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ECMO > ECMO Test Guide > Flashcards

ECMO Test Guide Flashcards

1
Q

The output on the roller head is dependent on what 4parameters?

A
  1. Occlusion pressure
  2. Pump RPM’s
  3. Adequate venous return to the pump.
  4. Correct tubing size selection on the pump.
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2
Q

List 3 ways of increasing oxygen delivery on a patient that is on ECMO.

A
  1. Increase O2 flow to the membrane.
  2. Increase FIO2 on the blender.
  3. Increase flow which will increase cardiac output.
  4. Transfuse PRBC. (Hg)
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3
Q

List the potential causes in the following pressures on the ECMO pump.
1 Pre-bladder pressures
2. Pre-MO pressures
3. Post MO pressures

A
  1. Pre-bladder– decreased venous return, low bed height, hypovolemia, kinked or misplaced cannula,
  2. Obstruction to flow pre-MO, kinks or clots in the MO or lines pre or post.
  3. Obstruction to flow pre-MO, kinks or clots in the MO or lines pre or post.
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4
Q

Know the heparin concentration used for ECMO as well as the loading doses when instituting ECMO.

A

The heparin concentration used is 100:1 and the loading dose is 25 units/kg, 400 units per unit of blood, and 300 units in the cyrstalloid solution pre blood.

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5
Q

What are the 4 phases of priming and what is involved in each phase?

A
  1. Gas prime- CO2 at 2 lpm for 2-3 min to flush out the nitrogen, which will eliminate bubbles.
  2. Cyrstalloid prime
  3. Albumin/heparin prime- add 300 units of heparin and 10ml albumin to cyrstalloid.
  4. Blood prime- each unit of blood is treated with 400 units of heparin, 40-50ml of albumin, 10 mEq of bicarbonate, 750mg of calcium gluconate.
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6
Q

How do the pressure transducers work on the ECMO pumps? What are the limits if each transducer?

A

Pressure transducers are read through the cap system.

  1. Pre-bladder pressure- indicates venous return and is set at -5. At -1 the pump will slow and at -3 the pump will stop.
  2. Pre-MO pressure- indicates pressure necessary to circulate blood through the circuit and MO. Set limit 50-100 above actual pressure. Pressures >500 are dangerous and an increase is indicative of clots in the MO or kinks in the line.
  3. Post-MO pressure- indicates pressure necessary to push blood to the patient. Should be set 50-100 above actual pressure. An increase is indicative of an obstruction between the MO and the end of the arterial cannula.
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7
Q

Be able to describe the safety sytems for the ECMO pumps?

A

CAPS- Allows for the monitoring of Pre-bladder, Pre-MO and Post-MO transducer pressures. The CDI allows for monitoring circuit blood gas and venous return saturation. The transonic will alarm for flow deviation and bubbles in the cicuit. The current heat exchanger built into the circuit works as a bubble trap.

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8
Q

What are the risks of air or clots in the circuit? Compare VA to VV ECMO

A

This is the most common mechanical complication and can cause MO failure, pulmonary and cerebral emboli. Clots can be found in the MO, in the bladder or heater, They can orignate in from cracks in pigtails/stopcocks, tears in the MO and each joint of the circuit. Dislodgement of the venous cannula can allow for air to be sucked in and poor venous return can allow for cavitation.

VV ECMO- Less chance of cerebral emboli, but still possible through open PDA and shunting. Pulmonary emboli are likely with clotting post MO. Ligation of the carotoid artery is not necessary.

VA ECMO- Greater chance of cerebral emboli with post MO clots, Higher flows allow bubbles or clots to sweep by quickly. carotoid artery must be ligated.

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9
Q

Transonic flowmeter: whereis it placed in the circuit and why? What does it monitor? What alarms does it have? Does it control the pump in anyway?

