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Types of ECMO Support Flashcards

1
Q

Who can benefit from ECMO?

A

Patients who have reversible lung and/or heart condition that has responded maximal medical therapy

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2
Q

What is ECMO utilized for?

A

Cardiac Failure

Respiratory failure

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3
Q

Cardiac Failure

A

the inability of the heart to supply sufficient blood flow meet the needs of the body

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4
Q

Respiratory Failure

A

inadequate gas exchange by the respiratory system, resulting in arterial O2 and/or CO2 levels failing to be maintained in normal ranges

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5
Q

Who’s Waiting for the “ECMO Train”?

A

Primary respiratory failure (neonatal)
Primary cardiac failure (all)
Primary respiratory failure (adults)
Primary respiratory failure (peds)

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6
Q

What causes Primary Respiratory Failure (Neonatal)

A

Meconium Aspiration
Sepsis
CDH (Congenital diaphragmatic hernia)
Persistent Pulmonary Hypertension (PPHN)

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7
Q

Increased PAP will lead to what?

A

Intrapulmonary shunting hypoxia and acidosis development

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8
Q

ELSO Neonatal ECMO Criteria: Indications

A

Oxygenation Index 20- consider ECLS

Oxygenation Index 40- ECLS indicated

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9
Q

Oxygenation Index Equation

A

(Mean Airway P x FiO2 x 100)/ Post ductal PaO2

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10
Q

What causes primary cardiac failure (Neonatal and Adult)

A 
Post-cardiotomy failure - unable to wean from CPB
Myocarditis
Cardiomyopathy
Cardiogenic shock
Sepsis
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11
Q

ELSO Cardiac Criteria

A

Cardiac Index -5 x 3 hours (but less than 12 hrs)

Mean BP w/ oliguria: NB

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12
Q

Primary Respiratory Failure (Adults and Peds)

A 
ARDS
Pneumonia
Viral
Trauma
Primary graft failure following lung transplanation
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13
Q

ELSO Pediatric Criteria (Indications)

A

While no absolute indicators are known, consideration for ECMO is best within the first 7 days of mechanical ventilation at high levels of support

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14
Q

ELSO Adult Respiratory Criteria

A

Hypoxic respiratory failure due to any cause (primary or secondary) ECLS should be considered when the risk of mortality is 50% or greater, and is indicated when the risk of 80% of greater

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15
Q

50% mortality risk can be identified by….

A

PaO2/FiO2 90% and/or Murray score 2-3

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16
Q

80% mortality risk can be identified by…

A

PaO2/FiO2 90% and Murray score 3-4

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17
Q

Adult Respiratory Criteria

A

CO2 retention due to asthma or permissive hypercapnia with a PaCO2 > 80
Inability to achieve safe inflation pressures (Pplat = 30 cm HO) is an indication for ECLS
Severe air leak syndromes

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18
Q

Who else gets on ECMO?

A

Patients that don’t always fit the criteria

last resort maneuver

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19
Q

Poor patient selection =

A

poor outcomes

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20
Q

Normal Techniques for ECMO Support

A

V-A
V-V
VV Dual Lumen (VVDL)

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21
Q

Modified Conversion Tehcniques

A

VA-V (VA gets additional venous return)
VV-A (VV becomes VVA)
VVDL-A (VVDL becomes VVDL-A)

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22
Q

What is the first big question in ECMO?

A

what type of ecmo do i need?

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23
Q

Types of ECMO

A

Cardiac support
Respiratory support
Cardiac and respiratory support

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24
Q

What is the second big question in ECMO?

