ECMO: Những lưu ý về huyết động - Kenneth Lyn-Kew, MD

 Treat by using additional drainage cannula or, preferably, by using a bicaval dual lumen cannula.. Take Home Message[r]

ECMO: Hemodynamic

Considerations

Kenneth Lyn-Kew, MD National Jewish Health

Denver, CO

 ExtraCorporeal Membrane Oxygenation (ECMO)

 ExtraCorporeal Life Support (ECLS)

 extracorporeal CardioPulmonary Resuscitation (eCPR)

 Technique for providing respiratory and/or cardiac support to patients whose native organs are so severely compromised that normal function/life is not possible

 General Indications

 Cardiac support

 Respiratory support

 Combination of the two

 Support during high risk interventions (cath lab)

ECMO

Avalon Elite bicaval dual lumen cannula in correct position From Hirose et al, 2012

 Drainage and Return

 Venous and venous

 Hemodynamics

 Provided by patient’s native cardiac pump function

Lifeinthefastlane.com

Indications – VV ECMO

 ARDS/hypoxemic respiratory failure

 PaO2 to FiO2 ratio less than 80, despite salvage therapies for 6+ hrs

 Hypercapneic respiratory failure (severe

COPD/asthma exacerbation)

 Lung transplant candidates as bridge therapy

 Severe air leak/bronchopleural fistula

requiring mechanical ventilation

 Interval development of right heart failure

 Acidosis due to reirculation

 Assess cannula sites – may need surgical intervention

 Decrease heparin (maximal pump flow on VV-ECMO allows for low to no heparin strategy – monitor

oxygenator)

 Assess for non-ECMO associated bleeding

Combes A et al N Engl J Med 2018;378:1965-1975

Bleeding Risk in EIOLA Trial

 Decrease sedation if able

 Interval development of right heart failure

 Switch to VA ECMO to unload right ventricle

 Oyxgenated blood does not reach tissues

 Pt develops lactic acidosis

 Monitor by following lactate and trending pre

oxygenator blood O2 saturation

 Treat by using additional drainage cannula or,

preferably, by using a bicaval dual lumen cannula

Take Home Message

 If your patient is on VV ECMO, generally manage

their hemodynamics just as you would any other patient

• Can be cannulated in a variety of ways

• Femoral vein – Femoral artery

• Internal jugular vein – Femoral artery

• Central – usually post cardiac surgery

• Femoral arterial cannulations require use of a distal perfusion cannula to preserve flow to leg

• Can also cannulate VAV by adding additional return cannula to venous side

 Drainage and Return

 Venous and arterial

Ecmosimulation.com

 VA Indications

 Cardiovascular support/Cardiogenic shock

 post-cardiotomy shock

 Cardiomyopathy (ex Post-partum, viral)

 Decompensated heart failure

 AMI

 Massive PE

• Systolic pressure of 85, CI<1.2 despite 2 pressors/IABP

• E-CPR

 V-A Management goals

 Hemodynamics

 Can wean pressors or ventricular assist device first

 These can cause heart to compete with ECMO pump

 MAP goals usual 65-90

 Maintain pulsatility

 Need to avoid formation of LV thrombus

 Avoid volume overload

 Also need to maintain sufficient volume to avoid chatter

Switch to VAV ECMO and ultimately to VV ECMO if lungs unable to provide oxygenated blood to recovering heart

Take Home Message

 If your patient is on VA-ECMO, your pump controls their hemodynamics until their heart recovers

Questions?