St Vincents 2024 ECMO Quiz Flashcards
What line does the flow/bubble detector go on?
a). The access line
b). The return line
c). The backflow
d). The venous line
B
In peripheral VA ECMO into what vessel is the return line inserted?
a). Aorta
b). Femoral artery
c). Carotid artery
d). Femoral vein
A
The Bioline coating on the cardio help HLS circuit contains what?(more than 1 correct
answer)
a). Protamine
b). Potassium
c). Heparin
d). Albumin
C and D
True or False
The main difference between VV and VA ECMO is that VV provides no direct cardiac support
True
CO2 removal in the membrane oxygenator is primarily dependent on:
a). RPMs
b). Sweep gas flow rate
c). ECMO flow
d). ECMO FiO2
B
Where on the ECMO circuit is the haemofilter attached?
a). Return to post oxygenator 3 way tap, Access to oxygenator 3-way tap
b). Return to post oxygenator 3-way tap, Access to pre oxygenator 3-way tap
c). Return to pre oxygenator 3-way tap, Access to post oxygenator 3-way tap
C
On peripheral ECMO, into what vessel is the venous access line inserted?
a). Brachial vein
b). Left internal jugular vein
c). Femoral vein
C
True or False
VV ECMO improves the patient’s oxygenation and removes CO2 from the patient’s
blood. This allows the level of ventilator support to be reduced which in turn reduces
ventilator induced lung injury.
True
Complications related to ECMO cannulation include:
1). Infection
2). Vascular injury (dissection, intimal tear)
3). Obstruction (kinking, positional)
4). Bleeding
5). Leg ischaemia
a). 1 & 3
b). 3
c). 2, 4 & 5
d) All of the above
D
True or False
Patients with central cannulation cannot be turned.
False
True or False
During VV ECMO a clear indication of severe recirculation is well saturated bright red blood
in the return and access limbs.
True
What is the best indicator of adequacy of oxygenation on VA ECMO?
a). Arterial SaO2
b). SVO2
c). Arterial Oxygen Saturation
d). ABG pO2
B
What are the indications for doing a post oxygenator gas? (more than 1 correct answer)
a). Falling Delta p
b). Reducing patient saturations
c). Rising Delta p
d). Rising CO2 despite high fresh gas flow rates
e). Visible clots and fibrin deposition on oxygenator
B, C, D and E
Your patient’s ABG shows a low pCO2. What is the appropriate action to take?
a). Decrease ECMO flow rate
b). increase the fresh gas flow rate
c). Increase ECMO flow rate
d). Reduce the fresh gas flow rate
D
Oxygen Delivery to the VA ECMO patient can be increased by: (more than 1 correct answer)
a). Reduce minute ventilation
b). increasing the ECMO flow rate
c). Increasing the patient’s Hgb
d). Reducing FiO2
B and C
In the post operative cardiac VA ECMO patient which of the following could be the cause of
inadequate venous return? (More than 1 answer)
a). Hypervolaemia
b). Bleeding
c). Cardiac Tamponade
d). Hypovolaemia
B, C and D
Decreased venous return during ECMO can be caused by (more than 1 correct answer):
a). Tamponade
b). Bleeding
c). Sedation bolus
d). Reduced volume status
e). Pneumothorax
f). High intra-abdominal pressure
g). High ECMO flow rate
h). Return cannula too low
i). Access cannula too low
j). Patient straining
ABCDFGIJ
What is the greatest risk to the patient when the patient is cannulated femorally for VA
ECMO?
a). Pain
b). Limb ischaemia
c). Bleeding
d). Hematoma
B
The Oxygen Delivery formula is CO x (Hb x 1.34 x SO2) + (PaO2 x 0.003). How can the
oxygen delivery be increased in a patient on ECMO? (More than 1 correct answer):
a). Increase Hgb
b). Increase fresh gas flow rate
c). Increase ECMO flow
d).Reduce the patient’s heart rate
e). Increase afterload
f). Ensure adequate preload
A, C and F
What is the gold standard anticoagulant used with ECMO?
a).Argatroban
b). Warfarin
c). Heparin
d). Clexane
C
What is the gold standard anticoagulant used with ECMO?
a).Argatroban
b). Warfarin
c). Heparin
d). Clexane
C
What is the most common complication associated with ECMO?
a). Infection
b). Systemic thromboembolism
c). Bleeding
d). Death
C
What are the required daily investigations for a patient on ECMO?
a). Daily Chest X-Ray, Daily LDH/D-Dimer, BD FBC,UEC, CMP, LFT, COAGS,Anti-Xa
b). Daily Chest X-ray, BD LDH/D-Dimer, 6/24 FBC,UEC, CMP, LFT, COAGS,Anti-Xa
c). Second daily Chest X-ray, Daily LDH/-Dimer, FBC,UEC, CMP, LFT, COAGS,Anti-Xa
d). Second daily Chest X-Ray, BD LDH/-Dimer, FBC,UEC, CMP, LFT, COAGS,Anti-Xa
B
What are some pathologies that can cause acute cardiac failure that may be potentially
suitable for ECMO?
a). PE
b). Fulminant myocarditis
c). Aortic dissection
d). AMI with cardiogenic shock and MSOF
e). Drug overdose with severe cardiac depression
A,B D and E
True or False
There are no absolute contraindications to ECMO.
