E C M O : W H AT C A N G O W R O N G

D E I R D R E M U R P H Y A L F R E D I C U

– M U R P H Y

“what can go wrong will go wrong at the worst possible moment”

H O W T O B E A T M U R P H Y ’ S L A W

Know what can go wrong

Avoid it

Tell others!- share “the knowledge”

Troubleshoot new problems

W H A T I S E C M O ?

• VV ECMO #1 (Vin

K N O W I N G W H A T C A N G O W R O N G

Stages of ECMO support

Initiation

Cannulation

Maintenance

Weaning

What next?

I N I T I A T I O N

Choose right patient

Right type of ECMO (VV vs VA)

Right configuration (site/set up/possible complications)

R I G H T PA T I E N T

Will benefit from ECMO

Not too sick to benefit (duration of organ failure)

Has an “out” clause

R I G H T PA T I E N T

Decision support

Indications and exclusions

Many relative- requires experience - 2nd opinion

Often very limited time

Can get it wrong

Review all decisions

Share cases/ Registry

R I G H T C O N F I G U R A T I O N

Provides best support for that patient

e.g. VV in setting of severe hypoxaemia

VA in setting of cardiac failure

C A N N U L A T I O N

Cannulas ranging from 15F to 31F in major vascular structures..

!

What could possibly go wrong …..

!

Not simply same as arterial line and venous line only bigger…..

F E M O R A L A R T E R I A L A C C E S S

How good are landmarks?

Not Very!

0-11 cm (6.5 cm mean) between inguinal ligament and groin crease

Maximal femoral pulse less variable ..if there is a pulse..

Bifiurcation of CFA above groin crease in 75%

P R O B L E M S W I T H L A N D M A R K B A S E D F E M O R A L A P P R O A C H

Too high- retroperitoneal haematoma

!

Too low- pseudoaneuysms

W H Y I S S I T E S O I M P O R TA N T

prevent complications

access superficial femoral for leg perfusion to avoid ischaemia

P L A C I N G “ B A C K F L O W ” C A N N U L A E

Backflow Cannula No Backflow Cannula

S O L U T I O N

Ultrasound guided vascular access

Size vessels (avoid cannulas that are too big)

Put right sized cannula in the right part of the vessel

size = 3 xD

K I N K E D / E X T R A VA S C U L A R

S O L U T I O N

D E E P P E LV I C O B S T R U C T I O N K I T

D E E P P E LV I C O B S T R U C T I O N K I T

Stiff guidewire (e.g. Amplatz) Long exchange catheter to get around

tortuosity in the pelvic vessels

A N G I O G R A P H I C D O ’ S A N D D O N T ’ S

Never underestimate the amount of damage you can do with a needle and guidewire

!

Always visualise the guide wire (unless it is soft tipped and an experienced operator) (I- I)

!

Always try and visualise what is happening to the tip of the guide wire even when it is not visible

C A N N U L A I N R I G H T V E S S E L B U T W R O N G S P O T

T R O U B L E S H O O T I N G C A N N U L A P R O B L E M S

Not always easy

Percutaneous cannulation in shocked patient

Cardiogenic shock complicating cardiac surgery necessitating return to OR

C A N N U L A T I O N

Complicated by presence of IABP

V shocked patient

Seemed to go smoothly

P O S T C A N N U L A T I O N

High pressures in ECMO circuit limiting support

Ultrasound of cannulas- in vessels

Venous cannula appropriately placed

F U R T H E R T E S T S ?

abdo X ray

A LW A Y S D O F R E S H P U N C T U R E

Re-wiring existing lines problematic

May be high entry point to vessel/near inguinal ligament etc

C A N N U L A T I O N D U R I N G A R R E S T

C A N N U L A T I O N D U R I N G A R R E S T

Identify vessels anatomically (guidewire in aorta/ guidewire in IVC)

Don’t cut corners

Entire team needs to be co-ordinated- simulation training

M A I N T E N A N C E

Patient complications

Bleeding, bleeding , bleeding

Clotting including HITT

Pump thrombosis

(Murphy’s law of mechanical devices)

Infection

M A I N T E N A N C E P H A S E . . A T T H E W O R S T P O S S I B L E M O M E N T. .

Circuit complications

disruption of circuit

venous (pre-pump)

arterial (Post pump)

All life threatening emergencies

Day 1 Day 12 Day 14

Day 1 Day 14Day 12

P R E V E N T I O N

M A N A G E M E N T O F C I R C U I T D I S R U P T I O N

Cannula disruption !

Arterial cannula !

3-4 l/min

A I R E M B O L I S M

Prevention- No taps on venous (low pressure) side of circuit

Training to deal with- simulation

P U M P FA I L U R E . . A T T H E W O R S T P O S S I B L E M O M E N T

Back up console always plugged in and ready to go

Low battery-pump won’t turn back on…

Checklist to include battery standby

Handcrank

P U M P H E A D T H R O M B O S I S

Haemolysis, noisy pump Rx; Change ciruit (URGENT)

T R A N S P O R T

A F T E R E C M O

Decision making

Timing of removal/separation

Defining the response to failure clearly

What next- destination therapy? bridge to bridge

H O W C A N Y O U R E S P O N D A D E Q U A T E LY A T A L L T I M E S O F D A Y A N D N I G H T

Robust system

Centre volume

All staff caring for the patient trained in emergency responses

Frequent rehearsal of key responses e.g. clamping circuit

H O W T O A V O I D

Logistics:

ECMO safety/ set up

Clamps/spare circuit primed

Training for life threatening emergencies

Simulation training

Checklists

Maintenance of training -re-accreditation

B E A T I N G M U R P H Y

cognitive challenges

share experiences, write up results, registry data, case conferences, M and Ms, evidence based decision support

technical challenges

training (individual and team)

learning from errors as a team/ craft group/ specialty

on the spot trouble shooting

B E A T I N G M U R P H Y

!

there are some things we don’t have time not to do…..