ECMO

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ECMO:

MANAGEMENT AND COMPLICATIONS

ECMO:

MANAGEMENT AND COMPLICATIONS

Antonella Degani

Fondazione - Policlinico “S. Matteo” Dipartimento di Cardiochirurgia

Università degli Studi di Pavia ITALIA

Bergamo 15-16 Dicembre 2007 Corso ECMO SICCH

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ECMO CIRCUIT

_{Minimize contact areas} _{Avoid stagnant flow areas} _Measure:

- Venous line pressure – before pump (40–60 mmHg)

- Pressure before Oxygenator (press. drop 40–100 mmHg) - Pressure after Oxygenator (160–200 mmHg)

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ECMO SUPPORT

_{ABGs are obtained once connected to ECMO}

_{Repeated after adjustments in FiO}₂ _{and gas sweep} _PaCO₂ _{achieved 40-45 mmHg and pO}₂ _{> 150 mmHg} _{ACT150 – 180 sec, checked every 20 min, then every}

hour

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ECMO CIRCUIT MANAGEMENT

_{Safety checks, alarm control checked every 2h} _{Pre/Post membrane pressure}

_{Emogasanalysis if possibile on line}

_{Check oxygen venous saturation : sVO}₂_{> 70%}

_{Patient temperature is tightly controlled – when above 36}

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ECMO MANAGEMENT

_{ABG oxygenator every 4 h} _{ABG to patient every 2 hours}

_O₂_{persist low at high FiO}₂_{, and Hct is > 35%, flow is}

increased and an arterial ECMO line ABG is performed

_pCO₂ _{changes gas sweep is adjusted}

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Check the gas pipe connection, when you are out of the operating room

BLENDER

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_{No external drive heating}

_{Never change centrifugal pump} _{No clots}

_{The battery life is measured in volt not in percentage} _{The pump says “sig”…: Add ultrasonic cream}

PROS and CONS

ROTA FLOW

PROS and CONS

ROTA FLOW

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_{Quadrox Oxygenator: None}

_{Affinity Oxygenator: plasma leakeage} _{Maxima Oxygenator: plasma leakeage} _{Sci Med : bleeding of the patient}

COMPLICATIONS

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QUESTIONS

If you reach the maximum duration time of the oxygenator

_{Should you change it immediately?}

_{Should you wait the failure of the oxygenator?}

_{Should you consider other parameters: platlets loss,}

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DIFFERENCES BETWEEN

V-A AND V-V ECMO

DIFFERENCES BETWEEN

V-A AND V-V ECMO

Not affected by flow Decrease in proportion to ECC flow PA Pressure Not helpful Accurate guide to volume status CVP Pulse is full Pulse is damped Art. BP Cardiac output Circuit flow and

cardiac output Systemic perfusion

V-V

V-A

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Slowly Rapidly Decrease ventilator setting Same as VA Depends of gas sweep and surface area of membrane CO2 removal 80-95% sat common for maximum flow Sat controlled by ECC flow Arterial oxygenation

V-V

V-A

Gas exchange

DIFFERENCE BETWEEN

V-A AND V-V ECMO

DIFFERENCE BETWEEN

V-A AND V-V ECMO

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DRAWING BLOOD

Hensley: “The practice of cardiac anesthesia”

Low flow (A) and moderate return flows (B) delivered to the femoral artery.

High return flows (C and D) to the femoral artery and the aortic root

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Femoral Venous line

Femoral Arterial line

ECMO

FEMORO-FEMORAL

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_{Heparin cannulae}

_{Percutaneos introduction}

(when possibile) with dilatator (diam 10F to 22F)

_{Art. cann. size 17F/19F ,} _{Vent. cann. size}

19F/21F

_TEE

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COMPLICATIONS

_{Leg ischemia}

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COMPLICATIONS

_{Loss of venous return}

a) Increase the volume b) Flow overshoot

c) Check Venous Cannula position d) Check circuit integrity, kink, clamp

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COMPLICATIONS

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ANTICOAGULATION

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THROMBOEMBOLISM

Visible thrombus in blood pump or cannula: _{Neurologic changes} _Seizures _Hemiparesis _Paralysis _{Hepatic or renal} dysfunction

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ANTICOAGULATION

MONITORING

ANTICOAGULATION

MONITORING

>250 sec Flow <2 l/min 180-200 sec Flow 2-2,5l/min 160-180 sec Flow >2,5l/min ACT FLOW

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ANTICOAGULATION

MONITORING

ANTICOAGULATION

MONITORING

_{Check every day circuit/oxy} _{Flow > 2 L/min}

_{Continue infusion of heparin (15-30 U/kg/die)} _{ATIII >80%}

_TEG _TEE

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LEFT ATRIAL DRAINAGE

Left atrial drainage cannula 14F

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COMPLICATIONS

_{Insufficient left atrial drainage :}

Change the luer connection to ¼” connection

_{Air into the left atrial drainge}

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☺

☺☺

Lifebridge

☺

☺☺

Levitronix

☺

Rotaflow

☺

Biomedicus COST SET UP HANDINESS WEIGHT PUMP

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PAVIA EXPERIENCE

7 2,33±1,78 55,67±11,78 3 VAD SINISTRO 118 4,92±2,65 58,13±10,24 24 VAD DESTRO 8 4,00±1,00 51,00±4,00 2 VAD BIVENTRICOLARE 6 3,00±1,00 60,50±16,50 2

PASSAGGIO VAD SX-ECMO

65 6,50±3,9

60,40±6,52 10

PASSAGGIO VAD DX-ECMO

155 11,07±6,66 49,29±7,61 14 ECMO VENO-VENOSO 594 3,69±2,27 55,99±13,67 161 ECMO VENO-ARTERIOSO Total time Average time Average age Total Assistance

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0,89 4,13 ±2,57 116 Polipropilene 0,04 4,71 ±3,41 97 Polimetilpentene Oxy/ECMO change rate Average Life Total Oxygenator

PAVIA EXPERIENCE

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Timing Flow Cost Cannulation Management TEAM Patient Tecnology

ECLS

CONCLUSIONS

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