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Study Guide Flashcards

1
Q

What anticoagulant is used for the neonatal and pediatric patients?

A

Heparin

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2
Q

What anticoagulant is a direct thrombin inhibitor?

A

bivalirudin and aragtroban

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3
Q

What is the desired range for ACTs?
bolus dose of heparin for Neonate?
pt slightly bleeding?
pt with severe bleeding?

A

180-220 seconds
>300 seconds
160-180 seconds
<150 seconds

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4
Q

What factors affect how ACTs are determined?

A

platelet dysfunction
temperature
anemia
coagulation factor deficencies
thrombocytopenia

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5
Q

What elements are required for heparin to work?

A

anti-thrombin iii (AT)

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6
Q

What test measures the effectiveness of bivalirudin?

A

aPTT
ACT
TEG

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7
Q

What does PTT measure?

A

partial thromboplastin time

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8
Q

What is a normal PTT?

A

25-36 seconds

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9
Q

What range of PTT do we use for ECMO pts?

A

60-80 seconds (will increase if stranding/clots are seen)

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10
Q

What are the two pathways in the coagulation cascade?

A

Intrinsic Pathway - activated by foreign body and inflammation (Tissue Factor 12)

Extrinsic Pathway - tissue injury; trauma (Tissue Factor 3 to 7)

both lead to common pathway at Factor 10

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11
Q

What test are used to evaluate anticoagulation in neonates?

A

ACT and TEG initially, then Anti-Xa assay and PTT

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12
Q

What is the bolus of heparin given to large pediatrics or adults?

A

10,000 units

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13
Q

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

A

100 units/kg (10,000 units max)

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14
Q

Which drug will CRRT affect?

A

heparin

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15
Q

What is the reversal agent/antidote for heparin? bivalirudin?

A

protamine

none - time it takes for the kidneys to clear

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16
Q

What is the ACT?

A

Activated Clotting Time; whole blood coagulation test

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17
Q

What does ACT measure?

A

time it takes for clot to form in whole blood in seconds

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18
Q

What device is used to run an ACT?

A

POC Hemochron - Signature Elite

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19
Q

Why is the ACT elevated in the prime?

A

only RBCs are used to prime the circuit so there are no clotting factors

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20
Q

What anticoagulant does the ACT measure best?

A

heparin

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21
Q

What are factors that affect anticoagulation?

A

platelet function, temperature, ATiii Deficiency, Hypotension, Sepsis, Liver Dysfunction, DIC, Body Habitus

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22
Q

What is the dose of heparin to place in the adult circuit?

A

0

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23
Q

What is the dose of heparin for the neonatal circuit?

A

.2 mls (20 units)

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24
Q

What is PRBCs?

A

packed red blood cells

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25
Q

When are PRBCs given and why?

A

Hgb <7 for peds/adults, <10 for neonates

increase Hgb and to increase oxygen carrying capacity

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26
Q

What is Cryoprecipitate?

A

precipitate of thawed FFP; rich in fibrinogen - small volume (good for peds/neonates)

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27
Q

When is Cryoprecipitate given and why?

A

Fibrin <100 mg/dL

increase fibrin to promote clotting

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28
Q

What is FFP?

A

fresh frozen plasma

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29
Q

When is FFP given and why?

A

INR >1.5

pts with a coagulopathy who are bleeding or at risk of bleeding

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30
Q

What are Platelets?

A

manufactured by whole blood and binds to fibrinogen

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31
Q

When are Platelets given and why?

A

Peds/Neonates - <80,000
Adults - do not get platelets unless they are actively bleeding <50,000

help with clotting factors

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32
Q

How are blood products given to adults on ECMO?

A

peripheral IV

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33
Q

Where are the blood products given in the neonatal circuit?

A

Venous Cannula - pigtails/manifold; PRBCs, FFP
Arterial Cannula - bridge; Cryo-, Platelets (pushed manually; 5 cc every 5 mins - flush with saline after given)

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34
Q

What is the usual dose or volume of blood products given to small peds/neonates?

A

10-15 mls/kg (if bleeding, 20 mls/kg)

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35
Q

What does it mean to use emergency release blood?

A

blood that is used is not cross matched with the patient

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36
Q

What does blood type mean?

A

presence or absence of antigens

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37
Q

What blood type is the universal donor?

A

O-

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38
Q

What blood type is the universal recipient?

