ECMO: Monitoring and
intervention
dr. Eva Miranda, Sp.A
Ibnu sofa
Introduction
To
The goal of this discussion
is converting this
this!!
Patient related monitoring
All devices which are attached or not attached to the patient will guide
clinicians to achieve the goal of either VV ECMO or VA ECMO
In VV ECMO the goal is to achieve lung recovery in a relative stabile
hemodynamic
In VA ECMO the goal is to achieve cardiac recovery in a relative stabile
pulmonary function or in bad pulmonary function.
Most patients with severe respiratory failure require inotropic support before
ECMO initiation. When high doses of inotropes are used, conversion to VA-
ECMO may be indicated, in order to avoid adverse effects of catecholamine
doses and to optimize myocardial oxygen consumption.
Bartakke AA, Peek GJ . Extracorporeal Membrane Oxygenation. In : Gosh S, Falter
F, Cook DJ, eds. Cardiopulmonary bypass Cambridge University Press 2009 p: 176-86
Common goal
Cardiac output in neonates
2,5 -5,75 l/min/m2
Cardiac output in children 3
– 4,5 l/min/m2 (child)
Cardiac output in
adolescent 2,5 – 4 l/min/m 2
Emmanouilides GC etal. Cardiac output in newborn infant. Bio.Neonate 1970; 15: 186-97
Boville B, Young LC. Quick Guide to Pediatric Cardiopulmonary Care. Edwards Lifesciences Corporation 2015
Ventilator monitoring VA and VV
ECMO
Ventilation – settings should be adjusted to provide lung protective ventilation, i.e. airway
pressures should be restricted to <30 cm cmH2O irrespective of tidal volumes to avoid barotrauma
or volutrauma; PEEP of 10–15 cmH2O should be used to prevent further atelectasis; respiratory rate
should be limited to 8–10 breaths per minute; and FiO 2 is reduced to the lowest possible setting to
avoid further damage through generation of free oxygen radicals.
If the lungs are “stiff ” due to poor compliance, high-frequency oscillatory ventilation (HFOV) can be
initiated on ECMO. Ventilation in the prone position has been found to improve gas exchange by allowing
adequate aeration of the posterior segments of the lungs. However, turning the ECMO patient should be
undertaken with extreme care to avoid dislodgement of ECMO cannula, other vascular lines and the
endotracheal tube.
ECMO flow, Inotrope and
ventilator
ECMO flow, Inotrope and ventilator are aimed at achieving DO2/VO2 at least > 2.
When the DO2 is less than twice the
VO2, oxygen supply is inadequate to
maintain aerobic metabolism and
anaerobic metabolism ensues, producing
lactic acid rather than CO2. A DO2:VO2
ratio less than 2:1 leads to supply-
dependency hypoxia and systemic acidosis,
with resultant organ failure
Bartlett R, Conrad SA. The physiology of extracorporeal life support
In: Brogan TV etal eds. The extracorporeal life support the ELSO red
book 5th ed. ISBN 978-0-9656756-5-9
VA ECMO goal
• Pulse pressure at least 10
• Pa O2 60-80 mmHg
• Hgb 13-15, HCT : 40
• SVO2 65-70%
• pH 7,35-7,45
• PCO2 35-45
• DO2:VO2 = 3:1
• Echo: Monitoring during ECMO
must fundamentally focus on the
systolic function of the left
ventricle.
