Sunrise Neonatal ECMO Education & Training Program. Sunrise Children s Hospital Las Vegas, Nevada
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1 Sunrise Neonatal ECMO Education & Training Program Sunrise Children s Hospital Las Vegas, Nevada Martin J. Blahnik, MD Sunrise Neonatal ECMO Director Sunrise Neonatal Intensive Care Unit 2013
2 Sunrise Neonatal ECMO Education & Training Program DIDACTICS: ECMO Lecture Series 12 sessions 4 tests WET LAB: Primed ECMO Circuit 3 days 1 test ECMO Specialist Training Manual 3 rd Ed. Billie Lou Short, MD. Extracorporeal Cardiopulmonary Support in Critical Care 4 th ed RED BOOK OBJECTIVE: documentation of special professional skills as ECMO healthcare providers
3 Sunrise Neonatal ECMO Education & Training Program SYLLABUS 1. Introduction to ECMO 2. The Pre-ECMO Patient 3. Concepts: Oxygenation, Oxygen Content, Oxygen Delivery 4. The Decision to go on ECMO 5. ECLS Physiology 6. VV & VA ECMO 7. ECMO Equipment & Devices 8. Management of the Neonate on ECMO 9. Anticoagulation & Blood Products 10. ECMO Complications 11. ECMO Team Members Responsibilities & Case Scenarios 12. Open Review
4 Sunrise Neonatal ECMO Education & Training Program SYLLABUS 1. Introduction to ECMO 2. The Pre-ECMO Patient 3. Concepts: Oxygenation, Oxygen Content, Oxygen Delivery 4. The Decision to go on ECMO 5. ECLS Physiology 6. VV & VA ECMO 7. ECMO Equipment & Devices 8. Management of the Neonate on ECMO 9. Anticoagulation & Blood Products 10. ECMO Complications 11. ECMO Team Members Responsibilities & Case Scenarios 12. Open Review
5 Sunrise Neonatal ECMO Education & Training Program OBJECTIVES Introduction to ECMO: 1. Explain what ECMO/ECLS is & what it s used for 2. Concept of cardiac shunts 3. Tour through the circuit components 4. Describe the indications & contra-indications 5. Understand the fundamental principles of management of the pre-ecmo patient 6. Selection criteria to go on ECMO 7. Describe the differences between VV & VA ECMO 8. Know the components of the ECMO circuit
6 Extra Corporeal Membrane Oxygenation What is ECMO? What is it used for? 1. Cardio-pulmonary bypass using external circuitry 1. Supports gas exchange i.e. lung function 2. Supports cardiac output VA ECMO 2. Oxygenation, ventilation, non-pulsatile CV support = ECLS: Extra Corporeal Life Support 3. Highest bypass is 80% cardiac output 4. VA ECMO: right-to-left cardio-pulmonary shunt in parallel cardiac output = shunt + native heart 5. Right-to-left intrapulmonary shunts (pneumonia) 6. Right-to-left cardiac shunt w/ PPHN (ductus) 7. VV ECMO: technically not bypass b/c the shunt is in series
7 SHUNTS 1. FETAL: ductus venosus; foramen ovale; ductus arteriosus 2. FETAL cardiac output in parallel = RV + LV 3. NEWBORN transition to cardiac output in series 4. VA ECMO: right-to-left cardio-pulmonary shunt in parallel cardiac output = shunt + native heart 5. VV ECMO: technically not bypass b/c the shunt is in series
8 Extra Corporeal Membrane Oxygenation HISTORY 1. Artificial lung, artificial cardiovascular support 2. Dr. Robert Bartlett, 1975, MAS w/ PPHN neonates by 1980 treated w/ ECMO 4. By 1986, 18 centers had an ECMO program 5. CHLA cases / yr 6. ECMO standard of care: neonatal hypoxic respiratory failure unresponsive to conventional therapy 7. ELSO = Extracorporeal Life Support Organization 1989: guidelines, textbooks, registry 8. Survival: 98% MAS, 55% CDH, 85% overall
9 Extra Corporeal Membrane Oxygenation ELSO Data on ECMO Centers
10 Extra Corporeal Membrane Oxygenation ECMO Changes Over Time 1. Drop in ECMO late 1990s 2. BPD: lung stretch & high Fi02 vs safer ECMO devices 3. New generation of membrane lungs, safe centrifugal pumps, etc vs 80% mortality risk 4. A new generation of ECMO therapy: These [new] devices make ECMO safe and simple enough to be managed by the regular ICU staff -- Dr. Robert Bartlett 5. Reversible neonatal hypoxemic lung disease and / or cardiovascular collapse, unresponsive to conventional therapy
11 VA ECMO Circuit: Vessel Anatomy VENOUS: internal jugular ARTERIAL: common carotid
12 VENOVENOUS
13 VENOVENOUS
14 VA ECMO Circuit
15 1. PUMP: centrifugal 2. OXYGENATOR: hollow fiber 3. polymethylpentene 4. Inlet pressure (servo-regulated) 5. Outlet pressure (servo-regulated) VA ECMO Circuit
16 Maquet: Rotaflow Centrifugal Pump 1. OUTLET PRESSURE servo-regulated: 300mmHg 2. Flow sensor / bubble detector 3. Pressure! flow! resistance! length! 1/r4 4. RPM / LPM
17 1. Low priming volume 32ml 2. Minimal stagnation zones 3. Low heat generation 4. Flow sensor / bubble detector Maquet: Rotaflow (Pump Head)
