16 short course:”critical care in cardiothoracic surgery ...thaists.org/news_files/news_file_626....

16th Short Course:”Critical Care in Cardiothoracic Surgery” Perfusionist Session:Running ECMO:How I do it

Friday ,May 16,2014 Novotel Bangkok on Siam Square

Who need ECMO?

Respiratory ECMO vs

Cardiac ECMO

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VV ECMO vs

VA ECMO

VA ECMO

Veno-Arterial Support (Fem-fem bypass)

Jugular vein

Aorta

RA/ Jugular vein

Veno-Venous ECMO

Femoral vein

Internal jugular vein

Closed system vs Open system

ECMO machine and the circuit without reservoir

Close system

pump

Blood drained from the venous circulation and return to the arterial circulation

oxygenator

ECMO circuit with reservoir Open system

VA ECMO

Cardiac ECMO

RAAorta Central VA ECMO

ECMO equipment and circuit

ECMO Components

Commercial set ราคา 6-80,000 บาท

ไมรวม Hemoconcentrator

Close system

Close system & centrifugal pump

Homemade set รวม Hemoconcentrator ราคา 19,600 บาท

Open system

Open system & Roller pump

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Monitoring during ECMO

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Parameters for assessment

-HR -BP -CVP -Metabolic acidosis -Capillary refill -Pulses -Temperature of extremities

-Neurological sign status -GI status -Intake&output

Biomarker of systemic circulatory failure



VA ECMO

VV ECMO

VA ECMO

VV ECMO

-Blood flow -Oxygen delivery -Oxygen consumption -Venous saturation -Serum Lactate level -Urine output

3.3 3.3 3.2 3

2.8 3

3.5 3.5 3.5 3.5

0

0.5

1

1.5

2

2.5

3

3.5

4

baseline 6hr 12hr 24hr ECMO day 2 ECMO day 3 ECMO day 4 ECMO day 5 ECMO day 6 ECMO day 7

Pump flow (L/min)

ECMO pump flow target 80-100 cc/kg/min

Blood flow (n=9)

396

667

560 597 592 584

552 581 561

533

0

100

200

300

400

500

600

700

800

baseline 6hr 12hr 24hr ECMO day2

ECMO day3

ECMO day4

ECMO day5

ECMO day6

ECMO day7

Oxygen Delivery during ECMO (n=9)

Normal DO2 520-720 ml/min

DO2 = arterial oxygen content x pump flow x 10

0

20

40

60

80

100

120

140

160


Mean Oxygen consumption during ECMO

VO2 = Art.O2 - Venous O2 content x Flow (L/min) x 10 normal VO2 = 100 -180 ml/min

Oxygen Consumption (VO2) n=9

Increase in metabolism/ Seizures Decrease in Hb /CO

Increase Oxygen depth

Venous saturation (SVO2) n=9

SVO2 65-75% reflective of adequate cardiopulmonary function or ECMO support

0102030405060708090

100


SVO2

mixed venous oxygen saturation (SVO2) เปนคาหนงทแสดงถงความสมดลของ

รางกายระหวางความตองการออกซเจน (oxygen consumption) และการสงออกซเจนไปเลยงเนอเยอตางๆ (oxygen delivery)

Factors affecting DO2,VO2,SVO2

-Hb -PaO2 -Oxygen saturation -Oxygen extraction or O2 demand -Blood flow (CO)

7.4

9.4

8.7

9.0

8.6 8.7

7.9

8.8

8.4

7.9

6.5

7

7.5

8

8.5

9

9.5

10


Mean Hb during ECMO

Degree of hemodilution- low peripheral oxygen delivery

Temperature Systemic vascular resistance-hypoperfusion

Prolong cardiopulmonary bypass time

Vasopressor drugs

Perfusion related factors

Hyperlactatemia

Severe acidosis and tissue hypoxia

15.2

17.8

15.4

19.3 18.4

21 19.5

22 20.6

19.7

0

5

10

15

20

25


Normal Serum Lactate level 0.5-1 mmol/L

Serum Lactate changes during ECMO

ECMO management (ชวยผปวยไดอยางไร?)

0

0.5

1

1.5

2

2.5

3

3.5

4


Pump flow (L/min)

Pump takeover heart function 100%

Increase pump flow rate to maintain blood pressure

X

ECMO pump flow target 100-120 cc/kg/min

Very poor EF ECMO pump flow target 80-100 cc/kg/min

Blood flow (n=9)

396

667

560 597 592 584

552 581 561

533

7.4

9.4 8.7

9.0 8.6 8.7

7.9

8.8 8.4

7.9

0

1

2

3

4

5

6

7

8

9

10

0

100

200

300

400

500

600

700

800


Relationship between mean DO2 and mean Hb level

DO2

Hb

Oxygen Delivery

Hematologic management : Target Hb 12 -15gm%

Massive bleeding & massive transfusion

Maintain DO2 in normal range

1200

1648

1333

1550

1360

1229 1307

1006 1097

1029

42

68

55

62

51

43

49 44

48 45

0

10

20

30

40

50

60

70

80

0

200

400

600

800

1000

1200

1400

1600

1800


MAP & SVR changes during ECMO

SVR MAP

X

X

Antihypotensive Agents

137

104

80 69

54

37

16 5 0 0

-20

0

20

40

60

80

100

120

140

160


Mean Urine output during ECMO (cc/hr) Target 2 cc/kg/hr

nongchana klangsuk,Rajavithi Hospital

• continuous ultrafiltration • Hemodiafiltration • Cell washing / Lactate Removal / (Hemodilution with Hemoconcentration technique)

