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7/29/2019 Extra corporeal membrane oxygenation
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Management of Infants
requiring ECMO
Sixto F. Guiang, III
Dept. of PediatricsUniversity of Minnesota
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Extracorporeal membrane
oxygenation- ECMO Mode of cardiopulmonary support
Pulmonary failure
Cardiovascular insufficiency
Adapted from cardiopulmonary bypass done
in OR
Infants, children, and adults
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Neonatal ECMO = 73 % of all ECMO
VV ECMO = 20% of all Neonatal Pulmonary
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Recent ECMO Pediatrics 2000;106:1334-1338
Fewer patients
Longer ECMO runs
Longer time prior to ECMO
Higher mortality
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Extracorporeal Life Support
Organization: ELSO Develop guidelines for use
Quality assurance
Education Text
Regulatory issues
Database
Clinical needs Research needs
www.elso.med.umich.edu/
http://localhost/var/www/apps/conversion/tmp/scratch_8//ecmo%20nutrition%20talk/exrtraslides.ppthttp://localhost/var/www/apps/conversion/tmp/scratch_8//ecmo%20nutrition%20talk/exrtraslides.ppt7/29/2019 Extra corporeal membrane oxygenation
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Inclusion ECMO Criteria Gestational age of at least 34 weeks
Weight >1.7-2.0 kg
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Inclusion / Exclusion
Guidelines age of at least 34 weeks
Weight >1.5-2.0 kg
Potentially reversible process Absence of uncorrectable cardiac defect
Absence of major intracranial hemorrhage
Absence of uncorrectable coagulopathy
Absence of lethal anomaly
Absence of prolonged mechanical ventilationwith high ventilatory settings
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Reversible Lung Disease No prospectively defined criteria have been
developed
Pre-ECMO gas exchange is not predictive ofbaseline lung capability
ECMO utilized in Lung hypoplasia
Congenital diaphragmatic hernia
Renal anomalies
Hydrops fetalis
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Oxygenation Failure Alveolar - arterial oxygen tension gradient
[760 - 47)-paCO2] - paO2
605 - 620 torr for greater than 4-12 hours
Oxygenation index
Mean Airway Pressure x FiO2 x 100/ paO2
> 35-60 for greater than 1-6 hours
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Oxygenation Failure paO2
PaO2 < 35 for 2 hours
paO2 < 50 for 12 hours
Acute decompensation
paO2 < 30 torr
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Myocardial Failure Refractory hypotension
Low cardiac output
pH
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Predicted / Measured
Outcomes Historical Mortality 80%
Mortality RCT- conventional tx 50%
ECMO mortality 15-25%
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Arterial Cannula
Venous CannulaPump
Oxygenator
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Gas
Flow
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Gas
Flow
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Gas Exchange - Oxygenator
Gas permeable surface
Blood flow
pO2 - 32Oyxgen saturation 70%
pCO2 - 45
pO2
450+Oyxgen saturation 100%
pCO2 - 40
100% FiO2
pO2 - 700+
pCo2 - 0
pO2 - lower
pCo2 - higher
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Gas Exchange Gas flow rate (sweep gas flow)
Determines CO2 removal
Gas Flow FiO2
Small effects on infant oxygen saturation
Changes paO2 of ECMO output only
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ECMO Modes Venoarterial - VA
Blood drains-venous system
Blood returns-arterial system Complete cardiopulmonary support
Venovenous - VV
Blood drains-venous system Blood returns-venous system
Pulmonary support only
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Pre ECMO Evaluation ABG, electrolytes, Ionized Ca++
Cardiac echo
Evaluate pulmonary artery pressures
Evaluate right and left ventricular function
Rule out cyanotic congenital heart disease
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Unsuspected Heart disease 2% of all ECMO for presumed respiratory
disorders
33.5% were TAPVR
10.5% Transposition of the great arteries
7.5% Ebsteins Anomaly
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Pre ECMO Evaluation Head US
Rule out severe IVH
Coagulation studies
INR, PTT, TT, fibrinogen, platelets
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ECMO Goals Maintain adequate tissue oxygenation to
allow recovery from short termcardiopulmonary failure
Adjust ventilator settings allowing for LungRest minimizing further ventilator /oxygen
induced lung injury. Not necessarily lowersettings
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Adequacy of Support - SvO2Right Atrium
Tissue
Oxygen consumption
Aorta
70%
100%
ArteryVein
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ABGPre
Post
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Adequacy of Support Tissue oxygenation
Not the same as arterial oxygenation
Oxygen Delivery Oxygen content Blood
Arterial oxygen saturation
Hemoblobin
Blood flow ECMO
cardiac
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Adequacy of Support - SvO2Vena cava
Tissue
Oxygen consumption
Ao
70%
85%
