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STUDY GUIDE ECMO > Study Guide > Flashcards

Study Guide Flashcards

1
Q

What anticoagulant is used for neonatal/peds patients?

A

Heparin
Neonate loading dose 100 units/kg

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2
Q

What anticoagulant is a direct thrombin inhibitor?

A

Bivalrudin

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3
Q

What is the desired range for ACT?

A

ACT in bleeding = 160-180 sec

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4
Q

What is the desired range for AntiXa

A

Normal 0.3-0.7
Bleeding 0-2-0.25

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5
Q

What factors affect how this range is determined?

A

Bolus dose of Heparin in Neonate with ACT >300.
Maintenance dose 180-220 sec.

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6
Q

What elements are required for heparin to work?

A

ATIII

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7
Q

What test measures the effectiveness of bivalirudin?

A

PTT, ACT, TEG

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8
Q

What does PTT measure?

A

How long it takes for a clot to form.

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9
Q

What is normal PTT?

A

25-35 sec

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10
Q

What is the normal range of PTT while on ECMO?

A

60-80 sec.
If stranding/clots seen will increase range.

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11
Q

What are the 2 pathways in the coagulation cascade?

A

Extrinsic and Intrinsic

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12
Q

How is each pathway activated?

A

Extrinsic = tissue injury (Factor 3 to Factor 7)
Intrinsic= foreign body and inflammation (TF 12)
They both lead into the common pathway at Factor 10.

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13
Q

What are the tests used to evaluate anticoagulation in the neonate?

A

ACT & TEG initially then AntiXa & PTT.

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14
Q

What is the bolus dose of heparin given to a large ped/adult ?

A

10,000 IU/KG

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15
Q

What is the bolus dose of heparin given to an infant or small child?

A

100 IU/KG

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16
Q

Which drug with CRRT affect?

A

Heparin

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17
Q

Why will heparin affect CRRT?

A

it pulls across the membrane and clear it out

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18
Q

What is the reversal agent or antidote for heparin?

A

Protamine

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19
Q

What is the reversal agent or antidote for Bivalrudin?

A

NONE

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20
Q

Calculate the bolus dose of heparin for 4Kg patient? The concentration of heparin = 1,000 units/1ml

A

4 KG x 100 IU/kg= 400 IU
400 % 1000= .4ml
(bolus dose =100)

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21
Q

Calculate the infusion rate of heparin with the following:
Concentration = 100 units/ml
Dose = 30 units/kg/hr (infusion)
Pt weight = 4KG. If the ACT came back with level of 240 s what would I do?

A

Decrease the dose per protocol. Could do nothing and wean per AntiXa NOT ACT.

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22
Q

What is ACT?

A

Activating Clotting Time

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23
Q

What does ACT measure?

A

Measures the entire time it takes for a clot to form from whole blood.

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24
Q

What are the unit of measure for ACT?

A

Seconds.

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25
Q

What bedside test device(s) are used to run the ACT?

A

POC Hemochron
Signature Elite

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26
Q

Why is the ACT elevated in the prime?

A

Only PRBC’s are used in the prime then there are no clotting factors.

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27
Q

What anticoagulant does the ACT measure best?

A

Heparin
A Kaolin activated ACT will give a false high measurement for Bivalrudin.

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28
Q

Is the ACT an exact measurement?

A

No, has a +/- 20 % error

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29
Q

What are the factors that affect anticoagulation?

A

Platelet function, temp, ATIII deficiency, Hypotn, Sepsis, Liver Dysfunction, DIC, Body habitus.

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30
Q

What is the dose of Heparin goes into the adult circuit?

A

NONE.. bolus is given to the patient.

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31
Q

What is the dose of Heparin for the neonatal circuit?

A

0.2 mls (20 units)

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32
Q

What are PRBC?

A

Packed Red Blood Cells

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33
Q

When is PRBC given?

A

Adults <7
Neonates <10

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34
Q

Why is PRBC given?

A

To increase O2 carrying capacity

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35
Q

What is Cryoprecipitate ?

A

Small volume is rich in fibrinogen

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36
Q

When is Cryoprecipitate given?

A

Good to give to peds because it is low volume dosage with high yield.

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37
Q

Why is Cryoprecipitate used?

A

Fibrinogen helps stabilize bleeding, its ideal to use in neonates who commonly bleed from cannulation sites

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38
Q

What is FFP?

A

Fresh Frozen Plasma

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39
Q

When is FFP given?

A

INR > 1.5

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40
Q

Why is FFP given?

A

To give clotting factors to a bleeding patient.

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41
Q

What are platelets?

A

Manufactured by whole blood and binds to fibrinogen

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42
Q

When are platelets given?