A

Peripheral

central

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25
Central vs Peripheral Cannulation: Advantages
Flow from Central ECMO is directly from the outflow cannula into the aorta provides antegrade flow to the arch vessels, coronaries and the rest of the body. In contrast, the retrograde aortic flow provided by peripheral leads to mixing in the arch
26
Central vs Peripheral Cannulation: Disadvantages
Previously insertion of central ECMO required leaving chest open to allow the cannula to exit. Central cannula are costly (approx 4x times as much as peripheral)
27
What is the risk of leaving the chest open?
Increased risk of bleeding and infection
28
How are the newer cannulas designed?
Newer cannula are designed to be tunneled through the subcostal abdominal wall allowing the chest to be completely closed
29
Venoarterial (V-A) ECMO
venous blood is drained through a single lumen venous cannula, oxygenated, heated and return to patient via a single lumen arterial cannula
30
What is the standard ECMO procedure used in most neonatal ICUs?
Veno-arterial bypass
31
Why choose V-A ECMO?
Almost complete cardiopulmonary support | Allows significant cardiac and pulmonary rest
32
Why NOT choose VA ECMO?
``` Increases LV afterload Lowers pulse pressure Coronary oxygenation by LV blood "Cardiac Stun" Decreased cerebral autoregulation neonatal carotid loss ```
33
Pathological Processes Suitable for V-A ECMO (Common)
Cardiogenic shock Post cardiac surgery Drug overdose with profound cardiac depression Myocarditis Early graft failure: heart-lung transplant
34
Pathological Processes Suitable for V-A ECMO (Other)
``` pulmonary embolism cardiac or major vessel trauma pulmonary hemorrhage pulmonary trauma actue anaphylaxis sepsis bridge to transplant ```
35
Venovenous ECMO
Venous blood is drained through a double lumen cannula, oxygenated, heated and returned to patient via holes in the distal ends of the cannula
36
How are the cannulas placed in V-V EcMO?
In VV ECMO, a double-lumen cannula is placed through the right jugular vein into the right atrium
37
How is blood circulating in V-V ECMO?
Desaturated blood is drawn from the RA, through the outer fenestrated venous catheter wall, and oxygenated blood is returned through the inner lumen of the catheter and is angled to direct blood across the TV
38
How do you avoid mixing?
Cannula position
39
V-V ECMO Diagnosis (Common)
Severe pneumonia ARDS ACute lung (graft) failure following transplant pulmonary contusion
40
V-V ECMO Diagnosis (Other)
Smoke inhalation Status asthmaticus Airway obstruction Aspiration syndromes
41
Common Cannulation Sites: VA
Right internal jugular vein (or femoral vein) | Right common carotid (axillary or aorta)
42
Common Cannulation Sites: VV
Internal jugular vein alone; jugular-femoral, femoro-femoral or sapheno-saphenous veins or right atrium
43
Usual Arterial PaO2 in VA vs VV
VA: 60-150 torr VV: 45-80 torr
44
Indicators of oxygen sufficiency: VA
Mixed venous saturation of PaO2 | Calculated oxygen consumption
45
Indicators of oxygen sufficiency: VV
combination of SaO2 or PaO2, cerebral venous saturation, and premembrane saturation trend
46
Cardiac Effects: VA
Decreased preload; increased afterload | CVP varies, pulse pressure low, Coronary oxygenation provided by left ventricular blood. "Cardiac stun" syndrome
47
Cardiac Stun Syndrome
Narrow pulse pressure and equal pt/circuit ABGs
48
Cardiac Effects: VV
Negligible effects | CVP, pulse pressure unaffected. May improve coronary oxygenation. May reduce RV afterload
49
Oxygen delivery capacity: VA
High
50
oxygen delivery capacitiy: VV
Moderate. Improves with a cephalad drain
51
Circulatory Support: VA
Partial to complete
52
Circulatory Support: VV
No direct support, but increased oxygen delivery to coronary and pulmonary circulation can improve cardiac output
53
Benefits of VA ECMO
Cardiac and respiratory support
54
Benefits of VV ECMO
``` preserves physiologic pulsatility decrease for ischemic lung injury thromboembolic enter pulmonary circulation avoids ligation of carotid artery may decrease risk of neurologic injury ```
55
How does VV decrease risk of neurologic injury?
Blood entering cerebral arterial tree is less highly oxygenated and under less pressure
56
Disadvantages of VA ECMO
ligation of carotid artery | lack of normal pulsatility
57
Disadvantages of VV ECMO
decline in renal function during first 48 hours Requirement of two site cannulation for larger patients no direct circulatory support
58
Recirculation
The shunting of arterial blood back into the venous lumen, common occurs during V-V ECMO and renders the monitoring of the venous line oxygen saturation no longer reflective of patient mixed venous oxygen saturation SvO2
59
How do you know if theres more recirculation?
Higher SVO2
60
Recirculation Fraction Calculation
R = [SO2 (preox) - SVO2 (pt)] / [SO2 (postox) - SvO2 (pt)] R= recirculation factor % SvO2 is the PATIENT not the venous line
61
VA ECMO Flows
Neonate: 100-150 cc/kg/min Pediatric: 75-100 cc/kg/min Adult: 50-75 cc/kg/min
62
VV ECMO Flows
Neonate: 100-120 cc/kg/min Pediatric: 90-100 cc/kg/min Adult: 75-90 cc/kg/min
63
VV Conversion to VVA
Addition of an arterial cannula when you're already on VV Requires: "Y" venous lines of both arms of the dual lumen cannula or both venous lines to the single venous line to the pump Cannulate artery and put the ECMO outflow line to it in need of arterial support after VV cannulated: have ot come off bypass
64
VA Conversion to VAV
In need of more venous return after V-A cannulated start with V-A ECMO need to add another venous to increased drainage
65
VV conversion to VAV
addition of a venous cannula when youre already on VA Requires: "Y" Cannulated artery and put hte ECMO added to venous line and 2 venous cannulas not flow to the pump

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