A

It is placed distal to the heateradn after the last pigtail of the arterial limb, but proximal to the patient. It detects bubbles in the circuit and the actual flow the the patient is receiving. There will be an approximate 100ml difference between the set flow and the transonic flow due to the CDI shunt. It has high and low flow alarms that are set 50 above and below actual flow and also has a bubble alarm.

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10
Q

What is the oxygen index (OI), how is it calculated and what does this number represent?

A

OI = MAPxFIO2x100/PAO2
The OI is the only way to measure the severity of respiratory failure and quantifies the pressure required to maintain oxygenation. If the OI is >40, the prognosis is poor.

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11
Q

VV vs. VA ECMO- what is the difference in cannulas, their postitioning and the vessels used, and the pros and cons of both modes?

A

VV ECMO- Uses a double lumen single cannula that is inserted into the right IJ and positioned so it dumps blood directly into the right atrium. A double cannula sytem can also be used draining blood from the femoral vein and returning blood to the right IJ.
PROS include minimizing t
.he possibility of cerebral emboli, no ligation to the carotoid artery, percutaneous placement, and faster cannulation. offers pulmonary support allowing lower ventilator settings so the lungs can rest.

CONS include greater possibilty of pulmonary emboli, no cardiac support, no good on a dying patient and possibility of recirculation of blood.

VA ECMO uses two cannulas. Blood is drained from either the right IJ and positioned just above the right ventrical or femoral vein and returned to the right carotoid artery and positioned at the aortic root.

PROS include both cardiac and pumonary support, lower ventilator settings than that of VV ECMO, SVO2 is a true value, decreased preload.

CONS include the ligation of the carotoid artery, higher possibility of a cerebral emboli, longer cannulation time, myocardial stun.

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12
Q

How to troubleshoot and deal with emergencies (ECMO circuit and pump problems, patient problems)

A

CIRCUIT FAILURE - Very Bad Accident. Clamp venous line, open bridge, clamp arterial line.
OXYGENATOR FAILURE- pre-MO pressures increase secondary to clots. VBA and change out the oxygenator.
AIR IN CIRCUIT- Found at the top of the MO, bladder and heater. Secondary to cracked pigtails/stopcocks, tear in the MO, venous cannula dislodgement and cavition in the pump.
DECREASED VENOUS RETURN - Cannula placement, kinking or collapse. hypovolemia, inadequate bed height. indicated by a decrease in pre-bladder pressures.

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13
Q

Procedures and responsibilties of the ECMO specialist during their shift.

A
  1. Protect the circuit, the pump, the cannula, and the patient.
  2. Hourly circuit (including flashing the bridge and massaging the bladder) and cannula checks, ACT’s and vitals with appropriate documentation.
  3. Assist in cannula dressing, repostioning, xrays.
  4. Drawing blodd gases and calibrating equipment.
  5. Ordering and administering blood prducts and medications.
  6. Verify drips and drugs
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14
Q

How do you remove air and clots from the circuit and where are the common places air can be trapped in the circuit?

A

Air is most commonly found in the bladder, the MO and the heat exchanger. Pigtails are located at the top of all these spots and a syringe may be used to remove air and clots from these points.

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15
Q

Blood product administration: differences in administering, placement in the circuit, additives and how much, if any, are added to these products?

A

BLOOD (PRBC’s)- Given to increase Hct/Hgb levels to maintain Hct levels >35. Ordered as 15ml/kg for neonates and 2-3 units for peds/adults. Added to the top of the bladder.
PLATELETS- Given for thrombocytopenia to maintain platelet levels >110,000cells/mm3. Order as 15ml/kg for neonates and per MD order for peds/adults. Added post MO and 2units/ml of heparin are added.
FFP- Given for coagulation disorders and profolacticly every other day. Ordered as 40ml and given post initiation of ECMO. Can be added post MO or the top of the bladder.
CYRO- Given to increase fibrinogen levels to maintain fibrinogen >100mg/dL, or if factor XIII deficient, or if Von Willebrand factor deficient. 2 units given per MD order. Added post MO and treated with 2 units/ml of heparin.
ALBUMIN- given to increase blood volume and added pre MO, but post rolle head and only on MD order.