A

AB+

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39
Q

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

A

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

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40
Q

What part of the blood carries the antibodies?

A

plasma

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41
Q

What is thrombocytopenia?

A

low platelets

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42
Q

What factor is given when thrombocytopenia occurs?

A

heparin; Heparin Induced Thrombocytopenia (HIT)

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43
Q

When does RH matter?

A

women of pregnancy age as well as pregnant woman

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44
Q

How long may blood stay in the unit refrigerator?

A

none; can stay in coolers for 12 hrs

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45
Q

What factors may be placed in the refrigerator?

A

FFP and pRBCs - no platelets

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46
Q

Trace blood flow from cannula tip to tip: Cardiohelp Adult

A

-Venous Drainage Cannula
-Venous Pre-pump/Pre-oxygenator pigtail/CRRT return
-Venous Sat Probe
-Centrifugal Pump
-Connection for Pressure Monitoring Cable
-Post-pump/Pre-oxygenator/VBG pigtail
-De-Airing Membrane/Yellow Cap
-Oxygenator
-Post-Pump/Post-Oxygenator/De-airing pigtail/CRRT draw
-Post-pump/Post-oxygenator/ABG pigtail
-Arterial Flow Probe/Air bubble detector
-Arterial Return Cannula

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47
Q

Trace blood flow from cannula tip to tip: Cardiohelp Pediatric

A

-Venous Drainage Cannula
-Port to Bridge (V)/CRRT return
-Venous Manifold Port
-Venous Sat Probe
-Centrifugal Pump
-Connection for Pressure Monitoring Cable
-Post-pump/Pre-oxygenator/VBG pigtail
-De-airing Membrane/Yellow Cap
-Oxygenator (HLS 5)
-Post-pump/Post-oxygenator/De-airing Pigtail/CRRT draw
-Arterial Manifold
-Arterial Flow Probe/Air bubble detector
-Port to Bridge (A)
-Arterial Return Cannula

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48
Q

Trace blood flow from cannula tip to tip: Rotaflow Adult

A

-Venous Drainage Cannula
-Venous Sat Probe
-Pre-pump/Pre-oxygenator/CRRT return pigtail
-Centrifugal Pump
-Post-pump/Pre-oxygenator/VBG pigtail
-De-Airing Membrane/Yellow Cap
-Oxygenator
-Post-pump/Post-Oxygenator/De-airing port/CRRT draw
-Post-pump/Post-oxygenator pigtail/ABG
-Spectrum Arterial Sat Probe
-Spectrum Arterial Flow Probe
-Arterial Return Cannula

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49
Q

Trace blood flow from cannula tip to tip: Neonatal Circuit

A

-Venous Drainage Cannula
-Venous Sat Probe
-Venous Manifold
-Port to Bridge (V)/CRRT return
-Venous Pressure Line (DLP)
-Infusion Ports x2
-Centrifugal Pump
-Post-pump/Pre-oxygenator Pressure Line
-Oxygenator
-De-Airing Membrane/Yellow Cap
-Post-Pump/Post-Oxygenator Pressure Line/CRRT draw
-Arterial Manifold
-Spectrum Arterial Sat Probe
-Port to Bridge (A)
-Spectrum Arterial Flow Probe
-Arterial Return Cannula

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50
Q

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

A

manifold
bridge
more venous pigtails (infusion ports)
size of oxygenator
size of tubing

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51
Q

Function/Location Arterial and Venous Sat Probes:
CardioHelp
RotaFlow
Neonatal Circuit

A

CardioHelp:
venous: pre-pump/pre-oxygenator; Hgb/Hct/SvO2
arterial: post-oxygenator near the post-oxygenator pigtail

Rotaflow:
venous: external probe on the venous side of the circuit; SvO2 (Spectrum Monitor)
arterial: external probe on the arterial side of the circuit; SaO2, Hgb, Hct (Spectrum Monitor)

Neonatal:
venous: external probe placed proximal to the pt; SvO2 (Spectrum Monitor)
arterial: external probe placed proximal to the pt; SaO2, Hgb, Hct (Spectrum Monitor)

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52
Q

Function/Location Pigtails:

A

Adults CardioHelp: 4 (venous line, post-pump/pre-oxygenator, de-airing/CRRT draw, post-pump/post-oxygenator pigtail)

Pediatric CardioHelp: 2 (post-pump/pre-oxygenator, de-airing pigtail (post-pump/post-oxygenator)

