is the function and location in the circuit of the
Rotaflow Centrifugal Pump
Preoxy, pushed blood into the oxygenator.
70
What is the function and location in the circuit of the
CardioHelp Centrifugal Pump
One unit with the oxygenator (still technically preoxy within the circuit).
71
What is the function and location in the circuit of the
Bridge in neonatal/ped CardioHelp
Neonatal= Venous side is placed between the manifold recirculation line and the venous pressure line, Arterial side is Closer to the patient.
72
Is there a bubble detector in the neonatal circuit?
No, not in the true sense. Spectrum monitor does have the ability to track emboli.
73
Where is the blood flow measured in the neonatal circuit?
Spectrum monitor flow probe closest to the patient on the arterial side.
74
Where is blood flow measured in the CardioHelp circuit?
Flow probe closest to the patient on the arterial side.
75
Where is the blood flow measured in the
Adult Rotaflow circuit?
Spectrum monitor flow probe closest to the patient on the arterial side.
Needs addition of past t the pump head directly out of the pump. Not accurate for flows < 1L, does not account for flows lost in shunts within the circuit (bridges and manifold.)
76
Where is the blood flow measured in the
LifeSparc Circuit
Flow probe closest to the patient on the arterial side.
77
Where is the blood flow measured in the
Centrimag circuit
Flow probe closest to the patient on the arterial side.
78
What is the difference between the CardioHelp and Rotaflow Centrifugal pump?
CardioHelp is on unit with an oxygenator, has internal measurements, and used 4 channels to disperse the blood throughout the oxygenator.
Rotaflow is a single outlet, resting on a sapphire pin.
79
How does the Centrimag compare to the other pumps?
Centrimag full magnetic levitation (no bearing). The bearing is a place for a clot to form and and area where temperature can increase, causing hemolysis.
80
How does the LifeSparc compare to the other pumps?
LifeSparc has a single port ruby bearing with a 16 ml priming volume and is why it needs higher RPM's to reach the same amounts of flows as the others.
81
Describe oxygenator failure?
Decreased oxygen exchange. Unable to add oxygen and remove CO2 even with increased sweep.
82
What parameters do you evaluate every day to determine how well the oxygenator is working?
VA ecmo
Delta P and venous sats
VV ecmo
you would look at the patient's saturation . Recirculation can cause an increased venous saturation.
83
What would you see on a patient's blood gas that might make you think failure?
PaO2 < 50
Acidosis
High PCO2
84
What physical things do you check on the circuit to determine the functional status of the oxygenator?
Check for clots, check the gas line.
85
What factors might cause an oxygenator to fail?
Clots, condensation in the oxygenator, occluded gas exhaust causing increased gas pressures on the membrane.
Sighing the membrane is done to expel the condensation from the oxygenator.
86
What might the gas exhaust look like in a failing oxygenator?
If it is pink/red condensation
87
What might you see in lab values of a failing oxygenator?
High plasma free HBG, poor ABG (pump and patient), decreased patient SAO2.
88
What is the minimum/maximum sweep for
Neonatal Quadrox
0.1-3 L/min
89
What is the minimum/maximum sweep for
Pediatric Quadrox
0.1-5.6 L/min
90
What is the minimum/maximum sweep for
Small adult Quadrox & 5.0 CardioHelp
0.25-10 L/min
91
What is the minimum/maximum sweep for
Adult Quadrox & 7.0 CardioHelp
0.25- 14L/min
92
What is the minimum/maximum sweep for
Neonatal Euroset
0.1-3 L/min
93
What is the minimum/maximum sweep for
Nautilus ECMO Smart Oxygenator
0.25-14 L/min
94
What is the minimum/maximum blood flow
Neonatal Quadrox
0.2-1.5 L/min
95
What is the minimum/maximum blood flow
Pediatric Quadrox
0.2-2.8 L/min
96
What is the minimum/maximum blood flow
Small Adult Quadrox & 5.0 CardioHelp
0.5-5.0 L/min
97
What is the minimum/maximum blood flow
Adult Quadrox & 7.0 CardioHelp
0.5-7.0 L/min
98
What is the minimum/maximum blood flow
Neonatal Euroset
0.2-1.5 L/min
99
What is the minimum/maximum blood flow
Nautilus ECMO Smart Oxygenator
0.5-7.0 L/min
100
What is an indicator of clot formation in your circuit?
