Review Articles
- Best Post-Pump Crit Care Paper
- Management_of_Peripheral_Venoarterial ECMO
- Troubleshooting Adult ECMO
Monitoring
Debate over whether these pts benefit from PAC
Differential Hypoxemia
Flow
Classically in Card. Shock, shooting for 60 ml/kg/min; in ECPR we will tolerate lower flows.
Shooting for SvO2 >=65-70%
Both fluids and vasoconstriction allow increased flow (SHOCK, Vol. 51, No. 5, pp. 650–658, 2019)
Anticoagulation
Ideally before start INR<2, PLT>50, Fibrinogen>150
STC uses PTT 45-55 for non-clot, 60-80 for clotted pt
if Heparin dose > 25 Units/kg/hr and still not therapeutic, measure ATIII
if ATIII activity <60%, consider admin
((120-ATIII)*Kg)/1.4
check 20 min and 12 hours after admin
Chattering/Drainage Insufficiency
Crit Care 2020;24:151
LV Distension (Must have Ejection of LV)
aortic root blood stasis will occur despite heparin
must see aortic valve opening
if a clot has formed, then the goal is to try to stop ejection
Hireche-Chikaoui (Crit Care Med. 2018;46(5):e459-e464. [PubMed])
flow continues even if heart is not beating from Bronchial and Thebesian veins
Best review of LV Distension and Solutions
Higher Flow impairs LV Function (J Transl Med (2015) 13:266)
from Circ Heart Fail. 2018;11:e004905. DOI: 10.1161/CIRCHEARTFAILURE.118.004905
LA-VA ECMO (mulstistage placed perc. through atrial septum)
Transaortic catheter left ventricle venting–may be insufficient drainage
In the Columbia Study (on actual patients rather than simulation modelling) Impella was maangement for LVD++ (ASAIO J. 2017 May/Jun;63(3):257-265. doi: 10.1097/MAT.0000000000000553)
Recent Retrospective Study shows association with better outcomes with LV offloading in cardiogenic shock
Labs
from ALfred
LDH for hemolysis
