Peripartum Extracorporeal Life Support Flashcards
Indications for VV ECMO
Primarily Respiratory:
- ARDS
- Primary graft dysfunction after lung transplantation
- COPD
- Asthma
Indications for VA ECMO
Primarily Cardiac:
- Acute MI
- Cardiomyopathy
- Shock after cardiotomy
- Septic shock
- Hypertension
- Blunt cardiac injury
- Massive PE
- Arrhythmias
Cardiovascular changes in pregnancy
- Increased CO by 50% at 12/40 and 150% at 40/40
- Increased end-diastolic volume and therefore stroke volume
- Increased heart rate
- Reduced SVR (30% lower in the second trimester)
Driven by increases in relaxin, progesterone, oestrogen and RAAS
Highest risk time in labour for patients with cardiomyopathy
Hours after delivery due to autotransfusion of blood.
Due to loss of low resistance placental flow and release of aortocaval pressure -> big increase in pre-load -> risk of right and left heart failure
Respiratory changes in pregnancy
- Progesterone = Increase in MV
- Oestrogen = upper airway oedema and friability
- Increased chest wall compliance increases tidal volumes by 40% despite upward displacement of the diaphragm
- Compensated respiratory alkalosis
- Reduced FRC, RV and IRV
Criteria to start VV ECMO (EOLIA Trial)
- P:F ratio <80mmHg for >6hrs
- P:F ratio <50mmHg for >3hrs
- Arterial pH <7.25 + PaCO2 >8 for 6 hrs despite RR 35 and Plat pressure <32
Haematological changes in pregnancy
- increased blood volume mainly from increased plasma therefore relative anaemia
- Increased: fibrinogen, ferritin, factors VII & VIII and vWF
- Gestational thrombocytopaenia
- All add up to hypercoagulable state
When should you consider delivering the foetus in a pregnant patient on ECMO
> 32 weeks. No data to support mode of delivery vaginal/ assisted/ caesarean
Anaethetising a patient for caesarean on ECMO
- IV drugs not volatiles
- Oxytocin ok
- Ergo and haemobate- careful consideration given bronchoconstriction and hypertension
- TXA ok
- 6x RBC, 6x FFP, cryo and platelets