Dark spots in the circuit, increase in Delta P, increase in venous pressure and chugging (if clot is in venous cannula) increased arterial pressures if the arterial cannula is unable to flush/draw from pigtails.
101
What does venous pressure tell me about my patient and the circuit?
An increased venous pressure(chugging) indicates that the patient is hypovolemic . Could also indicate misplacement in the cannula (try decreasing flows some and the flow back up)
102
Describe the phenomena of recirculation
When drainage and return cannulas are too close together they will recirculate the blood throughout the circuit and not deliver it to the patient.
103
What mode is recirculation likely to be seen?
VV ECMO
104
How do you resolve recirculation in VV ECMO
Reposition cannula, decrease flows. Most of the time you will be asked to decrease flows first because the repositioning of cannulas is risky.
105
What factors affect recirculation?
Increased blood flow, cannula position
106
What determines if a patient is ready to be weaned from VV ECMO
Improved blood gases with less support. Underlying issue treated/ recovered.
107
What determines if a patient is ready to be weaned from VA ECMO
Improved cardiac function, hemodynamics, EF 30%, weaning of supporting meds,. Underlying issue treated/recovered.
108
How is a patient tested to see if they are ready to be weaned from VA ECMO
Peds/Neos have many clamp out trials, adults will do a low flow trial at 1L or will utilize zero flow mode momentarily (under the direction of a physician) as well as a sweep around 1-2 with 50% is FIO2.
109
How is a patient tested to see if they are ready to be weaned from VV ECMO
Cap the oxygenators (Peds/Neos- 12 hours, adults 24 hours). Draw periodic patient ABG's.
110
Describe how the patient is weaned from VV ECMO
Only wean the sweep. Don't change the flows. Adults off sweep for 24 hours+, peds 12 hours+
111
Describe how the patient is weaned from VA ECMO
Wean flows and sweep
112
Why is weaning different between VA and VV Ecmo
VA ECMO supports the cardiac system. Need to wean based on cardiac function
VV ECMO support the pulmonary system. Need to wean based on lung function
113
What are the potential air traps in the ECMO circuit
Oxygenator
Top of the oxygenator, remove the air with de-airing membrane and pigtail
114
What are the potential air traps in the ECMO circuit
Cannula
At the connectors, remove air at the nearest pigtail.
115
What are the potential air traps in the ECMO circuit
Centrifugal Head
With enough air, will stop forward flow. Remove air at the nearest pigtail
116
Trick Question:
When assessing a patient's oxygenation status on VA ECMO, which is the best indicator of adequacy of oxygenation?
Pre-membrane Saturation
117
Define hemolysis
When blood cells rupture.
118
What caused hemolysis?
Turbulent flow, increased heat caused by pump, high pressures due to increased resistance ( small cannulas, clot in oxygenator), severe acidosis (making changes to quickly)
119
What lab test is drawn to evaluate degree of hemolysis
Plasma free Hbg
120
How do you treat the circuit when hemolysis occurs
Check for clots, kinks in the tubing, pre-membrane pressure <300 mmHg, possibly add albumin to prime, limit negative venous pressure.
121
What is the normal range for Plasma free HGB
<12 mg/dL ( when >50 mg/dL, discussion to change circuit begins, can cause renal impairment.