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16
Q

ECMO warming unit function and trouble shooting

A

The warming unit is used to maintain the patients blood to maintain an ordered body temperature. Make sure the heater is turned on and the water is flowing, the valves are open and the temperature is set at the correct setting. Ensure the the temp probe is connected correctly

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17
Q

Evaluating adequacy of oxygen delivery in patients.

A

Monitoring blood gases, labs, Somanetics, pulse ox, urine output and the CDI

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18
Q

Correct response on ECMO specialist during a power failure

A

Ensure the pump is in battery mode and crank by hand until pump can be restarted.

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19
Q

Neonatal diseases

A

CDH, MAS, PPHN, RDS, Sepsis

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20
Q

Criteria for starting ECMO

A

> 34 weeks gestational age. >1800 grams. OI>40 for 4 hours or two poor ABG’s. < grade 2 ICH. Pateint has acute reversible respiratory failure and an agreement between 2 attending physicians that current medical therapy is ineffective and prognosis is good if ECMO is implemented.

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21
Q

Contraindications for ECMO

A

< 34 gestational weeks, < 1800 grams, > grade 2 ICH, congenital abnormalities considered terminal, or excessive number of days on mechanical ventialtion. (at MD discretion)
Pt. 8yrs- , <7 days

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22
Q

ECMO circuit: Where meds/blood products are given in the circuit?

A

PRE-BLADDER- Nothing
TOP OF BLADDER- Blood, Lasix, Bumex
PRE-MO (post roller)- Lipids, Most meds, and Heparin(alone and via Alaros pump)
POST-MO- Platelets, Amphotericin, Vancomycin, Diflucan and Hydrocortisone
LAST PIGTAIL(arterial side before patient)- Adenosine, Atropine and Insulin

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23
Q

ECMO circuit: Where are blood samples drawn from the circuit?

A

VBG samples are drawn pre-bladder. ABG samples drawn Post MO

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24
Q

ECMO circuit: What is the location of the CDI, transducers, and transonic on the circuit?

A

The CDI venous blood sensor is placed pre-bladder and the arterial sensor is located on the CDI shunt. Transducers are located pre-bladder and pre and post MO. The Transonic is located post MO, distal to last pigtail and proximal to the patient.

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25
Q

ECMO circuit: Where is air removed from the circuit?

A

Air is typically removed from the pigtails at the top of the bladder, heat exchanger and the front of the MO.

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26
Q

CDI recalibration and routine monitoring

A

CDI calibration should be done Q1 x2 after initiating ECMO and until patient is stable. Then Q6 for 24 hours and then Q8

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27
Q

Decreased venous return: Causes and corrective actions.

A

Cannula problems like tight sutures, kinks/collapse, or inappropriate size can be corrected by raising the bed, repostioning the baby, or by giving volume.

Cardiac problems such as cardiac tamponade, myocardial stun, pneumopericardium and pneumothorax can be addressed by giving blood or fluid blous if patient is hypotensive. Sedation and suction can also help. A resolving pneumo can also be a cause for decreased venous return.

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28
Q

Gas flow to MO: Minimum and maximum flows, control of oxygen and CO2

A

O2 flows/CO2- max combined flow on the neo MO is 5.6lpm.

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29
Q

MO failure: symptoms, causes and correct action:

A

As the MO gets older it loses permeability which decreases O2 and CO2 gas exchange. MO’s fail due to clots or tears in the silicone wrapping. Symptoms will include an increase in the pressure gradient between the pre and post MO transducers or the pre-MO pressure steadily increasing. You can also have a low PaO2 despite having a high FIO2 and high flows.

