Ebook ECMO in the adult patient - Core critical care: Part 2
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Ebook ECMO in the adult patient - Core critical care: Part 2
Chapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2ling lungs. The cardiovascular system remains intact, and the heart continues to pump the blood around the patient’s body.A simplified view of veno-venous ECMO is that the blood is taken from and returned to die venous system. If the blood is circulated through a functioning oxygenator, gas exchange Ebook ECMO in the adult patient - Core critical care: Part 2 will happen. If there is no oxygenator (or no gas flow through tlie oxygenator), the blood will just return in the same state as it drained (perhapsEbook ECMO in the adult patient - Core critical care: Part 2
a bit cooler if no heat exchanger is in place). The whole-blood volume (including the proportion dial went through the ECMO circuit) is pumped by the Chapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2tion and co2 removal and allows die implementation of safer ventilation sưategies. This is inaccurately referred to as ‘protective’ ventilation (any positive-pressure ventilation is deemed to cause damage to the lung) and could be called the ‘least-damaging lung ventilation’.Veno-venous ECMO can be Ebook ECMO in the adult patient - Core critical care: Part 2continued for as long as appropriate; investigations are directed at confirming die underlying diagnosis and ensuring specific dierapy is administeredEbook ECMO in the adult patient - Core critical care: Part 2
.Patients supported with veno-venous ECMO frequently have additional non-pulmonary organ failure and require a high level of critical care support (e.Chapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2cific elements. This chapter describes tiiose specific elements.Locally agreed protocols for the care of ECMO patients should be incorporated into training.Monitoring of die patient on veno-venous ECMO has been described in ChapterJ.Stabilization on veno-venous ECI Insertion of ECMO cannulas should Ebook ECMO in the adult patient - Core critical care: Part 2ideally take place in an operating room. A variety of configurations can be used. It is often striking how rapidly ventilation and other support can bEbook ECMO in the adult patient - Core critical care: Part 2
e modified after veno-venous ECMO support has been started.Lung ventilation can be adapted immediately after veno-venous ECMO lias been established. TChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2would agree to aim for a standard setting (Table 8.1). Veno-venous ECMO circuits are very efficient at exchanging co2. While unproven, it makes sense to decrease the patient PaCO2 progressively to avoid extreme vasoactive responses. Tills can easily be achieved by initiating veno-venous ECMO with a Ebook ECMO in the adult patient - Core critical care: Part 2low gas sweep tlirougli the oxygenator (e..g 2 L'min) that is progressively increased (e.g. within the first hour). A low gas sweep will usually not aEbook ECMO in the adult patient - Core critical care: Part 2
ffect oxygenation as transfer of o2 will be limited by other factors (as long as the delivered fraction of 02 in the sweep gas is 100%). In veno-venouChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2veno-venous ECMO is dependent on the blood flow in the circuit in relation to the patient’s cardiac output.Table 8.1 Example of standard ventilation settings while on veno-venous ECMOPeak airway pressure <25 cmH2O (strictly less than 30 cmH2O)Tidal volume < 6 mL'kgPositive end-expiratory pressure (P Ebook ECMO in the adult patient - Core critical care: Part 2EEP) at 10 cmH20Respiratory rate at 10 minFiO2 30-50%Inspiratory: expiratory ratio of 1 : 2Allow spontaneous breatlis within pressure and volume paramEbook ECMO in the adult patient - Core critical care: Part 2
etersInotropes and other vasoactive drugs will often have been increased to very high levels to maintain some haemodynamic stability in critically illChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2ay and intrathoracic pressure, low o2 levels, high doses of sedative agents, high co2 and profound acidosis. The rate of infusion of these drugs can (and should) very often be decreased rapidly.Red blood cell transfusion is advocated by some, as the 02 content in extra red blood cells will increase Ebook ECMO in the adult patient - Core critical care: Part 2 the o2-carrying capacity; Others aovocate me use or restrictive transfusion policies identical to those used in other critically ill patients. JustifEbook ECMO in the adult patient - Core critical care: Part 2