122
Normal Lab
PH
7.35-7.45
123
Normal Lab
PCO2
35-45
124
Normal Lab
PO2
on ECMO > 200
125
Normal Lab
Lactate
0.5-2
126
Normal Lab
Bicarb (HCO3)
22-28
127
Normal Lab
Base deficit
+/- 4
128
Normal Lab
HGB/HCT
12-15 women
13-17 men
On ECMO Adults >7
On ECMO Peds >10
129
Normal Lab
Sodium (Na)
135-145
130
Normal Lab
Potassium (K)
3.6-5.1
131
Normal Lab
Serum calcium
8.9-10.7
132
Normal Lab
Ionized Calcium
1.16-1.32
133
Normal Lab
Ionized Magnesium
0.46-0.64
134
Normal Lab
PT
12.3-14.8 sec
135
Normal Lab
PTT
25-36 sec
on ECMO 60-80 sec
136
Normal Lab
AntiXa
unfractionated heparin
On ECMO 0.3-0.7
if bleeding 0.2-0.5
137
Normal Lab
ATIII activity (<30 days, >30 days
<30 days = 44-76%
> 30 days = 80-120 %
ATIII binds with heparin to work as an anticoagulant, heparin does not work by itself.
138
Normal Lab
Cultures
Goal is negative cultures in blood, urine, respiratory
139
Normal Lab
Plasma HGB
<12
140
Normal Lab
Fibrinogen
200-400
141
Normal Lab
INR
<2
On ECMO < 4.9
142
Normal Lab
Troponin
0-0.4
143
Normal Lab
CK
40-350
144
Normal Lab
CK mb ( creatinine)
0-5
145
Normal Lab
ALT
0-40
146
Normal Lab
AST
0-95
147
Describe the relationship of tests on ECMO
Head Ultrasound
Neonates/Infants
148
When is Head US done?
Pre-cannulation and then once a day for the first 3 days, then every other day.
149
What does Head US results show
ICH, blood in the ventricles.
150
Why is the importance of getting Head US for ECMO
ICH is a contraindication for ECMO, it is a grade 1-2 then they will monitor closely, it is a grade 3 or larger , will either DC ECMO or not start ECMO.
151
Describe the relationship of tests on ECMO
Chest X-ray
This is done on all ECMO patients
152
When is the Chest Xray done
After cannulation and daily/PRN
153
What does the Chest X-ray results reveal
Cannula placement
154
What is the importance of getting Chest X-ray for ECMO
Misplaced cannulas can cause decreased flows, chugging, recirculation (VV), high negative and positive pressures.
155
When is a Cardiac Echo done for ECMO
Adults- during weaning and PRN to confirm placement of cannula
Neonates- Pre-Ecmo and PRN to confirm placement of cannula
156
Are Cardiac Echo's done on all patients
Yes
157
What do we learn from Cardiac Echo?
Cardiac function, pulmonary artery pressure
158
Are the results of a Cardiac Echo usually normal or abnormal
Normal for VV ECMO
Abnormal for VA ECMO
159
When are CT done for ECMO
A change in the patient's status
160
What do we learn from CT Scan
Check for head bleed, abdominal function with contrast
161
What does the CT scan affect the care of the patient
Gives immediate results, Patient may not tolerate test. If results are poor, then a conversation may happen to DC ECMO
162
Do all patients have CT Scans
No, would only need one done for specific change in status.
163
When would Fluoroscopy be used for ECMO
to place a double lumen cannula safely
164
What does Fluoroscopy tell the practitioner
Cannula placement
165
What ECMO are most likely to use Fluroscopy
VV ECMO
166
When would a patient get a Cardiac Cath done for ECMO
If the patient has had a STEMI, any patient on ECPR, create balloon septostomy in neonates
167
Can patients on ECMO to the Cath Lab
YES
168
What information is gained from the Cardiac Cath Lab
Check for coronary blockages
169
What is the ultimate goal of ECLS
Buy time for treatment modalities to work
170
What is the most common bacterial pneumonia caused by
Streptococcus is the most common community acquired pna
171
What is the minimum weight for Neonatal ECMO and why
2 KG
cannula sizing
172
What is the maximum weight for ECMO and why
VV-50 BMI with lots of support
40 BMI normally
173
What is the minimum gestational age
34 weeks
174
What does the perfusionist need on arrival for ECMO
Cannulation cart, 100 IU/kg heparin, clamps, sterile instruments, dilators, blood , meds for the blood prime (ECMO priming kit from pyxis, open bed.
