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6. radiologic imaging in ecmo #beach2019 (nieboer)

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This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.

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6. radiologic imaging in ecmo #beach2019 (nieboer)

  1. 1. - 3rd Beach Course - The Radiology of ECMO Koenraad Nieboer MD FESER Emergency & Intensive Care Radiology UZ Brussel
  2. 2. Speaker - GE Healthcare Disclosure
  3. 3. 1) Pré ECMO imaging 2) Per ECMO imaging 3) Imaging findings / canula positions 4) Haemodynamic changes important for CT imaging 5) Complications Learning objectives
  4. 4. Pré ECMO imaging
  5. 5. Pré ECMO Imaging Important for decision making Baseline Before or soon after cannulation if possible Involve Radiology at an early stage where possible Done at the refferring centre if possible
  6. 6. Pré ECMO Imaging Reasons not to start with ECMO:
  7. 7. Pré ECMO Imaging Compare for evolution Case: F 35y EW: Abdominal pain Vomiting One day post PS AKI + Sepsis Chest X-ray + CT
  8. 8. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 1: EW 3:31 am
  9. 9. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 2: ICU 3:31 am 11:04 am
  10. 10. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 3: ICU 3:31 am 11:04 am 1:44 pm
  11. 11. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 4: ICU 3:31 am 11:04 am 1:44 pm 3:06 pm
  12. 12. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 5: ICU Decision for ECMO 5:02 pm
  13. 13. Per ECMO imaging
  14. 14. Per ECMO imaging Imaging modalities Imaging protocol
  15. 15. Per ECMO imaging Imaging modalities X-ray Ultrasound CT scan
  16. 16. Per ECMO imaging Imaging modalities X-ray: Mobile DX X-ray device > Image on device! Ultrasound CT scan - Check lines and tubes / canulas - Extent of consolidations - Follow up of effusions - Pneumothorax
  17. 17. Per ECMO imaging Imaging modalities X-ray: Mobile DX X-ray device > Image on device! Ultrasound CT scan - Check lines and tubes - Extent of consolidations - Follow up of effusions - Pneumothorax Measurement on X-ray device screen
  18. 18. Per ECMO imaging Imaging modalities X-ray: Mobile DX X-ray device > Image on device! Ultrasound CT scan - Check lines and tubes - Extent of consolidations - Follow up of effusions - Pneumothorax Immediate adjustment and control
  19. 19. Per ECMO imaging Imaging modalities X-ray: Mobile DX X-ray device > Image on device! Ultrasound CT scan - Check lines and tubes - Extent of consolidations - Follow up of effusions - Pneumothorax Companion view
  20. 20. Per ECMO imaging Imaging modalities X-ray Ultrasound: - ∆ effusions – consolidation CT scan - Abdominal organ evaluation - Intraperitoneal free fluid - US guided interventions - Mobile / portable and good equiped - But: Operator and patient dependent!
  21. 21. Per ECMO imaging Imaging modalities X-ray Ultrasound CT scan: - Clinically driven - Transport - Communication - Examination Planning - Patiënt positioning - Iodinated contrast access: CVC / peripheral https://intensiveblog.com/on-the-move-ecmo-transport/
  22. 22. Imaging findings / canula positions
  23. 23. Imaging findings / Canula positions ARDS VV ECMO > VA ECMO
  24. 24. Imaging findings / Canula positions ARDS: Acute Respiratory Distress Syndrome “Berlin definition” (2011): ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance. ALI: Acute Lung Injury = obsolete DAD: Diffuse Alveolar Damage = the histopathologic pattern
  25. 25. Imaging findings / Canula positions ARDS: Acute Respiratory Distress Syndrome “Berlin definition”: Key components: - Acute onset over 1 week or less - Bilateral opacities consistent with pulmonary edema on Chest X-ray or CT - Reduced oxygenation (PF ratio < 300mmHg, min 5cmH2O PEEP (or CPAP) ) - Exclusion of Cardiac failure or Fluid overload
  26. 26. Imaging findings: ARDS chest X-ray
  27. 27. Imaging findings: ARDS CT scan
  28. 28. Imaging findings / Canula positions ARDS: Acute Respiratory Distress Syndrome Clinical and Radiological Mimics Hydrostatic pulmonary edema Pneumonia Aspiration Diffuse alveolar hemorrhage Acute hypersensitivity pneumonitis Organising pneumonia Acute eosinophilic pneumonia Acute fibrinous organising pneumonia Radiol Clin N Am 54(2016) 1119-32
