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ECMO > ECMO > Flashcards

ECMO Flashcards

1
Q

Venous blood is drained via a cannula from what location(s) of the patient body?

A

Right Internal Jugular (RIJ)
Superior Vena Cava (SVC)/Right Atrium/Inferior Vena Cava (IVC)

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2
Q

Veno-Arterial ECMO oxygenated blood is returned to the patient via a cannula in what location(s) of the body?

A

Aorta (neck/central)
Femoral Artery (peripheral)
Carotid Artery (neonates)

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3
Q

Veno-Venous ECMO oxygenated blood is returned via a cannula in what location of the body?

A

RA/Tricuspid Valve

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4
Q

BASIC path of blood flow via ECMO?

A
  1. Patients blood is drained via Venous Drainage Cannula
  2. Venous line to the Pump
  3. Pump to the Oxygenator
  4. Oxygenator to the Return Cannula
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5
Q

The Centrifugal pump is preload … and afterload …

A

dependent
sensitive

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6
Q

What is the “heart” of the ECMO circuit?

A

the pump

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7
Q

How does the Centrifugal pump pull-in blood?

A

fluid/blood is pulled into the center of the vortex (pump inlet) and pushed toward the outer edge of the path of rotation (pump outlet)

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8
Q

Patients mush have sufficient … to support desired …

A

preload volume
flow

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9
Q

A decrease in volume will decrease

A

flow; “chatter”

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10
Q

Anything that increases resistance in the circuit will decrease …

A

flow; including pts SVR on V-A ECMO

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11
Q

Pump flow is controlled by:

A

RPMs

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12
Q

To increase flow, what do you increase?

A

RPMs

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13
Q

Are Centrifugal pump flow pulsatile?

A

NO, they are NON-pulsatile

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14
Q

What is the oxygenator made out of?

A

Polymethylpentene (PMP) - gas permeable fibers

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15
Q

Where does blood flow in the oxygenator?

A

around the outside of the fibers

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16
Q

In the oxygenator, gas exchange occurs by:

A

true diffusion (surface area, concentration, pressure gradients)

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17
Q

What controls ECMO PO2?

A

FiO2 on blender

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18
Q

What controls ECMO PCO2?

A

Sweep Gas (flow meter); can also affect PO2

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19
Q

The heater-cooler is incorporated where?

A

the oxygenator; water flows around one side and blood on the other side

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20
Q

Cardio Quip heater-cooler allows for:

A

temperature management (normo- or hypothermia)

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21
Q

What is the ECMO Circuit made of?

A

PVC tubing and heparin-coated to help prevent thrombosis (bioline)

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22
Q

What are the three locations we can cannulate for ECMO?

A

Central
Neck (neonates/small peds)
Femoral (peds/adults)

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23
Q

Femoral cannulation allows:

A

rapid cannulation in an emergency

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24
Q

Femoral cannulation may compete with:

A

native cardiac output; retrograde flow

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25
Q

Femoral cannulation requires what to be placed?

A

re-perfusion line to prevent lower limb ischemia

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26
Q

Neck cannulation placement for V-A ECMO:

A

RIJ vein and R carotid artery

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27
Q

Veno-venous ECMO is ONLY for:

A

respiratory support; NO cardiac support

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28
Q

Veno-venous ECMO draws blood from … and returns the blood …: (dual-lumen tube - Avalon)

A

SVC + IVC
directly to the tricuspid valve

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29
Q

Veno-venous ECMO, other cannulation site(s):

A
  • femoral vein - femoral vein
    access cannula is low (sub-diaphragmatic)
    return cannula is in the Right Atrium
  • Femoral vein - RIJ
    access cannula is low
    return cannula is in RIJ
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30
Q

Indication of ECMO for Adults:

A

ARDS
Pneumonia
Pneumonitis
Status Asthmaticus
Trauma/Pulmonary Contusion
Post-cardiotomy shock
Bridge to/from heart transplant/MCS
hypothermic cardiac arrest
cardiogenic shock
cardiomyopathy
myocarditis
Massive MI
Massive PE
Cardiac Arrest

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31
Q

Indications for ECMO Pediatric:

A

more often resp. indications; viral PNA, asthma
cardiogenic shock
myocarditis

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32
Q

Indications for ECMO Neonates:

A

PPHN
Diaphragmatic Hernia
Meconium Aspiration
Asphyxia
Hypoxic-Ischemic Encephalopathy (HIE)

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33
Q

When do we place a patient on ECMO?

