Mechanical Circulatory Support – A Practical Approach
(1) What is the Primary Problem?
- cardiac failure (VAD or VA ECMO)
- respiratory failure (VV ECMO)
- cardiorespiratory failure (VA ECMO or VAD)
(2) Is the patient on a VAD or ECMO?
VAD
- flow and pump speed
- short pipes
- blood all the same colour
ECMO
- oxygenator
- heater
- oxymeter
- longer pipes
- venous and arterial coloured pipes
(3) ECMO – Central of Peripheral Cannulation?
Central
- aorta or subclavian
Peripheral
- VV: femoral-femoral, femoral-IJ
- VA: femoral-femoral (look for back flow distal perfusion cannula)
- VAV: uncommonly used (cardio-respiratory failure)
(4) Assess level of ECMO support
- Flow
— max 7L/min
— full 4-6L/min
— partial < 3.5L/min - MvSpO2
- LV ejection
- PAC – pulmonary pressures
(5) Assess Respiratory function
- ventilator settings
- compliance
- CXR
- state of underlying disease process
- ABG
(6) Neurological Assessment
- sedation
- pupils
- BIS
(7) Kidney Function
- dialysis
- urine output
- biochemistry and acid-base
(8) Circuit stability
- Hb
- heparin
- APTT
- ACT
- product requirement over 24 hours
- suck down
- inflow pressure
- fluid balance
- post oxygenator gas (PO2 > 50kPa)
- transoxygenator pressure gradient
- haemolysis (free Hb)
(9) Nutrition and Bowel Function
(10) Microbiology
- change in WCC, vasoplegia -> blood culture + antibiotics
(11) Pressure Areas
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC