ECMO

Question 1

Indications/Disease Processes indicated for VA ECMO

Answer 1

Acute MI with refractory cardiogenic shock
Failure to wean from CPB postcardiotomy (hypocontractility, graft failure, persistent pulmonary HTN
Acute myocarditis
Acute Massive Pulmonary Embolism
Other forms (eg, endocrine) of cardiogenic shock
For support during interventional cardiology
Preoperative support (post infarct VSD or papillary rupture)
Acutely decompensated cardiomyopathy

Question 2

Inflow cannula size for adult ECPR/flows

Answer 2

Greater than 60-70 mL/kg/min or 5 LPM may be needed

3.5-4 LPM requires 15-17 Fr femoral cannula

Question 3

VA ECMO and transpulmonary flow

Answer 3

The higher the ECMO Q the lower the RV filling.
The lower the RV filling the lower the transpulmonary flow
Decreased lung perfusion increases the rate of lung injury and infection
Central cannulation fully achieves CPB and worsens the transpulmonary Q

Question 4

Usual Venous cannula size

Answer 4

18-28 Fr in adults

Question 5

Usual arterial cannula size

Answer 5

16-20 Fr in adults

Question 6

Optimum placement of femoral venous line

Answer 6

Mid right atrium, at the middle of the SVC-RA junction

Question 7

Distal perfusion catheter size

Answer 7

6-8 Fr

Question 8

Axillary artery cannulation for ECMO

Answer 8

8 mm vascular end to side graft following exposure of the vessel below the right clavicle.
The most significant side effect is hypoperfusion with 20% developing compartment syndrome of ipsilateral arm

Question 9

Hypoperfusion/compartment syndrome in axillary artery cannulation for ECMO; causes and treatment

Answer 9

Causes can be arterial narrowing from atherosclerotic disease distal to the graft, or narrowed arteries due to type A dissection. Venous causes are from decreased limb drainage from bleeding, DVT, poor placement of venous cannula, and cardiac tamponade.
Treatment usually is decreasing Q ECMO and elevate the arm. If a DVT is suspected then the arterial flow site must be changed

Question 10

Techniques of LV unloading during VA ECMO

Answer 10

Additional inotropic support to increase contractility
IABP
Impella
Main PA cannulation (retrograde transpulmonary decompression)

Question 11

Most common ECMO complication

Answer 11

Major Bleeding, affects 30-42% of ECLS patients.
One of the most common sites is intracranial hemorrhage.
(?AKI occurs in 47-56% of patients)
Treatment includes blood products, protamine, and avoidance of acidosis and hypothermia

Question 12

Anticoagulation Recommendation

Answer 12

ACT 180-220

aPTT 1.5-2.5 times the normal.