A

Adults don’t get platelets transfused unless bleeding.
Adult platelet count <15,000.
Peds/neo platelet count < 80,000. Pt dependent

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43
Q

How are platelets given to adult ECMO patients?

A

Peripherally via nurse

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44
Q

What are the blood components given into the neonatal circuit?

A

PRBC, FFP, Platelets

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45
Q

Where are the ports used to give blood products on neonatal circuit?

A

PRBC= one of the venous pigtails, manifold on venous side ran on a syringe pump.
FFP= one of the venous pigtails, manifold on venous side. Ran on syringe pump.
Platelets= Arterial side of the bridge. Pushed manually , 5cc every 5 min, after giving full amount, flush line with saline to clear.

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46
Q

What is the usual dose or volume of PRBC, FFP, platelets for a 4 KG child?

A

10-15 cc/kg (if the patient is exsanguinating then 20 cc/kg)

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47
Q

What does it mean to use emergency release blood?

A

Not crossed-matched
O (-) blood

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48
Q

What does blood type mean?

A

Blood types are determined by the presence or absence of certain antigens.

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49
Q

What blood type is the universal donor?

A

O negative

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50
Q

What blood type is the universal recipient?

A

AB positive

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51
Q

What are the special requirements for infants <4 months with respect to blood?

A

Initial sample at birth
sample is good for 4 months due to immature liver not making anitgens.

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52
Q

What part of the blood carry antibodies?

A

Plasma

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53
Q

What is thrombocytopenia?

A

Low platelet level

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54
Q

What is given when someone has thrombocytopenia?

A

Platelets

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55
Q

When does RH matter?

A

Women of pregnancy age as well as pregnant women?

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56
Q

How long does blood stay in the unit refrigerator?

A

There is NO UNIT refrigerator but can stay in the coolers for 12 hours.

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57
Q

What factors may be placed in the refrigerator?

A

PRBC, FFP
NO PLATELETS

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58
Q

Trace the blood flow through your circuit from cannula tip to cannula tip on CardioHelp (ADULT)

A

CardioHelp (ADULT)

  1. Venous Cannula
  2. Pre-pump/Pre-oxygenator/CRRT- Return pigtail
  3. Venous sat probe (hb,hct venous temp)
  4. Centrifugal Pump
  5. Connection for pressure monitor cable
  6. Yellow de-airing cap
  7. Oxygenator (7.0)
  8. Post-pump/post- oxygenator/De-airing/CRRT Pull pigtail.
  9. Post-pump/Post oxygenator/ABG pigtail
  10. Flow probe & bubble detector
  11. Arterial Cannula
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59
Q

Trace the blood flow through the circuit from cannula tip to cannula tip on CardioHelp (PEDS).

A
  1. Venous Cannula
  2. Bridge (Venous side) & CRRT Return
  3. Venous Manifold Port
  4. Venous Sat probe (hb, hct, venous temp)
  5. CardiHelp Centrifugal Pump
  6. Connection for Black Pressure Monitor Cable. Post pump/preoxygenator/ VBG pigtail
  7. Yellow De-airing Cap
  8. Oxygenator (5.0)
  9. Postpump/post oxygenator De-airing pigtail
  10. Post pump/Post oxygenator Arterial Manifold Port
  11. Flow probe & bubble detector.
  12. Bridge (arterial side)
  13. Arterial Cannula
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60
Q

Trace the blood flow through the circuit from cannula tip to cannula tip on Rotaflow (ADULT)

A
  1. Venous Cannula
  2. Venous Spectrum Sat probe (SV02)
  3. Pre-pump /pre-oxygenator/CRRT Return pigtail
  4. Rotaflow Centrifugal Pump
  5. Post pump/preoxygenator/ VBG pigtail.
  6. Yellow De-airing Cap
  7. Post-pump/Post oxygenator/de-airing/CRRT Return Pigtail
  8. Post-pump/post oxygenator/ABG pigtail
  9. Spectrum Arterial sat probe (hb, hct )
  10. Spectrum Flow Probe
  11. Arterial Cannula
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61
Q

Trace the blood flow through the circuit from cannula tip to cannula tip on neonatal circuit with Spectrum.

A
  1. Venous Cannula
  2. Venous Spectrum Sat Probe
  3. Venous Manifold Port
  4. Bridge (Venous side) & CRRT Return
  5. Pre-pump/pre-oxygenator Venous Pressure line (DLP RED BOX
  6. (2) Pre-pump/Pre-oxygenator pigtails for MED infusions
    7.Rotaflow Centrifugal Pump
  7. Pre-oxygenator Pressure Line (DLP RED BOX)
  8. Oxygenator (5.0)
  9. Yellow De-airing Cap
  10. Post Oxygenator Arterial Pressure Line (DLP RED BOX) & CRRT pull access.
  11. Post-pump/Post oxygenator Arterial Manifold port
  12. Spectrum Arterial Sat Probe (hb,hct)
  13. Bridge (Arterial side) & Platelet Infusion Access.
  14. Spectrum Flow Probe
  15. Arterial Cannula
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62
Q

What is the different about the neonatal circuit from the adult Rotaflow and CardioHelp?