175
What is my role in setting up circuit for a patient
Plug it in, plug in gas lines, make sure oxygen is hooked up, water for the heater/cooler, go through pre-initiation checklist, getting ECMO specialist patient cart to the room, do EQC for signature elite for ACT
176
What side of the neck is prepped for ECMO
Right side
177
What things do I check to confirm the circuit is ready
The checklist
178
How do I help the perfusionist
Assistance
179
ABG=7.25/35/210/BE -7.0
What would the perfusionist do
Nothing, look at the patient's ABG and let acidosis work itself out
180
What would the flow be for a
10 FR arterial cannula/12 FR venous cannula
Normal flow for infant/peds patient is 100-150 ml/kg
Should get full flow with these cannulas
181
What would the range be for 10 F arterial /12 F venous cannula
350-525 ml/min
182
What would happen to the flow if both cannulas were 8F
Flows would decrease due to increased resistance.
183
Pt=752/32/52
Pump= 748/36/240
sweep= 0.4
FIO2 50%
Q8=0.38
What would I change
Decrease sweep, increase flow
184
When would fluid be removed during hemofiltration
Occurs due to pressure gradients
184
What are signs of oxygenator failure
Increased Pre membrane pressure
Decreased oxygen and CO2 transfer
Hemoturia
Blood leak from the gas egress
185
When would Heparin doses need to be altered when CVVH is added to the system
The hemodiafilter absorbs all heparin.
186
What mechanism improves ECMO oxygenation delivery
Stabilization of HBG saturations
Taking over at least 60% of the blood flow through a functioning membrane lung, away from sick native lung
Taking over at least 60% of the CO through the ECMO pump
All of the above
187
Membrane failure can be characterized by a raising pump CO2 level .. why?
Changes is blood flow patterns caused by a clot
Changes in sweep gas flow patterns caused by clot
Alteration in membrane surface area caused by fibrin formation
Changes in oxygen concentration due to fibrin formation
188
What is the ultimate goal of ECLS?
To maximize oxygen delivery
189
What supplies are needed from the cannulation cart for VA ECMO
Dilators (pikA,sorin dilators) , Venous and Arterial cannula(s) Re-profusion cannula (7" tubing & double male adapter, may need Micropuncture introducer set) Sterile instrument box, silk of prolene suture ( size 0)
190
What supplies are needed from the cannulation cart for VV ECMO
Dilators(venous dilators only), Venous Cannula(s) Sterile instrument box and sutures.
191
What is a re-profusion cannula?
Low limb extremity to prevent ischemia.
192
When is a reprofusion cannula used
VA ECMO
193
What is Cardiac Output
Amount of blood pumped by the heart in L/min
194
What is Cardiac Index
CO/BSA
Hemodynamic parameter that relates to the CO from the left ventricle in 1 min to the BSA
195
What is BSA
Body surface area
196
CO=HR x SV
for native Cardiac Function
Cardiac Output
197
CI=CO/BSA=SV x HR/BSA
Cardiac Index
198
CO=CI x BSA
Used to assess our ECMO Flow
199
What is viscosity
Thickness of blood
200
How does viscosity affect ECMO flow?
Increase in thickness= decrease in flow
201
What is afterload
The amount of resistance that the heart has to overcome to open the aortic valve. On ECMO, afterload is the patient's BP or cannula size resistance.
202
What is preload
Volume of blood in the ventricle and end diastolic pressure
203
What does increase in preload do to ECMO flow
Can flow more, negative pressure would become less negative. Would not limit ability to flow
204
What does decrease in preload to do ECMO flow
Decrease in preload=decrease in flow due to less volume in patient
205
How does increased afterload affect ECMO
Increased afterload=decrease in flow
Increased afterload=increased arterial pressure
206
How does decreased afterload affect ECMO
Decreased afterload=increase in flow
207
What is the initial bolus of heparin for a 3.5 kg infant
100 units/kg
350 IU
208
What is the initial bolus of heparin for a 100 kg adult?
