von Jared Bienstock Vor 1 Jahr
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Mehr dazu
[https://intensiveblog.com/cardiac-arrest-vv-ecmo/ Cardiac Arrest]
Recirculation
Weaning VV ECMO Strategy Recommendation 1: -Increase ventilator to appropriate settings -Reduce FiO2 on ECMO blender -Reduce ECMO sweep flow rate Strategy Recommendation 2: -Progressively decrease sweep -Increase ventilation to meet patient needs -Weaning is successful when patient is stable at sweep of 0 for 4-24 hours (or MDs decision) *Sweep of 0 = essentially off ECMO
Dual Lumen Cannulation VV ECMO
Dual Cannulation VV ECMO
VV ECMO Ranges FiO2= 100% Sweep= 1:1 w/ Q SaO2 = >80% tolerable PaO2=55-90mmHg Flow= 2/3 of CO 50-80 ml/kg/min PP= Nl 40mmHg
VV Vent Settings PIP< 30cmH2O PPlat<30cmH2O TV<6 ml/KG IBW RR = 4-6 B/Min PEEP =10-15 cmH2O FiO2 <40%(0.40)
Catastrophes
Complications: -Cannula dislodgment -Air entrainment
Sedation, Analgesia and Paralytics
Medication
Checklist
Sample: -Console connected to AC -Hand crank available -Spare O2 tank available -Pressure lines flushed -Inspect oxygenator for clots -Clamps available -Lines are not kinked
Personnel
Key members: -Surgeon -Intensivist -Perfusionist -Physician Assistant -Nurse/Nurse Practitioner -Respiratory Therapist -ECMO Specialist
Preparation
Have available: -Primed Circuit -Gas Source -Cannulas (proper sizes) -Heparin/Other Drugs -Ultrasound -Clamps -Sterile Scissors -Pik-A/V -Venous dilator kit
Equipment
Machines: 1. Centrimag - Abbott 2. Bioconsole - Medtrnoic 3. Rotaflow - Getinge 4. SCPC - Livanova 5. Cardiohelp -Getinge
Cardiohelp
Bioconsole
SCPC Livanova
Rotaflow
Centrimag
Such as (but not limited to...) -ECMO circuit -Heparin -Saline/Plasmalyte -Pressure infusion bag -Pressure Transducer Set Double set -Backup O2 Cylinder -Backup console -Cable ties to all connections -Clamps medium x 4 -Oxygen Tubing -Sterile tubing scissors -Emergency Hand crank x -ACT machine -Heater-cooler -Record keeping
Anticoagulation
Complications
[https://intensiveblog.com/cardiac-arrest-on-ecmo-does-it-still-count/ Cardiac Arrest]
1. [https://www.youtube.com/watch?v=NGGA-8zXVGE Differential Hypoxia, north-south syndrome, mixing cloud, aka harlequin syndrome (all the same)] 2. [https://intensiveblog.com/differential-hypoxia-reverse/ Pseudo-differential hypoxia and Reverse-differential hypoxia]
Weaning
Weaning VA ECMO Strategy Recommendation 1: -Optimize: Vent settings, vascular fluid balance, cardiac drugs, support devices (IABP/Impella), slowly reduce blood flow to minimum -Consider raising ACT if ECMO blood flow is low (<2 LPM) Strategy Recommendation 2 -ECMO flows are dropped -A successful weaning means no significant deterioration in the hemodynamic variables and improvement in cardiac function should be seen by echocardiography -Values of successful wean: 1) Aortic VTI (>10cm), 2) TDSa mitral annulus (>6cms-1), 3)LVEF (>20-25%) *Do NOT turn off the sweep while weaning
Initiation
Cannulation
VA ECMO Cannulation
ECMO Management
ECMO Ranges FiO2=100% Sweep= 1:1 w/Q SaO2 = 97-100% PaO2 >200mmHg Flow= 60ml/kg/min PCWP <20 mmHg PP= 10-15 mmHg
Vent Management
VA Vent Settings TV= 6-9 ml/kg IBW RR= 6-12 B/min PEEP=10-15cmH2O FiO2>50% *Little literature exists on optimal vent management for VA ECMO