Extracorporeal Membrane Oxygenation Cannulation

W22 Extracorporeal Membrane Oxygenation Cannulation



Penny Lynn Sappington



image Before Procedure



Indications



• Venovenous extracorporeal membrane oxygenation (ECMO)
• Inability to oxygenate and/or ventilate a patient due to the following:
image ARDS

image Pneumonia

image Lung transplantation (graft failure)
• Reperfusion ischemic injury

• Rejection

• Infection

• Technical issues

• Bridge to lung transplantation

• Failure to achieve adequate PaO2 (>50) on 100% FiO2 or persistent shunt >25% despite optimally tolerated positive end-expiratory pressure (PEEP) through the following therapies:
image Failed trial of pressure control/inverse ratio

image Trial of diuresis

image Trial of paralytics

image Trial of nitric oxide

image Trial of high-frequency oscillator ventilation

image Consider trial of prone positioning

• Venoarterial ECMO
• Indication for ECMO in adult cardiac failure is cardiogenic shock. Inadequate tissue perfusion manifested as hypotension and low cardiac output despite adequate intravascular volume.
image Typical causes:
• Acute myocardial infarction

• Myocarditis

• Peripartum cardiomyopathy

• Decompensated chronic heart failure

• Postcardiotomy shock

• Heart transplantation (graft failure)
image Ischemic reperfusion injury

image Rejection

image Pulmonary hypertension

image Technique issues

• Bridge to heart or heart-lung transplantation

• Shock persists despite the following therapies:
image Volume administration

image Inotropes and vasoconstrictors

image Intraaortic balloon counterpulsation if appropriate


Contraindications



• Absolute contraindications:
• Age older than 65 years

• Significant life-limiting disease:
image Significant baseline lung disease including home O2 dependence or heart disease
• Not a transplant candidate

image Encephalopathy

image Cancer

image Cirrhosis

image HIV

• Recent stroke/intracranial hemorrhage

• Suspicion of anoxic brain injury

• Relative contraindications:
• Bleeding diathesis

• Gastrointestinal bleed

• Greater than 14 days of mechanical ventilation

• Encephalopathy


Equipment



• Permanent equipment:
• BioMedicus 540 centrifugal pump console/Rotoflow/Levitronix

• TX-40 flow transducer for BioMedicus

• ECMO cart (including instrument tray)

• Oxygenator bracket (for Affinity or Quadrox D)

• Pump external drive

• Heater/cooler with appropriate water lines and connectors (BioCal or Sarns) or heating blanket

• Oxygen medical air blender with appropriate-length (20 feet each) gas lines and connectors for all operating rooms and intensive care areas

• Cardiotomy reservoir holder

• Hemochron Jr Signature + activated clotting time (ACT) device

• Manifold for pressure readings on the BioPump 540 transducer, Medtronic DLP pressure display

• 6 Tubing clamps and scissors

• Hand crank

• Bed plate with two long poles

• Blue roller clamp assembly for recirculation line (10-mm Keck roller clamp from Cole Parmer)

• 2 Full 100% oxygen E cylinders with tubing adapter

• Set of each: 4 types of gas connectors

• Possible Accessory Equipment
• Hemoconcentrator bracket

• Disposable supplies:
• ECMO Carmeda-bonded (CB) Medtronic custom tubing pack or Maquet custom tubing pack; Quadrox Bioline or Levitronix pump head

• Cardiotomy reservoir

• Walrus extension connectors with high-flow stopcocks

• Terumo extensions, high flow (one positive and one negative for kidney)

• Pressure veil and isolator tubings or DLP pressure display set

• 3/16-inch to male connectors

• Extra 3/8-inch CB straight connectors with Luer-Lok

• 3/8-inch Non-Carmeda-bonded connector

• 3/8-inch Perfusion adapter
image Plasmalyte-A pH 7.4, 2000 mL (prime the circuit)

image Sterile water for irrigation for BioCal or Sarns water heater (approximately 3 to 4 L)

• Hemochron Jr. ACT + cuvettes

• Syringes: 3 mL, 10 mL, and 60 mL

• Blood filter

• Extra supplies for ECMO site:
• CB BioMedicus cannulae:
image 50-cm venous: 29F, 27F, 25F
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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Extracorporeal Membrane Oxygenation Cannulation

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