A
  • deteriorating cardiopulmonary status despite cardiovascular/respiratory support
    1.) 3+ high dose inotropic and/or vasopressor agents, IABP, Impella
    2.) Hypotension, low CO, worsening acidosis, increasing lactate, decreased U/O
    3.) High Vent Support (PIP, PEEP, Paw, FiO2, HFOV/HFJV, iNO)
    4.) Hypoxemia, hypercarbia, acidosis, worsening CXR
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34
Q

VIS - Vasoactive and Inotropes Score for ECMO consideration

A

> 61

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35
Q

Cardiac Index of pt that requires ECMO

A

<2.0 L/min/m2 ( cardiac output / BSA )

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36
Q

P/F Ratio potentially requiring ECMO

A

<50 x3 hrs or <80 x6 hrs

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37
Q

Ventilation Index potentially requiring ECMO

A

> 50 x4 hrs

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38
Q

Oxygenation Index potentially requiring ECMO

A

> /= 40

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39
Q

Murray Score potentially requiring ECMO
(P/F Ratio, Compliance, PEEP, CXR)

A

> 3

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40
Q

When NOT to place pt on ECMO

A
  • Mechanical Ventilation >7 days w/ high settings
  • End-Stage COPD
  • Metastatic CA
  • Multi-System Organ Failure (MSOF)
  • Severe Sepsis
  • CNS Injury ( traumatic, ischemic, embolic, hemorrhagic)
  • Age >70
  • Active Hemorrhage
  • Inability to withstand Anti-coagulation
  • Lack of informed consent/experienced staff/proper equipment
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41
Q

When NOT to place Neonates on ECMO

A

<34 weeks
<2 kgs
Intracranial Hemorrhage
Lethal Chromosomal Anomaly

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42
Q

ECMO is NOT a … and only buys …

A

cure
time for healing or medical therapies

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43
Q

Goal of ECMO is to maintain

A

homeostasis

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44
Q

Veno-arterial ECMO supports CO with

A

pump flow

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45
Q

ECMO “full support” in adults: pediatrics:

A

Cardiac Index 2-2.5L/min/m2 (V-A); 3-4 L/min (V-V), 4-5 L/min (V-A)

100-150 ml/kg (V-A); 80 ml/kg (V-V)

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46
Q

MAP goal on ECMO
CVP goal on ECMO
LAP goal on ECMO

A

35-70 (age dependent)
>10
<10

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47
Q

Venous Gas PO2, PCO2, pH, Sat normal:

A

35-50
40-55
7.30-7.45
65-75

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48
Q

ECMO Gas PO2, PCO2, pH, Sat normal:

A

200-300
35-45
7.35-7.45
100

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49
Q

Arterial Gas PO2, PCO2, pH, Sat normal:

A

50-150
35-50
7.30-7.45
>90

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50
Q

Typical heparin infusion

A

20-40 units/kg/hr

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51
Q

Direct Thrombin Inhibitor

A

Bivalirudin

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52
Q

Renal function; normal MAP with pulsatile flow to maintain

A

urine output

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53
Q

Venous cannula malposition may cause hepatic congestion so watch for climbing

A

CVP with decreasing flow

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54
Q

How often should you change cannula site dressing?

A

every 3 days or PRN

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55
Q

Secure ECMO cannulas to .. and circuit tubing to …:

A

the patient
the bed

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56
Q

Cardiohelp has an integrated

A
  • centrifugal pump and oxygenator
  • pressure sensors (pre-pump, post-pump, post-oxygenator)
  • temp. sensor (arterial) and optical measurement via infra-red sensor (venous)
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57
Q

Cardiohelp has 2 different HLS sizes:

A

5.0 (max flow)
7.0 (max flow)

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58
Q

Venous Cannula/Pre-Pump creates what kind of pressure?

A

NEGATIVE

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59
Q

Post-Pump/Arterial Cannula creates what kind of pressure?

