Ecmo 3 Flashcards
What should CRRT circuits be plugged into?
Red outlet. Not a power strip.
Cardio help: what does alarm “pump disposable error” mean?
Pump was dislodged, reseat it and then go to deep zero.
On Nautilis oxygenator- set alarms to what?
0-290- not less then zero. And X will show.
What kg gets a femoral cannulation?
20kg, usually 2y.o. Whose been walking
When cannulating or circuit change- when should you send down your VBG instead of doing an istat?
When your on iNO
What surgeon gets paged in a cardiac blast page?
Both CV and general
Does an isolet have fleuro?
No
When water accumulates and you need to sigh, what do you see first?
Decreased ability to remove CO2(page 8), it rarely affects oxygenation. But then page 29 says you see lower post oxy pO2 and rising gas pressure. Page 42 says both
What meds cause an interference with the gas exchange of the oxygenators?
Protocol & lipids
What is the limiting factor for getting faster flow?
The venous cannula size
What is the usual max flow rates needed for just cardiac failure in neo/peds/adults?
100ml/kg/min neo
80ml/kg/min peds
60ml/jg/min adults
When the LV function is minimal & there is lung dysfunction- what’s going on with the coronaries? On ecmo
The LV diastolic pressure rises which causes reduction in coronary perfusion. And if you have some cardiac function; but bad lungs the blood getting to the coronaries is less oxygenated since the heart is perfusing the coronaries not the Ecmo pump. As long as the aortic valve is opening the primary source of coronary blood flow is from the heart.
What happens when the LV is distended?
Pulmonary edema & hemorrhage. And worsens LV dysfunction. And a clot can form in LV
Roughly what amount of femoral cannulations need a reprofusion cannula?
1/3- so if femorally cannulated watch the perfusion closely!
Signs of North south syndrome
Low cerebral NIRS, low sats on one/both arms, bad ABG on radial gasses. Fix with arterial catheter to RIJ
To improve oxygenation in VA ECMO with no native lung function:
More hgb, flow, FIO2, improve CO, sedate/paralyze. If lung function can try vent setting changes
Why are VV goal sats 80-95 if no lung function?
ECMO blood with always mix with patients venous blood, so it’s always mixed
When we say to increase Ecmo flow when initiating Ecmo at a 1:1 ration- what does that mean
If the patient is on 100mls/kg/min sweep is 1.
What do you do if your VV Ecmo patient isn’t achieving adequate oxygenation? (You already have good placement, flow, hgb…)
Add another venous drainage cannula so you can get more more Ecmo flow.
What is the main contributor to oxygen delivery?
Ecmo flow. Check SVO2 to judge adequate oxygen delivery to tissue. Flow is also the primary way to affect patient sats.
Why won’t FIO2 adjustments help increase the SVO2 much?
Because all of the blood is usually 100% saturated leaving the oxygenator
How is the SVO2 on VV Ecmo?
Inaccurate, recirculation
Raising the FiO2 on the sweep above what is needed to fully saturate blood leaving the oxygenator….
Adds very little to oxygenation. You need more flow or hemoglobin
On a cardiohelp, the main limiting factor to flow is cannula size, so at some point increasing RPMs…
Doesn’t increase flow and only causes a more negative bladder pressure and hemolysis
If a circuit is primed, but then not used, how long till we have to monitor the gas/lytes?
1hr. It’s good for 4hrs
If a patients SVO2 is slower than the parameters, what other things can we look at to determine if that SVO2 is okay for them?
Lactate, urine output, vitals. They may not want to increase flow in order to rest the stressed ventricles (don’t want LV distention)
To increase oxygen delivery:
Flow, hemoglobin, FiO2…. Sedate, paralyze, use vent…
If your LV is distended from high flow and low function, how are your coronaries feeling?
Not great. There is less coronary blood flow
On VV, what flow rates are typical going to cause too much recirculation?
120-150mls/kg/min
4 things that affect VV recirculation
Flow, position, volume, cardiac output (any tamponade?)
On VV, is patient has poor sats or SVO2 (we think, this value will be inaccurate)- how do you improve oxygenation?
Potentially more cardiac output- so inotropes, increasing pump flow as long as you’re not overcirculating, more hemoglobin, increase Fso2, ventilator settings
What happens to patients who have too much metabolic alkalosis (from diuretics and blood products?)
Hemoglobin doesn’t unload oxygen well, and hearing loss. Give diamox
At
Any time cannula is in RCCA you may have trouble…
Picking up sats in R arm
What kind of cannula cannot be stented?
Femoral venous cannulas
VV weaning recommendations
Flow 40, then wean sweep
What is the preferred volume replacement for the initial capillary leak/third spacing phase?
FFP, to provide clotting factors
Best way to decrease plasma hemoglobin in setting of an aging circuit?
Circuit change
Considerations of PEEP when first on Ecmo?
Peep 12 for capillary leak unless normal lungs and cardiac dysfunction to preserve preload
Pneumo’s on Ecmo
Can leave to be reabsorbed if asymptomatic. Keep vent settings low.
Management of pulmonary hemorrhage
High PEEP for tamponade effect and racemic Epi for vasoconstriction. Or remove ventilation and allow lungs to collapse. Was the plum hemmorage from LV distention and a septostomy is needed?
Things that cause hemolysis
Sepsis, clots (in circuit or patient), negative pressure, over heating, or dying organs.