False
Who can benefit from ECMO?(more than 1 correct answer):
a). Those with a reversible disease
b). Patients <65 years
c). Patients with advanced COAD
d). Patients with isolated respiratory or cardiac failure
e). Patients >75 years
f). Patients with established multi-organ failure
A, B and D
What are some of the pathologies potentially suitable for VV ECMO?
a) ARDS
b) pneumocystis pneumonia in a 55 year old who has HIV with AIDS
c) status asthmaticus
d) exacerbation of COAD
e) Aspiration pneumonitis after overdose
A, C and E
When is VV ECMO indicated?
a). Cardiac failure
b). Cardiac and respiratory failure
c). Isolated respiratory failure
d). Post cardiac surgery
C
When is VA ECMO indicated?
a). Failure to wean off bypass
b). chronic cardiomyopathy
c). severe pneumonia
d). septic shock with severe left heart failure
A
On the ECMO console what may indicate that recirculation is occurring?
a). Low venous O2 saturations
b). A decrease in ECMO flow in L/min
c). An increase in delta P
d). High venous O2 saturations
D
True or False:
Arterial pulsatility reflects native cardiac output on VA ECMO
True
Limb perfusion on VA ECMO is monitored using:
a). INVOS tissue perfusion monitoring hourly
b). Checking backflow cannula for flow using handheld Doppler hourly
c). Measuring dorsalis pedis or posterior tibial pulses once per shift
d). Checking lower limb skin temperature and color hourly
e). Palpating thighs and calves monitoring for compartment syndrome
A,B, D and E
On VV ECMO the usual goal for acceptable arterial saturations is:
a). 100%
b). 80-90%
c). 65-75%
d). 40-50%
B
Loss of pulsatility on the arterial waveform during VA ECMO can be due to:(more than 1 correct answer)
a) Arrhythmia VT or VF
b) Mechanical Obstruction (Tension pneumothorax, tamponade)
c) Poor contractility
d) Inadequate preload (bleeding, excessive ECMO flow rate)
e) Artefact/kinked arterial line
All of them
True or False
The pressure drop across the oxygenator membrane (delta p) is calculated by subtracting
the pArt from the pInt.
True
On VA ECMO the ideal range for the venous saturations are:
a). 100%
b). 40-50%
c). 65-75%
d). 80-90%
C
True or false:
Loss of pulsatility can cause LV thrombus and LV distension
True
True or False:
Maintenance of native cardiac function is a primary aim of VA ECMO support.
True
What is the minimum pulse pressure that would be appropriate while on VA ECMO?
a). 5mmHg
b). 10-15mmHg
c). 30-40mmHg
B
What would you expect to see if the oxygenator was failing?( more than 1 correct answer):
a). decreasing delta p
b). high CO2
c). low pO2
d). increasing delta p
B, C and D
Where are the three basic pressure transducer locations on a HLS ECMO circuit?
a). pVen- near oxygenators outlet, pInt- in the pump, pArt- near the pump inlet
b). pVen- near oxygenators inlet, pInt- post oxygenator near its outlet, pArt-pre oxygenator
c).pVen-pre pump on venous inlet, pArt-post oxygenator near its outlet, pInt- near
oxygenators inlet
C
Which pressure reflects the resistance in the return limb of the circuit?
a). pVen
b). pArt
c). pInt
d). Delta p
B
True or False
Increasing pVen with a stable pArt can indicate possible clots and impending oxygenator
failure
False
You are caring for a patient with VV ECMO. What are some of the signs of recirculation that
you would be observing for?
a). Low SVO2 on access limb
b). High SVO2 on access limb
c). Little color difference between access and return cannula
d). High patient oxygen SaO2
e). Low patient oxygen SaO2
B, C and E
True or False:
Recirculation is a possible complication on VV and VA ECMO
False - VV
What pressure change may indicate that your patient may be becoming increasingly
hypovolaemic?
a).pVen
b). pInt
c). pArt
d). Delta p
A
True or false:
Differential hypoxia is a possible complication of VV and VA ECMO
False - VA
What pressure change may indicate that there is a partial obstruction in the return cannula?
