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Bleeding while on Pump

Lab Management

from Anesthesia & Analgesia 2018;126(4):1262

Avoiding ICH

Watch the Lecture from Maryland CC Project

 

by Dr. Erik Osborn

eeosborn@aim.com

 

Risk Factors

  • Low PLT
  • Renal Failure
  • Rapid Drop in CO2
  • Shock
  • Prior Anticoagulant Use
  • Severe Coagulopathy

ECMO causes a multi-factorial bleeding dyscrasia

Heparin

1/3 Heparin is biologically active

the other 2/3 may have variable effects (inflammation, complement cascade, plt activation)

Use smallest amount possible

45-55 (60-80 in pts with confirmed clots)

Give a low bolus on initiation <=50 Units/kg

Many bleeds may preexist the ECMO, consider CT early on

 

ICH Prevention

Management of ICH

Auto-Regulatory Index

NIRS to MAP?????

 

Multimodal Neuro Monitoring

CT Pre, 24 hrs, 72 hrs

EEGS (cont. for first 72hrs)

TCDs

NIRS

Neurlogical Pupillary Index

Biomarkers-NSE, S100b, GFAP (mostly just at the research phase)

 

Who Should Get ECMO

  • Reversible process or transplant candidate
  • Good Neuro Outcome Possible
  • Ability to tolerate anticoag
  • Age-performance and functional status
  • Exit Strategy exists

 

 

Reversal

If you give protamine, try to use 1/4 or 1/2 dose and see if that is enough

 

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