A

POSITIVE

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60
Q

Delta P on Cardiohelp

A

Pressure difference between Post-Pump/Pre-Oxygenator Internal Pressure and Post-Oxygenator Arterial Pressure

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61
Q

Part on cardiohelp

A

Post-Oxygenator Arterial Pressure

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62
Q

Pint on cardiohelp

A

Post-Pump, Pre-Oxygenator Internal Pressure

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63
Q

Pven on cardiohelp

A

Pre-Pump Venous Pressure

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64
Q

The Cardiohelp can detect and react to …

A

retrograde flow of blood; back-flow protection - activates zero flow mode automatically to prevent backflow

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65
Q

How long does the battery last on Cardiohelp?

A

90 mins

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66
Q

Cardiohelp screen automatically locks after how long?

A

3 mins of inactivity

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67
Q

Adult Quadrox-I recommended flow range

A

.5-7 l/min

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68
Q

Small Adult Quadrox-I recommended flow range

A

.5-5 L/min

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69
Q

Pediatric Quadrox-I max flow

A

2.8 L/min

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70
Q

Neonatal Quadrox-I max flow

A

1.5 L/min

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71
Q

Nautilus Oxygenators have what type of flow

A

transverse flow path with circular profile

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72
Q

Transverse Flow in Nautilus Oxygenators minimize

A

surface contact area while achieviing a low side pressure drop

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73
Q

Circular profile in Nautilus Oxygenators eliminates

A

corners where low flow and stasis are known to occur; improvesw long term gas transfer

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74
Q

Nautilus Oxygenator recommended blood flow rate

A

0.5-7 L/min

75
Q

CentriMag:
Typical RPM?
Typical flow?
Target ACT?
Target PTT?
Max Pump flow?
Max Pressure?

A
  • 3000-4000
  • 4-5 LPM
  • 160-180 ses
  • 50-60 secs
  • 10 LPM
  • 600 mmHg
76
Q

A CentriMag (pump) requires a …

A

motor; each primary console supports 1 CentriMag

77
Q

If CentriMag RPMs are below 1000, what must happen?

A

outflow tubing must be clamped

78
Q

Cardio Quip Normal Mode puts out how much wattage

79
Q

Cardio Quip Low Mode puts out how much wattage

80
Q

Cardio Quip:
Water Min … Max …
Max flow rate
Temp. Control

A

1 gal (3.8L) ; 2.5 gal (9.5L)
20 lpm
0-42*

81
Q

Spectrum Monitor; Transit time is the phase delay between

A

the pair of sensors measuring up stream transit time and down stream transit time

82
Q

Spectrum Monitor;
Transit time decreases when
Transit time increases when

A

traveling down stream
traveling up stream

83
Q

Spectrum Monitor; What does it mean if transit times are equal

A

blood flow is static

84
Q

Spectrum Monitor; Emboli is measured by

A

detecting reduction in the ultrasonic signal strength

85
Q

Spectrum Monitor; the level of emboli volume within the flowing blood will be dependent on

A

the level of signal reduction multiplied by the number of signal reduction events

86
Q

Spectrum Monitor;
measures HCT
measures Hgb

A

15-50%
5-17%

87
Q

Veno-Arterial ECMO used in
Veno-Venous ECMO used in
Veno-Arterial/Veno ECMO used in

A

pts with failing hearts
pts with failing lungs
pts with failing heart and lungs; mixing can occur distal to coronaries and lung support is required to perfuse the heart

88
Q

Veno-Arterial ECMO sites:

A

Femoral Vein drainage and Femoral Artery Return
Femoral Vein drainage and Axillary Artery Return
Right Atrium or Femoral Vein drainage and Aorta Return

89
Q

Veno-Arterial/Veno ECMO Site:

A

femoral cannulation with an additional cannula inserted into the Right Atrium and connected to the arterial limb of the circuit

90
Q

Veno-Venous ECMO sites:

A

Internal Jugular w/ Avalon (dual lumen)
Femoral Veins
Internal Jugular and Femoral Vein

91
Q

What do we bolus a patient with before placing ECMO?

