12. the ecmo simulator #beach2019 (malbrain)
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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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12. the ecmo simulator #beach2019 (malbrain)
- 1. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 1 3rd BEACH Course BElgian Annual eCmo Hands-on course Auditorium Kiekens Course Director: Prof. Dr. Manu Malbrain WORKSHOP UZ Brussels – Belgium: Oct 11 – 2019
- 2. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 2 ECMO Simulator Manu Malbrain manu.malbrain@uzbrussel.be @manu_malbrain @Fluid_Academy
- 3. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 3 An Introduction toVV ECMO Presentation by Andy Pybus Saint George Private Hospital MSE (Australia) PL www.ecmosimulation.com
- 4. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 5 Simulator available at: www.ecmosimulation.com/downloads/ECMOSim260.zip
- 5. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 6 Workshop Program: • Simulator components • The VV ECMO Paradigm • Patient selection • System / circuit design • Cannula selection and insertion • Anti-coagulation management • Basic VV ECMO manoeuvres • Ventilator management during VV ECMO • Basic problem solving during VV ECMO • Weaning from VV ECMO • Case Simulation
- 6. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 7 Workshop Program: • Simulator components • The VV ECMO Paradigm • Patient selection • System / circuit design • Cannula selection and insertion • Anti-coagulation management • Basic VV ECMO manoeuvres • Ventilator management during VV ECMO • Basic problem solving during VV ECMO • Weaning from VV ECMO • Case Simulation
- 7. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 8 Workshop Program: • Simulator components • The VV ECMO Paradigm • Patient selection • System / circuit design • Cannula selection and insertion • Anti-coagulation management • Basic VV ECMO manoeuvres • Ventilator management during VV ECMO • Basic problem solving during VV ECMO • Weaning from VV ECMO • Case Simulation
- 8. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 9 Simulator Components: • Documentation Window • MonitorWindow • TherapyWindow • DeviceWindow • (Supervisor Window)
- 9. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 10
- 10. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 11
- 11. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 12 Minimum Configuration = ‘Stick PC’ + Mobile Phone
- 12. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 13 Your Resources:
- 13. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 14
- 14. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 15
- 15. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 16
- 16. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 17 Models: • Physiological – Cardiac, Respiratory, Neurological etc… • Pharmacodynamic – Relaxants, sedatives, Anticoagulants etc… • Mechanical – Ventilator, ECMO system, Defibrillator etc… • Update at between 0.4 and 100 Hz • Autonomous
- 17. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 18 Models: • Lung Model – Riley – West • ECG Model – VF synthesis – Conduction pathway – ST Segment synthesis • Arterial tree Model – Aortic Valve – Eadyn • PK PD Models – Effect of ECMO – On coagulation – On fluid distribution
- 18. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 19 Blood Gases Thermal Behaviour Vascular Pressures Myocardial Contractility ECG Respiratory Mechanics V:Q Relationship Starling Behaviour Baro - Reception CO2 Sensitivity Hypoxic Responses Chronotropy Inotropy PK Models Fluid Spaces NM Transmission Cannula Flow Mechanical Pumps BIS Hb Dissociation Model
- 19. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 20
- 20. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 39 Drainage (Venous ) Cannula: Extracorporeal membrane oxygenation using a centrifugal pump and a servo regulator to prevent negative inlet pressure. Pedersen TH, Videm V, Svennevig JL et al. Ann Thorac Surg. 1997 May;63(5):1333-9.
- 21. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 40 Pressure Drop:
- 22. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 41 Return (Arterial) Cannula: Basis for recommendation: ? Blood Flow: 5.0 lpm
- 23. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 42
- 24. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 47 BasicVV ECMO manoeuvres: We can change: • Gas flow. • Blood flow. • Temperature.
