티스토리 뷰
- ECMO의 정의 및 유사어
- 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
- 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