A

10,000 units of heparin; 5,000 units of heparin if pt is known to be on heparin

92
Q

ECMO Start:
Initial RPM start
Initial FiO2
Initial Sweep

A

1700 RPMs
80-100%
2-3

93
Q

Indications for ECMO in Neonates

A

Meconium Aspiration
CDH (Congenital Diaphragmatic Hernia)
RDS (Respiratory Distress Syndrom)
Sepsis/PNA
PPHN (Persistant Pulmonary Hypertension)
Air Leak Syndrome
Congenital Airway Abnormalities
Pre-Post Cardiac Surgery

94
Q

Physiologic Criteria for ECMO in Neonates

A
  • Reversible cardiorespiratory failure
  • Oxygenation Index (OI) >40 for >/= 4 hrs
  • OI >20 despite max therapy >/= 24 hrs or decompensation
  • Severe hypoxic respiratory failure w/ acute decompensation (PaO2 <40)
  • Progressive respiratory failure and/or pulmonary hypertension with evidence of right ventricular dysfunction or continued high inotropic requirement
95
Q

Indications for ECMO in Pediatrics

A
  • Post Cardiac Surgery
  • Pulmonary Vasoactive Crisis
  • Cardiomyopathy due to renal failure, myocarditis, burns
  • Acute viral respiratory infections
  • Severe Asthma
  • Bridge to transplant (CF pts)
96
Q

Absolute Contraindications for ECMO in Neonates/Pediatrics

A
  • Catastrophic brain injury without prospect for recovery
  • untreatable metastatic malignancy
  • End-stage organ failure without prospect for recovery or transplant
97
Q

Relative Contraindications for EMCO in Neonates/Pediatrics

A
  • Severe multi-organ failure
  • Severe trauma with coagulopathy and hemorrhage
  • Severe immunocompromised
  • Extremes of age
  • Severe aortic regurgitation
  • Unfavorable vasculature such as aortic dissection
98
Q

Exclusion Criteria for Neonates

A

Gestational Age < 32-34 weeks
Weight < 2 kgs
ICH grade greater than 2
Coagulopathy
Lethal Congenital anomalies
Congenital heart disease rule out
Duration on vent; 10-14 days

99
Q

Exclusion Criteria for Pediatrics

A

Severe CNS injury
Malignancy
Severe immunodeficiency
Advanced liver failure
Pulmonary Fibrosis
Active Hemorrhage
Prolonged Ventilation

100
Q

VV ECMO supplies high oxygenated blood to the:

A

pulmonary circulation and myocardium

101
Q

VV ECMO in neonates spares the

A

carotid artery and may result in shorter cannulation time

102
Q

Neonates: On VV ECMO, the pulmonary bed serves as a

A

filter for any emboli that may occur

103
Q

Neonates: VA ECMO requires

A

ligation of the carotid artery

104
Q

Neonates: VA ECMO provides what kind of blood flow to the body

A

non-pulsatile

105
Q

Neonates: VA ECMO supplies less oxygenated blood to the

A

myocardium

106
Q

Neonates: VA ECMO risks what in the circuit?

A

thrombus that will embolize to the systemic circulation

107
Q

Neonatal: On VA ECMO, they have an increase risk of developing what?

A

neurological complications/developments

108
Q

Technical Complications of ECMO in Neonates

A

bleeding
rupture IVC
vein retraction
rupture atrium
kinking of cannulas
too far in/not in far enough
hepatic perfusion
dislodgement
limb ischemia
“north-south” syndrome

109
Q

Flow (Q)

A

volume - time (ml/min or L/min) movement of a fluid or gas

110
Q

Velocity (V)

A

speed at which fluid moves in a given direction

111
Q

Resistance (R)

A

internal or external forces which oppose flow

112
Q

Pressure (P)

A

force exerted causing fluid movement

113
Q

Pressure Gradient (P1-P2)

A

difference in pressure between two points

114
Q

Viscosity (h)

A

thickness of fluid

115
Q

Fluid flow varies directly with

A

velocity and cross sectional area of its conduit

116
Q

A larger diameter conduit allows

A

the same flow at a reduced velocity

117
Q

A smaller diameter conduit requires

A

an increased fluid velocity to maintain the same flow rate

118
Q

Velocity changes are achieved by

A

changes in pressure

119
Q

To achieve the same flow in a smaller conduit, what must happen

A

velocity must be higher

120
Q

A smaller diameter conduit creates/needs:

A

higher velocity (requires higher pressure)
higher resistance
lower flow
lower volume

121
Q

Fluid ALWAYS moves from:

A

highest to lowest pressure; path of least resistance

122
Q

Flow varies directly with … and varies inversely with …

A

pressure gradient
resistance

123
Q

Two types of flow:

A

laminar flow
turbulent flow

124
Q

Things that cause resistance:

A

conduit length (L)
fluid viscosity (h)
conduit radius

125
Q

Resistance varies directly with … and … and inversely with …

A

conduit length ; fluid viscosity
radius to the 4th power

126
Q

2 ways to Resist

A

Series
Parallel

127
Q

Increase in viscosity:

A
  • lower temperature
  • higher hematocrit
  • higher density (very high platelets, WBC, protein count)
128
Q

Poiseuille Law:
Flow varies directly with … and …
Flow varies inversely with … and …

A

1.) the pressure gradient (P1-P2) and vessel radius to the 4th power (r4)
2.) vessel length (L) and fluid viscosity (h)

129
Q

Poiseuille; to increase flow

A

bigger pressure gradient
bigger diameter conduit (radius)
shorter length conduit
decrease fluid viscosity

130
Q

Poiseuille; things that decrease flow

A

smaller pressure gradient
smaller diameter conduit (radius)
longer length conduit
increased fluid viscosity

131
Q

Centrifugal pumps being afterload sensitive; increased resistance reduces flow with:

A

smaller tubing
smaller cannula
increased SVR
higher hematocrit
circuit geometry (twists, turns, kinks)
clot in oxygenator

132
Q

To maintain flow when resistance increases:

A

increase pressure (increase pump RPMs)

133
Q

A sudden change in flow at the same RPMs indicates:

A

a change in systemic resistance

134
Q

Centrifugal pumps being pre-load dependent; flow will be reduced if:

A
  • venous cannula or venous line has more resistance; cannula too small or cannula mal-positioned (cannula tip pushed against the vessel wall)
  • low CVP (not enough blood volume)
135
Q

Points of high resistance:

A

oxygenator
connectors
small diameter tubing segments
cannulas
kinks
clots
anything w/ a clamp

136
Q

Fluid will always find take the path of least resistance such as:

A

shunts
open bridge
purge lines
leaks

137
Q

Boyles Law

A

gas volume varies inversely with pressure; Increase pressure/Decrease volume - Decrease pressure/Increase Volume

138
Q

Charles Law

A

gas volume varies directly with tempurate; Increase in temperature/Increase volume - Decrease in temperature/Decrease volume

139
Q

Gay-Lussacs Law

A

gas pressure varies directly with temperature;
Increase pressure/Increase Temp - Decrease pressure/Increase Temp

140
Q

Avogadros Law

A

equal volumes of all gases, at the same temperature and pressure, have the same number of molecules

141
Q

Daltons Law

A

the total pressure exerted to equal to the sum of the partial pressure of the individual gases

142
Q

The Ideal Gas Law

A

volume of a gas is directly proportional to the number of moles and temperature of a gas and inversely proportional to the gas pressure

143
Q

Henrys Law of Solubility

A

amount of gas that dissolves in a liquid is directly proportional to the gas solubility coefficient, and the partial pressure of that gas in equilibrium with that liquid

144
Q

Ficks Law of Diffusion

A

the rate of membrane diffusion varies directly with the surface area of the membrane and pressure gradient across the membrane nad varies indirectly with the membrane thickness

145
Q

Oxygen Content (CaO2)

A

(Hgb x 1.34 x SaO2) + (PaO2 x .003)

146
Q

Oxygen Delivery (DO2)

A

CaO2 x CO (or Q=flow rate)

147
Q

Hemoglobin picks up and holds on to oxygen in the lungs and increase HbO2 (Oxy-Hemoglobin) affinity:

A

decrease in hydrogen (acid)
decrease in PCO2
decrease temperature

148
Q

Hemoglobin unloads oxygen at the tissues and has a decreased in HbO2 affinity:

A

increase in hydrogen (acid)
increase PCO2
increase Temperature

149
Q

Oxygen Consumption (VO2)

A

CO L/min x (CaO2 - CvO2)ml/L

150
Q

O2 Extraction Ratio (O2ER)
O2ER normal or DO2:VO2 ratio

A

VO2/DO2 x 100
20-25% or 4-5:1

151
Q

CO2 is transported as:

A

Dissolved CO2 in plasma - 5%
Bound to plasma proteins - 5%
Bound to Hemoglobin in RBC - 20%
Bicarbonate in Plasma - 70%

152
Q

CO=

A

HR x Stroke Volume (mL/beat)

153
Q

Stroke Volume depends on:

A

preload
contractility
afterload

154
Q

Normal CO:
Adults
Neonates

A

60-70 mL/kg/min or 2.6-3.2 L/min/m2
150-200 mL/kg/min

155
Q

Preload - how full is the heart/circulatory system?