10, 000 units
209
What is the initial bolus of heparin for a 75 kg adult
10,000 units
210
What is the priming volume for a Rotaflow pump
32 ml
211
What is the priming volume for the CentriMag pump
31 ml
212
(HB x 1.34 x SaO2) + (PaO2 x 0.0031)
Oxygen Content
213
What are the 2 most important variables in Oxygen content calcuation?
HB and SaO2
214
For each oxygen content delivery variable, what can improve the O2 content /O2 delivery
Increase in flow, FIO2 and HB
215
CaO2 x CO
Oxygen Delivery calculation
216
What is the best indicator of oxygen delivery in VA ECMO
ECMO SvO2
217
What is the best indicator of oxygen delivery in VV ECMO
Patient SpO2, patient gasses
218
What influences oxygen delivery on VV ECMO
Patient lungs, recirculation , Hb , CO, FIO2
219
What influences oxygen delivery on VA ECMO
Hb, CO, FIO2
220
What pressures are monitored in a neonatal/ped circuit?
Venous pressure
Pre-membrane pressure
Post membrane pressure
221
What does the venous pressure monitor in neo/peds circuit
Venous=patients volume status
Pre-membrane= oxygenator for clots
Post membrane= afterload
222
What pressures are monitored on the the CardioHelp circuit
Venous pressure
Pre-membrane pressure
Post membrane pressure
223
What does the venous pressure monitor on the CardioHelp
Venous=patients volume status
Pre-membrane= oxygenator for clots
Post membrane= afterload
224
What pressures are monitored on the Rotaflow circuit
Quadrox=NO pressure monitoring
Nautilus= Pre-and Post membrane
Pre-membrane=oxygenator for clots
Post membrane= monitors afterload
225
What parameters are monitored by the venous probe on CardioHelp
Hb,Hct, SvO2, venous temp
226
What parameters are monitored by the Spectrum
Venous probe (SvO2)
Arterial probe ( Hb, Hct, SaO2)
Flow probe (Blood flow, bubbles
227
Mode that can be manually set to periodically allow for the pump RPMs to be on to adjust for just enough flow to prevent backflow but not have any forward flow. Used to assess a patient's native CO during weaning without having to place clamps on the line.
Zero Flow
228
What is the most common complication of ECLS?
Bleeding , anticoagulation
229
4 reasons to emergently remove ECMO
Excessive bleeding
ICH
Air embolism/clots
Accidental decannulation
230
5 causes of air entrainment
Venous pigtail open on negative pressure side.
Air from central lines, (albumin on a pressure bag)
High negative pressures causing cavitation
Cracked hard plastics within the venous side of circuit
From the oxygenator= blocked gas exhaust causing increased gas membrane pressures that can rupture the membrane and allow gas bubble straight into the blood side.
231
When blood from return cannula is pulled directly into the pull cannula without being directed to the patient
Recirculation
232
4 factors that affect recirculation
Cannula position
Pump flow
CO
Intravascular Volume
233
What is the major limiting factor for ECLS blood flow
Decreased Preload
234
If PaCO2 is high, how do I adjust sweep gas flow rate
Increase
235
At what increments is the sweep gas flow rate changed
Adults=0.5-1L/min
Neo = 0.1 L/min
Ped = 0.2-0.5 L/min
236
How is the sweep gas flow adjustment assessed
Redraw an ABG
237
What is measured by the Hemochron Signature Elite
ACT
238
How is the parameter "armed" for the CardioHelp
Chain link page
Go to each parameter and arm manually or disarm manually
239
Steps for getting CardioHelp circuit ready for surgeon
Clamp the venous and arterial lines near the oxygenator with the tubing clamps
Clamp all 4 big white robertson clamps
Break it apart using quick connects and connect them forming a loop
Open the circuit to be handed up to the surgeon sterile
Instruct to clamp and cut the circuit. (clamp at the stickers indicated, cut between the clamps and quick connect
240
What is the difference between CardioHelp and Rotaflow pump heads
CardioHelp is built into the oxygenator, and it has 4 outflow channels to distribute flow more uniformly throughout the oxygenator'
Rotaflow is a single outlet pump that uses a sapphire bearing
241
What are the signs of cardiac tamponade on VA ECMO
Decreased flows, Venous line chugging and more negative venous line pressure due to decreased venous return to the heart causing decreased preload. Pulsatility would decrease or go away completley
242
What are signs of pneumothorax on VV ECMO
Decreased lung compliance, decreased SpO2, decreased flow due to decreased venous return to the heart causing decreased preload.
