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Extracorporeal Membrane Oxygenation, Mechanical Circulatory Support, Cardiac Failure, Cardiopulmonary Bypass Circuit, Dynamics of Ecmo, Femoral Vein, Respiratory Failure are some points in Introduction to General Medicine lecture. This lecture is one of 61 lectures you can find here for this course.
Typology: Slides
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1000 patients supported on ECMO at the University of Michigan were reviewed (retrospectively)
VV-ECMO for respiratory failure provided survival to discharge: 88% of 586 cases of respiratory failure in neonates 70% for 132 cases of respiratory failure in children 56% for 146 cases of respiratory failure in adults
ECMO is instituted for the management of life threatening pulmonary or cardiac failure (or both), when no other form of treatment has been or is likely to be successful.
ECMO is essentially a modification of the cardiopulmonary bypass circuit which is used routinely in cardiac surgery.
Instituted in an emergency or urgent situation after failure of other treatment modalities.
It is used as temporary support, usually awaiting recovery of organs.
Divided into two type
Cardiac Failure
Respiratory Failure
Post-cardiotomy when unable to get pt off cardiopulmonary bypass following cardiac surgery
Post-heart transplant usually due to primary graft failure
Severe cardiac failure due to almost any other cause Decompensated cardiomyopathy Myocarditis Acute coronary syndrome with cardiogenic shock Profound cardiac depression due to drug overdose or sepsis
Several considerations must be weighed: Likelihood of organ recovery.: only appropriate if disease process is reversible with therapy and rest on ECMO Cardiac recovery: to either wait for further cardiac recovery to allow implant of device (LVAD) or to list for transplantation. Disseminated malignancy Advanced age Graft vs. host disease Known severe brain injury Unwitnessed cardiac arrest or cardiac arrest of prolonged duration. Technical contraindications to consider: aortic dissection or aortic incompetence
ECMO can be inserted in 2 configurations:
Veno-venous
Veno-arterial
Veno-Venous (VV) configuration Provides oxygenation Blood being drained from venous system and returned to venous system. Only provides respiratory support Achieved by peripheral cannulation, usually of both femoral veins.
Advantages
Flow from Central ECMO is directly from the outflow cannula into the aorta provides antegrade flow to the arch vessels, coronaries and the rest of the body
In contrast, the retrograde aortic flow provided by peripheral leads to mixing in the arch.
Mechanical ventilation must be continued during ECMO support to try to maintain oxygen saturation of blood ejected from the left ventricle to at least above 90%.
ECMO flow can be very volume dependent
ECMO flow will drop: Hypovolemia Cannula malposition Pneumothorax Pericardial tamponade.
Actual ECMO flows do not need to be altered to assess native respiratory function Done by altering gas flow through the ECMO circuit
Pt may be weanable: Gas exchange is able to be maintained with a low FiO2 (<30%) Low fresh gas flow rates into the circuit (<2 L/min)
Caveat: RR and PEEP set on ventilator are not too high (e.g. <25 breaths/min and <15cmH2O, respectively).
Falls into one of three major categories
Bleeding associated with heparinization
technical failure
neurologic sequelae
Bleeding/Hemolysis
Out of proportion to the degree of coagulopathy and patient platelet count
Coagulopathy Continuous activation of contact and fibrinolytic systems by the circuit Consumption and dilution of factors within minutes of initiation of ECMO