A

Bridge, more venous pigtails and manifold

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63
Q

What is the function and location in the circuit of the following

Arterial and venous sat probes

A

CardioHelp Venous= Pre-pump on the mounted sensor
CardioHelp Arterial=Post oxygenator near the pigtail for ABG access.
Rotaflow Venous=(Spectrum Monitor)=External probe near venous cannula
Rotaflow Arterial (Spectrum Monitor) External probe near arterial cannula
Neonatal Venous= (Spectrum Monitor)=External probe placed close to the patient from the recirculation line from manifold.

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64
Q

What is the function and location in the circuit of the

Pigtail

A

Adult CardioHelp =
4 pigtails
1. venous line post-
pump/preoxygenator,
2. post-pump /post
3. oxygenator/de-airing/post
4. pump/post oxy/ABG

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65
Q

What is the function and location in the circuit of the

Venous Pressure

A

Adult /Pediatric CardioHelp
Internal reading pre-pump

Neonatal Circuit
On a red box connected to the post-pump/preoxy port (Y’d in with the preoxy pressure)

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66
Q

What is the function and location in the circuit of the

Pre oxygenator pressure

A

Adult/Ped CardioHelp
Internal post-pump/preoxy

Neonatal Circuit
On a red box connected to the post pump/preoxy port (Y’d in with the post oxy pressure)

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67
Q

What is the function and location in the circuit of the

Post oxygenator pressure

A

Adult/Peds CardioHelp
Internal near the post-pump/post oxy/ABG pigtail

Neonatal Circuit
On a red box connected to the post-pump/post oxygenator port( Y’d in with the preoxy pressure)

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68
Q

What is the function and location in the circuit of the

Oxygenator

A

Oxygenates the blood, removes CO2, also acts as the heat exchanger between the circuit and heater/cooler. Placed Post pump.

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69
Q

What is the function and location in the circuit of the

Rotaflow Centrifugal Pump

A

Preoxy, pushed blood into the oxygenator.

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70
Q

What is the function and location in the circuit of the

CardioHelp Centrifugal Pump

A

One unit with the oxygenator (still technically preoxy within the circuit).

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71
Q

What is the function and location in the circuit of the

Bridge in neonatal/ped CardioHelp

A

Neonatal= Venous side is placed between the manifold recirculation line and the venous pressure line, Arterial side is Closer to the patient.

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72
Q

Is there a bubble detector in the neonatal circuit?

A

No, not in the true sense. Spectrum monitor does have the ability to track emboli.

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73
Q

Where is the blood flow measured in the neonatal circuit?

A

Spectrum monitor flow probe closest to the patient on the arterial side.

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74
Q

Where is blood flow measured in the CardioHelp circuit?

A

Flow probe closest to the patient on the arterial side.

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75
Q

Where is the blood flow measured in the

Adult Rotaflow circuit?

A

Spectrum monitor flow probe closest to the patient on the arterial side.
Needs addition of past t the pump head directly out of the pump. Not accurate for flows < 1L, does not account for flows lost in shunts within the circuit (bridges and manifold.)

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76
Q

Where is the blood flow measured in the

LifeSparc Circuit

A

Flow probe closest to the patient on the arterial side.

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77
Q

Where is the blood flow measured in the

Centrimag circuit

A

Flow probe closest to the patient on the arterial side.

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78
Q

What is the difference between the CardioHelp and Rotaflow Centrifugal pump?

A

CardioHelp is on unit with an oxygenator, has internal measurements, and used 4 channels to disperse the blood throughout the oxygenator.
Rotaflow is a single outlet, resting on a sapphire pin.

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79
Q

How does the Centrimag compare to the other pumps?

A

Centrimag full magnetic levitation (no bearing). The bearing is a place for a clot to form and and area where temperature can increase, causing hemolysis.

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80
Q

How does the LifeSparc compare to the other pumps?

A

LifeSparc has a single port ruby bearing with a 16 ml priming volume and is why it needs higher RPM’s to reach the same amounts of flows as the others.

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81
Q

Describe oxygenator failure?

A

Decreased oxygen exchange. Unable to add oxygen and remove CO2 even with increased sweep.

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82
Q

What parameters do you evaluate every day to determine how well the oxygenator is working?