30
Q

Procedure for emergently discontinuing ECMO

A

Very- Clamp venous side
Bad- Open the bridge
Accident- Clamp the arterial side

31
Q

Factors affecting ACT

A

Normal ACT range is 180-220
Increased heparin requirements include:
recent platelet or cryo infusion, hemofiltration, increased urinary output and low pump flows.
Decreased heparin requirements include:
low fibrinogen and platelet levels, renal failure and circuit DIC

32
Q

Shift report; what should it include?

A 
Baby age, gender, weight, diagnosis, delivery, and Hx.
ECMO type and day
Flow
Sweep gas
Cannula size and placement
Labs (When, what and where)
Medications (What and when)
Most recent labs
Weaning?
ACT's
Any emergencies 
Circuit check
33
Q

Individual circuit check: When/how to do it and what to include?

A

Check cannula’s
Flash bridge
Check for air, clots and make sure all tie bands and stopcocks are okay
Zero transducers and check for alarm limits for pump and transonic flow
Check for raceway scuffing and ensure proper tubing size is selected.
Clamp venous side to ensure pump shut down.
Cannula position and sutures.
Check that pump is in auto restart

34
Q

Two purposes of heat exchanger

A

To use as a bubble trap and to maintain an ordered core temperture.

35
Q

How to interpret pre-bladder, pre-MO and post-MO pressures.

A

Pre-bladder- A measurement of the venous return pressure. A decrease in pressure is a sign of decreased venous return.
Pre-MO- Pressure needed to pump blood through MO and on to the patient. An increase in pressure will likely indicate clots in the MO or kinks in the cannula downstream.
Post-MO- Pressure needed to pump blood on to the patient after passing through the MO. An increase in pressure will indicate kinks or obstruction in the line or cannula.

36
Q

Interpret mixed venous gas saturation

A

SvO2 is an indicator of oxygen consumption. Knowing the SaO2 of the blood being delivered and analyzing the SvO2 of the venous return you can evaluate the oxygen consumption and tissue oxygenation of the patient. In VV ECMO using a single cannula, an abnormally high SvO2 can be an indicator of re-circulation of blood being delivered. This can mean either the pump flows are too high or the cannula is not properly positioned at the right atrial.

37
Q

Where is the hemofilter is placed in the circuit.

A

Blood enters the hemofilter from the venous return post roller head. before or after the MO and is returned to the circuit pre roller head.

38
Q

What are the paremeters that need to be monitored during hemofiltration?

A

ACT’s will react differently on hemofiltraion due to greater heparin clearance. Electrolyte levels will also change due to filtration.

39
Q

What are the parameters that determine the output of the rollerhead?

A

The flow through the rollerhead is determined by the rpm’s, the diameter of the tubing, the occlusion pressure and the length of the stroke. (the stroke length is fixed and based off the internal circumferance of the of the raceway.

40
Q

Describe how to adjust the occulsion and troubleshoot problems with the occlusion.

A

After overriding the lid alarm and raising the cover over the raceway, you can manually increase the occlusion pressure by turning the center vertical wheel. While monitoring the Transonic flow meter, increase the pressure until the flow stops rising. Once the flow stops rising, reduce the occlusion pressure just until the flow starts to drop. Thats the sweet spot. Too little occlusion wil give false calculated flow on the pump and could lead to malperfusion. Occlusion pressure that is too tight may cause spallation, hemolysis and raceway rupture.

41
Q

What is the difference between ECMO and cardiopulmonary byppass?

A

ECMO is frequently instituted using only cervical cannulation and is used for longer term support for either cardiac or pulmonary problems that can be resloved with resting these organs. ECMO is generally counted in days. Cardiopulmonary bypass (CPB) is generally instituted with thoracic cannulation in the OR and used for support during an operation. CPB is short term, counted in hours and the circuit uses a reservoir to hold more blood to compensate for what is lost in surgery.

42
Q

What are the flows used for VV and VA ECMO for “full flows”?

