Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
PHYSIOLOGY ,CANNULATION
AND
MONITORING OF
VENO-ARTERIAL ECMO
Dr.Manoj.P.
Lead Consultant Cardiovascular and Thoracic
Surge...
Extra corporeal Life Support is achieved by
- Draining venous blood
- Removing CO2
- Adding oxygen
- Returning to circulat...
Types of ECMO
ECMO can be categorised according to the
circuit used
• Veno-arterial - VA ECMO provides both gas
exchange a...
Modes of ECMO
Veno -arterial (VA)ECMO
•Provides both respiratory and cardiac support
•Blood is drained from venous system ...
VA ECMO – Technical Specifications
 Peripheral-FA, pump outflow is retrograde,
admixing at arch level.
 If Respiratory f...
First successful ECMO patient,
1971
J Donald Hill MD and Maury Bramson BME, Santa
Barbara, Ca, 1971. (Courtesy of Robert B...
First Neonatal ECMO
survivor..
Esperanza, Age 1 day 1975
Esperanza, age 21
FROM THIS
TO THIS
Advantages and
Disadvantages
Advantages Disadvantages
Both cardiac and pulmonary support Cannulation of major artery and s...
ECMO ??????
• Several considerations must be weighed
- Likelihood of organ recovery
- Cardiac re-recovery
- Disseminated m...
• The physiologic goal is to improve tissue oxygen
delivery , remove CO2 and allow normal aerobic
metabolism whilst the lu...
Dual
circulation
• Native circulation + ECMO circulation
• Sometimes Results in North South syndrome if the
return cannula...
• Reduces preload
• Increases afterload Myocardial
stunning
• Left sided decompression
• Use of inodilators
In Veno Arterial
ECMO
• Perfusate saturation is 100%
• Without lung function LV saturation=RV saturation
• ABG reflects Pe...
Increase in Systemic PO2 may
result from..
•Improved lung function at constant
flow
•Increased ECC flow at constant CO
CO2
removal..
• Mainly depends on oxygenator surface
area and sweep gas flow rate
• Independent of blood flow
• Moderately...
During Veno arterial
ECMO..
• O2 consumption decreases ( catecholamines
reduced,less metabolic stress)
• Arterial saturati...
• Knowledge of the physiology of ECMO support
the management of ECMO patient
• O2 content is of utmost importance in the
p...
CANNULATIO
N
The establishment and maintenance of
adequate vascular access is essential
for ECMO
CANNULATION
- Patient age and size
- Underlying disease & condition
- Cause of the cardiorespiratory compromise
- Type of ...
CANNULATI
ON
• For each modality, there are different
kinds and sizes of cannulae that can be
used
• Target ACTshould be a...
Cannula
Consideration
• Venous cannula should be with the largest
lumen and shortest length possible.
• Venous cannula sho...
Veno-Arterial (VA) ECMO
Provides cardiac as well as
respiratory support and is
mainly used for post op cardiac
case
Cannulation can
either be..
• Through neck vessels(RCC artery and RIJV
and or an additional vein)
• Central cannulation
or...
Access and return cannula
sites
Access Return
RA Aorta
Femoral Vein Femoral Artery
Subclavian Vein Axillary artery
Interna...
CANNULATION
TECHNIQUE
• Open
• Semi-open
• Percutaneous
CANNULATION
• In central cannulation Aorta and RA are
cannulated
• LV decompression is important
:Can be done either by cr...
CANNULATIO
N
Right atrium
and
Ascending aorta
CANNULATION
A Left atrial vent
line can be utilized
to monitor the LA
pressure
CANNULATIO
N
Internal jugular vein
and the common
carotid artery
Veno arterial access via the neck
vessels
CANNULATI
ON
Femoral vein
and
Femoral artery
Venoarterial access via the femoral
vessels
Peripheral Femoral Cannulation – VA ECMO
Femoral artery cannulation:
•Chances of distal limb ischemia
•Distal perfusion catheter is commonly
used
Distal Leg Perfusion 7/9 Fr Cannula
CANNULATIO
N
-In situations where ECMO
support is anticipated
-Chest will be left open and
covered by a Silastic
patch
-Pu...
CANNULATION
PROBLEMS
• Threading the venous catheter
• Vein division
• Proximal vein lost in
mediastinum
• Lack of venous ...
Complicatio
ns
• Vascular injury( tear,
intimal dissection,
perforation).
• Obstruction (kinking,
positional).
• Misplacem...
Monitorin
g
• Success lies with vigilant monitoring which helps in early
recognition and diagnosis of problems and timely ...
Clinical
parameters
• Vital parameters(ECG rhythm,Pulse rate,Blood
Pressure ,Temperature , and respiratory rate)
• Arteria...
• Hematological parameters(CBC,HCT 35-
40%,Plasma Free Hemoglobin <0.1g/dl)
• If possible cerebral oxygenation with NIRS
•...
Coagulation
Monitoring
•Pre ECMO ACT 300 seconds
•On ECMO –Check ACT 2 hourly till
ACT drops to 200 seconds
•Maintenance w...
Circuit
monitoring..
