Initiation/Decannulation

Question 1

signs pt can wean from VV

Answer 1

improvement in CXR
inc lung compliance (dec plateau p)
higher tidal vol
inc spo2
inc pa02
lower co2 (if acidotic)

Question 2

VV weaning trials

Answer 2

o2 challenge
capping trial

Question 3

5 rights ecmo

Answer 3

right pt
illness
time
therapy
thing to do (ethically)

Question 4

main ecmo goal

Answer 4

maintain systemic o2 del. and co2 removal in proportion to pt systemic metab/needs
prevents further vent induced lung injury
and or improves systemic perfusion

Question 5

personnel

Answer 5

ICU
attending
charge RN
bedside RN
RT
Surgery
surgeon/interventionalist
OR team
anesthesiology
ECMO
specialist
coordinator
perfusionist
Other
blood bank
cards for echo
xray

Question 6

equipment

Answer 6

cannulas
circuit
surgical instruments
headlamps/ stools
ecmo cart

Question 7

ecmo cart

Question 8

neonatal/ ped blood products- circuit

Answer 8

type and cross match
circuit primed 2-3 units blood
<10-20 kg pts or unstable peds

plts (circuit-induced thrombocytopenia)

Question 9

adult blood products- circuit

Answer 9

type and cross match
2-4 prbc bedside
plt recommended for circuit-induced thrombocytopenia

Question 10

Pre-cannulation labs

Answer 10

baseline lactate, ABG/VBG
hgb/hct
plt
pt/aptt
fibrinogen

Question 11

Pre-cannulation exams

Answer 11

echo
cxt xr
neuro us (peds), eeg or CT
US bedside for vessel visualization

Question 12

Pre-cannulation nursing tasks

Answer 12

foley
ng/og
a line and cvl
piv

Question 13

heparin bolus neonates/peds

Answer 13

1000u/mL
neonates 40u/kg
peds 50u/kg
minimum!!
max dose for b/ 100 u/kg

Question 14

heparin bolus adults

Answer 14

> 50 kg= 5,000 u max dose

Question 15

emergency volume

Answer 15

seperate from circuit prime
isotonic crystalloid
blood cooler
5% albumin

Question 16

airway

Answer 16

suction cannisters
ambu bag
once on- bridge to reliance on ecmo sweep vs vent fi02

Question 17

ideal vent settings after initiation

Answer 17

“rest” fio2 less than or = to 40%
peep 5-15
PIP about 20 cm h20
TV 1-5 ml/kg
rate <= 10 b/min

Question 18

flow/ sweep ratio for initiation

Answer 18

1/1
during run max flow to sweep is 3/1

inc sweep = dec co2
dec sweep = inc co2

Question 19

initiation checklist/procedure

Answer 19

time out
confirm correct connections (ex. for protec is drain vs return on right lumens)
for VA
red to red and blue to blue

remove clamps

slowly start pump flow
inc too quickly r/f htn and cerebral edema

Question 20

how to inc o2 delivery via ecmo

Answer 20

inc flow
correct anemia (give prbc)- inc hct
change oxygenator

Question 21

stabilization period- labs

Answer 21

abg
lactate
recheck coags (cbc, pt/aptt, fibrinogen, antixa)
cmp

Question 22

stabilization- pot. complications

HTN

Answer 22

htn
slow flow rate
wean vasopressors/ inotropes
inc sedation

Question 23

stabilization- pot. complications

pt sao2 does not improve or DEC

Answer 23

check bridge is clamped and off to circuit (otherwise recirc half of arterial blood back to venous side)

inc flow
ensure gas is connected
does memb fio2 need to inc?
check airway intact
consider VA

Question 24

stabilization- pot. complications

Loss of venous return

Answer 24

check cannulas are connected and positioned correctly
verify positioning w/ xr
dec flow temporarily
tubing kinks
leaks in circuit or pt
give volume
may need additional drain line

Question 25

stabilization- pot. complications high post memb P

Answer 25

cannot achieve flow despite inc RPM check kinks is pt adeq sedated dec flow temporarily need larger return cannula? verify cannula position and all connections

Question 26

circuit-specific complications

Answer 26

fibrin strands clots air bubbles oxygenator depriming cannula migration and perf

Question 27

what can persistent high lactate indicate after initation

Answer 27

inadeq flow

Question 28

Resuscitation period- main goals

Answer 28

correct hemodilution/ hypovolemia prbc, plt, cryo/ffp thermoregulation cooling if neuroprotective correct abg adjust sweep and fio2 maintain sedation and analgesics

Question 29

pulm patency interventions

Answer 29

bronch nebs postural drainage and suctioning

Question 30

stabilization- pot. complications FVO

Answer 30

Daily echo to assess heart function and cannula position diuretics CCVHDF

Question 31

minimum roller flow

Answer 31

200 mL/min dec flow beyond that w/ Hoffman clamp or clamp off totally- flow through bridge and flash cannulas

Question 32

signs pt can wean from VA

Answer 32

inc EF dec inotropes/vasopressors inc CO/ native cardiac function absence metab. acidosis

Question 33

VA weaning trial called w/ bridge

Answer 33

low flow trial and or clamping trial wean by x ml/min clamping trial clamp off pt - inc circuit flow- open bridge q5-10 min, dec flow, unclamp and flash blood to cannulas to maintain patency

Question 34

Components for maintaining VA wean

Answer 34

periodic echo guidance transition drips to pt flow rates weaned slowly trend lactate and abg

Question 35

VA wean and SVO2 changes

Answer 35

expect dec 60-70% as native function improves (sending more blood through pulm circ)

Question 36

Capping trial

Answer 36

wean sweep, fio2 and LPM overtime remove sweep gas line from oxygenator wait 20-30 min + look for color change draw abg min 40-50 mL/kg/min peds min 2L/min in adults

Question 37

o2 challenge

Answer 37

fio2 on vent 100% for 15 min sao2 should rapidly inc to 100% and Pao2 should inc by 50-100% *can be done daily

Question 38

VA weaning w/out bridge

Answer 38

adults (~ 500 mL/ couple hrs/days) can only hard clamp off ~3-5 min before circuit will clot

Question 39

Decannulation- heparin management adult v peds

Answer 39

adult- stop x hrs before peds- stop right before if pt already on drip before ecmo initiation cut dose in half and transition to pt line