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Adequacy of Support - SvO2Vena cava
Tissue
Oxygen consumption
Ao
55%
100%
If inadequate oxygen delivery
Anerobic metabolism
Lactic adidosis
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SvO2 Generally good indicator of adequacy of
oxygen delivery
SvO2 will drop with decreasing tissue oxygendelivery
Low SvO2
More support is needed PRBC
More flow
ECMO
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Adequacy of Support - SvO2Vena cava
Tissue
Oxygen consumption
Ao
55%
100%
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Right Atrium
SvO2
SVC
IVC
Brain
Kidney
Intestines
Liver
Upper extremities
Heart
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SvO2 - Problems Cannot be used with VV ECMO
because of recirculation
Affected by intracardiac shunt Patent foramen ovale
Gives a macro picture of oxygen supply
and demand Ignores potential differences in regional
(organ) blood flow
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SvO2 - Alternatives Tissue oxygen saturation via near
infrared spectroscopy (NIRS)
Transcutaneous measurement Detection of blood saturation in the tissues
Primarily venous blood sampled
Can be used as a indicator of organspecific venous oxygen saturation
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VA ECMO Cannula sites
Internal jugular vein (12-10F)
Cannula tip low in the right atrium
Right common carotid artery (10-8 F) Cannula tip at the aortic arch
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Cannulation Preparation
Remote vascular access
Extension tubing on central venouscatheter and arterial catheter
Accessible easily away from the sterile
surgical field
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Medications Fentanyl 25-30 micrograms/kg
Atropine 0.01 mg/kg
Neuromuscular blocking agent Heparin 100 units/kg bolus
Needed even if continuous heparin gtt willnot be used
Ca Volume
NS, PRBC, FFP, Albumin
Prime oxygenated circuit blood
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Venous Cannula
Arterial Cannula
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PA
PA
Ao
Ao
LV
ECMO Carotid
RV
PDA
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Ventricles ECMO
Po2 - 45
Sat - 88%Po2 - 450
Sat - 100%
Po2 - 150
Sat - 100%
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Ventricles ECMO
Po2 - 450
Sat - 100%
Po2 - 450
Sat - 100%
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Ventricles ECMO
Po2 - 32
Sat - 70%Po2 - 150
Sat - 100%
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Ventricles ECMO
Po2 - 32
Sat - 70%Po2 - 150
Sat - 100%
Po2 - 70
Sat - 97%
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Ventricles ECMO
Po2 - 32
Sat - 70%Po2 - 150
Sat - 100%
Po2 - 50
Sat - 88%
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Management Fluids / Nutrition
Respiratory
Hemodynamic
Anticoagulation
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Fluids / Nutrition Obligate need to maintain intravascular
volume
90-100+ ml /kg/day
Exacerbated by capillary leak and 3rdspacing of fluid
Activation of cytokines / complement /
leukocytes Vasodilatation
Increased vascular permeability
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Na Generally total body sodium overloaded
Volume expansion with NS
Blood products Delayed Na increases with PRBC
Na/k ATPase pump turned off
High intracellular Na
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Potassium Potential problems with Hyperkalemia
Hemolysis
Circuit Stored blood
High serum K in PRBC bag
Na/K ATPase pump inactivated Hemodynamically significant only in VV
ECMO
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Calcium Hypocalcemia
Low ionozed Ca
Normal total Ca Ca binding to citrate from blood
products
Standing order for Ca Gluconate after100 ml colloid infusion
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Energy Delivery Non protein calories
50-60 kcals/kg/day
Carbohydrate Fat
No direct studies suggesting ideal mix
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Lipid infusions
Technical problems relating to the ECMO circuit
Promoting clot formation
Layering out of the emulsion
Fat deposition
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Rate ofAppearanceOf CO2
J Ped Surg 1999; 34:1086-1090
Avoid Excessive Calories
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J Ped Surg 1999; 34:1086-1090
Avoid Excessive Calories
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High Caloric intake
Increasing caloric intake associated with:
Increased amino acid oxidation (r=0.85, p
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Pulmonary Management
Aim to control pH and paCO2 only with
the ECMO circuit
Changes in sweep gas Flow Rate will
increase CO2 removal
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Pulmonary Management
Maintain lung aeration
PEEP 12-16 If lung disease
PEEP 6-8 If no lung disease
Early Surfactant replacement
Minimize ongoing lung injury - VILI
Pressure preset vent PIP - 20, RR - 10
PIP adjusted for recruitment
HFOV
Provide adequate myocardial oxygenation
FIO2 40%
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PA
PA
Ao
Ao
LV
ECMO Carotid
RV
PDA
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Rest ventilator settings