  29. 29. Imaging findings: ARDS vs Acute Pulmonary Edema Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 33582
  30. 30. Imaging findings: Canula positions ARDS VV ECMO > VA ECMO: Canula positions Echocardiography: initial placement confirmation X-ray series: reaffirmation canula position use bonelandmarks and carina CT scan: clinically driven problems
  31. 31. Imaging findings / Canula positions: VV ECMO
  32. 32. Imaging findings / Canula positions: VV ECMO
  33. 33. Imaging findings / Canula positions: VV ECMO
  34. 34. Imaging findings / Canula positions: Central VA ECMO
  35. 35. Imaging findings / Canula positions: Periferal VA ECMO
  36. 36. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
  37. 37. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
  38. 38. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
  39. 39. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
  40. 40. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
  41. 41. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
  42. 42. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
  43. 43. Haemodynamic changes important for CT imaging
  44. 44. Haemodynamic changes important for CT imaging More pronounced in VA ECMO compared to VV ECMO VV ECMO: Larger “vascular” volume Right Atrial / Inferior caval vein siphon effect
  45. 45. Haemodynamic changes important for CT imaging: VV ECMO
  46. 46. Haemodynamic changes important for CT imaging: VV ECMO
  47. 47. Haemodynamic changes important for CT imaging More pronounced in VA ECMO compared to VV ECMO VA ECMO: Retrograde aortic flow > inconsistent flow from heart and EC circuit Other factors also cause heterogeneous enhancement: Native ejection fraction Flow rate Total amount of contrast medium administered Scan delay time Cannulation (central vs peripheral)
  48. 48. Haemodynamic changes important for CT imaging: VA ECMO
  49. 49. Haemodynamic changes important for CT imaging: VA ECMO
  50. 50. Haemodynamic changes important for CT imaging: VA ECMO KJR 2014; 15(3) Aortic Pseudolesions
  51. 51. Haemodynamic changes important for CT imaging: VA ECMO AJNR 2017;38:773-76 Pseudothrombosis
  52. 52. Haemodynamic changes important for CT imaging: VA ECMO Aortic Stasis • Inadequate flow can lead to stasis thrombus forming in the LV, LVOT and ascending aorta proximal to the arterial cannula • High density thrombus is easily seen on non-contrast enhanced CT Insights Imaging 2014; 5:731
  53. 53. Haemodynamic changes important for CT imaging Optimizing CT for pulmonary emboli Poor RV function will predispose to pulmonary arterial thrombosis Venous cannula will siphon off contrast media before opacifying the pulmonary trunc and arteries Can reduce flow to 500 cc/min or discontinue flow for 10-15 sec to allow normal pulmonary circulation and prevent siphon effect (Risk for thrombosis)
  54. 54. Haemodynamic changes important for CT imaging Optimizing CT for pulmonary emboli: Repeat scan if necessary! Poor RV function will predispose to pulmonary arterial thrombosis Venous cannula will siphon off contrast media before opacifying the pulmonary trunc and arteries Can reduce flow to 0,5 l/min or discontinue flow for 10-15 sec to allow normal pulmonary circulation and prevent siphon effect (Risk for thrombosis) Courtesy: Dr Bobby Agrawal
  55. 55. Complications
  56. 56. Complications CNS: Ischemic infarction (hypoexemia, acidosis, hypotension) Hemorrhage (anticoagulatio related) Thoracic: Canula migration Effusions Pneumothorax Pulmonary embolism / Hemorrhage Others: Hemorrhage: intra / retroperitoneal / adrenal gland Hepatic infarction Arterial occlusions Deep venous thrombosis
  57. 57. CNS complications
  58. 58. CNS complications
  59. 59. Thoracic complications
  60. 60. Other complications
  61. 61. Take to your Work: • Pré ECMO = Baseline for Follow Up • Always compare imaging with prior exam • CT = Communication and Planning • Involve your (ICU) Radiologist • Be aware of haemodynamic changes in CT • Be aware of complications
  62. 62. Thank you for your attention! Koenraad.nieboer@uzbrussel.be
  • fluidacademy

    Oct. 15, 2019
  • DwightDumay

    Oct. 13, 2019

This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.

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