Heart Failure Essentials for Cardiology Fellows 2016
July 30, 2016
Eastin Grand Sathorn Hotel, Bangkok
Basic ECMO
for Cardiologists
Teerapat Yingchoncharoen MD, FASE
Ramathibodi hospital
Slides
Mahidol University ECMO for cardiologists
Powervote Setting
b.socrative.com
TEERAPAT
กรอกชื่อ
Mahidol University ECMO for cardiologists
Extracorporeal Membrane Oxygentation (ECMO)
Uses a centrifugal pump to drive blood from the patient to a membrane oxygenator
system for carbon dioxide and oxygen exchange (same principle as CPB)
Mahidol University Cleveland Clinic Journal of Medicine 2016;83,5:373
ECMO Vs CPB
Mahidol University ELSO Ann Arbor MI, USA
Extracorporeal life support (ECLS)
Acute circulatory failure
VA
ECMO
CO2 retention states Acute respiratory failure
ECCO2R VV
ECMO
Cardiac arrest ECPR Hybrid Combined failure
EDCD
Organ donation
Mahidol University ECMO for cardiologists
Indications for ECMO
Mahidol University J Am Coll Cardiol 2014;63:2769–78
Contraindications for VA-ECMO
1. Aortic disease (aortic dissection, unrepaired
coarctation of aorta)
2. Severe aortic regurgitation
3. Unrecoverable heart and not a candidate for
VAD implantation or heart transplantation
4. Irreversible or end-stage underlying disease
5. Contraindication for anticoagulation
6. Severe peripheral artery disease
Mahidol University ECMO for cardiologists
Veno-venous (VV) ECMO
Air blender Oxygenator
return cannula
Console
pump
nula
can
age
in
dra
Mahidol University J Am Coll Cardiol 2014;63:2769–78
Peripheral VV ECMO
Mahidol University ECMO for cardiologists
Veno-arterial (VA) ECMO
Air blender
Console
Oxygenator
pump
nula nula
can c an
age t urn
in re
dra
Mahidol University J Am Coll Cardiol 2014;63:2769–78
VA ECMO : The circuit
Mahidol University ECMO for cardiologists
VA ECMO : The circuit (2)
Mahidol University ECMO for cardiologists
Peripheral VA ECMO
Mahidol University ECMO for cardiologists
Central VA ECMO
Mahidol University ECMO for cardiologists
Circuit of VA ECMO
Mahidol University ECMO for cardiologists
Quiz # 1: สิ่งนี้คืออะไร เอาไว้ใช้ทำอะไร
Mahidol University ECMO for cardiologists
Centrifugal pump
Cones Curved Straight
blades blades
Mahidol University ECMO for cardiologists
Centrifugal pump
Rotaflow
Mahidol University ECMO for cardiologists
Rotaflow centrifugal pump
Mahidol University ECMO for cardiologists
Centrifugal pump
Centrimag
Mahidol University ECMO for cardiologists
Console
Rotaflow CardioHelp Centrimag
Mahidol University ECMO for cardiologists
Understanding ECMO Console Parameters
MARQUET ROTAFLOW
Mahidol University ECMO for cardiologists
Basic ECMO Physiology
ECMO effect on patient
Patient effect on ECMO
Mahidol University ECMO for cardiologists
ECMO effect on patient
venous return afterload
to LA
- AV close
- Increased
LVEDP and LVEDV
anti-physiologic
Mahidol University ECMO for cardiologists
Hemodynamic Change in ECMO
Mahidol University LVAD for cardiologists
Patient effect on ECMO
Mahidol University ECMO for cardiologists
Preload
Mahidol University ECMO for cardiologists
Preload
Volume status
Venous tone
Position of the venous cannula
Diameter and length of the venous cannula
Diameter and length of the venous tubing
Mahidol University ECMO for cardiologists
Afterload
Mahidol University ECMO for cardiologists
Afterload
Systemic vascular resistance
Oxygenator resistance
Diameter and length of the tubing
From pump to oxygenator
Diameter and length of the arterial line after oxygenator
Diameter and length of the arterial cannula
Position of the arterial cannula
Mahidol University ECMO for cardiologists
Scenario#1: 35 YOM S/P VA ECMO for myocarditis. After the
surgeon left, there an ECMO alarm. What would you do ?
Scenario#2: ท่านถูก notify ในเวรว่ามีความผิดปรกติ
ของสาย ECMO ดังนี้ จงบอกสาเหตุ และ management
Mahidol University ECMO for cardiologists
Scenario#3: ผู้ป่วย Anterior wall STEMI with cardiac
arrest ใส่ VA ECMO (ECPR) plan จะ transfer ไป PCI แต่มี
ปัญหา VF upon transfer แม้ทำ Defib x3 แล้ว ทำยังไงดี ?
Mahidol University ECMO for cardiologists
Scenario#4: ผู้ป่วย myocarditis ใส่ VA-ECMO มีปัญหา SpO2
drop ในช่วง 2-3 วันที่ผ่านมา จาก parameter บนหน้าจอนี้ ตัวเลข
ไหนที่ใช้บอกว่าผู้ป่วยอาจจะมีปัญหา clot ใน oxygenator?