Neonates: 2 (venous pigtails for meds)

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53
Q

Function/Location Venous Pressure:

A

measures pressure from patient

Adult & Pediatric CardioHelp: internal reading pre-pump

Neonatal Circuit: DLP, just past venous bridge port

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54
Q

Function/Location Pre-Oxygenator Pressure:

A

measures pressure of the oxygenator

Adult and Pediatric CardioHelp: internal sensor - post-pump/pre-oxygenator

Neonatal Circuit: DLP connected to post-pump/pre-oxygenator port (Y’d with post-pump/post-oxygenator port)

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55
Q

Function/Location Post-Oxygenator Pressure:

A

measures pressure from return cannula/tubing, and the patient

Adult & Pediatric CardioHelp: internal sensor near post-pump/post-oxygenator port

Neonatal Circuit: DLP connected to post-pump/post-oxygenator/de-airing port (Y’d with pre-oxygenator port)

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56
Q

Function/Location Oxygenator:

A
  • oxygenates blood
  • gas exchange to blow off CO2
  • heat exchanger between circuit and heater/cooler
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57
Q

Function/Location Rotaflow Centrifugal Pump:

A
  • pulls blood from patient and pushes blood into the oxygenator
  • pre-oxygenator
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58
Q

Function/Location CardioHelp Centrifugal Pump:

A
  • pulls blood from patient and pushes into the oxygenator
  • pre-oxygenator - attached/one-unit
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59
Q

Function/Location of Bridge:

A

Neonatal Circuit: venous side placed between the manifold and venous pressure line; arterial side is placed proximal to the pt

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60
Q

Where is the blood flow measured in the neonatal circuit?

A

Spectrum Monitor flow probe proximal to the pt on the arterial side

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61
Q

Where is blood flow measured in the CardioHelp circuit?

A

flow probe proximal to the patient on the arterial side

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62
Q

Where is blood flow measured in the adult Rotaflow circuit?

A
  • Spectrum Monitor flow probe proximal to the patient on the arterial side
  • needs additional paste to pump head directly out of pump (not accurate with <1L flow)
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63
Q

Where is the blood flow measured in the LifeSPARC circuit?

A

flow probe proximal to the patient on the arterial side

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64
Q

Where is the blood flow measured in the Centrimag circuit?

A

flow probe proximal to the patient on the arterial side

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65
Q

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

A

CardioHelp has 4 channels for blood flow and the Rotaflow is a single outlet resting on a sapphire pin

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66
Q

How does the Centrimag compare to other pumps?

A

full magnet levitation with no bearings or seals

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67
Q

How does the LifeSPARC compare to other pumps?

A

magnetically levitated with Single Point Ruby pivot bearing

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68
Q

What is an oxygenator failure?

A

inability for gas exchange or oxygenation with increased sweep

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69
Q

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

A

Delta P
SvO2 (VA ECMO)
SpO2 (VV ECMO)

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70
Q

What would you see on a patients blood gas that might make you think the oxygenatory is failing?

A

PaO2 <50
acidosis

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71
Q

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

A

the oxygenator itself for clots
gas outlet

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72
Q

What factors might cause an oxygenator to fail?

A

Clots
Air
Power Failure
Occluded Gas Outlet

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73
Q

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

A
  • little/no exhaust
  • pink/red condensation
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74
Q

What lab values would you see with a failing oxygenator?

A

Plasma Free Hgb increased
poor post-oxygenator gases
acidosis
poor patient gases

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75
Q

Minimum/Maximum Sweep: Neonatal Quadrox

A

.1L
3L

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76
Q

Minimum/Maximum Sweep: Pediatric Quadrox

A

.1L
5.6L

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77
Q

Minimum/Maximum Sweep: Small Adult Quadrox & 5.0 CardioHelp

A

.25L
10L

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78
Q

Minimum/Maximum Sweep: Adult Quadrox & 7.0 CardioHelp

A

.25L
14L

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79
Q

Minimum/Maximum Sweep: Neonatal Euroset

A

.1L
3L

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80
Q

Minimum/Maximum Sweep: Nautilus Smart ECMO Oxygenator

A

.25L
21L

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81
Q

Minimum/Maximum Blood Flow: Neonatal Quadrox

A

.2L
1.5L

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82
Q

Minimum/Maximum Blood Flow: Pediatric Quadrox

A

.2L
2.8L

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83
Q

Minimum/Maximum Blood Flow: 5.0 CardioHelp

A

0.5L
5L

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84
Q

Minimum/Maximum Blood Flow: Adult Quadrox & 7.0 CardioHelp

A

.5L
7L

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85
Q

Minimum/Maximum Blood Flow: Neonatal Euroset

A

.2L
1.5L

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86
Q

Minimum/Maximum Blood Flow: Nautilus Smart ECMO Oxygenator

A

.5L
7L

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87
Q

What is an indicator of clot formation within your circuit?

