ECMO Specialist Crouse Adult 2015

Question 1

During VA ECMO what should we expect in regard to the pulse pressure?

Answer 1

• Dampened Arterial Waveform

- Pulse Pressure 10 mmHg

Question 2

Anything that changes the volume status of the patient will change the ratio of pump to heart flow, such as ?

Answer 2

IV
Urine
Edema
Hemoconcentrator

Question 3

CVP (bladder pressure) =

Answer 3

Preload to the pump

Question 4

How does the mixing cloud happen?

Mixed Arterial Blood Gas

Answer 4

Blood flow from the heart crashes with Blood from from the arterial cannula.

Question 5

Minor cardiac contribution with High flow rate through femoral cannulation would result in a mixing cloud at what region ?

Answer 5

Ascending Aorta

Question 6

Moderate cardiac contribution with Moderate Flow Rate through femoral cannulation would result in a mixing cloud at what region ?

Answer 6

Aortic Arch

Question 7

Large cardiac contribution with minimal Flow Rate through femoral cannulation would result in a mixing cloud at what region ?

Answer 7

Abdominal Aorta

Question 8

To change the PaO2 what knob would you adjust ?

Answer 8

FiO2

more true for VA than VV

Question 9

To change the PCO2 what knob would you adjust ?

Answer 9

Sweep gas rate

more true for VA than VV

Question 10

To change the SVO2 what knob would you adjust ?

Answer 10

Pump Flow

more true for VA than VV

Question 11

How would you evaluate adequacy of perfusion with a blood gas?

Answer 11

Compare PreOxygenator with Patient ABG

Question 12

How would you evaluate Oxygenator Function with a blood gas?

Answer 12

Compare PreOxygenator with Post Oxygenator

Question 13

How would you evaluate Pulmonary contribution with a blood gas?

Answer 13

Compare PostOxygenator with Patient ABG

Question 14

Evaluate Oxygenator
Function:

Pre  = PCO2 50   PO2 45
Post = PCO2 49  PO2 350

Answer 14

Increase Sweep

Question 15

Evaluate Oxygenator
Function:

Pre  = PCO2 50   PO2 35
Post = PCO2 20  PO2 350

Answer 15

Decrease Sweep

Question 16

Evaluate Oxygenator
Function:

Pre  = PCO2 50   PO2 35
Post = PCO2 20  PO2  90

Answer 16

Increase FiO2

Question 17

Evaluate Adequacy of Perfusion:

Pre=   PCO2 50 PO2 35 SAT 65%
Post= PCO2 40 PO2 100 SAT 100%

Answer 17

Perfect

Question 18

Evaluate Adequacy of Perfusion:

Pre=   PCO2 45 PO2 35 SAT 65%
Post= PCO2 60 PO2 100 SAT 100%

Answer 18

More Ventilation

Increase Sweep

Question 19

Evaluate Adequacy of Perfusion:

Pre=   PCO2 35 PO2 35 SAT 65%
Post= PCO2 25 PO2 100 SAT 100%

Answer 19

Less Ventilation

Decrease Sweep

Question 20

Evaluate Adequacy of Perfusion:

Pre=   PCO2 45 PO2 30 SAT 60%
Post= PCO2 35 PO2 60 SAT  85%

Answer 20

More Oxygenation

Increase FiO2

Question 21

Evaluate Adequacy of Perfusion:

Pre= PCO2 55 PO2 28
Pt ABG = PCO2 35 PO2 100

Answer 21

More Blood Flow

Question 22

What is the measure of adequacy of perfusion ?

Answer 22

Mixed Venous Saturation (SVO2)

Question 23

Under what circumstances is the SpreO2 NOT a true SVO2 ?

Answer 23

• VV Recirculation
• AV Shunts
• Circuit Shunts (Hemoncentrator in circuit)
• Patient Shunts (LV Vent)

Question 24

To initiate cannulation what 3 things must be accomplished ?

Answer 24

• Anesthetize
• Paralyze
• Heparinize

Question 25

What is the patient Heparin loading dose?

Answer 25

100 u / Kg

Question 26

Target metric for Heparin dosing ?

Answer 26

PTT 1.5 - 2 greater than normal

ACT 160 - 240 sec

Question 27

ACT targets are based on patient acuity and blood flow in the circuit.

ACT for Bleeding or high flows =
ACT for Not bleeding or low flows =

Answer 27

ACT for Bleeding or high flows = (160 - 200)

ACT for Not bleeding or low flows =(200 - 240)

Question 28

what are the 4 Heparin dosing steps ?

Answer 28

1.) Check ACT before initiation
2.) Turn Heparin GTT ON once
heparin falls into range.
3.) Start GTT at 35-50 u/kg/hr
4.) Titrate GTT to maintain
target ACT.

Question 29

In order to provide flow to the pump, the CVP must stay positive normally above what?

Answer 29

8 - 12

Question 30

VLP =

Answer 30

CVP + Height of the table

before flow starts

Question 31

If the VLP is dropping quickly . . . . . . . What is going to happend ?

Answer 31

The pump is about to stop pumping.

Question 32

What will indicate if the RA collapses onto the cannula and blood flow stops?

Answer 32

Chatter in the venous line

Question 33

ALP =

Answer 33

ABP + 200 mmHg

Question 34

What 4 factors dictate ALP ?

Answer 34

• Cannula size
• Cannula position
• Patients BP
• Pump Flow

Question 35

What is the target Pump Flows?

Answer 35

2.0 -3.0 CI ( 3.5 - 5.0 LPM)

Question 36

My patients PaO2 is 69%, we are failing to Oxygenate. What are the 3 Hallmarks of a failing oxygenator?

Answer 36

1.) Widening pre-post pressures
(consider flow & SVR variations)

2.) Decreased CO2 clearence
(consider sweep gas flow variations)

3.) Decreased Oxygenaion
(consider FiO2 variations)

Question 37

What is happening if i notice the water in the water bath is colored ?

What will happen i f water pressure exceeds blood pressure?

Answer 37

-Blood to water leak
Turn off the water bath to reduce water pressure.

Water will leak into the blood = hemolysis & sepsis

Question 38

VA ECMO trial Off sequence ?

Answer 38

1. ) Increase Vent settings
2. ) Turn off oxygenator sweep gas
3. ) Clamp cannulas, flow through bridge
4. ) Check Pt & circuit ACT Q 20 min
5. ) Flash cannulas Q 20 min
6. ) Check SVO2 to assess pt during flash

Question 39

VV ECMO trial Off sequence ?

Answer 39

1. ) Increase Vent settings
2. ) Turn off oxygenator sweep gas
3. ) Check ACT Q 60 min
4. ) Check SVO2 to assess pt continuously