A

VA ecmo
Delta P and venous sats

VV ecmo
you would look at the patient’s saturation . Recirculation can cause an increased venous saturation.

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83
Q

What would you see on a patient’s blood gas that might make you think failure?

A

PaO2 < 50
Acidosis
High PCO2

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84
Q

What physical things do you check on the circuit to determine the functional status of the oxygenator?

A

Check for clots, check the gas line.

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85
Q

What factors might cause an oxygenator to fail?

A

Clots, condensation in the oxygenator, occluded gas exhaust causing increased gas pressures on the membrane.
Sighing the membrane is done to expel the condensation from the oxygenator.

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86
Q

What might the gas exhaust look like in a failing oxygenator?

A

If it is pink/red condensation

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87
Q

What might you see in lab values of a failing oxygenator?

A

High plasma free HBG, poor ABG (pump and patient), decreased patient SAO2.

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88
Q

What is the minimum/maximum sweep for

Neonatal Quadrox

A

0.1-3 L/min

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89
Q

What is the minimum/maximum sweep for

Pediatric Quadrox

A

0.1-5.6 L/min

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90
Q

What is the minimum/maximum sweep for

Small adult Quadrox & 5.0 CardioHelp

A

0.25-10 L/min

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91
Q

What is the minimum/maximum sweep for

Adult Quadrox & 7.0 CardioHelp

A

0.25- 14L/min

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92
Q

What is the minimum/maximum sweep for

Neonatal Euroset

A

0.1-3 L/min

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93
Q

What is the minimum/maximum sweep for

Nautilus ECMO Smart Oxygenator

A

0.25-14 L/min

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94
Q

What is the minimum/maximum blood flow

Neonatal Quadrox

A

0.2-1.5 L/min

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95
Q

What is the minimum/maximum blood flow

Pediatric Quadrox

A

0.2-2.8 L/min

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96
Q

What is the minimum/maximum blood flow

Small Adult Quadrox & 5.0 CardioHelp

A

0.5-5.0 L/min

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97
Q

What is the minimum/maximum blood flow

Adult Quadrox & 7.0 CardioHelp

A

0.5-7.0 L/min

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98
Q

What is the minimum/maximum blood flow

Neonatal Euroset

A

0.2-1.5 L/min

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99
Q

What is the minimum/maximum blood flow

Nautilus ECMO Smart Oxygenator

A

0.5-7.0 L/min

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100
Q

What is an indicator of clot formation in your circuit?

A

Dark spots in the circuit, increase in Delta P, increase in venous pressure and chugging (if clot is in venous cannula) increased arterial pressures if the arterial cannula is unable to flush/draw from pigtails.

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101
Q

What does venous pressure tell me about my patient and the circuit?

A

An increased venous pressure(chugging) indicates that the patient is hypovolemic . Could also indicate misplacement in the cannula (try decreasing flows some and the flow back up)

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102
Q

Describe the phenomena of recirculation

A

When drainage and return cannulas are too close together they will recirculate the blood throughout the circuit and not deliver it to the patient.

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103
Q

What mode is recirculation likely to be seen?

A

VV ECMO

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104
Q

How do you resolve recirculation in VV ECMO

A

Reposition cannula, decrease flows. Most of the time you will be asked to decrease flows first because the repositioning of cannulas is risky.

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105
Q

What factors affect recirculation?

A

Increased blood flow, cannula position

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106
Q

What determines if a patient is ready to be weaned from VV ECMO

A

Improved blood gases with less support. Underlying issue treated/ recovered.

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107
Q

What determines if a patient is ready to be weaned from VA ECMO

A

Improved cardiac function, hemodynamics, EF 30%, weaning of supporting meds,. Underlying issue treated/recovered.

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108
Q

How is a patient tested to see if they are ready to be weaned from VA ECMO

A

Peds/Neos have many clamp out trials, adults will do a low flow trial at 1L or will utilize zero flow mode momentarily (under the direction of a physician) as well as a sweep around 1-2 with 50% is FIO2.

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109
Q

How is a patient tested to see if they are ready to be weaned from VV ECMO

A

Cap the oxygenators (Peds/Neos- 12 hours, adults 24 hours). Draw periodic patient ABG’s.

110
Q

Describe how the patient is weaned from VV ECMO

A

Only wean the sweep. Don’t change the flows. Adults off sweep for 24 hours+, peds 12 hours+

111
Q

Describe how the patient is weaned from VA ECMO

A

Wean flows and sweep

112
Q

Why is weaning different between VA and VV Ecmo

A

VA ECMO supports the cardiac system. Need to wean based on cardiac function
VV ECMO support the pulmonary system. Need to wean based on lung function

113
Q

What are the potential air traps in the ECMO circuit

Oxygenator

A

Top of the oxygenator, remove the air with de-airing membrane and pigtail

114
Q

What are the potential air traps in the ECMO circuit

Cannula

A

At the connectors, remove air at the nearest pigtail.

