Circuit Troubleshooting ECMO FINAL

Question 1

How would you troubleshoot venous drainage issues ?

Answer 1

• Anticipated flow = 100 - 150 ml/kg
• Pump calibrated correctly
• Bed Height
• Verify cannula size & position
• Kinks on venous line.
• Evaluate patient CVP = bladder pressure.
• If CVP is low transfuse volume and reassess.

Question 2

Transfusing volume to a neonate, what is the rate ?

Answer 2

10 mL/Kg

Question 3

Clamp placed on the venous line before the bladder, how will the pump react ?

Answer 3

• Better bladder will collapse, generating a negative pressure, which will turn off the pump.

Question 4

Clamp placed on the venous line after the bladder, how will the pump react ?

Answer 4

No change in pressures, it will just cavitate air out of the fluid and collapse the tubing.

Question 5

Clamp placed near the platelet port, how will this effect the pump?

Answer 5

Pre and post pressures will increase and shut of the pump

Question 6

Clamp placed on the raceway tubing between pump and oxygenator, how will the pump react ?

Answer 6

This is a no pressure monitoring zone, no change in pressures, possible rupture of tubing.

Question 7

Clamp placed on the arterial line after bridge, how will the pump react ?

Answer 7

Pre and post pressures will increase and shut of the pump

Question 8

What will you examine if you encounter a LOW post membrane pressure ?

Answer 8

Examine the Oxygenator

Question 9

What will you examine if you encounter a HIGH post membrane pressure ?

Answer 9

• Re-zero transducer
• Examine the arterial line up for kinks, size, & position.
• Examine the patient as well, the cannula sutures may be too tight.
• CXR to reveal a dissection, twisted artery, or if its introduced too far.

Question 10

How would you troubleshoot a patient with failure to oxygenate ?

Answer 10

• What is the Post oxygenator PO2 ?
  = HIGH = Check Pulse Pressure
• Pulse Pressure = Low = Repeat Gas
• Pulse Pressure = Low again = Check FiO2, SvO2, Pump flow

Question 11

What information do you request to diagnose an Oxygenator Failure?

Answer 11

1. ) Widening Pre-Post pressures.
2. ) Decreased CO2 Clearance
3. ) Decreased Oxygenation

Question 12

What will you consider with Widening Pre-Post pressures ?

Answer 12

Flow & SVR variations

Question 13

What will you consider with Decreased CO2 Clearance ?

Answer 13

Sweep &

Gas flow variations

Question 14

What will you consider with Decreased Oxygenation ?

Answer 14

FiO2 Variations

Question 15

During your pre-shift check, you notice that the water in the water bath is colored. What does this mean ?

How will you manage this ?

Answer 15

Blood to water leak

Management:
- Turn off the water bath to reduce water pressure.
- Circulate through bridge to reduce air embolus
-

Question 16

Under what conditions would a blood to water leak allow water to get into the blood phase ?

Answer 16

If water exceeds blood pressure, water will leak into the blood.

This will in turn cause hemolysis and sepsis

Question 17

You are on ecmo, day 10, and notice that in the last 30 minutes the CVP has gone from 4 to 14. The blood in the arterial line after the heat exchanger is darker than the blood at the platelet port. The patients blood pressure is beginning to drop despite a larger pulse pressure. What is happening ?

Answer 17

Water to blood leak

Question 18

Raceway rupture management ?

Answer 18

• We have a raceway rupture!!
• Turn on Emergency Ventilator settings please!
• Call one of my perfusion colleagues for support.
  1. ) Isolate the patient (VBA)
  2. ) Turn the pump OFF
  3. ) Clamp inlet and outlet to the pump
  4. ) Remove raceway tubing, cut rupture out, inset connector, connect wet to wet (air free), Re-insert raceway tubing with connector on the pre-pump side.
  5. ) Turn the pump on, recirculate through the bridge assessing for any air in the system.
  6. ) Free of air, now perform (ABV) and reinstitute ECMO.

Question 19

You have been on VA ECMO for 30 minutes. You are at full flow. The surgeon noticed on the CXR that the arterial cannula was in a little further than desired as is currently at the bed side pulling the cannula back. Your hear, “Oh, my god, we have a problem up here!” and look up to discover that the surgeon, and her assistant are both spattered in blood.
How would you manage this situation ?

Answer 19

1.) Clamp out the arterial line & venous line.
2.) Apply a clamp on the venous line in a way that will allow you to flow from the arterial line > Bridge > Venous line above the bridge > patients right side.
3.) Connect fluids to the IV push port.
Remove the first clamp on the venous line and begin transfusing.