- 25. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 48 VV ECMO: Basic Manipulations: Summary: • Adjusting Gas Flow will affect the PaCO2. • Adjusting Blood Flow will affect the PaO2. • Adjusting Temperature will affect the SvO2. Gas Flow Blood Flow Temperature (VO2)
- 26. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 50 FGF = Fresh Gas Flow VV ECMO: Effect Of Gas Flow
- 27. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 53 PaO2 and Blood Flow
- 28. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 57 ECMO andTemperature Blood Flow: 5.0 lpm
- 29. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 60 Ventilator Management Parameter Before After ECMO Blood Flow (lpm) 5.0 5.0 ECMO Gas Flow (lpm) 2.5 5.0 Ventilator Tidal Volume (mls) 500 200 Ventilator Frequency (bpm) 15 4 Ventilator PEEP (cm H2O) 10 10 Ventilator FiO2 1.0 0.6 PaO2 PaCO2 RESTING THE LUNG
- 30. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 66 Oxygen Transfer
- 31. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 76 Haematocrit and PaO2
- 32. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 77 VV ECMO: Effect of ↑ Cardiac Output Competing influences: • PaO2 tends to rise because: – As CO ↑, so SvO2 ↑. – As SvO2 ↑↑, so SaO2 ↑↑.
- 33. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 78 Competing Influences: • PaO2 tends to fall because: – As CO ↑, so fraction of CO passing through the oxygenator ↓ – As CO ↑, so Qs/Qt ↑ Lynch JP, Mhyre JG, Dantzker DR. Influence of cardiac output on intrapulmonary shunt. J Appl Physiol. 1979 Feb;46(2):315-21. VV ECMO: Effect of ↑ Cardiac Output
- 34. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 79 VV ECMO: Net Effect of ↑ Cardiac Output Net Effect: As CO ↑, so PaO2 ↓.
- 35. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 80 PK-PD (anti)coagulation
- 36. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 81 Volume loading
- 37. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 82 Blood loss
- 38. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 89 VV-ECMO Case Simulation
- 39. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 90 VV-ECMO Case Simulation
- 40. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 91 VV-ECMO Case Simulation
- 41. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 92
- 42. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 93 RXThorax: ARDS
- 43. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 94 ECG: Bigeminie
- 44. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 95 TTEchocardio: Nl LVEF
- 45. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 96 Lab Results
- 46. 3rd BEACHCourse Introduction 11-10-2019 ⎮ 97
Editor's Notes
- Before I start, I need to declare a conflict of interest in that: Much of the data used in this talk was prepared using this ECMO simulator in which I have a significant commercial interest.
- There are three considerations: The first thing to say is that the cannula size should be matched to the expected flow rate… Second, the Drainage cannula should be larger than the return cannula because sub-atmospheric pressure is much more harmful to the blood than supra-atmospheric pressure. Third, we may wish to consider the use of ‘Special’ cannulae – but more of this later. http://www.smartcanula.com Adult Cannula 15F – 36F http://www.avalonlabs.com
- Return Cannula Close to the tricuspid valve. Drainage Cannulae As central as possible But not so close to the return cannula that re-circulation occurs… The ‘Goldilocks’ zone!
- This is the ‘Avalon’ cannula. The cannula must be positioned via the RIJ. As you can see, SVC and IVC drainage occurs through the upper and lower fenestrations. Arterialised return via the central fenestration (opposite the Tricuspid valve). The cannula should be positioned using ultrasound. The arterialised return is easily visualised using colour Doppler.
- If we look at the drainage cannula first: The consensus seems to be that you shouldn’t allow the inlet pressure to fall below ~ 60 mm Hg. If you wish to achieve a flow rate of 5 lpm this corresponds to a drainage cannula no smaller than 21 F. The background to this is shown in the left hand graph. The data are from an ‘in vitro’ experiment in which they pumped bank blood through an ECMO system for three days. On the inlet side of the oxygenator they subjected the blood to 3 different levels of sub-atmospheric pressure. They used the level of plasma free haemoglobin as an indicator of red cell damage. As you can see, as suction pressure was increased, so plasma free haemoglobin increased.
- Let’s first consider the basic manipulations which we can make using a VV ECMO system… As I’ve said here, ECMO is essentially: “A simple technique for use in a complex system.” The system is so simple, that when all is said and done, there are only 3 things you can do with it. Adjust the Gas Flow which will affect the patient’s PaCO2. Adjust the Blood Flow which will affect the patient’s PaO2. Using the system’s heat exchanger adjust the patient’s temperature which will: Initially affect their metabolic rate Then their SvO2. Finally their arterial PO2.