Filtration Techniques

142 145

139 135 134

138 135

141

149

141

125

130

135

140

145

150

155


Serum Sodium level during ECMO

3.2

4.8 4.3 4.4

4.9 4.7 4.4 4.0

5.8 5.1

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0


serum potassium level during ECMO

Changes in small size molecular weight: mean potassium concentration, mean sodium concentration

137

104

80 69

54 37

16 5 0 0

-200

20406080

100120140160


Mean Urine output during ECMO (cc/hr)

0

5

10

15

20

25


Cell washing Technique

Non Lactate remove

Lactate Remove

Left heart decompression during ECMO

PA /Apex venting

OPEN CHEST

Protein derangement during ECMO

Foreign surface contact PLT function Thrombocytopenia Loss of coagulation factors

Minimize by good anticoagulation Use: -albumin / FFP/Platelets -Aprotinin -Methypredisolone (SoluMedrol) -Hemofiltration

Complications

Bleeding

Thrombus

Anticoagulation Anticoagulation

Coagulation monitoring Maintain ACT 180-200 sec Check ACT ทก 2 hrs.

ถาม Bleeding รอบๆ cannulae ใหใช pressure dressing

ถามปญหา heparin resistance ทมสาเหตจาก

AT III ใหFresh Frozen Plasma

หมนตรวจด Clot formation ใน สายและHead pump

Anticoagulation Protocol

• Post operative insertion of ECMO

– No protamine

• Heparin by infusion

– Do not start heparin until bleeding has stopped

– ACT for the first 24 hours 180-200 seconds

• Platelets transfusion ≥100,000/mm3

540

243

194 210

237 258

227 244

229 233

0

100

200

300

400

500

600


mean ACT level during ECMO

Activated clotting time (ACT) 200- 250 sec. Target ACT:

Bleeding

Thrombus

Anticoagulation Anticoagulation

Coagulation monitoring Look for signs of coagulation impairment active bleeding hemorrhagic diathesis

Check: skin & mucosa

Vascular observations of lower limbs Limb temperature Limb colour Pedal pulse Capillary refill Size

Mechanical complications

• Oxygenator malfunction

• Pump malfunction

• Tubing rupture

• Cracks in connectors

• Air / clot in circuit

• Cannulation displacement/ kink

• Power failure

Oxygenator monitoring Check for Clot & thrombus Air Plasma leak

Pump head monitoring

ตรวจสอบทงระบบ คอ pump head, oxygenator & tubing

Connections monitoring

Cannulae and lines monitoring

Notify M.D.

• Vital signs outside of ordered parameters • Any deterioration in assessment status • Bleeding >10 ml/hour from cannulae site • Change in level of sedation

Indicators for improvement

• Indicator of lung recovery – SVO2 – pO2 – pCO2 – Increase compliance – Cleansing chest X-ray

• Improving contractility • Urine out put • Vital signs • Pump blood flow • Blood gas

ประโยชนของ ECMO • Useful therapy for the support of both

cardiac and respiratory failure patients

• Easy & Quickly to deploy (dedicated therapy)

• cheap

Overall out come

Results • Respiratory support

– Neonatal respiratory support 77% survival to discharge

– Paediatric support 56% survival

– Adult 53% survival

• Cardiac support – Neonate 38% survival

– Paediatric 43% survival

– Adult 33% survival

Indications for use : Rajavithi Hospital

a. Bridge to transplantation b. Perioperative Hemodynamic instability c. Postoperative myocardial / lung dysfunction

Operations (1 Jan 2554- 31 Dec 2556)

Age Bypass time

Days of support

Type of Support

Result Complications

IE&AVR&shock 40 yrs 3 hrs 45 min 3 AV ECMO A Bleeding

Redo AVR&CABG 65 yrs 1 hrs 57 min 2 AV ECMO A Bleeding

Heart Transplantation 26 yrs 3 hrs45min 2 AV ECMO & IABP

A Bleeding

Redo AVR & root replacement 32 yrs 6hrs48 min 3 AV ECMO & IABP

A* Bleeding & Myocardial

failure

CABG 74 6 hrs 23 min 16 hrs AV ECMO &LVAD& IABP

D Myocardial failure

CTOF 31 yrs 2 hrs12min 5 VV ECMO &RVAD&IABP

D Bleeding& Myocardial

failure

Redo AVR&MVR 40 yrs 6 hrs 40 min 8 AV ECMO D Bleeding

Redo Hemi Arch replacement

66 yrs 5 hrs 45min 8 AV ECMO D Bleeding

Single Lung Transplantation 52 yrs Non CPB 14 AV ECMO D Bleeding

44.5% survival rate in Adult Cardiac ECMO

CVT Unit, Rajavithi Hospital

Operations (1 Jan 2554- 31 Dec 2556)

Age Bypass time

Days of support

Type of Support

Result Complication

Rastelli’s operation 3 yrs 2 hrs19 min 7 AV ECMO A bleeding

Redo Ao. Root replacement &

Aortic Homograft

7 yrs 6 hrs29min 9 AV ECMO

D bleeding

Redo Ao. Root replacement &

Aortic Homograft

6 yrs 5 hrs 26 min 2 AV ECMO D bleeding

33% survival rate in Pediatric Cardiac ECMO

Result ไมดทาไปทาไม? -ใหโอกาส recover (Bridge to -รอ Tx (Bridge to Transplant -ซอเวลา (Bridge to Destinatio

Important: ECMO is offered only to patient/child whose lung and/or heart disease is thought to be reversible.

Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesia 1994

16 short course:”critical care in cardiothoracic surgery ...thaists.org/news_files/news_file_626....

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