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

Definitions

 ExtraCorporeal Membrane Oxygenation (ECMO)  ExtraCorporeal Life Support (ECLS)

 extracorporeal CardioPulmonary Resuscitation (eCPR)

ECMO

 General Indications

 Cardiac support

 Respiratory support

 Combination of the two

 Support during high risk interventions (cath lab)

 eCPR

ECMO

 Two primary types

 Veno-venous support

 Primarily respiratory

 Veno-arterial support

 Cardiac/cardiopulmonary support

 Components

 Centrifugal pump

 Membrane oxygenator

 Tubing/canulas

 Controller

VV-ECMO

VV-ECMO

 Drainage and Return

 Venous and venous

 Hemodynamics

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

Hypotension on VV-ECMO: Causes

 Primary cause of ARDS is Sepsis

 Bleeding

 Under resuscitation

 Over sedation

 Interval development of right heart failure

Hypotension on VV-ECMO: Treatment (1)

 Sepsis associated hypotension

 Vasopressor support

 Consider VA ECMO

 Bleeding

 Assess cannula sites – may need surgical intervention

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

oxygenator)

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

Hypotension on VV-ECMO: Treatment (2)

 Under resuscitation

 “chatter”

 Judicious volume

 Over sedation

 Decrease sedation if able

 Interval development of right heart failure

Hypotension on VV-ECMO: Treatment (3)

 Recirculation:

 Blood is brought out of body and then upon return to body immediately taken back up by pump

 Oyxgenated blood does not reach tissues

 Pt develops lactic acidosis

 Monitor by following lactate and trending pre oxygenator blood O2 saturation

Take Home Message

VA-ECMO

• 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

VA-ECMO

 Drainage and Return

 Venous and arterial

 Hemodynamics

 Provided by the mechanical pump, bypassing the patient’s heart

 However, unlike cardiopulmonary bypass surgery, the patient’s heart is not placed into a state of

VA-ECMO

 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 pressors/IABP

VA-ECMO

 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

VA-ECMO

 V-A Management goals

 Saturation

 Check on right hand/ear-furthest from device/cannula

 Harlequin Syndrome

 Volume status

 Avoid volume overload

VA-ECMO

 V-A Management

 Algorithms

 Frequent echo

 Wean pressors but concentrate on ECMO flows-need stability off ECMO to deccanulate

Take Home Message

ECMO