• Circuit blood flow
• Circuit gas flow
• Circuit pressure
• Circuit integrity
These variables should...
Factors affecting Circuit Blood
flow
Increased Blood flow Decreased Blood flow
Increased RPM Decreased RPM
Decreased Resis...
Circuit
Pressure
• Pre pump pressure: too much negative pressure
results in Hemolysis, cavitation, endothelial
damage of R...
•Pre membrane pressure
•Post membrane pressure
•Transmembrane pressure
Circuit
integrity
• Check for : Clot
: Air
: Leak
• Pump is checked for abnormal noise or crack
Clot in the oxygenator
Other things to be checked
regularly.
•Insertion site/dressing security
•Functioning of heat exchanger
•Access line for ki...
Thank You
Ecmo presentation final
Ecmo presentation final
Ecmo presentation final
Upcoming SlideShare
Loading in …5
×

Ecmo presentation final

0 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Ecmo presentation final

  1. 1. PHYSIOLOGY ,CANNULATION AND MONITORING OF VENO-ARTERIAL ECMO Dr.Manoj.P. Lead Consultant Cardiovascular and Thoracic Surgeon Aster Medcity
  2. 2. Extra corporeal Life Support is achieved by - Draining venous blood - Removing CO2 - Adding oxygen - Returning to circulation - Through either a vein or artery
  3. 3. Types of ECMO ECMO can be categorised according to the circuit used • Veno-arterial - VA ECMO provides both gas exchange and circulatory support (Heart & Lung failure) • Veno-venous –VAECMO allows gas exchange only (Isolated Lung failure)
  4. 4. Modes of ECMO Veno -arterial (VA)ECMO •Provides both respiratory and cardiac support •Blood is drained from venous system and given to arterial system. Low flow veno-arterial ECMO is a transitory form of ECMO support in which small cannulae (quicker to insert) are inserted. It is an emergent resuscitative intervention, (Ecmo CPR)
  5. 5. VA ECMO – Technical Specifications  Peripheral-FA, pump outflow is retrograde, admixing at arch level.  If Respiratory failure co exists, heart pumps poorly oxygenated blood to coronaries and brain, while ECMO supports body distal to Aortic arch.  For this reason R Radial line is prudent  Mechanical ventilation continued to maintain Sao2 of blood ejected from LV at 90%
  6. 6. First successful ECMO patient, 1971 J Donald Hill MD and Maury Bramson BME, Santa Barbara, Ca, 1971. (Courtesy of Robert Bartlett, MD)
  7. 7. First Neonatal ECMO survivor.. Esperanza, Age 1 day 1975
  8. 8. Esperanza, age 21
  9. 9. FROM THIS TO THIS
  10. 10. Advantages and Disadvantages Advantages Disadvantages Both cardiac and pulmonary support Cannulation of major artery and sacrifice of one carotid in newborn More experience Poor coronary and pulmonary perfusion Instant hemodynamic support Systemic thromboembolism No recirculation Nonpulsatile flow Right and left heart Myocardial stunning and LV distension Increased incidence of neurological events
  11. 11. ECMO ?????? • Several considerations must be weighed - Likelihood of organ recovery - Cardiac re-recovery - Disseminated malignancy - Advanced age - Graft vs . Host disease - Known severe brain injury - Unwitnessed cardiac arrest - Aortic dissection or aortic incompetence
  12. 12. • The physiologic goal is to improve tissue oxygen delivery , remove CO2 and allow normal aerobic metabolism whilst the lung rests • ECMO circulation: - Dual circulation - Nonpulsatile flow
  13. 13. Dual circulation • Native circulation + ECMO circulation • Sometimes Results in North South syndrome if the return cannula is in femoral artery • In most cases ECMO provides 60-80 % of CO resulting in a discernible pulse contour
  14. 14. • Reduces preload • Increases afterload Myocardial stunning • Left sided decompression • Use of inodilators
  15. 15. In Veno Arterial ECMO • Perfusate saturation is 100% • Without lung function LV saturation=RV saturation • ABG reflects Perfusate+RV saturation • If 50% blood flows through lungs,50% through oxygenator –O2 saturation of arterial blood becomes 90%
  16. 16. Increase in Systemic PO2 may result from.. •Improved lung function at constant flow •Increased ECC flow at constant CO
  17. 17. CO2 removal.. • Mainly depends on oxygenator surface area and sweep gas flow rate • Independent of blood flow • Moderately depends on inlet CO2
  18. 18. During Veno arterial ECMO.. • O2 consumption decreases ( catecholamines reduced,less metabolic stress) • Arterial saturation >95 % and flow adjusted to maintain arterial/venous saturation • Bleeding Decreased venous return Decrease in flow Transfusion • Without lung function and ejection of heart arterial saturation decreases
  19. 19. • Knowledge of the physiology of ECMO support the management of ECMO patient • O2 content is of utmost importance in the physiologic management of critically ill patients • DO2/VO2 ratio is reflected by mixed venous saturation - most important monitor in critically ill patients
  20. 20. CANNULATIO N The establishment and maintenance of adequate vascular access is essential for ECMO
  21. 21. CANNULATION - Patient age and size - Underlying disease & condition - Cause of the cardiorespiratory compromise - Type of support: • Veno-venous (VV) ECMO • Veno-arterial (VA) ECMO - Time of the event in relation to the peri- operative period - Location
  22. 22. CANNULATI ON • For each modality, there are different kinds and sizes of cannulae that can be used • Target ACTshould be accomplished before ECMO (heparin 100 units/kg) 3 minutes before cannulation.