a).pVen
b). pInt
c). pArt
d). Delta p
C
Your VA ECMO patients pulsatility has been increasing over your shift and now your right
hand arterial SaO2 have decreased from 99% to 86%. What might be happening?
a). Recirculation
b). Access insufficiency
c). Differential hypoxia
d). Hemolysis
C
What factors contribute to recirculation?
a). Pump flow rate
b). Cannula position
c). Cardiac output
d). Fresh gas flow rate
e). Venous return
A, B, C
In differential hypoxia some of the management strategies may include:(more than 1 correct
answer)
a). Increase FiO2 on the ventilator
b). Decrease PEEP level
c). Nitric Oxide Therapy
d). Diuresis
e). Convert VA to VAV ECMO
A, C, D & E
What pressure change may indicate that there are clots forming in the oxygenator?(more
than 1 correct answer)
a).pVen
b). pInt
c). pArt
d). Delta p
B and D
What would you expect a post oxygenator gas to be on an FiO2 of 100% on a fully functional
oxygenator?
a). 50-100mmHg
b). 200mmHg
c). 300mmHg
d) 400-500mmHg
D
If the pO2 on a post oxygenator gas was <200mmHg on FiO2 of 100% what should you do?
a). Turn up the fresh gas flow rate
b). Turn up the ECMO flow rate
c). Prepare for a circuit change
C
A decrease in Preload may be secondary to (more than 1 answer)
a). Commencement of Noradrenaline
b). Hypovolaemia
c). Bradycardia
d). Bleeding
B and D
True or False?
Centrifugal pumps are preload dependent and afterload sensitive. Preload dependent
meaning that if the preload falls, the pump will continue to spin at the same RPM but the
resultant blood flow will fall.
True
Centrifugal pumps exhibit the following characteristics:(More than 1 answer)
a). Preload dependent
b). Clamping the circuit anywhere will stop flow
c). Afterload sensitive
d). If the circuit is clamped the pump will continue to pump
A, B and C
ECMO flows need to be monitored for changes. In the setting of stable RPM, a drop in flow in a circuit with a centrifugal pump may be caused by:
a). Decreased afterload or excessive preload
b). Decreased preload or excessive afterload
c). Decrease in PaO2 or increase in PaCO2
d). Increase in PaO2 or decrease in PaCO2
B
Centrifugal pump is set to 3600 RPM giving a flow of 4.3LPM. If the patient’s blood pressure
increases, what would you expect the LPM to do?
a). Decrease
b). Increase
c). Remain the same
A
What is the lowest recommended flow when weaning VA ECMO?
a). 2.5LPM
b). 1LPM
c). 0.5LPM
d). 2LPM
C
True or False
When trialing off of VV ECMO the arterial and venous lines must be clamped
False
True or False
When weaning a patient off of VA ECMO, it is common to wean sweep gas to zero.
False
Select all correct answers in relation to weaning VV ECMO:
a). the ECMO flow rate is reduced
b). the ECMO flow rate is not reduced
c). Fresh gas flow rate is reduced by 1L increments with concurrent increases in ventilation
and oxygenation
d). When the fresh gas flow rate is at 0L/min the patient can be decannulated immediately
B and C
In VA weaning: (more than 1 correct answer)
a). ECMO flow rate is reduced to 0L/min
b). Fresh gas flow rate is reduced by 1L/min
c). ECMO flow rate is reduced by 0.5-1L/min and at each stage the heart is assessed via TTE
or TOE
d). Heparin bolus doses should be given prior to moving to low ECMO flow rate
C
True or False:
4 clamps should be available on the ECMO console at all times.
True
True or false:
A primed ECMO circuit must be available at all times when a patient is on ECMO.
True
Your patient is on VA ECMO. You notice that their BP is 50/40mmHg. The rhythm is VT. What
should you do?
a). Start CPR
b). Defibrillate the patient
c). Stop ECMO flow
d). Increase their noradrenaline and do not defibrillate
B
Your patient is on VV ECMO and goes into VF. What should you do? (more than 1 correct
answer)
a). Increase ECMO flow rate
b). Defibrillate the patient
c). Start ALS
d). Decrease the ECMO flow rate if access is a problem
B and C
You are turning your patient on VA ECMO and the return cannula is accidentally pulled out.
What is the first thing to do?
a). Place pressure on the insertion site to control bleeding
b). Reinsert the cannula
c). Give volume to replace blood loss
d). Clamp the circuit and turn pump off
D
True or False
When the cardiohelp is in emergency mode, only the RPM may be adjusted?
True
You are caring for an ECMO patient and the ECMO console stops suddenly. After calling for
help you look at the console and there seems to be no power. What should you do?
a). Clamp the circuit and wait for a new console
b). Increase the RPM
c). Clamp the circuit and commence hand cranking until a new console arrives
d). Press the Emergency Mode Button
D