ication for a liberal transfusion strategy is that veno-venous ECMO rarely increases the PaO2 to normal physiological levels. In the absence of a guarChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2 by red blood cell transfusion may be added benefit in critically ill patients in whom the systemic inflammatory response is increased by the use of an ECMO circuit.If the Pa()2 remains low despite optimal blood flow through the EC MO circuit, it can be presumed tliat the issue is either inadequate Ebook ECMO in the adult patient - Core critical care: Part 2flow for body weight (especially in patients in excess of 100 kg) or high cardiac output leading to a small proportion of circulating blood going throEbook ECMO in the adult patient - Core critical care: Part 2
ugh the ECMO circuit. Solutions to tills problem include: (1) the insertion of an additional drainage cannula to increase flow through the ECMO circuiChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2re temperature using the heater/cooler in the ECMO circuit to modify the patient’s body temperature) or actions to reduce the cardiac output (P-blockers are sometimes used to acliieve tills, but questions remain on the overall physiological impact this may have). (Note that double-lumen cannulas hav Ebook ECMO in the adult patient - Core critical care: Part 2e an optimized return lumen size for the drainage lumen size, and tliat adding an extra cannula to improve flow will have only a limited effect.)If thEbook ECMO in the adult patient - Core critical care: Part 2
e venous blood is highly desaturated, a second oxygenator may be incorporated into the circuit. Willie tills is difficult to model, tills definitely iChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2iple non-invasive tests to determine the cause and remedy the insult that led to respiratory failure.Oxygenation during veno-venous ECMODuring veno-venous ECMO support, fully o2-sanuated blood from the ECMO circuit mixes in tile right atrium with deoxygenated venous return that has not passed throug Ebook ECMO in the adult patient - Core critical care: Part 2h the F.CMO circuit, and then passes into the right ventricle and pulmonary artery.Systemic arterial oxygenation is determined by the relative proportEbook ECMO in the adult patient - Core critical care: Part 2
ions of oxygenated ECMO blood flow and deoxygenated venous return, and by the degree of pulmonary dysfunction, 02 consumption, amount of recirculationChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2a of the ECMO circuit, without passing througn me lungs ano systemic circulation. Recirculation can be identified by high o? saturation in die drainage limb (pre-oxygenator) of the ECMO circuit, and often by visual inspection of the drainage limb for ‘flashes’ of red oxygenated blood mixing with deo Ebook ECMO in the adult patient - Core critical care: Part 2xygenated blood. The recirculation fraction increases with increasing ECMO flow. At higher ECMO flow rates, the beneficial effect of increasing flow oEbook ECMO in the adult patient - Core critical care: Part 2
n the proportion of oxygenated blood entering die pulmonary artery will be offset by an increase in recirculation. In these circumstances, reducing puChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2he tip of two cannulas is said to be 10 cm), low cardiac output and low intravascular (specifically right atrial) volume.ECMO blood flow should initially be set to deliver the maximum flow, typically 5 L’min, without excessive negative pressure in die drainage limb of the ECMO circuit; this should p Ebook ECMO in the adult patient - Core critical care: Part 2roduce a rise in arterial o2 saturation. Sweep gas should be kept at 100% o2. Thereafter, oxygenation can be controlled by adjusting circuit blood floEbook ECMO in the adult patient - Core critical care: Part 2
w and not by altering FiO2 or positive end-expiratory pressure (PEEP) on the ventilator. Generally a PaO2 greater than 6 kPa (50 mmHg) and o2 saturatiChapter 8Management of the patient on veno-venous ECMO: general principlesIntroductionVeno-venous ECMO allows gas exchange and is used to support fail Ebook ECMO in the adult patient - Core critical care: Part 2s outlined in Table 82.Table 8.2 Assessment and management of hypoxaemia during veno-venous ECMOProblemCausesReduction or loss of circuit flowLow intravascular volume, kink in circuit tubing, obsưuction from large dirombus in circuiưoxygenator/cannula, cannula malposition, cardiac tamponade, tension Ebook ECMO in the adult patient - Core critical care: Part 2 pneumothoraxPost-oxygenator blood not fully saturatedFailing oxygenator, accidental interruption of sweep gas supplyIncreased recirculationECMO circuEbook ECMO in the adult patient - Core critical care: Part 2
it flow too high, suboptimally positioned ECMO cannula, low cardiac output, low intravascular volumeGọi ngay
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