- So let’s start by examining the effect of changing gas flow through the device. The first thing that we can say is that Gas flow through the artificial lung is analogous to the minute ventilation of the patient’s normal lung. As with the normal lung, there is an inverse relationship between PaCO2 and ventilation. “The more we ventilate, the lower the PaCO2 .” Finally, as we’ll see, during VV ECMO, PaCO2 is almost always easily controlled. This is largely because the whole blood CO2 dissociation curve is essentially linear over the clinical range and.. This is importantly different from the shape of the Oxygen dissociation curve.
- Now let’s examine the effect of changing blood flow through the device. The first thing we can say is that as blood flow through the device is increased, so the PaO2 tends to rise. “The more blood flow we put through the artificial lung, the higher the patient’s PaO2 .” However, we shouldn’t forget that what’s really important is blood flow as a fraction of the patient’s total cardiac output. If we’re able to capture the patient’s entire venous return and fully arterialise it, then there will be no need for the patient’s own lungs to participate in gas exchange at all. On the other hand, if we can only capture half the return, then we’ll leave the patient’s lungs with plenty of work to do. Failure to capture the entire venous return coupled with the non-linearity of Hb dissociation curve limit the achievable PaO2 .
- Again, if we look at this graphically…. In the left hand graph, I’ve put our patient on VV ECMO and explored the effect of changing the blood flow through the device. As you can see, as the blood flow is increased from zero to five lpm, so the patient’s PaO2 rises steadily. The right hand graph summarises the same data after a ten minute equilibration period at each blood flow rate. This gives us our second law of ECMO that “PaO2 is controlled by adjustment of blood flow through the artificial lung.”
- Finally, let’s examine the effect of heating or cooling the patient. As the temperature falls, various things happen: Metabolic rate will fall, Mixed venous saturation will rise and this will lead to a secondary increase in PaO2 As we’ll see, the artificial lung itself will tend to become more efficient. However, we shouldn’t forget that SvO2 is also importantly affected by haematocrit and Cardiac Output.
- So let’s examine this graphically… On the right I’ve shown you the effect of changing the patient’s temperature on the metabolic rate. As you can see, a change in temperature of about seven degrees more or less doubles the metabolic rate. In the left-hand graph, I’ve shown you the effect of cooling our patient by only three degrees on the patient’s PaO2. Throughout the cooling period I’ve maintained the ECMO flow steady at 5 lpm. As a result of the reduction in metabolic rate, PaO2 rises from about 69 mm Hg to about 78 mm Hg. This leads us to our eighth law that we can improve oxygenation by cooling.
- Let’s first consider the basic manipulations which we can make using a VV ECMO system… As I’ve said here, ECMO is essentially: “A simple technique for use in a complex system.” The system is so simple, that when all is said and done, there are only 3 things you can do with it. Adjust the Gas Flow which will affect the patient’s PaCO2. Adjust the Blood Flow which will affect the patient’s PaO2. Using the system’s heat exchanger adjust the patient’s temperature which will: Initially affect their metabolic rate Then their SvO2. Finally their arterial PO2.
- In this slide I’ve explored the effect of ‘resting the lung’ on gas exchange. At the start of the experiment, The patient is on ECMO at 5 lpm, but is fully ventilated. At the black arrow, the ventilator is turned right down, and the gas flow through the oxygenator is increased. As you can see, there is a small fall in PaO2, but PaCO2 remains virtually unchanged. Oxygen transfer through the natural lung is occurring by means of ‘Apnoeic Oxygenation’. This gives us our tenth law of ECMO which is to ‘Rest the Lung’.
- The venous cannula has the potential to act as a threshold resistor. Diagnosis: Chatter Reduced flow ↑ Suction pressure Management: Reduce rpm Raise CVP Reposition cannula Institute dual drainage And we have the sixth law of ECMO which is that we should maintain the venous pressure.
- Here we can see that the IVC and return cannulae are too close together. High blood flow rates can be achieved, but less gas transfer occurs as the blood is ‘recycled’ continuously.
- Thermodilution is possibly the most elegant way. The graph reminds us of the fifth law of ECMO which is that we must look out for recirculation.
- In general intensive care, 4 reasons for avoiding hypothermia are usually cited: Infection / Immunosuppression . Arrhythmias. Coagulation impairment. Drug metabolism. In the context of VV ECMO, the possibility of an increased rate of infective complications is probably the only valid reason to avoid hypothermia.