VV ECMO Part 3: Troubleshooting the circuit & preparing for early rehab
May 8, 2023
auto_awesome
Guest Jenna Miller, Associate Professor of Pediatrics, discusses troubleshooting the VV-ECMO circuit and preparing for early rehab. Topics include nutrition for patients on VV-ECMO, moving towards early extubation and mobilization, breastfeeding and feeding on ECMO, waking up patients on ECMO, and early rehabilitation and sedation approach for pediatric patients.
Monitoring circuit variables is crucial for optimal VV ECMO performance, including FIO2, sweep rates, and pressure in different components.
Dehydration and bleeding can impact circuit pressures, while recirculation and CO2 levels should be carefully managed in VV ECMO patients.
Deep dives
Understanding Circuit Variables in VV ECMO
In VV ECMO, monitoring circuit variables is crucial for maintaining stable gas exchange. These variables include the FIO2 and sweep rates. FIO2, which ranges from 0.5 to 100%, should be set below 100% to avoid taxing the oxygenator. Sweep rates, ranging from 0.5 to 10, impact ventilation defect, with higher rates indicating worse ventilation. Additionally, pressure monitoring in different components of the circuit, such as inlet pressure, pressure after the pump, and pressure after the oxygenator, is essential for troubleshooting and assessing oxygenator health. Changes in pressures can indicate factors like cannula size, hydration status, and oxygenator resistance to flow. Keeping a close eye on these circuit variables can help ensure optimal ECMO performance.
Implications of Dehydration and Bleeding on Circuit Pressures
Dehydration and bleeding can impact circuit pressures in VV ECMO patients. Dehydration may cause a more negative inlet pressure, while bleeding can result in constantly alarming pressures. Large fluid shifts from intermittent lasix doses may also affect circuit pressures. In terms of the delta pressure or transmembrane pressure, an increase in this value may suggest an unhappy oxygenator due to impediments to flow caused by factors like cellular debris or blood products in the oxygenator. Rising delta pressure, exceeding 50 or even higher than 100, may indicate the need for a new oxygenator. Furthermore, the role of nears (near-infrared spectroscopy) as a tool for evaluating perfusion in ECMO patients is being explored.
Managing Recirculation and CO2 Levels in VV ECMO Patients
Mitigating recirculation and maintaining appropriate CO2 levels are important considerations in VV ECMO. Recirculation can occur when highly oxygenated blood is drawn back into the cannula, causing arterial and venous saturations to become unbalanced. Repositioning the cannula and adjusting the patient's head position can help alleviate recirculation. In the case of CO2 levels, if a patient is effectively ventilating on their own, CO2 may need to be added back into the circuit to maintain normal levels as the patient's lungs are not actively being used for ventilation. Slowly normalizing CO2 levels is key for avoiding cerebral vasculature issues, and the approach may vary depending on the patient's initial pH and CO2 levels.
Jenna Miller, MD is an Associate Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine. She completed her medical school and residency in Kansas City before moving to Texas Children’s for critical care fellowship. She is the director of the pediatric ECMO program and the pediatric critical care medicine fellowship at Children’s Mercy Kansas City. Her professional and research interests include trimethoprim-sulfamethoxazole ARDS, ECMO and medical education.
Dr John Daniel, MD is an Associate Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine. He completed his pediatric residency at the University of South Carolina and his neonatology fellowship at the University of Kentucky. He now is a practicing Neonatal Cardiac Intensivist and the director of the neonatal ECMO program at Children’s Mercy Kansas City.
Learning Objectives:
After listening to this episode, learners should be able to:
The Identify key networking opportunities within the ECMO world.
Understand the risks and benefits of VV-ECMO cannulation.
Discuss common and newer indications for VV-ECMO cannulation in neonates and school-aged children.
ECMO Patient Stories from Children’s Mercy Kansas City:
Maclare, Graeme, et al. Extracorporeal Life Support: The ELSO Red Book. 6th Edition.
Pelosi, er al. Close down the lungs + keep them resting to minimize ventilator induced lung injury.
Maharaj et al, Right Ventricular Dysfunction is Associated with Increased Mortality in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019
Nirmal S Sharma et al. Flexible Bronchoscopy Is Safe and Effective in Adult Subjects Supported With Extracorporeal Membrane Oxygenation.
Rosner EA et al. Flexible Bronchoscopy in Pediatric Venovenous Extracorporeal Membrane Oxygenation.
Gurnani et al. Outcomes of Extubated COVID and Non-COVID Pat
How to support PedsCrit: Please complete our Listener Feedback Survey Please rate and review on Spotify and Apple Podcasts! Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.
Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
Get the Snipd podcast app
Unlock the knowledge in podcasts with the podcast player of the future.
AI-powered podcast player
Listen to all your favourite podcasts with AI-powered features
Discover highlights
Listen to the best highlights from the podcasts you love and dive into the full episode
Save any moment
Hear something you like? Tap your headphones to save it with AI-generated key takeaways
Share & Export
Send highlights to Twitter, WhatsApp or export them to Notion, Readwise & more
AI-powered podcast player
Listen to all your favourite podcasts with AI-powered features
Discover highlights
Listen to the best highlights from the podcasts you love and dive into the full episode