A

VA ECMO should be started slowly at 20ml/kg/min and slowly increased over 20-30 min to a max flow of 120ml/kg/min.
VV ECMO is started at 20ml/kg/min and increase over the next 10 to 15 min to a maximum flow of 150ml/kg.min.

43
Q

Know how to interupt pre and post-ductal saturations.

A

A differnential between pre and post-ductal saturations is indicative of right to left shunt cardiac anomolies and PPHN. A change in differential can also show a reversal of these conditions. A mixing of blood and shunting through the PDA allows the extremities receiving blood pre PDA to have saturations higher than the lower extremities which get their blood post PDA. TPGV can show a reversal of this differential.

44
Q

Know how to adjust the heparin, the standard concentration of heparin, and the bolus dose of heparin.

A

Heparin adjustments should always be made to the dose and not the rate. The standard concentration is 100:1 and the bolus dose is either 15 or 30units/kg depending on the range you’re compensating for. Always check the protocol and dont try to memorized it.

45
Q

Why is it important that the patient is paralyzed during cannulation?

A

Paralyzing the patient is important in ECMO cannual placement because the patients deep breathing could entrap an air bubble.

46
Q

What is the sash?

A

The sash is an IV bag used to prime a new ECMO circuit. It is cut away by the surgeon prior to attatching the EMCO lines to the cannula.

47
Q

How do you pass equipment in an OR or sterile setting?

A

All items placed on blue surgical towels are considered sterile. Gloves, mask and hair covering should be worn at all times and new sterile items should be opened, not touched and dropped onto the sterile work space at the surgeons request.

48
Q

Describe the Origen cannula.

A

The Origen is a double lumen, Y-shaped cannula used for VV ECMO with the venous return lumen approximently twice the size of the arterial side.

49
Q

Describe the Biomedicus arterial and venous cannulas.

A

Biomedicus makes single lumen cannulas for VA ECMO and the venous cannula is fennestrated as where the arterial cannula only has one orfice.

50
Q

Where should the cannulas be in VV and VA ECMO?

A

VA arterial cannula ends at the arotic arch and the VA venous canula ends at the right atrium. The VV canula is inserted to where the artertial return ends at the right atrium.

51
Q

When do you give FFP?

A

FFP is given for coagulation disorders to maintain PT INR <2 and is given at the start of ECMO and then every other day per physician order.

52
Q

What are the symptoms and action taken for DIC?

A

The symptoms fo disseminated intravascular coagulation are increased ACT’s, increased PT INR’s and acute bleeding. Treatment may include decreasing ACT parameters, giving platelets, cyro, and other blood products as indicated, changing the ECMO circuit if necessary, treat bleeding source if localized, treating sepsis and hypertention if necessary.

53
Q

Who is the “father” of ECMO and why?

A

Dr. Bartlett is considered the father of ECMO for successfully treating the first neonate at the university of Michigan in 1976.

54
Q

How do you determine PPHN?

A 
Clinical picture:
Pre-ductal SpO2 > Post-ductal SpO2
Lability of oxygenation
Cyanosis and pallor
Heart murmur
onset of symptoms within 12 hours of age
Diagnosis:
Hyperoxia test
Echocardiagram
Differential SaO2 or PaO2
CXR- infiltrates, atelectasis, and hyperinflation
Response to pulmonary vasodialators.
55
Q

What determines oxygen delivery?

A

oxygen content x cardiac output

56
Q

What are the two components of cardiac output?

A

Heart rate x stroke volume

57
Q

What are the three comonents of stroke volume

A

contractility, preload, and afterload.

58
Q

How does pre-load and afterload relate to the patient? How does it relate to the ECMO pump?

A

Pre-load relates to the stretch of the heart and the end diastolic volume. This is in direct correlation to the patient volume and venous return to the pump. If the patient is hypotensive and the pre-load is low, there may not be enough venous return to maintain flows. After load relates to the contractility of the heart and the pressure needed to overcome vascular resistance, as seen in the end systolic pressure. The afterload is also dependent upon what the pump gives back and is directly related to the pre-load.