  23. 23. Cannula Consideration • Venous cannula should be with the largest lumen and shortest length possible. • Venous cannula should have side holes. • M-number • Resist kinking • Smallest double lumen cannula is size 12 Fr ( for V V ecmo in neonate)
  24. 24. Veno-Arterial (VA) ECMO Provides cardiac as well as respiratory support and is mainly used for post op cardiac case
  25. 25. Cannulation can either be.. • Through neck vessels(RCC artery and RIJV and or an additional vein) • Central cannulation or • Cannulation of groin vessels
  26. 26. Access and return cannula sites Access Return RA Aorta Femoral Vein Femoral Artery Subclavian Vein Axillary artery Internal Jugular Vein Carotid artery
  27. 27. CANNULATION TECHNIQUE • Open • Semi-open • Percutaneous
  28. 28. CANNULATION • In central cannulation Aorta and RA are cannulated • LV decompression is important :Can be done either by creating an atrial communication or by a Left atrial vent
  29. 29. CANNULATIO N Right atrium and Ascending aorta
  30. 30. CANNULATION A Left atrial vent line can be utilized to monitor the LA pressure
  31. 31. CANNULATIO N Internal jugular vein and the common carotid artery
  32. 32. Veno arterial access via the neck vessels
  33. 33. CANNULATI ON Femoral vein and Femoral artery
  34. 34. Venoarterial access via the femoral vessels
  35. 35. Peripheral Femoral Cannulation – VA ECMO
  36. 36. Femoral artery cannulation: •Chances of distal limb ischemia •Distal perfusion catheter is commonly used
  37. 37. Distal Leg Perfusion 7/9 Fr Cannula
  38. 38. CANNULATIO N -In situations where ECMO support is anticipated -Chest will be left open and covered by a Silastic patch -Purse-string sutures will be left snared in place
  39. 39. CANNULATION PROBLEMS • Threading the venous catheter • Vein division • Proximal vein lost in mediastinum • Lack of venous return • Intrathoracic vein perforation
  40. 40. Complicatio ns • Vascular injury( tear, intimal dissection, perforation). • Obstruction (kinking, positional). • Misplacement( AI, afterload LV failure). • Bleeding.
  41. 41. Monitorin g • Success lies with vigilant monitoring which helps in early recognition and diagnosis of problems and timely and accurate action • Monitoring includes: -Clinical parameters -Biochemical and Laboratory parameters -Radiologic monitoring -Circuit monitoring
  42. 42. Clinical parameters • Vital parameters(ECG rhythm,Pulse rate,Blood Pressure ,Temperature , and respiratory rate) • Arterial and venous saturation(MAP and mixed venous saturation) • Daily Echocardiography • Right hand saturation gives hints regarding coronary perfusion
  43. 43. • Hematological parameters(CBC,HCT 35- 40%,Plasma Free Hemoglobin <0.1g/dl) • If possible cerebral oxygenation with NIRS • EtCO2 • RBS : 80-140 mg/dl • ABG and RBS to be done every 4-6 hours • Vascular and neurological status • Urine output and urine colour
  44. 44. Coagulation Monitoring •Pre ECMO ACT 300 seconds •On ECMO –Check ACT 2 hourly till ACT drops to 200 seconds •Maintenance with ACT 160-200 seconds •ACT to be repeated every 6-8 hours •aPTT : 60-70 seconds
  45. 45. Circuit monitoring.. • Circuit blood flow • Circuit gas flow • Circuit pressure • Circuit integrity These variables should be monitored continuosly
  46. 46. Factors affecting Circuit Blood flow Increased Blood flow Decreased Blood flow Increased RPM Decreased RPM Decreased Resistance :Vasodilation :Improved arterial cannula position Increased Resistance :vasoconstriction :Kinking of tubing :Improper cannula position Increased preload :Increased filling :Improved venous cannula position Decreased preload :Hypovolemia :Improper cannula position :Kinking of tubing
  47. 47. Circuit Pressure • Pre pump pressure: too much negative pressure results in Hemolysis, cavitation, endothelial damage of Right atrium and vena cava • Reasons : Hypovolemia, Improper catheter placement, Inadequate cannula size.
  48. 48. •Pre membrane pressure •Post membrane pressure •Transmembrane pressure
  49. 49. Circuit integrity • Check for : Clot : Air : Leak • Pump is checked for abnormal noise or crack
  50. 50. Clot in the oxygenator
  51. 51. Other things to be checked regularly. •Insertion site/dressing security •Functioning of heat exchanger •Access line for kinking/movement
  52. 52. Thank You

×