A

CVP (central venous or right atrial pressure)
LAP (Left Atrial Presure) - PCWP (pulmonary capillary wedge pressure) or PAD (pulmonary artery diastolic pressure)

156
Q

Afterload - how much resistance does the heart push againts?

A

SVR - systemic vascular resistance (LV)
PVR - pulmonary vascular resistance (RV)

157
Q

Stroke Volume + afterload =

A

blood pressure (Arterial BP or PAP)

158
Q
  1. Normal PAP Systolic/Diastolic
  2. Normal Right Atrium
  3. Normal Right Ventricle
  4. Normal Aorta Systolic/Diastolic
  5. Normal Left Atrium
  6. Normal Left Ventricle
  7. Normal Pulmonary Artery Wedge Pressure
A
  1. S: 15-25 mmHg, D: 8-15 mmHg
  2. 0-8 mmHg
  3. S: 15-25 mmHg, D: 0-8 mmHg
  4. S: 110-130 mmHg, D: 70-80 mmHg
  5. 4-12 mmHg
  6. S: 110-130 mmHg, D: 4-12 mmHg
  7. 8-12 mmHg
159
Q

Frank Starling Law of the Heart

A

increased filling pressure stretches the heart and increases its force of contraction

160
Q

Increasing the force of contraction expels more blood from the left ventricle so that …

A

cardiac output increases when the preload increase

161
Q

ECMO can augment, support, or replace all of the patients requirements for:

A
  • Oxygenation in respiratory failure (O2 content)
  • CO2 clearance in ventilatory/resp. failure (CO2 transport)
  • Circulatory support in the acute heart failure or circulatory collapse (Cardiac Output and O2 Delivery)
162
Q

Clotting Cascade:
Contact Activation/Intrinsic Pathway

A
  • XII -> XIIa -> XI -> XIa -> IX -> IXa -> X -> Xa
  • twelvE -> EleveN -> NinE -> eight -> Ten
163
Q

Clotting Cascade:
Tissue Factor - Extrinsic Pathway

A

VII -> VIIa -> Xa

164
Q

Clotting Cascade:
Common Pathway

A

X -> Xa -> Prothrombin (II) -> Thrombin (IIa) -> Fibrinogen (I) -> Fibrin (Ia)(binds platelets)

165
Q

Clotting Cascade:
Clot formation

A

ADP/Thromboxane/Thrombin
Platelet ——–^——>
Platelet Activation –(GP IIb/IIIa)–> Platelet Aggregation (platelet activation + fibrin (Ia)

166
Q

Platelet activation occurs due to

A

thrombin generation

167
Q

Thrombocytopenia occurs due to

A

increased platelet activation and aggregation

168
Q

Factor XIIa reaches max concentration within … of ECMO initiation

169
Q

Activation of the intrinsic and extrinsic pathways lead to activation of

170
Q

Thrombin:

A

increases expression of pro-inflammatory mediators causing neutrophil activation
induces endothelial cell production of platelet activating factor

171
Q

Fibrin:

A

clot formation

172
Q

Complement Activation elevate levels within … of ECMO initiation

173
Q

Increase complement products contribute to

A

platelet activation and aggregation

174
Q

Thrombin stimulates the release of

A

tissue plasminogen activator (t-PA)

175
Q

t-PA converts plasminogen to

176
Q

Plasmin breaks down

A

fibrin (and fibrinogen) into fibrin degradation products; fibrinolysis

177
Q

Unfractionated Heparin binds to:

A

anti-thrombin III (AT) and inactivates thrombin (factor IIa) and factor Xa; prevents conversion of fibrinogen to fibrin

178
Q

Initiation of Heparin prior to cannulation:
Check aPTT every … from bolus until aPTT …

A

10,000 units
1 hr from 10,000 heparin bolus ; <80

179
Q

Target aPTT on Bivalirudin

A

60-80 seconds

180
Q

ACT goal

A

180-220 seconds

181
Q

anti-Xa assay goal

A

0.3-.7 IU/ml

182
Q

aPTT assay goal with Heparin

A

70-110 seconds correlates with anti-Xa 0.3-.7 IU/ml
MAX aPTT 150 seconds

ECMO (3 decks)

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