243
What parameters do you inspect when doing your circuit checks
All of the parameters
Pressures, flows, sweep, FIO2, Temps, sats, circuit clear of clots/air, gas exhaust is free from obstruction
244
How often are parameters checked
Q1=charting /reprofusion cannula check
Q2=sigh the membrane
Q4= flush pigtails,( more as clots form)
245
What screen on CardioHelp allows to store lab values
Press little folder button within either the SvO2, Hct, Hb
246
What machine is used for CRRT
NxStage
247
What line is clamped on CentriMag when changing pump to another external drive
Both Venous and Arterial lines closest to the patient.
248
What is he minimum RPM for forward flow on CentriMag, CardioHelp, Rotaflow pumps
1700 RPM
Backflow is bad
249
Where are primed ECMO circuits stored
OR =outside OR21
Neomart
PICU= ECMO room
CSICU=outside of room 134
250
List 4 blood products that a patient may receive.
pRBC=venous side, infusion port, syringe pump
FFP= venous side, infusion port, syringe pump
Platelets= Arterial side of bridge, manually pushed 5cc/every 5 min, flush after giving full dose
Cryo= Arterial side of bridge, manually pushed 5cc/5min, flush after giving full dose.
251
Does is make a difference if your patient is a neo or adult for giving blood products
Adults= all products given peripherally
Peds= still give pRBC and Albumin in the venous side. Prefer to give platelets peripherally but will give on the arterial side of the bridge is access is limited.
252
Why are crystalloid, albumin (5% and 25%) blood products transfused
Hypovolemia causes a decreased preload that causes decreased flow. Nothing placed on the pressure bag for ECMO patients in the CSICU
Crystalloid is used when Hct is high and volume is needed
Albumim is used to pull any volume that is 3rd spacing in the extravascular space
Blood products are used to treat specifics.
253
Euroset (Infant) Blood flow rates
0.2-1.5 L/mim
254
Euroset (Infant Sweep gas )
0.1-3.0 L/min
255
Quadrox-I (neonatal) Blood flow
0.2-1.5 L/min
256
Quadrox-I (neonatal) Sweep gas
0.1-3.0 L/min
257
Quadrox-I (peds) Blood flow
0.2-2.8 L/min
258
Quadrox-I (peds) Sweep gas
0.1-5.6 L/min
259
CardioHelp 5.0 Blood Flow
0.5-5.0 L/min
260
CardioHelp 5.0 Sweep Gas
0.25-10.0 L/min
261
Quadrox-I (small adult) Flow
0.5-5.0 L/min
262
Quadrox-I (small adult) Sweep
0.25-10.0 L/min
263
Quadrox-i (adult) flow
0.5-7.0 L/min
264
Quadrox-i (adult) Sweep
0.25-14.0 L/min
265
Nautilus smart (adult) flow
0.5-7.0 L/min
266
Nautilus smart (adult) Sweep
0.25-21.0 L/min
267
CardioHelp 7.0 (adult) Blood
0.5-7.0 L/min
268
CardioHelp 7.0 (adult) Sweep
0.25-14.0 L/min
269
