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 in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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