A
  • Increase in Delta P
  • Increase in Venous Pressures if clots are in the venous side of the circuit
  • Increase in Arterial Pressure if clots in arterial side of circuit
  • unable to draw/flush pigtails
  • dark spots in circuit/oxygenator
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88
Q

What does venous pressure indicate in your patient and the circuit?

A

Decrease in Volume Status; chugging - increase in venous pressure
Kink, tubing/cannula positioning, Clots

89
Q

What does recirculation mean?

A

oxygenated blood from the return cannula goes back into the drainage cannula; occurs only in V-V ECMO

90
Q

How do you fix recirculation?

A

reposition cannulas
decrease flows

91
Q

What factors affect recirculation?

A

cannula positioning
increased pump flow

92
Q

How do you determine if a patient is ready to be weaned off of V-V ECMO?

A
  • successful treatment of the underyling disease
  • improved blood gases with less support
93
Q

How do you determine if a patient is ready to be weaned off of V-A ECMO?

A
  • EF of 30%
  • improved hemodynamics/cardiac function
  • weaning of support meds
  • underlying issue treated/recovered
94
Q

How do you test a patient to see if they’re ready to be weaned off ECMO?

A

V-A:
peds/neonates: several clamp out trials
adults: low flow trial at 1L/Zero Flow as well as sweep around 1-2

V-V: cap the oxygenator (12 hrs peds; 24 hrs adults)

95
Q

How do you wean off of V-V ECMO? V-A ECMO?

A

V-V: only wean sweep; do not change flows

V-A: decrease flow as well as sweep

96
Q

What are potential air traps in the Oxygenator?

A

top of the oxygenator; de-airing pigtail, de-airing membrane

97
Q

What are the potential air traps in the ECMO Circuit Cannulas?

A

clamp out patient and get air to the oxygenator or closest pigtails/port

98
Q

What are potential air traps in the Centrifugal Pump Head?

A

clamp out patient, and flush the cannulas with volume to push air to oxygenator or closest pigtail/port

99
Q

What is Hemolysis?

A

destruction of RBC

100
Q

What factors cause hemolysis to occur in the ECMO circuit?

A
  • clots
  • turbulent flow from increased resistance
  • high/low temperature
  • acidosis
101
Q

What lab test is drawn to evaluate the degree of hemolysis?

A

Plasma Free Hgb

102
Q

How do you treat your circuit when hemolysis occurs?

A

Check for clots
Check for kinks in tubing
Pre-membrane pressure <300 mmHg
Add albumin during priming
Limit negative venous pressure

103
Q

What is the normal range for Plasma Free Hgb?

A

<12 ; >50 mg/dL = hemolysis

104
Q

Normal Value pH:

A

7.35-7.45

105
Q

Normal Value PaCO2:
Normal Value pt on ECMO:

A

35-45

106
Q

Normal Value PaO2:
Normal Value pt on ECMO:

A

80-100

> 200

107
Q

Normal Value Lactate:

A

0.5-2

108
Q

Normal Value Bicarb:

A

22-28

109
Q

Normal Value Base Deficit:

A

+/- 4 from 0

110
Q

Normal Value Hgb:
Normal Value pt on ECMO:

A

12-15 - women
13-17 - men

adults >7, neonates >10

111
Q

Normal Value Hct:

A

3x your hgb

112
Q

Normal Value Sodium:

A

135-145

113
Q

Normal Value Potassium:
Normal Value pt on ECMO:

A

3.6-5.1

3-5

114
Q

Normal Value Serum Calcium:

A

8.9-10.7

115
Q

Normal Value Ionized Calcium:

A

1.16-1.32

116
Q

Normal Value Ionized Magnesium:

A

.46-.64

117
Q

Normal Value PT:

A

12.3-14.8 seconds

118
Q

Normal Value aPTT:
Normal Value pt on ECMO:

A

25-36 seconds
60-80 seconds

119
Q

Normal Value Anti Xa:

A

.3-.7

if bleeding .2-.25

120
Q

Normal Value ATIII activity:
<30 days
>30 days

A

44-76%

80-120%

121
Q

Normal Value Plasma Free Hgb:
Normal Value pt on ECMO:

A

<12
< 50

122
Q

Normal Value Fibrinogen:

A

200-400 mg/dL

123
Q

Normal Value INR:
Normal Value pt on ECMO:

A

<2

</= 4.9

124
Q

Normal Value Troponin:

A

0-0.4

125
Q

Normal Value CK:

A

40-350

126
Q

Normal Value CK mb:

A

0-5

127
Q

Normal Value ALT:

A

0-40

128
Q

Normal Value AST:

A

0-95

129
Q

When do we get a head ultrasound?

A

pre-cannulation of neonates to rule out possible ICH

130
Q

How often do we get head ultrasounds?

A

daily for the first three days than every other day

131
Q

What do head ultrasounds tell us and why is it important?

A

ICH and it’s important because it’s a contraindication for cannulation; grade 3 or higher

132
Q

When are chest x-rays done on ECMO patients?

A

post cannulation and daily/PRN

133
Q

Why are chest x-rays important with ECMO Patients?

A

to ensure placement of cannulas

134
Q

When are cardiac ECHOs done for adults? neonates?

A

during weaning to check native cardiac function - ramp down; PRN to confirm cannula placement

pre-cannulation to rule out cyanotic congenital heart disease

135
Q

What supplies do you take from the cannulation cart for an adult being cannulated for V-A ECMO?

A

Dilators (pikA, sorin)
Venous Cannulas
Arterial Cannulas
Reperfusion cannula
7” tubing
Male to Male adaptor
Sterile Utensils
Sutures

136
Q

What supplies do you take from the cannulation cart for an adult being cannulated for V-V ECMO?

A

Dilators (venous)
Venous Cannula(s)
Sterile Utensils
Sutures

137
Q

What is a reperfusion cannula?

A

a cannula placed on the same side as the arterial cannula to perfuse the lower limb with oxygenated blood

138
Q

When is a reperfusion cannula used?

A

V-A ECMO

139
Q

Why is a reperfusion cannula used?

A

to provide blood flow to the lower limb of the side the arterial cannula is placed; prevent the lower limb from dying

140
Q

What is Cardiac Output?

A

quantity of blood pumped by the heart in L/min

141
Q

What is Cardiac Index?

A

cardiac output from the left ventricle in one minute to BSA

142
Q

What is BSA?

A

body surface area

143
Q

CO=

A

native heart function; used to assess ECMO flow

Heart Rate (HR) x Stroke Volume (SV)

CI x BSA

144
Q

CI=

A

Cardiac Output/BSA

145
Q

What does Viscosity mean?

A

thickness of a fluid

146
Q

How does viscosity affect ECMO flow?

A

an increase in viscosity increases resistance which decreases flow

147
Q

What does afterload mean?

A
  • the amount of resistance the heart has to overcome to open the aortic valve and pump blood out (SVR)
  • afterload reflects pts BP (increase BP, decrease flows), afterload also affected by by cannula size
148
Q

What does preload mean?

A

the force that stretches the cardiac muscle prior to contraction; filling pressure of the heart during diastole (LVEDP)

149
Q

What happens to ECMO flow with increased preload:

A

increase flow due to more volume; negative pressure would become less negative

150
Q

What happens to ECMO flow with decreased preload:

A

decrease in flow due to less volume; chugging occurs

151
Q

What happens to ECMO flow when afterload increases:

A

decrease in flow and an increase in post-oxygenator pressure

152
Q

What happens to ECMO flow when afterload decreases:

A

flows increase and post-oxygenator pressure decreases

153
Q

What is the priming volume for the Rotaflow pump?

A

32 mls

154
Q

What is the priming volume for the Centrimag pump?

A

31 mls

155
Q

Oxygen Content (CaO2)=

A

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

Most important variables- Hgb and SaO2

156
Q

Oxygen Delivery (DO2)=

A

CaO2 x CO

157
Q

What is the best indicator of oxygen delivery on V-A ECMO?

A

SvO2

158
Q

What is the best indicator of oxygen delivery on V-V ECMO?