18 Maquet: QUADROX Oxygenator 1. Hollow fiber non-microporous POLYMETHYLPENTENE: less plasma leakage; less micro-bubble formation 2. BIOLINE coating: less platelet activation; less thrombus formation; less complement / inflammatory stimulation
19 Maquet: QUADROX Oxygenator 1. Gas exchange surface area: 0.8m2 2. Low priming volume 81ml = less foreign SA / less blood bank 3. If high percentage SA w/ clot: high resistance, less efficiency
20 Maquet: QUADROX Oxygenator 1. Countercurrent gas-blood flow 2. Gas exchange: membrane partial pressure differences 3. RATED FLOW = maximum LPM to saturate blood 75% to 95%. 4. Sweep gas rate! PC02 clearance; use of carbogen
21 Extra Corporeal Membrane Oxygenation INDICATIONS Congenital diaphragmatic hernia Meconium aspiration syndrome Idiopathic PPHN GBS pneumonia E coli septic shock Air leak syndrome Respiratory distress syndrome Perinatal asphyxia TAPVR w/ PPHN CONTRA-INDICATIONS <2000g & <34wks gestation No significant IVH No severe HIE No severe CHD No severe syndrome No parental consent Inadequate conventional therapy Prolonged mechanical ventilation
22 The Pre-ECMO Patient Principles of Management 1. CONCEPT: the provision of oxygen delivery to end organs 2. Persistent pulmonary hypertension of the newborn 1. DELIVERY: CDH, no breathes, Vygon, UV access 2. DELIVERY: Neonatal Resuscitation Program 3. NEURO: sedation, paralysis, minimize external stimuli 4. RESPIRATORY: optimize VQ, reduce PVR (vent, surfactant, ino) 5. CARDIO-VASCULAR: MBP (pressors, volume, steroids) 3. Sepsis +/- shock w/ DIC: 1. Antibiotics 2. Fluid, pressors, steroids 3. DIC management 4. Pneumothorax: chest tubes
23 The Pre-ECMO Patient Principles of Management 1. CONCEPT: the provision of oxygen delivery to end organs vs hypoxemia & lactic acidemia 2. Failure of PPHN conventional therapy 1. Hypoxemia & lactic acidemia = oxygen debt 2. Hypercarbia = respiratory acidosis 3. Hypotension w/ low UOP, poor perfusion, slow capillary refill, poor cardiac contractility on ECHO 4. Pneumothoraces 3. Sepsis w/ SIRS +/- shock w/ DIC: 1. Hypotension w/ capillary leak syndrome 2. DIC w/ bleeding 3. The Golden Hour 4. Pneumothorax: chest tubes
24 Entry Criteria for ECMO Therapy The Art of Medicine vs Evidence-Based 1. Historical 80% mortality risk 2. Candidacy 1. Reversible pathophysiology 2. No contra-indications 3. Objective parameters to predict mortality: 1. Alveolar arterial 02 gradient (A-aD02 = PA02 Pa02) -- >600+mmHg over time 2. Oxygenation Index (Fi02 x100 x MAP / Pa02) -- >40 for 2 hours 3. ph < 7.15 & Pa02 <40 for 2 hours 4. Subjective clinical judgment 1. Barotrauma & oxygen toxicity 2. Duration of max settings
25 VV vs VA ECMO VENOARTERIAL VENOVENOUS 1. Non-pulsatile CV support 2. Ligation of carotid artery 3. Cardiac stun 4. Lung rest settings 1. Rapid wean off ino & inotrophic support 2. Particles from the circuit enter the arterial circulation 1. CV support dependent on native CO 2. End organ pulsatile flow 3. High 02 content to pulmonary vasculature & coronary arteries 1. Recirculation catheter position 2. Risk for needing conversion 3. Greater bedside maintenance
26 VV vs VA ECMO VENOARTERIAL VENOVENOUS
27 VV vs VA ECMO VENOARTERIAL VENOVENOUS
28 What is A, B & C?
29 Describe This CXR
30 Describe This CXR
31 ECMO Circuit: tour through its components VENOVENOUS 1. Cannulas 2. Bridge / Bladder 3. Sensors & monitors: Flow / pressures Sats / gases / Hgb Bubbles Safety 4. Centrifugal pump vs roller pump 5. Med / fluid ports 6. Oxygenator
32
33 ECMO Circuit: tour through its components 1/4 PVC w/ plasticizers Biocompatible surfaces Closed circuit w/ servoregulation A-V bridge VBA = Very Bad Accident Cross clamp trial Bladder: VS pressure transducer Collapse w/ negative pressure Hypovolumemia Kinked cannula Vessel injury, cavitation & hemolysis
34 Tour of the Circuit -- ANTI-COAGULATION MONITORING Point-of-care coagulation status monitoring: a. ACTs: ITC Hemochron Signature Elite b. PTT / Anti-factor Xa activity / AT III / TEG c. ELSO Anti-coagulation Task Force 2. Non-invasive measurement of critical real-time parameters -- Spectrum Medical: -- Sv02, Sa02 -- Gases -- Hct / hgb -- Flow / emboli detection
35 Sunrise Neonatal ECMO Education & Training Program SYLLABUS 1. Introduction to ECMO 2. The Pre-ECMO Patient 3. Concepts: Oxygenation, Oxygen Content, Oxygen Delivery 4. The Decision to go on ECMO 5. ECLS Physiology 6. VV & VA ECMO 7. ECMO Equipment & Devices 8. Management of the Neonate on ECMO 9. Anticoagulation & Blood Products 10. ECMO Complications 11. ECMO Team Members Responsibilities & Case Scenarios 12. Open Review
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