115
Q

What are the potential air traps in the ECMO circuit

Centrifugal Head

A

With enough air, will stop forward flow. Remove air at the nearest pigtail

116
Q

Trick Question:
When assessing a patient’s oxygenation status on VA ECMO, which is the best indicator of adequacy of oxygenation?

A

Pre-membrane Saturation

117
Q

Define hemolysis

A

When blood cells rupture.

118
Q

What caused hemolysis?

A

Turbulent flow, increased heat caused by pump, high pressures due to increased resistance ( small cannulas, clot in oxygenator), severe acidosis (making changes to quickly)

119
Q

What lab test is drawn to evaluate degree of hemolysis

A

Plasma free Hbg

120
Q

How do you treat the circuit when hemolysis occurs

A

Check for clots, kinks in the tubing, pre-membrane pressure <300 mmHg, possibly add albumin to prime, limit negative venous pressure.

121
Q

What is the normal range for Plasma free HGB

A

<12 mg/dL ( when >50 mg/dL, discussion to change circuit begins, can cause renal impairment.

122
Q

Normal Lab
PH

123
Q

Normal Lab
PCO2

124
Q

Normal Lab
PO2

A

on ECMO > 200

125
Q

Normal Lab
Lactate

126
Q

Normal Lab
Bicarb (HCO3)

127
Q

Normal Lab
Base deficit

128
Q

Normal Lab
HGB/HCT

A

12-15 women
13-17 men
On ECMO Adults >7
On ECMO Peds >10

129
Q

Normal Lab
Sodium (Na)

130
Q

Normal Lab
Potassium (K)

131
Q

Normal Lab
Serum calcium

132
Q

Normal Lab
Ionized Calcium

133
Q

Normal Lab
Ionized Magnesium

134
Q

Normal Lab
PT

A

12.3-14.8 sec

135
Q

Normal Lab
PTT

A

25-36 sec
on ECMO 60-80 sec

136
Q

Normal Lab
AntiXa
unfractionated heparin

A

On ECMO 0.3-0.7
if bleeding 0.2-0.5

137
Q

Normal Lab
ATIII activity (<30 days, >30 days

A

<30 days = 44-76%
> 30 days = 80-120 %
ATIII binds with heparin to work as an anticoagulant, heparin does not work by itself.

138
Q

Normal Lab
Cultures

A

Goal is negative cultures in blood, urine, respiratory

139
Q

Normal Lab
Plasma HGB

140
Q

Normal Lab
Fibrinogen

141
Q

Normal Lab
INR

A

<2
On ECMO < 4.9

142
Q

Normal Lab
Troponin

143
Q

Normal Lab
CK

144
Q

Normal Lab
CK mb ( creatinine)

145
Q

Normal Lab
ALT

146
Q

Normal Lab
AST

147
Q

Describe the relationship of tests on ECMO

Head Ultrasound

A

Neonates/Infants

148
Q

When is Head US done?

A

Pre-cannulation and then once a day for the first 3 days, then every other day.

149
Q

What does Head US results show

A

ICH, blood in the ventricles.

150
Q

Why is the importance of getting Head US for ECMO

A

ICH is a contraindication for ECMO, it is a grade 1-2 then they will monitor closely, it is a grade 3 or larger , will either DC ECMO or not start ECMO.

151
Q

Describe the relationship of tests on ECMO

Chest X-ray

A

This is done on all ECMO patients

152
Q

When is the Chest Xray done

A

After cannulation and daily/PRN

153
Q

What does the Chest X-ray results reveal

A

Cannula placement

154
Q

What is the importance of getting Chest X-ray for ECMO

A

Misplaced cannulas can cause decreased flows, chugging, recirculation (VV), high negative and positive pressures.

155
Q

When is a Cardiac Echo done for ECMO

A

Adults- during weaning and PRN to confirm placement of cannula
Neonates- Pre-Ecmo and PRN to confirm placement of cannula

156
Q

Are Cardiac Echo’s done on all patients

157
Q

What do we learn from Cardiac Echo?

A

Cardiac function, pulmonary artery pressure

158
Q

Are the results of a Cardiac Echo usually normal or abnormal

A

Normal for VV ECMO
Abnormal for VA ECMO

159
Q

When are CT done for ECMO

A

A change in the patient’s status

160
Q

What do we learn from CT Scan

A

Check for head bleed, abdominal function with contrast

161
Q

What does the CT scan affect the care of the patient

A

Gives immediate results, Patient may not tolerate test. If results are poor, then a conversation may happen to DC ECMO

162
Q

Do all patients have CT Scans

A

No, would only need one done for specific change in status.

