Extracorporeal Membrane Oxygenation (ECMO) by Jared Bienstock, MS, CCP, LP, CES-A Copyright © 2021 (All Rights Reserved)

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I worked on this concept map on ECMO for a course through the University of Nebraska Medical Center. There are articles, videos, websites linked to different concepts (when underlined or icon on the side of each bubble), and also information on COVID ECMO. Please click around, explore and add me on LinkedIn. Try viewing the concept map as a slide show presentation, which presents the material in sequential order. All recommendations are welcomed. I hope this helps you learn more about ECMO. Thank you - Jared W. Bienstock, MS, CCP, LP, CES-A *Disclaimer: The information contained in these topics is not intended nor implied to be a substitute for professional medical advice, it is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Extracorporeal Membrane Oxygenation (ECMO) by Jared Bienstock, MS, CCP, LP, CES-A Copyright © 2021 (All Rights Reserved)

COVID and ECMO Info

[https://www.elso.org/COVID19.aspx ELSO COVID Overview]

Other Modes of ECMO

Boutique Models of ECMO

What is ECMO?

Course Structure

Perfusion Board Exam Materials

Quizzes and Exams

Readings

Numbers and Formulas Sheet

[https://intensiveblog.com/ecmo/ Alfred Scenarios]

Protocol

Presentations

[https://prezi.com/view/v2LYyYN2nC1yf7yGI0FT/ Intro to ECMO]

Students Pick Topic

Major Organizations

Extracorporeal Life Support Organization ([https://www.elso.org/ ELSO])

[https://www.elso.org/AwardofExcellence/CentersofExcellence.aspx List of ELSO Distinguished Centers of Excellence]

[https://www.elso.org/AboutUs/JoinELSO.aspx Membership]

[https://www.elso.org/TrainingCourses.aspx?action=0 Training Course]

[https://www.elso.org/Registry.aspx Registry]

[https://www.elso.org/Resources/Guidelines.aspx Guidelines]

American Society of Extracorporeal Technology ([https://www.amsect.org AmSECT])

[https://www.amsect.org/page/join-amsect-now Membership]

[https://www.amsect.org/page/amsect-university Education]

National Certification Exam ([https://intbbm.org/ces-certification/ CES-A])

2 Main Types of ECMO

Veno-Veno (VV)

Respiratory Support Only (VV)

[https://intensiveblog.com/cardiac-arrest-vv-ecmo/ Cardiac Arrest]

Recirculation

Weaning VV ECMO Strategy Recommendation 1: -Increase ventilator to appropriate settings -Reduce FiO2 on ECMO blender -Reduce ECMO sweep flow rate Strategy Recommendation 2: -Progressively decrease sweep -Increase ventilation to meet patient needs -Weaning is successful when patient is stable at sweep of 0 for 4-24 hours (or MDs decision) *Sweep of 0 = essentially off ECMO

Dual Lumen Cannulation VV ECMO

Dual Cannulation VV ECMO

VV ECMO Ranges FiO2= 100% Sweep= 1:1 w/ Q SaO2 = >80% tolerable PaO2=55-90mmHg Flow= 2/3 of CO 50-80 ml/kg/min PP= Nl 40mmHg

VV Vent Settings PIP< 30cmH2O PPlat<30cmH2O TV<6 ml/KG IBW RR = 4-6 B/Min PEEP =10-15 cmH2O FiO2 <40%(0.40)

Veno-Arterial (VA)

Both

Catastrophes

Complications: -Cannula dislodgment -Air entrainment

Sedation, Analgesia and Paralytics

Medication

Checklist

Sample: -Console connected to AC -Hand crank available -Spare O2 tank available -Pressure lines flushed -Inspect oxygenator for clots -Clamps available -Lines are not kinked

Personnel

Key members: -Surgeon -Intensivist -Perfusionist -Physician Assistant -Nurse/Nurse Practitioner -Respiratory Therapist -ECMO Specialist

Preparation

Have available: -Primed Circuit -Gas Source -Cannulas (proper sizes) -Heparin/Other Drugs -Ultrasound -Clamps -Sterile Scissors -Pik-A/V -Venous dilator kit

Equipment

Machines: 1. Centrimag - Abbott 2. Bioconsole - Medtrnoic 3. Rotaflow - Getinge 4. SCPC - Livanova 5. Cardiohelp -Getinge

Cardiohelp

Bioconsole

SCPC Livanova

Rotaflow

Centrimag

Such as (but not limited to...) -ECMO circuit -Heparin -Saline/Plasmalyte -Pressure infusion bag -Pressure Transducer Set Double set -Backup O2 Cylinder -Backup console -Cable ties to all connections -Clamps medium x 4 -Oxygen Tubing -Sterile tubing scissors -Emergency Hand crank x -ACT machine -Heater-cooler -Record keeping

Anticoagulation

Cardiac and/or Respiratory Support (VA)

Complications

[https://intensiveblog.com/cardiac-arrest-on-ecmo-does-it-still-count/ Cardiac Arrest]

1. [https://www.youtube.com/watch?v=NGGA-8zXVGE Differential Hypoxia, north-south syndrome, mixing cloud, aka harlequin syndrome (all the same)] 2. [https://intensiveblog.com/differential-hypoxia-reverse/ Pseudo-differential hypoxia and Reverse-differential hypoxia]

Weaning

Weaning VA ECMO Strategy Recommendation 1: -Optimize: Vent settings, vascular fluid balance, cardiac drugs, support devices (IABP/Impella), slowly reduce blood flow to minimum -Consider raising ACT if ECMO blood flow is low (<2 LPM) Strategy Recommendation 2 -ECMO flows are dropped -A successful weaning means no significant deterioration in the hemodynamic variables and improvement in cardiac function should be seen by echocardiography -Values of successful wean: 1) Aortic VTI (>10cm), 2) TDSa mitral annulus (>6cms-1), 3)LVEF (>20-25%) *Do NOT turn off the sweep while weaning

Initiation

Cannulation

VA ECMO Cannulation

ECMO Management

ECMO Ranges FiO2=100% Sweep= 1:1 w/Q SaO2 = 97-100% PaO2 >200mmHg Flow= 60ml/kg/min PCWP <20 mmHg PP= 10-15 mmHg

Vent Management

VA Vent Settings TV= 6-9 ml/kg IBW RR= 6-12 B/min PEEP=10-15cmH2O FiO2>50% *Little literature exists on optimal vent management for VA ECMO