ECMO 학회 정리

1. ECMO의 정의 및 유사어
1. CBP와 ECMO의 차이 : CPB는 venous reserve 를 가지고 있고 cardiotomy sucker & venting 을 사용하기 때문에 혈액의 stasis를 초래하고 blood component에 많은 sheer stress를 주기 떄문에 혈전방지를 위하여 충분한 heparin을 사용하여야하고 ECMO는 venous reserve가 없고 cardiotomy sucker & venting을 사용하지 않기 때문에 낮은 ACT를 유지하여도 되고 hemolysis 또한 적다
2. ECMO와 Assist device (LVAD, RVAD, BiVAD) 차이

	OR CPB	ICU ECMO
Venous Reserve	YES	NO
Heparin	high dose (>600 sec)	Titrated(180~200sec)
Mediastinal shed blood transfusion(sucker)	Yes	No
Hypothermia	Yes	No
Blood Flow	Low	Normal
Hematocrit	Low	Normal
Arterial filter	Usually yes	No

 

 

ECMO monitoring

Pt.

VBGA 

MvO2

ScvO2

Lactate 

Procalcitonin

Heparin function survival 

ECMO 

Oxigenator ABGA 

Hemoglobin thrombus 

Anticoagulation heparin ACT(bedside) <aPTT(double check q4-6hr) <anti-Xa heparin effect good correlation good

AntifactorXa 는 hyperbilirubin  상태엔 별로 안좋다

TEG ROTEM 전반적인 heparin 의 coagulation effect 알 수 있다 hyperfibrionolysis 볼 수 있다

Antithrombin (III) measurement 

check 낮다고 replace 하지는 않는다 teg xa 를 체크해서 채워넣는다

Continuous cardiac output

Mixed venous O2 = RA hemoglobin 

VO2/DO2 = 20% tissue에서 쓴다 

SVO2 = tissue perfusion > 70 % 이상이면 생존에 좋다

VA 

Vv ecmo는 SVO2의미가없다 ???

Continous P

NIRs monitoring 

Oxygenated hb deoxygenated hb

Regional oxygen saturation

Cerebral oxygemetry

rSO2 <40 intervention

Superficial femoral a interruption 

Posterior tibial a : cut down 

Distal perfusion decision whether perform distal perfusion

Monitoring of lower extremity blood flow

Seldinger procedure

Continuous EEG monitoring 

>ECMO Indication

Zapol

1. Fast entry criteria(FiO2 1.0 & PEEP > 5mmHg -> PaO2 < 50mmHg over 2 hrs

2. Slow entry (for 48 hours, FiO2> 0.6 & PEEP > 5mmHg PaO2 < 50mmHg over 12 hrs

Cesar (murray score) > 3.0 or pH <7.0

Others

1. Pulmonary compliance < 0.5ml/cmH20 /kg

2. PaO2/FiO2 < 100 and response to standard therapies

3. Shunt fr. > 30% 

4. AaD02 > 600mmHg

Ventilator care less than 5-7 days 

Potential reversibility

Under 65 yrs??

ECMO COMPLICATION

1. Bleeding 

2. Brain injury 

3. Brain death 

4. Neonate 

5. Infection

EEG inability to detect subcortical injury : stroke 을 예상하진 못한다

>>ECMO MALFUCTION CASE

1. oxygenator thrombosis 

2. ECMO line 꼬임

3. IVC canula 깊이 박혀 coronary sinus

4. HTK Solution (hyponatremia ; generalized seizure)

5. Air 있으면Line 구멍이 있는가?

6. Clamping 되어있는지?

Acute Lung Injury ; PaO2:FiO2 < 300 

ARDS ; < 200

BEFORE

Pediatric CPB 기저 질환 따져보기

1. Lt. SVC

2. interruption of IVC

3. PDA case SVR/PVR flow 가 lung 으로 간다 coarctoplasty 

4. CoA ; double arterial canulation

5. Hypoplastic left heart syndrome >> norwood op

6. Target ACT regulation for example HIT 

EcMo setting 방법

ASD 160cm 55kg Hct 37% BSA 1.56

Target flow rate 3700 max flow

Hct

Priming solution 1300ml kg 65-70ml)

Cardiac canula (A 22 scv 24-30 ivc 28-30fr)

Tubing : 3/8 venus line 1/2 line

Pump roller or centrifugal?

Arterial filter : ok

Cardioplegia : HTK crystalloid .....

Filtration

VAVD

Steroid

VSD 20kg 110cm BSA 0.78

몸무게에 따라 점점 target flow 달라진다 

Bsa당 2.4 어리면 2.5 

500-700

VAV ECMO