163
Q

When would Fluoroscopy be used for ECMO

A

to place a double lumen cannula safely

164
Q

What does Fluoroscopy tell the practitioner

A

Cannula placement

165
Q

What ECMO are most likely to use Fluroscopy

166
Q

When would a patient get a Cardiac Cath done for ECMO

A

If the patient has had a STEMI, any patient on ECPR, create balloon septostomy in neonates

167
Q

Can patients on ECMO to the Cath Lab

168
Q

What information is gained from the Cardiac Cath Lab

A

Check for coronary blockages

169
Q

What is the ultimate goal of ECLS

A

Buy time for treatment modalities to work

170
Q

What is the most common bacterial pneumonia caused by

A

Streptococcus is the most common community acquired pna

171
Q

What is the minimum weight for Neonatal ECMO and why

A

2 KG
cannula sizing

172
Q

What is the maximum weight for ECMO and why

A

VV-50 BMI with lots of support
40 BMI normally

173
Q

What is the minimum gestational age

174
Q

What does the perfusionist need on arrival for ECMO

A

Cannulation cart, 100 IU/kg heparin, clamps, sterile instruments, dilators, blood , meds for the blood prime (ECMO priming kit from pyxis, open bed.

175
Q

What is my role in setting up circuit for a patient

A

Plug it in, plug in gas lines, make sure oxygen is hooked up, water for the heater/cooler, go through pre-initiation checklist, getting ECMO specialist patient cart to the room, do EQC for signature elite for ACT

176
Q

What side of the neck is prepped for ECMO

A

Right side

177
Q

What things do I check to confirm the circuit is ready

A

The checklist

178
Q

How do I help the perfusionist

A

Assistance

179
Q

ABG=7.25/35/210/BE -7.0
What would the perfusionist do

A

Nothing, look at the patient’s ABG and let acidosis work itself out

180
Q

What would the flow be for a
10 FR arterial cannula/12 FR venous cannula

A

Normal flow for infant/peds patient is 100-150 ml/kg
Should get full flow with these cannulas

181
Q

What would the range be for 10 F arterial /12 F venous cannula

A

350-525 ml/min

182
Q

What would happen to the flow if both cannulas were 8F

A

Flows would decrease due to increased resistance.

183
Q

Pt=752/32/52
Pump= 748/36/240
sweep= 0.4
FIO2 50%
Q8=0.38
What would I change

A

Decrease sweep, increase flow

184
Q

When would fluid be removed during hemofiltration

A

Occurs due to pressure gradients

184
Q

What are signs of oxygenator failure

A

Increased Pre membrane pressure
Decreased oxygen and CO2 transfer
Hemoturia
Blood leak from the gas egress

185
Q

When would Heparin doses need to be altered when CVVH is added to the system

A

The hemodiafilter absorbs all heparin.

186
Q

What mechanism improves ECMO oxygenation delivery

A

Stabilization of HBG saturations
Taking over at least 60% of the blood flow through a functioning membrane lung, away from sick native lung
Taking over at least 60% of the CO through the ECMO pump
All of the above

187
Q

Membrane failure can be characterized by a raising pump CO2 level .. why?

A

Changes is blood flow patterns caused by a clot
Changes in sweep gas flow patterns caused by clot
Alteration in membrane surface area caused by fibrin formation
Changes in oxygen concentration due to fibrin formation

188
Q

What is the ultimate goal of ECLS?

A

To maximize oxygen delivery

189
Q

What supplies are needed from the cannulation cart for VA ECMO

A

Dilators (pikA,sorin dilators) , Venous and Arterial cannula(s) Re-profusion cannula (7” tubing & double male adapter, may need Micropuncture introducer set) Sterile instrument box, silk of prolene suture ( size 0)

190
Q

What supplies are needed from the cannulation cart for VV ECMO

A

Dilators(venous dilators only), Venous Cannula(s) Sterile instrument box and sutures.

191
Q

What is a re-profusion cannula?

A

Low limb extremity to prevent ischemia.

192
Q

When is a reprofusion cannula used

193
Q

What is Cardiac Output

A

Amount of blood pumped by the heart in L/min

194
Q

What is Cardiac Index

A

CO/BSA
Hemodynamic parameter that relates to the CO from the left ventricle in 1 min to the BSA

195
Q

What is BSA

A

Body surface area

196
Q

CO=HR x SV
for native Cardiac Function

A

Cardiac Output

197
Q

CI=CO/BSA=SV x HR/BSA

A

Cardiac Index

198
Q

CO=CI x BSA

A

Used to assess our ECMO Flow

199
Q

What is viscosity

A

Thickness of blood

200
Q

How does viscosity affect ECMO flow?

