ecmo Flashcards
what is the half life of Heparin?
1.5 hours
Consideration of femoral VA ECMO patients?
Depending on mixing cloud, R Aline might not work for blood gasses, may need to use the pump arterial gas
Drugs that bind to ECMO circut
Fentanyl & Propofol
Normal Plasmahemoglobin level?
<30
IF bladder ( venous) pressure is becoming more negative
Kink, clot, position, preload, agitation, pneumo, tamponade
Reasons your delta P may DECREASE
decreased blood viscosity, decreased flow, opening of bridge
Heparin on the septic/inflamed patient
may need higher dose b/c of coagulopathy
Why don’t they irradiate blood ahead of time?
The K increases more with time post irradiation
Why don’t they irradiate blood ahead of time?
The K increases more with time post irradiation
Leukoreduced causes what to happen to PRBCs?
PRBCs lose efficacy to 85%
What does irradated mean?
donor lymphocytes are inactivated
What do you do if all of the sudden your pt isnt oxygenating and CO2 is rising?
check the sweep line for kinks (can try putting it on the tank), is your post oxygenator O2 low too? issue with oxygenator, look for clots, increase in delta P, increase RPMs,
Return/arterial pressure increasing
kinks, clots, position (check xray), is pt hypertensive? Sedation? zero lines
What to do if air is in the arterial line?
Emergency, stop pump/clamp above air, call for help, emergency vent settings/ escalation of inotropes, walk air to nearest leur connection or open bridge to get air out
Normal vs ECMO PT levels
PT normal 12-14 seconds, ECMO 15-16- correct with FFP
Normal vs ECMO PTT levels
PTT normal 24-36 seconds, ECMO 60-90. Correct with Heparin
PTT affected by ___, influenced by ___
affected by heparin, influenced by PTL/fibrinogen/clotting factors
What interferes with Hep U level
High bilirubin, high triglycerides, high plasmahemoglobin. Hep U is not inflienced by PTL or clotting factors
What might you need to give after giving factor 7?
FFP because it used up your
how does hypothermia affect clotting times?
it delays clotting time and alters PTL function
How does bilirubin affect coag labs?
increases PTT and decreases Hep U
How does hemolysis affect coag labs?
Decreases PTT and Hep U
If Hep U is normal, PTT/ACT are low
check AT3, give FFP
If Hep U is normal, PTT/ACT are high
r/o DIC (d-dimer), decrease heparin, give FFP
If Hep U is low, and PTT/ACT is low
give heparin bolus/increase gtt
If hep U is low, and PTT/ACT high
increase heparin, r/o DIC, give FFP.
what should you consider when weaning flows?
Going upon heparin & you may need to wean sweep
VA considerations with sweep
never turn it off,
What weight gets 1/4” circuit?
<10kg ]
name of our 2 heaters
cardioquip and microtemp
what color are the pediatric/adult oxygenators?
peds is blue (blue baby), and white is adult
how do you clamp roller pump?
VBA
On roller pump, where is CRRT access/return?
Idk anymore
When restarting from clamped/off cardiohelp..
unclamp slowly, RPMs at least 1500
what are the optimal RPMs for cardiohelp to reduce hemolysis
2,000-4,000
How late is perfusion usually around until?
4pm
what to check before a controlled new cannulation on a neo?
Head ultrasound
whats the formula to assess how well oxygenator is working?
your pump FiO2 x 3-5 = post oxygenator PaO2, if this is bad, consider sighing, old oxygenator.
To assess your patients lung, can do “cilley” test
go up on their vent FiO2 and see if sats go up
what should you assess if seeing multiple venous bubbles
assess site for proline deficiency
water heater… refilling..
do it slowly, water is cold
Your post oxygenator PaO2 shouldn’t be lower then..
150
As your diuresis on VA ecmo, your PaO2
may increase as less blood goes through heart, more through pump
On Cardiohelp, when accessing arterial side…
flush anything SLOWLY or bubble detector will alarm
your patient keeps getting PTL w/o solid gain in PTL level
DIC
How do you fix circuit DIC?
change the circuit so you stop consuming factors on y our old clotty circuit, may need a couple changes. Can also do plasmapheresis
clamp
off sweep
what an air lock in your cardiohelp?
the air in your pump stops forward flow
If you need to remove air on arterial side of oxygenator
add saline as you pull air so you don’t cavitate
on VV ecmo, sats 80s are ok if:
good lactate, UOP adn perfusion
VA ecmo, if PaO2 is too high
you may have no CO and LV stun, check echo to see if flows are too high assess need for septostomy
any baby with pulm HTN going on VV
R heart gets support when VV ecmo provides oxygen to PAs
ratio of sweep/flow when starting ecmo
1:1 unless there is chronic co2 retention
signs of cardiac distension
ART line is flat, PaO2 is high, CVP high
what happens to CVP when you start VA ecmo
it goes down due to VA steal
Ways to improve oxygen delivery (6)
-increase FiO2, increase flow (but not past max flow rate or O2 can worsen), increase hemoglobin, improve native cardiac output, new oxygenator, sedate/paralyze/cool
How to change CO2? (3)
Increase sweep, change oxygenator, sigh oxygenator
Hgb in VV vs VA patients
VV might be kept higher if there is no native lung function, VV had lower sats
250ml NS bag
<10kg
500ml NS bag
10-30kg
1L bag NS
> 30kg
What weight gets a blood prime?
<30kg
Excessive negative venous pressure can cause
Hemolysis, cavitation, vessel wall damage. If it’s sudden, may just be sucking up against vessel wall- gave fluid, reposition
What causes pre oxygenator pressure to increase?
Hypertension, clotting oxygenator, clots or kinds to cannula
Where can you NOT administer things with a string or large volume pump?
In the negative side of the circuit. But you can give fluid via push under constant supervision
Where should blood and FFP be given if it must be on the circuit?
Into a pre oxygenator pigtail with and IV pump. If more emergent, can give via push on negative limb prepump.
Where when needed, do you give platelets and cryo?
Post oxygenator on a pump
Where do you give medications on a circuit? Like vanco
Pre oxygenator
Where does the prismaflex access and return?
Access on venous limb, first set of pigtails by lab draw. Return to CDI by heparin
Venous pressure alarms- warning/alarm/max
-80/-100/-120
Pre oxygenator pressures warning/alarm/max
290/300/350
Post oxygenator pressures warning/alarm/max
280/290/340
Gas pressure warning/alarm
20/40
Where should the alarms be on the transonic flow meter?
20% above/below flow target
How often should you flush and zero transducers?
Flush q4
Zero q shift
The flow probe ONLY transonic.
Should be lubricated. And only repositioned above the bridge of circuit is deforming or signal is deficient
What can be plugged in on the ECMO cart?
The transonic and CDI. Nothing else.
When your done with heaters…
Don’t empty them! Or they have to go to biomed to be refilled
How do you calibrate CDI if the bridge is open?
With the Patient VBG, not pump, because pump is affected by open bridge
What do you do if you need to open the bridge?
Perfusion can be paged during daytime hours, otherwise include it in the morning page
Minimum quadrox flow for adult/peds
Adult is 0.5LPM
Peds 0.2LPM
But goal is always 1LPM
Minimum sweep/flow on VA patients? (Non cardiac)
0.1 sweep
30% FiO2