A

patient gases, SpO2

159
Q

What influences oxygen delivery on V-V ECMO?

A
  • patients lungs due to blood flowing through the patients native lungs
  • recirculation - not delivering O2
  • Hgb
  • CO
  • FiO2
160
Q

What influences oxygen delivery on V-A ECMO?

A
  • Hgb
  • CO
  • FiO2
  • Increase Flow
161
Q

What pressures are monitored on a neonatal/pediatric circuit?

A

Venous Pressure - monitors patient, tubing positioning/kinks
Pre-Oxygenator - monitors oxygenator/clot formation
Post-Oxygenator - monitors afterload/oxygenator, tubing positioning/kinks

162
Q

What pressures are monitored on the CardioHelp circuit?

A

Venous Pressure - monitors patient (preload dependent)/tubing positioning - kinks
Pre-Oxygenator Pressure - pressure of the oxygenator - clot formation
Post Oxygenator Pressure - monitors patient and oxygenator - afterload sensitive
Delta P - difference in post-oxygenator pressure minus pre-oxygenator pressure; reflects increased resistance of the oxygenator

163
Q

What pressures are monitored in the adult Rotaflow circuit?

A

With Quadrox none

With Nautilus - pre and post oxygenator pressures

164
Q

What parameters are monitored by the venous probe on the CardioHelp?

A

Hgb
Hct
SvO2
Temperature

165
Q

What parameters are monitored by the Spectrum Monitor?

A

Venous Probe:
SvO2

Arterial probe:
SaO2
Hgb
Hct

Flow probe:
Blood flow/air bubbles

166
Q

What does Zero Flow mode do on the CardioHelp?

A

turns the RPMs to 0 which allows us to check the patients native heart function and is a safety feature for backflow prevention

167
Q

What is the most common complication in ECLS?

A

bleeding due to anticoagulation

168
Q

List 4 reasons you might emergently remove a patient from ECMO:

A

air embolism/clots
membrane oxygenator failure
tubing rupture
centrifugal pump head failure
Excessive bleeding
ICH
Accidental Decannulation

169
Q

List 5 causes of circuit air entrainment:

A
  • high negative pressures from kinked tubing
  • cutdown/central cannulation with high negative pressures can pull air in around the sutures
  • air from central lines (NO PRESSURE BAGS)
  • oxygenator membrane rupture if exhaust port is blocked causing air to go into the blood
  • venous pigtail on negative pressure side/drawing labs
  • cracked tubing/circuit parts
  • patient accidentally decannulates
170
Q

What is recirculation?

A

oxygenated blood gets drained back into the venous drainage cannula

171
Q

4 factors that affect recirculation:

A
  • close proximity of cannulas
  • poor cardiac output
  • high ECMO flows
  • hypovolemia
172
Q

What is the major limiting factor for ECLS blood flow?

A

Decreased preload

173
Q

If your PCO2 is high, what do you do to the sweep gas?

A

increase sweep gas
Adults - .5-1L
Neonates - .1L
Peds - .2-.5L

174
Q

What is measured by the Hemochron Signature Elite?

A

ACT

175
Q

How is a parameter “armed” for the CardioHelp?

A

activate the chain link by selecting each parameter

176
Q

How do you prep the CardioHelp circuit for the surgeon?

A
  • clamp closes to the oxygenator w/ tubing clamps
  • clamp the reservoir w/ white clamps
  • disconnect the reservoir w/ quick connects
  • hand the circuit to the surgeon sterile
  • instruct to clamp and cut the circuit
177
Q

What are signs of cardiac tamponade on V-A ECMO?

A
  • flows would decrease due to decrease venous return - chugging
  • increased venous pressure (more negative) due to decrease venous return to the heart
  • pt hypotensive
  • decrease pulsatility
178
Q

What are signs of a tension pneumothorax on V-V ECMO?

A
  • Decreased lung compliance
  • Decrease SpO2
  • Decreased flows
  • Increased venous pressure (more negative)
179
Q

What parameters do you inspect when doing your circuit checks?

A

RPMs
blood flow
venous pressure
pre-oxygenator
post-oxygenator
Delta P
SvO2
SaO2
Hgb
Hct
Temperature
Sweep
FiO2

180
Q

Which screen on the CardioHelp allows you to store your lab values?

A

Press the folder button with either the SvO2, Hgb, or Hct

181
Q

What device is used for CRRT?