A

Increase in thickness= decrease in flow

201
Q

What is afterload

A

The amount of resistance that the heart has to overcome to open the aortic valve. On ECMO, afterload is the patient’s BP or cannula size resistance.

202
Q

What is preload

A

Volume of blood in the ventricle and end diastolic pressure

203
Q

What does increase in preload do to ECMO flow

A

Can flow more, negative pressure would become less negative. Would not limit ability to flow

204
Q

What does decrease in preload to do ECMO flow

A

Decrease in preload=decrease in flow due to less volume in patient

205
Q

How does increased afterload affect ECMO

A

Increased afterload=decrease in flow
Increased afterload=increased arterial pressure

206
Q

How does decreased afterload affect ECMO

A

Decreased afterload=increase in flow

207
Q

What is the initial bolus of heparin for a 3.5 kg infant

A

100 units/kg
350 IU

208
Q

What is the initial bolus of heparin for a 100 kg adult?

A

10, 000 units

209
Q

What is the initial bolus of heparin for a 75 kg adult

A

10,000 units

210
Q

What is the priming volume for a Rotaflow pump

211
Q

What is the priming volume for the CentriMag pump

212
Q

(HB x 1.34 x SaO2) + (PaO2 x 0.0031)

A

Oxygen Content

213
Q

What are the 2 most important variables in Oxygen content calcuation?

A

HB and SaO2

214
Q

For each oxygen content delivery variable, what can improve the O2 content /O2 delivery

A

Increase in flow, FIO2 and HB

215
Q

CaO2 x CO

A

Oxygen Delivery calculation

216
Q

What is the best indicator of oxygen delivery in VA ECMO

217
Q

What is the best indicator of oxygen delivery in VV ECMO

A

Patient SpO2, patient gasses

218
Q

What influences oxygen delivery on VV ECMO

A

Patient lungs, recirculation , Hb , CO, FIO2

219
Q

What influences oxygen delivery on VA ECMO

A

Hb, CO, FIO2

220
Q

What pressures are monitored in a neonatal/ped circuit?

A

Venous pressure
Pre-membrane pressure
Post membrane pressure

221
Q

What does the venous pressure monitor in neo/peds circuit

A

Venous=patients volume status
Pre-membrane= oxygenator for clots
Post membrane= afterload

222
Q

What pressures are monitored on the the CardioHelp circuit

A

Venous pressure
Pre-membrane pressure
Post membrane pressure

223
Q

What does the venous pressure monitor on the CardioHelp

A

Venous=patients volume status
Pre-membrane= oxygenator for clots
Post membrane= afterload

224
Q

What pressures are monitored on the Rotaflow circuit

A

Quadrox=NO pressure monitoring
Nautilus= Pre-and Post membrane
Pre-membrane=oxygenator for clots
Post membrane= monitors afterload

225
Q

What parameters are monitored by the venous probe on CardioHelp

A

Hb,Hct, SvO2, venous temp

226
Q

What parameters are monitored by the Spectrum

A

Venous probe (SvO2)
Arterial probe ( Hb, Hct, SaO2)
Flow probe (Blood flow, bubbles

227
Q

Mode that can be manually set to periodically allow for the pump RPMs to be on to adjust for just enough flow to prevent backflow but not have any forward flow. Used to assess a patient’s native CO during weaning without having to place clamps on the line.

228
Q

What is the most common complication of ECLS?

A

Bleeding , anticoagulation

229
Q

4 reasons to emergently remove ECMO

A

Excessive bleeding
ICH
Air embolism/clots
Accidental decannulation

230
Q

5 causes of air entrainment

A

Venous pigtail open on negative pressure side.
Air from central lines, (albumin on a pressure bag)
High negative pressures causing cavitation
Cracked hard plastics within the venous side of circuit
From the oxygenator= blocked gas exhaust causing increased gas membrane pressures that can rupture the membrane and allow gas bubble straight into the blood side.