59
Q

What is the formula for oxygen content and why is this important in ECMO?

A

CaO2 = (Hb x 1.34)+(PaO2 x .003)
This represents the total volume of oxygen, both bound and disolved, being delivered to the patient. This is important in ECMO because the pump is oxygenating the blood for the patient.

60
Q

What is catitation? When does this occur and when should it not happen?

A

Cativation is the release of gas bubbles in a liquid secondary to excessinve negative pressure. This can occur pre-rollerhead due to a kink or collapse of the circuit or cannula, or decreased venous return can all allow cor cavitation in the bladder and circuit.

61
Q

What diseases are treated with ECMO in pediatric patients?

A

ARDS, PPHN, CDH, congenital cardiac issues, sepsis, and pneumonias.

62
Q

What are the indications for ECMO?

A

> 34 gestational weeks
1800 grams
Optimal medical management has been achieved.
Patient condition is acute and reversible.
Maximum vent settings
Maximum medication administration
Oxygen index >40 for hours
Agreement between two attending physicians

63
Q

List the contraindications for ECMO

A

<1800 grams
Long term vent management
Terminal illness
Neurological devistation

64
Q

How do you adjust and troubleshoot the sweep gas?

A

Oxygen and CO2 are tee’d together and connected to the MO. An increase in O2 sweep gas will decrease CO2 in the circuit and conversly a decrease in O2 sweep gas will increase CO2. Adjusting the CO2 sweep gas in proportionate. An increase will raise CO2 and a decrease will lower CO2. The combination of both flows can not exceed the max flow of 5.6 lpm on a pediatric MO.

65
Q

What are the differences between weaning VA and VV ECMO?

A

Both types of ECMO are weaned by lowering the flows and support to allow the patient to do more of its own work While not lowering the flows below the limitations of the MO or the circuit. However, trialing off ECMO is different. In VA ECMO a patient can be trialled off simply by clampping out VBA. In VV ECMO the sweep gas line is removed from the source and reattatched to the bottom of the MO.

66
Q

What are the routine labs sent on ECMO

A

CBC, platlets, fibrinogen, CMP, BMP, patient gases

67
Q

What are the parts of the ECMO system and what are there intitial settings?

A

The rollerhead- is the pump
CDI- has a venous and arterial senor and displays real time abg info
Transonic- measures actual flow to the patient.
Stockert- display for bladder, pre and post MO pressures.
Heater- warms or cools blood depending on the need.

68
Q

What are the common medications used in ECMO and where are they added to the circuit?

A

Sedation, pressors, antibiotics, diuretics
Continuous infusions-After roller head
Intermittent infusions-After roller head
IV push medications-Injected into bladder
Urgent medications-Inject into patient if possible or into closest port

When in doubt - give post-MO

69
Q

What are the complications of hemofiltration?

A

Anemia and thrombocytopenia
Rbc’s and platelets are lost when filter and circuit are changed
Metabolic acidosis
Obligatory bicarb loss in ultrafiltrate
Hyponatremia or other electrolyte issues
High sodium content in ultrafiltrate
Hypovolemia
Careful monitoring of volume to be removed is required
Infection and Sepsis
Clot related problems
Drug dosage modifications

70
Q

What is cardiac stun and what do you do about it?

A

Cardiac stun is an exaggerated decrease in cardiac performance during ECMO. In VA ECMO cardiac stun can be caused by placing the arterial cannula too close to coronary arteries. Statisticlly regains normal function within 33 hours and nothing can be done while giving full suport.

71
Q

What are the complications of cannulation and what do you do when this happens?

A

Complications include: kinking or having the sutures too tight, acidental removal, bleeding or infection at the site, or preforation of the cava or RA. In the event of an accidental removal, VBA and then apply direct pressure to the site.

ECMO (2 decks)

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