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Post-Pump Critical Care

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

from Scancrit

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

 

 

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