PEEP Maintaining FRC probably agood lung protective strategy
Pediatrics 1992;120:107-13
Randomized clinical trial
N = 74
High PEEP = 12-14
Low PEEP = 3-5
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Rest ventilator settings
Similar survival
High PEEP
Higher (better) CXR scores
Shorter ECMO run
97.4 vs 131.8 hours
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PEEP
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Surfactant
Alteration of surfactant metabolism
Decreased SP-A levels in trachealaspirates in ECMO patients
Increased surfactant proteins andphospholipids in correlate withimprovement in lung function
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Surfactant Replacement
J Peds 1993;122:261-268
Randomized, blinded trial
N=56 Survanta 4 doses
Placebo
Dosing at 2, 8, 20 and 32 hours
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Surfactant Replacement
In surfactant group
Faster improvement in compliance
Faster increase in SP-A No difference in CXR scores
Shorter ECMO runs
Surfactant not beneficial for CDH
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Time course
Dependant on disease process
Meconium aspiration 3-5 days
Congenital diaphragmatic hernia 7-14 days
Lung hypoplasia syndromes 14+ days
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Cardiovascular Instability
Hypotension
Hypertension
Pressure = Flow x Resistance
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Ventricles ECMO
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Hypotension
Volume -If intravascular volume depletion Increase blood drainage to the ECMO pump
Increase preload to LV/RV
Ca Myocardial contractility
Vasopressors
Increase systemic vascular resistance (SVR) Increase LV and RV
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Anticoagulation
Systemic heparin
Bolus heparin at cannulation
100 units/kg
Continuous heparin gtt
20-50 units/kg/hour
Procoagulants factors
Anticoagulant factors
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Operating Parameters
Gas Exchange
pCO2 35-45
pH 7.35-7.45 SvO2 > 70%
PaO2 50-100
SaO2 >90%
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Operating Parameters
Hemodynamics
Capillary refill time - 2 seconds
Evidence of adequate organ perfusion Urine output
No metabolic acidosis
BP- dependant on gestational age SPB > 60
Mean BP > 45-50
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Advantages of VA ECMO
Able to give full cardiopulmonary support
No mixing of arterial / venous blood
Good oxygenation at low ECMO flows
Allows for total lung rest
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VA - VV Comparison studies
J Peds Surg1993;28:530-536
Multicenter data
N=243 VA = 135
VV = 108
Similar survival
10% conversion to VA
Shorter runs
Less Neurologic complications
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Operating Parameters
ECMO
Flow 10O-120+ ml/kg/min
HgB 10-12 Platelets >100K
Anticoagulation
Variable When fully anticoagulated
ACT 180-220 seconds
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ECMO outcomes
Mostly determined by
Dx
ECMO duration Hospital course
IVH
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Jugular venous drainage
Additional drainage facilities flow
2 site venous drainage lessens recirculationon VV ECMO
Enables venous oxygen saturation monitoring
on VV ECMO
One small study suggested decreased IVH
Jugular Venous Drainage
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Jugular Venous Drainage
Cephalad Cannula
J Pediatr Surg 2004;39:672-676
Review of ELSO database
Neonatal Respiratory Failure VV ECMO1989-2001
N = 2471
96% VV double lumem alone
3.7% with jugular venous drainage Similar Outcomes
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Complications - Infants
IVH 10%
Other Bleeding 15%
Hemolysis 15%
Ultrafiltraltion/dialysis 13%
Acute Renal failure 10%
Arrhythmia 3%
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IVH
Most serious long term complication
Highest Risk period 1-5 days
Risks J Peds 1999;134:156-159
ELSO database
N=3896 9.8% ICH
30% cause of death
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Increased Risk of IVH
OR CI
< 34 wks 12.1 6.6-22.0
34-36 wks 4.1 2.9-5.836-38 2.1 1.6-2.8
Epinephrine 1.9 1.5-2.5
Sepsis 1.8 1.4-2.4pH
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IVH
No difference in
Apgar
Fetal distress IUGR
Pneumothorax
Pulmonary hemorrhage
VV ECMO
Jugular venous drainage
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IVH - Lactate
Pediatrics 1995;96:914-917
Initial 10 vs 6.4 Maximal 12.4 7.9
Predicted ICH logistic regression
None 10 40% at lactate >25
60% at lactate >40
Lactate as Predictor of
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Lactate as Predictor of
Outcome
CCM 2002;30:2135-2139
Prospective trial
2 centers
N=74
20% Early mortality
9% additional infants died before 18 mo
follow up
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Lactate
Peak lactate >25 predicted early
mortality Sensitivity 47%
Specificity 100%
Positive predictive value 100%
Negative predictive value 88%
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Lactate
Peak lactate >15 predicted adverse
outcome
Sensitivity 35% Specificity 91%
PPV 89%
NPV 38%
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Time to Give up?