231
Q

When blood from return cannula is pulled directly into the pull cannula without being directed to the patient

A

Recirculation

232
Q

4 factors that affect recirculation

A

Cannula position
Pump flow
CO
Intravascular Volume

233
Q

What is the major limiting factor for ECLS blood flow

A

Decreased Preload

234
Q

If PaCO2 is high, how do I adjust sweep gas flow rate

235
Q

At what increments is the sweep gas flow rate changed

A

Adults=0.5-1L/min
Neo = 0.1 L/min
Ped = 0.2-0.5 L/min

236
Q

How is the sweep gas flow adjustment assessed

A

Redraw an ABG

237
Q

What is measured by the Hemochron Signature Elite

238
Q

How is the parameter “armed” for the CardioHelp

A

Chain link page
Go to each parameter and arm manually or disarm manually

239
Q

Steps for getting CardioHelp circuit ready for surgeon

A

Clamp the venous and arterial lines near the oxygenator with the tubing clamps
Clamp all 4 big white robertson clamps
Break it apart using quick connects and connect them forming a loop
Open the circuit to be handed up to the surgeon sterile
Instruct to clamp and cut the circuit. (clamp at the stickers indicated, cut between the clamps and quick connect

240
Q

What is the difference between CardioHelp and Rotaflow pump heads

A

CardioHelp is built into the oxygenator, and it has 4 outflow channels to distribute flow more uniformly throughout the oxygenator’
Rotaflow is a single outlet pump that uses a sapphire bearing

241
Q

What are the signs of cardiac tamponade on VA ECMO

A

Decreased flows, Venous line chugging and more negative venous line pressure due to decreased venous return to the heart causing decreased preload. Pulsatility would decrease or go away completley

242
Q

What are signs of pneumothorax on VV ECMO

A

Decreased lung compliance, decreased SpO2, decreased flow due to decreased venous return to the heart causing decreased preload.

243
Q

What parameters do you inspect when doing your circuit checks

A

All of the parameters
Pressures, flows, sweep, FIO2, Temps, sats, circuit clear of clots/air, gas exhaust is free from obstruction

244
Q

How often are parameters checked

A

Q1=charting /reprofusion cannula check
Q2=sigh the membrane
Q4= flush pigtails,( more as clots form)

245
Q

What screen on CardioHelp allows to store lab values

A

Press little folder button within either the SvO2, Hct, Hb

246
Q

What machine is used for CRRT

247
Q

What line is clamped on CentriMag when changing pump to another external drive

A

Both Venous and Arterial lines closest to the patient.

248
Q

What is he minimum RPM for forward flow on CentriMag, CardioHelp, Rotaflow pumps

A

1700 RPM
Backflow is bad

249
Q

Where are primed ECMO circuits stored

A

OR =outside OR21
Neomart
PICU= ECMO room
CSICU=outside of room 134

250
Q

List 4 blood products that a patient may receive.

A

pRBC=venous side, infusion port, syringe pump
FFP= venous side, infusion port, syringe pump
Platelets= Arterial side of bridge, manually pushed 5cc/every 5 min, flush after giving full dose
Cryo= Arterial side of bridge, manually pushed 5cc/5min, flush after giving full dose.

251
Q

Does is make a difference if your patient is a neo or adult for giving blood products

A

Adults= all products given peripherally
Peds= still give pRBC and Albumin in the venous side. Prefer to give platelets peripherally but will give on the arterial side of the bridge is access is limited.

252
Q

Why are crystalloid, albumin (5% and 25%) blood products transfused

A

Hypovolemia causes a decreased preload that causes decreased flow. Nothing placed on the pressure bag for ECMO patients in the CSICU

Crystalloid is used when Hct is high and volume is needed
Albumim is used to pull any volume that is 3rd spacing in the extravascular space
Blood products are used to treat specifics.

253
Q

Euroset (Infant) Blood flow rates

A

0.2-1.5 L/mim

254
Q

Euroset (Infant Sweep gas )

A

0.1-3.0 L/min

255
Q

Quadrox-I (neonatal) Blood flow

A

0.2-1.5 L/min

256
Q

Quadrox-I (neonatal) Sweep gas

A

0.1-3.0 L/min

257
Q

Quadrox-I (peds) Blood flow

A

0.2-2.8 L/min

258
Q

Quadrox-I (peds) Sweep gas

A

0.1-5.6 L/min

259
Q

CardioHelp 5.0 Blood Flow

A

0.5-5.0 L/min

260
Q

CardioHelp 5.0 Sweep Gas

A

0.25-10.0 L/min

261
Q

Quadrox-I (small adult) Flow

A

0.5-5.0 L/min

262
Q

Quadrox-I (small adult) Sweep

A

0.25-10.0 L/min

263
Q

Quadrox-i (adult) flow

A

0.5-7.0 L/min

264
Q

Quadrox-i (adult) Sweep

A

0.25-14.0 L/min

265
Q

Nautilus smart (adult) flow

A

0.5-7.0 L/min

266
Q

Nautilus smart (adult) Sweep

A

0.25-21.0 L/min

267
Q

CardioHelp 7.0 (adult) Blood

A

0.5-7.0 L/min

268
Q

CardioHelp 7.0 (adult) Sweep

A

0.25-14.0 L/min

STUDY GUIDE ECMO (1 decks)

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