ECMO: Những lưu ý về huyết động - Kenneth Lyn-Kew, MD

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ECMO: Hemodynamic

Considerations

Kenneth Lyn-Kew, MD
National Jewish Health

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Definitions

 <b>E</b>xtra<b>C</b>orporeal <b>M</b>embrane <b>O</b>xygenation (ECMO)
 <b>E</b>xtra<b>C</b>orporeal <b>L</b>ife <b>S</b>upport (ECLS)

 <b>e</b>xtracorporeal <b>C</b>ardio<b>P</b>ulmonary <b>R</b>esuscitation (eCPR)

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ECMO



General Indications

 Cardiac support

 Respiratory support

 Combination of the two

 Support during high risk interventions (cath lab)

 eCPR

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ECMO



Two primary types

 Veno-venous support

 Primarily respiratory

 Veno-arterial support

 Cardiac/cardiopulmonary support



Components

 Centrifugal pump

 Membrane oxygenator

 Tubing/canulas

 Controller

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VV-ECMO

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VV-ECMO



<b>Drainage and Return</b>

 Venous and venous



<b>Hemodynamics</b>

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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

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Hypotension on VV-ECMO:

Causes



Primary cause of ARDS is Sepsis



Bleeding



Under resuscitation



Over sedation



Interval development of right heart failure

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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)

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<b>Combes A et al. N Engl J Med </b>
<b>2018;378:1965-1975</b>

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Hypotension on VV-ECMO:

Treatment (2)



Under resuscitation

 “chatter”

 Judicious volume



Over sedation

 Decrease sedation if able



Interval development of right heart failure

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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

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Take Home Message

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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

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VA-ECMO



<b>Drainage and Return</b>

 Venous and arterial



<b>Hemodynamics</b>

 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

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VA-ECMO



<b>VA</b> 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 2 pressors/IABP

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VA-ECMO



<b>V-A</b> 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

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VA-ECMO



<b>V-A</b> Management goals

 Saturation

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

 Harlequin Syndrome

 Volume status

 Avoid volume overload

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VA-ECMO



<b>V-A</b> Management

 Algorithms

 Frequent echo

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

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Take Home Message

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ECMO

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