Membrane Oxygenation (ECMO) Support 3.7.1 The Need for ECMO Support
3.7.2 Circuit Monitoring During ECMO
The latest ECMO circuit is equipped with low resistance and high-efficiency gas exchange membrane lung. From a theoreti- cal point of view, the ECMO circuit (no matter what approach) should be a very linear system, reducing any connection use at minimum (Fig. 3.17).
In the act of monitoring ECMO, three issues appear to be essential:
• ECMO flow or blood flow (BF): oxygenation directly derives from BF rate. Good practice suggests to keep it at the mini- mal value able to provide adequate patient’s oxygenation.
Table 3.6 VV ECMO versus VA ECMO: Advantages and disadvantages
VA ECMO
VV ECMO High flow (>3 L/min)
VV ECMO Low flow (1–2 L/min)
Pump + + +
Circulatory support + − −
O2 delivery + + −
CO2 removal + + +
Right ventricular
loading − No effect No effect
Left ventricular
loading + No effect No effect
Arterial thrombosis
risk + − −
From patient Centrifugal pump Flow sensor Membrane Lung Gas In
To patient Pressure IN (P IN) Pressure monitor P IN = –10 mmHg P Pre = 100 mmHg P Pre = 30 mmHg
Pressure Pre Membane Lung (P Pre) Heat Exchanger Pressure Post Membrane Lung (P Post)
Gas Out
O2Air Fig. 3.17Standard ECMO circuit scheme with pressure monitoring sites and sampling point for blood checks
• Gas flow (GF): CO2 removal depends on sweep gas flow rate and on ventilatory setting.
• Fraction of inspired oxygen (FiO2) of GF: initial FiO2 setting is equal to 1 of, then gradually reduced according to patient’s oxygenation improvements.
Daily assessment of ECMO circuit by a perfusionist plus a continuous monitoring by the ICU bed nurse is strongly recommended [53–55]. Before any nursing care routine, a visual inspection is suggested and all the actions described in Table 3.7 at column “Monitoring” as well as Table 3.8.
Table 3.7 Key point for monitoring ECMO performance
Key point Gold standard Monitoring
How is the membrane lung performing?
FiO2 equal to 1 should provide a range value of PaO2 postoxygenator greater than 300/400 mmHg
At least once daily sampling as monitoring comparison pre- and postoxygenator arterial blood gas analysis should be performed What BF is
achieved?
Monitoring venous inlet pressure (P in):
it should not exceed negative values of 100 mmHg Any withdrawal impairment
should be managed via a boost in the RPM causing augmentation of negative pressure
Pump’s pressure in and RPM related
Extreme negative pressure leads into a BF reduction:
a typical swinging movement of the drainage cannula occurs
Check fluid balance status and patient’s position Any clot
presence in the circuit?
An ECMO circuit should be clot-free on a visual assessment
A comparison between pre- and postoxygenator pressure should not record any sudden spike in gap values. Keep those reference ranges ACT = 180–220 s PTT INR 1.5 e 2 AT III > 70%
Visual inspection of circuit with a source of light every shift
All the circuit pressures monitored (P in, P Pre, e P Post)
Sampling for ACT, aPTT, and platelets every 8 h at least.
Daily check of ATIII
P In: pressure before centrifugal pump
P in Membrane Lung: pressure before centrifugal pump P out: pressure after membrane lung
Take-Home Messages
• Respiratory assessment of critically ill patients should be per- formed through clinical and instrumental tools, with a multi- modal approach. SpO2 and EtCO2 are both standard in the basic respiratory assessment.
• Potential MV complications and methods to reduce ventila- tor-induced lung injury should be considered in all patients undergoing invasive MV support.
• Asynchronies are prevalent in ICU patients and negatively related to outcome, ranging from prolonged MV, prolonged ICU and hospital stays, and increased mortality.
• Detection of asynchronies mostly relies on a mismatch between surrogates of the patient inspiratory effort and the ventilator cycling.
• Nursing surveillance is required to provide a safe and effec- tive level of care for the patient receiving mechanical ventilation.
• Patients undergoing ECMO should be monitored to prevent artificial lung-related complications.
Table 3.8 Signs for suspicion about the presence of clots in the ECMO circuit
Issue Signs Action to take
Clots inside the pump
Changes of pump’s noise Recognizable clots
visually Augmentation of
plasmatic Hb value
Change of centrifugal pump’s housing or the whole ECMO circuit Heparin dosage
augmentation Clots inside the
membrane lung
Spikes of pressure values inside membrane oxygenator Postoxygenator PaO2
reduction and PaCO2 increment
Visual detection of clots in the oxygenator
Change of membrane lung or the whole ECMO circuit Heparin dosage
augmentation
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