Major intracranial haemorrhage, lethal malformation, severe neurological injury, untreatable cardiac or pulmonary malformation.
Clinical indications:
Failure to wean off cardiopulmonary bypass, oxygenation index >40 on two or more ABG despite maximum therapy [OI = (MAP * FiO2 * 100) / PaO2]
Intractable metabolic acidosis
Progressive intractable pulmonary or cardiac failure
Flow rates on full VA ECMO support:
In patients <10 kg aim for 100-150 ml/kg/min
In patients >10 kg aim for CI 2.4 L/min/m2
Consider higher flow rates in septic patients, univentricular hearts with open systemic-pulmonary shunts and extracardiac shunts
Flow rates on full VV ECMO support:
In patients <10 kg aim for 70-140 ml/kg/min
In patients >10 kg aim for CI 1.8 L/min/m2
Consider higher flow rates in septic patients, univentricular hearts (cave: inappropriate high SmvO2 might indicate recirculation)
Cannulation:
ABG, FBE, coags, UEC, Ca++, Mg++, LFT, SBR, ABG, obtain blood culture/urine for M, C and S/ETT aspirate for M, S and S, optimise coagulation if possible, consider blood sample storage for genetic analysis
Cephazolin (50 mg/kg IV) 30-60 min prior to procedure
CXR, ECHO, cranial ultrasound
Arterial line placed and secured, central line placed (not RIJ or R subclavian) and secured
Chest drain placed, if required and secured
Neck cannulation: position patient head outwards in bed space and neck overextended with roll under shoulders
Transthoracic cannulation: supine position with roll under back
2 x venous line extensions
Fentanyl 5 mcg/kg IV bolus, vecuronium 0.1 mg/kg IV, consider fluid resuscitation/enhance inotropic support if needed
Surgical preparation
Give heparin on surgical request (50-100 U/kg if appropriate for patient situation), surgical cannulation & connection of tubing (<15 kg → ¼”, >15 kg → 3/8″ circuit)
Set FiO2 100% and sweep gas flow, turn RPM to 1000-1200, unclamp venous line, unclamp arterial line, increase slowly RPM to desired flow
Keep ATIII level >80%: No. IU = (desired – actual level) X Wt, Heparin [Patients <10 kg: 5 KU/50 ml 0.9% NaCl; patients >10 kg: 25 KU/50 ml 0.9% NaCl]
Commence heparin on 20 U/kg/hr, adjust in regards to ACT.
ACT
Bolus (U/Kg)
% rate change
<160
50
+15%
160-180
30
+10%
180-200
20
+10%
200-220
0
0
220-240
0
-10%
240-260
0
-10%
260-280
0
-10%
Weaning in VA ECMO:
Ensure volume status is adequate
Ventilate patient with acceptable settings (as blood flow through lungs increased)
Decrease pump flows by 10 ml/min every 60 min down to a minimum of 40 ml/kg or 250 ml/min total flow through oxygenator
ABG 15 mins post each wean of flow
ECHO at lower flows, [do NOT turn sweep gas off – all flow going through circuit bypasses lungs. Minimum sweep gas setting is 200 ml/min], bridge or decannulate
Weaning in VV ECMO:
Commence full ventilation
Sweep gas FiO2 at 0.21 for approx 10 minutes to flush O2 from oxygenator
Turn sweep gas to minimum setting of 200 ml/min, run ACT’s 200-220 whilst pt still on ECMO circuit
Observe patient saturations, ABG after 30 mins (oxygenator continues to oxygenate for approx 20 mins after sweep gas flow is ceased)
Organise for decannulation
References:
[1] Cardiol Young, 2007; Sep;17 Suppl 2:104-15: Cooper et al: Cardiac extracorporeal life support: state of the art in 2007
[2]
[3] Lancet, 1996 Jul 13; 348(9020):75-82: UK collaborative randomised trial of neonatal extracorporeal membrane oxygenation. UK Collaborative ECMO Trail Group
[4] Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001340: Mugford et al: Extracorporeal membrane oxygenation for severe respiratory failure in newborn infants.
[5] Lancet. 2009 Oct 17;374(9698):1351-63: Peek et al: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial.
[6] Intensive Care Med (2012) 38:210-220: MacLaren et al: Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era
[7] Artif Organs. 2013 Jan;37(1):21-8. Kotani et al: Evolution of technology, establishment of program, and clinical outcomes in pediatric extracorporeal membrane oxygenation: the “sickkids” experience.
All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or Android. A list of contributors can be seen here.
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ECMO
Tags: decannulation, ecmo
Marc Anders. ECMO, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3778
Inclusion criteria:
>34/40 weeks gestation age, reversible cardiac, pulmonary, or cardiopulmonary failure, mechanical ventilation <14 days.
Exclusion criteria:
Major intracranial haemorrhage, lethal malformation, severe neurological injury, untreatable cardiac or pulmonary malformation.
Clinical indications:
Flow rates on full VA ECMO support:
Flow rates on full VV ECMO support:
Cannulation:
Anti-coagulation:
Keep ATIII level >80%: No. IU = (desired – actual level) X Wt, Heparin [Patients <10 kg: 5 KU/50 ml 0.9% NaCl; patients >10 kg: 25 KU/50 ml 0.9% NaCl]
Commence heparin on 20 U/kg/hr, adjust in regards to ACT.
Weaning in VA ECMO:
Weaning in VV ECMO:
Sweep gas FiO2 at 0.21 for approx 10 minutes to flush O2 from oxygenator
References:
[1] Cardiol Young, 2007; Sep;17 Suppl 2:104-15: Cooper et al: Cardiac extracorporeal life support: state of the art in 2007 [2] [3] Lancet, 1996 Jul 13; 348(9020):75-82: UK collaborative randomised trial of neonatal extracorporeal membrane oxygenation. UK Collaborative ECMO Trail Group [4] Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001340: Mugford et al: Extracorporeal membrane oxygenation for severe respiratory failure in newborn infants. [5] Lancet. 2009 Oct 17;374(9698):1351-63: Peek et al: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. [6] Intensive Care Med (2012) 38:210-220: MacLaren et al: Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era [7] Artif Organs. 2013 Jan;37(1):21-8. Kotani et al: Evolution of technology, establishment of program, and clinical outcomes in pediatric extracorporeal membrane oxygenation: the “sickkids” experience.All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or Android. A list of contributors can be seen here.
About Marc Anders
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