A

NxStage

182
Q

What line is clamped on the Centrimag when changing the pump to another external drive?

A

Venous and Arterial Lines closest to patient

183
Q

What is the minimum RPMs to be sure of forward flow in Centrimag, CardioHelp, and Rotaflow Pumps?

A

1700 - to prevent stagnant blood which could cause clotting and backflow

184
Q

List 4 blood products your patients may recieve:

A

pRBC
FFP
Platelets
Cryoprecipitate

185
Q

When is Crystalloid, Albumin (5%, 25%) and blood products transfused?

A
  • low flows due to hypovolemia; chugging, increased venous pressure
  • no pressure bags
186
Q

Normal cultures:

A

Negative

187
Q

What do we learn from ECHOs?

A

Cardiac function
Pulmonary artery pressures

188
Q

When do we perform a CT Scan?

A

Change in patient status

189
Q

What do we learn from CT Scans?

A

Check for head bleed, abdominal function (w/ contrast)

190
Q

How does a CT scan affect the care of our patient?

A

Sometimes not tolerated by patient; if poor results then conversation with family to end ECMO

191
Q

When do we go to Fluoroscopy?

A

To place a double lumen cannula safely

192
Q

What does fluoroscopy tell us?

A

Cannula placement

193
Q

What patients are most likely to have fluoroscopy?

A

VV ECMO pts

194
Q

When is a cardiac cath done?

A

Pt had a STEMI, any ECPR, check for coronary blockage

195
Q

What is the most common bacterial pneumonia?

A

Streptococcus

196
Q

Maximum weight for ECMO

A

VV ECMO - <50 BMI
VA ECMO - <40 BMI

197
Q

Minimum weight for ECMO

A

2 kg

198
Q

What is the minimum gestational age for ECMO?

A

> 34 weeks

199
Q

What tests must be obtained before going on ECMO for neonates?

A

Head ultrasound
Cardiac echo
Metabolic screening
Basic labs/cultures/chest xray

200
Q

How do I assist in setting up the circuit?

A
  • Plug in the pump
  • Plug in gas lines/make sure oxygen is hooked up and on
  • water for heater/cooler
  • go through pre-initiation checklist
201
Q

What side of the neck is prepared for neonate?

A

Right

202
Q

What do you check to confirm your circuit is ready?

A

Check the pre-initiation checklist

203
Q

Normal flow for neonate on ECMO?

A

100-150 mls/kg

204
Q

Fluid removed during hemofiltration occurs due to

A

The pressure gradient

205
Q

Heparin dosages may need to be altered when CVVH is added into the system because

A

Dialysis filter absorbs the heparin

206
Q

Signs and symptoms of oxygenator failure

A

Increased Pre-Membrane pressure
Increase in Delta P
Decreased O2 and CO2 exchange
Hematuria
Blood leak from gas outlet

207
Q

The ultimate goal of ECLS is

A

Maximize oxygen delivery

208
Q

What variable actions could you take to increase oxygen delivery?

A

Increase flows
Increase Hgb
Increase FiO2

209
Q

How is the change of sweep assessed?

A

ABGs

210
Q

How often do you sigh?

A

Q2

211
Q

How often do you chart?

A

Q1 unless a significant event occurs

212
Q

How often do you flush pigtails?

A

Q4; issues with clotting - Q2

213
Q

Where are primed circuits stored in the hospital?

A

OR - outside OR 21
NeoMart
ECMO room 531 in ChOR
CSICU - outside of 134

214
Q

How is pRBC/FFP given in Neonates?

A

Venous infusion ports w/ syringe pump

215
Q

How is platelets/cryo given with neonates?

A

Arterial side of the bridge

manually given; 5 cc every 5 mins until all is given then flush

216
Q

ECMO improves oxygen delivery by which mechanisms?

A
  • stabilizing of hemoglobin saturations
  • taking over at least 60% of the blood flow through functioning membrane lung, away from the sick native lungs
  • stabilizing by taking over at least 60% of the cardiac output through the ECMO pump
217
Q

Membrane failure can be characterized by raising pump CO2 levels because of:

A

alteration in membrane surface area caused by fibrin formation

218
Q

What items will your perfusionist need when they arrive with the circuit?

A
  • cannulation cart
  • heparin - 100 IU/kg
  • clamps
  • pre-initial check list

ECMO (3 decks)

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