Best estimate based on long runs of
congenital diaphragmatic hernia
Low additional survival past 21 days
PROPORTION OF INFANTS REMAINING ON ECMO WITH SUCCESSIVE DAY
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0.00
.10
.20
.30
.40
.50
.60
.70
.80
.90
1.00
0 10 20 30 40 50 60
DAYS ON ECMO
SURVIVORS
NON-SURVIVORS
PROPORTION OF INFANTS REMAINING ON ECMO WITH SUCCESSIVE DAY
P
E
R
C
E
N
T
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Daily Specific Survival Rate
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Second ECMO
J Peds Surg 2002;37:845-850
ELSO database
N=16,450 Second 1.22%
Third 4 infants
More complicated during second run
Survival 38% MAS still >85% survival
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Early ECMO
J Peds Surg 2002;37:7-10
Meconium Aspiration
ELSO database N=3235
Overall mortality 5.8%
Increased mortality with increasing time toECMO
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Mortality - MAS
0
1
2
3
4
5
6
7
8
9
4 days
Mortality
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ECMO Duration - MAS
0
50100
150
200
250
300350
400
450
500
4 days
Hours
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Weaning of ECMO
Assess pulmonary status
Compliance -
Vt with set Pmax, PEEP
Typical maximal vent setting Pmax 30
RR 35-40
FiO2 50%
HFOV Pulmonary hypertension
Cardiac echo
pre-post ductal saturations
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Recovery and Decannulation
Adequate gas exchange
PIP
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Weaning of ECMO
Assess hemodynamics
Ventricular funcion
Organ perfusion BP
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Weaning of ECMO - VA
ECMO flows weaned
Minimum ECMO flow 100 ml/min Risk for clot formation inceases with lower flows
(absolute flow rate) Frequent assessment of activated clotting time
(ACT) is needed
Ventilator settings at maximum Pmax to give
desired Vt Assessment of gas exchange via SaO2 and ABG
Additional preload frequently needed
Additional Ca
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VA ECMO Clamp Out
Cannula - clamped
Bridge - Opened
Stagnant blood
Tubing and cannula distal to the bridge
Intermittent flow in the cannula neededevery 5-10 minutes
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Future Management Issues
Hypothermia
Extracorporeal CPR
Follow up High incidence of late hearing loss
Routine late screening recommended
ECPR - Extraporporeal
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ECPR Extraporporeal
Cardioulmonary Resuscitation
CPR is not a contraindication for ECMO
End organ perfusion may be better post
CPR in infants treated with ECMO
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Pediatr Crit Care Med 2004;5:440-446
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Case VA ECMO for Sepsis
Infants ABG 7.34 / 40 / 350 / 19
Post oxygenator 7.34 / 40 / 450 / 19
Preoxygenator 7.30 / 46 / 20 / 19 CXR - White out
Systemic oxygen delivery is:
Low - pvO2 is low, SvO2 is low
Cardiac output is: Low - paO2 in infant is similar to the post
oxygenator paO2
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Case VA ECMO for Sepsis
Infants ABG 7.36 / 40 / 52 / 24
Post oxygenator 7.39 / 36 / 450 / 24
Preoxygenator 7.30 / 44 / 40 / 24
Systemic oxygen delivery is: High - PvO2 is high, SvO2 is high
Cardiac output is:
Good - large gradient between infant ABG and
post oxygenator gas Mixing of LV and ECMO output