D
B
C E= I don’t know
Mahidol University ECMO for cardiologists
ECMO circuit pressure monitoring
Veins Artery
P1 SvO2 SaO2
P2 P3
Mahidol University ECMO for cardiologists
Scenario#4: ผู้ป่วย myocarditis ใส่ VA-ECMO มีปัญหา
SpO2 drop ในช่วง 2-3 วันที่ผ่านมา จาก parameter บนหน้า
จอนี้ ตัวเลขไหนที่ใช้บอกว่าผู้ป่วยอาจจะมีปัญหา clot ใน
Venous pressure
Arterial
pressure
Internal
pressure
delta P
Mahidol University ECMO for cardiologists
ECMO circuit pressure
monitoring
(absolute value)
P1 P2 P3 Diagnosis
-50 to -100 200-300 250-350
Hypovolemia, Tamponade, Pneumothorax
Venous cannula malposition or
venous line kinking
Head pump failure
Oxygenator failure (thrombosis)
Increased pump afterload (hypertension,
arterial line kinking)
Mahidol University ECMO for cardiologists
Patient ECMO
HR, MAP, CVP Flow, RPM, Gas (Sweep, FiO2)
Right arm Sat Pressure : Prepump, Premembrane, post membrane, ΔP
Brain sat, distal perfusion pressure
Mahidol University ECMO for cardiologists
Management of ECMO (1)
Heart Rest
- Maintain MAP 60-90 mmHg
- Minimize use of inotropes/pressors
- Proper control of arrhythmias
Lung Rest
- Minimize ventilation
- FiO2 < 0.5
- Rate 10-15/min
- Peak airway pressure < 30 cmH2O
Mahidol University ECMO for cardiologists
Management of ECMO (2)
Target parameters for initial treatment
- ECMO Flow : 60-80 cc/kg/min
- SaO2 : 100%
- MvO2 : 60-75%
- SpO2 (right arm) : 95-100%
- pCO2 : 35-45 mmHg
- pH 7.35-7.45
- Platelet > 80,000
- Hematocrit > 28%
Mahidol University Laci G. Heart Lung and Circ 2014;23:10-23
Management of ECMO (3)
Anticoagulation
- Target ACT 180-220 sec with IV heparin
- aPTT 60-80 sec (40-60 sec in high risk
bleeding, try keeping high speed)
- ACT is less sensitive than aPTT for
anticoagulation testing in low to moderate
dose of heparin (esp. VV ECMO)
Mahidol University ECMO for cardiologists
Management of ECMO (4)
u PK/PD
u - Adjust med dose per Pharm D.
Courtesy Pitchaya dilokpattanamongkol,
Mahidol University B.SC(PHARM), BCPS(PHARMACOTHERAPY), BCCCP(CRITICAL CARE)
FACULTY OF PHARMACY, MAHIDOL UNIVERSITY
Complications of ECMO
Thrombosis (1-22%)
Bleeding, coagulopathy and hemolysis 5-79%
Infection 17-49%
Limb ischemia (13-25%)
- Prevented by distal perfusion
Mahidol University LVAD for cardiologists
CVC air entry
The Nightmare
Mahidol University ECMO for cardiologists
Low flow after initiation of ECMO
Common causes
- Bleeding
- Cardiac tamponade
- Relative hypovolemia (SIRS)
Management
- Give volume
- Decrease PEEP
- Search for cannulation complication : bleeding
- Echo to exclude tamponade
Mahidol University ECMO for cardiologists
Visible access insufficiency
(shaking of access line)
Common causes
- Hypovolemia/bleeding
- Excessive RPM
- Sub-optimal cannula position
- Positioning (after turning the patient)
- Increased abdominal pressure
Management
- Give volume
- Decrease RPM
- X-ray to confirm the cannula position
Mahidol University ECMO for cardiologists
Refractory VF on VA ECMO
Concept
- Organ perfusion can be maintained with ECMO
and defib to sinus rhythm is not the utmost urgent
- Should not waste time for unlimited defib and
delay other life-saving procedure e.g. PCI
Management
- Permissive VF
- Decide to go to cath lab
Mahidol University ECMO for cardiologists
Scenario#5: Amy is a 25-year-old woman suffering from
acute viral myocarditis, complicated with AKI, aspiration
pneumonia/ARDS on VA-ECMO for 5 days. She was
conscious and obeying command all along. She noticed to
be confused and agitated since this morning. SpO2 RA 85%,
LA 85%, RL 100%, LL 100% What is your management ?
Mahidol University ECMO for cardiologists
Differential Hypoxia
“Good heart bad lung”
“Harlequin syndrome"
: “Blue head” : deoxygenated
blood directed to the upper part of
the body
: “Red leg” : hyper oxygenated
blood in the lower part of the body
Rx : Switch to VV/VAV ECMO
Mahidol University ECMO for cardiologists
Change of Flow Interface according to Native CO
Mahidol University LVAD for cardiologists
ECMO Watershed
Mahidol University ECMO for cardiologists
ECMO Watershed
Mahidol University ECMO for cardiologists
VAV ECMO
Mahidol University ECMO for cardiologists
Pulmonary edema in VA ECMO
Increased in LV afterload
- Aortic / mitral regurgitation, LV dilation
- Increased LVEDP
- Pulmonary edema
Mahidol University ECMO for cardiologists
Management of Pulmonary
edema in VA ECMO
- IABP
- Impella
- Atrial septostomy
- Direct LV decompression (vent)
Mahidol University ECMO for cardiologists
Eur Heart J. 2015 Sep 1;36(33):2246-56.
Cardiogenic shock
n= 3,846
VA ECMO
Survival
Survival N=3,844
Risk factors of mortality Protective factors of mortality
Chronic renal failure Younger age
Longer duration of ventilation Lower weight
Pre-ECMO organ failure Acute myocarditis
Pre-ECMO cardiac arrest Heart transplant
Congenital heart disease Refractory VT/VF
Lower pulse pressure, Higher diastolic blood pressure
Lower serum bicarbonate (HCO3) Lower peak inspiratory pressure
Eur Heart J. 2015 Sep 1;36(33):2246-56.
http://www.save-score.com/
Area under AUC = 0.90 (95%CI 0.85-0.95)
THANK YOU
FOR YOUR ATTENTION
EMAIL : teerapat.yin@mahidol.ac.th
