Extracorporeal Membrane Oxygenation Cannulation

Published on 22/03/2015 by admin

Filed under Critical Care Medicine

Last modified 22/03/2015

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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

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