Emmanouilides GC etal. Cardiac output in newborn infant. Bio.Neonate 1970; 15: 186-97
Boville B, Young LC. Quick Guide to Pediatric Cardiopulmonary Care. Edwards Lifesciences Corporation 2015
Tritapepe, L., Greco, E., & Gaudio, C. (2019). Echocardiography Evaluation in ECMO Patients. Advances in Extracorporeal
Membrane Oxygenation - Volume 3. doi:10.5772/intechopen.85047
VV ECMO goal
• No alteration of hemodynamic
• Pa O2 45-80 mmHg
• SpO2 60% - 90% as long as
adequate systemic oxygen
delivery is achieved
• Hgb 13-15, HCT : 40
• pH 7,35-7,45
• PCO2 35-45
• DO2: VO2 > 2
• Echo: The right ventricle
echocardiographic assessment
in the ECMO patients with
acute respiratory distress
syndrome (ARDS) plays a key
role to reduce complications
and to improve the outcome
Emmanouilides GC etal. Cardiac output in newborn infant. Bio.Neonate 1970; 15: 186-97
Boville B, Young LC. Quick Guide to Pediatric Cardiopulmonary Care. Edwards Lifesciences Corporation 2015
Tritapepe, L., Greco, E., & Gaudio, C. (2019). Echocardiography Evaluation in ECMO Patients. Advances in Extracorporeal
Membrane Oxygenation - Volume 3. doi:10.5772/intechopen.85047
Circuit related monitoring
Larissa Yalon, BSN, RN,
CCRN, Kenneth A.
Schenkman, MD, PhD.
ECLS Safety and Other
Monitoring Devices. In:
Brogan TV etal. Ed ECMO
Specialist training
manual 4th Edition
Circuit related monitoring
Venous line/ inlet pressure
is measured prepump and
monitored for excessive
negative pressure, which
can lead to vessel or right
atrial damage, as well as
cavitation and resulting
hemolysis. The venous
pressure also reflects circuit
volume status. Pressure
depends on patient volume
status, circuit length,
cannula position, and FR
size. If a bladder is present,
the venous pressure may
be obtained from an access
site on the bladder.
Larissa Yalon, BSN, RN, CCRN,
Kenneth A. Schenkman, MD, PhD.
ECLS Safety and Other
Monitoring Devices. In: Brogan
TV etal. Ed ECMO Specialist
training manual 4th Edition
Circuit related monitoring
Post oxygenator/arterial line
pressure is measured after the
oxygenator and is a function of
the pump speed, the tubing
resistance,
cannula and the arterial
pressure of the patient. An
obstructed or kinked arterial
line will lead to an increased
pressure. If this pressure
exceeds 400 mmHg, the risk of
circuit interruption and
hemolysis increases.
Larissa Yalon, BSN, RN, CCRN, Kenneth A. Schenkman,
MD, PhD. ECLS Safety and Other Monitoring Devices. In:
Brogan TV etal. Ed ECMO Specialist training manual 4th
Edition
Lorusso R, Di nardo M, Wang IW etal. Venoarterial ECMO
in adult and pediatric patient. In Brogan TV etal. Ed ECMO
Specialist training manual 4th Edition
Circuit related monitoring
Pre-oxygenator/internal pressure
is measured at the inlet to the
oxygenator and is used in
correlation with the post-
oxygenator pressure to diagnose
oxygenator issues. If an outflow
problem exists, both the pre- and
post-oxygenator pressures rise
together. An independent
increase in pre-oxygenator
pressure is an indicator of
oxygenator clot formation or
flow disruption within the
oxygenator housing.
Larissa Yalon, BSN, RN,
CCRN, Kenneth A.
Schenkman, MD, PhD.
ECLS Safety and Other
Monitoring Devices. In:
Brogan TV etal. Ed ECMO
Specialist training
manual 4th Edition
Circuit related monitoring
Other monitoring
• Air/bubble detector
• Oxyhemoglobin monitoring
• Temperature monitoring
Larissa Yalon, BSN, RN,
CCRN, Kenneth A.
Schenkman, MD, PhD.
ECLS Safety and Other
Monitoring Devices. In:
Brogan TV etal. Ed ECMO
Specialist training
manual 4th Edition
ECMO machine check-list - Monitoring –
intervention Cycle
ICU Physician, cardiologist pathologist
Physical
exam
ECMO specialist
ECMO Target
and perfusionist machine aim Labs
role is prominent checked
checked and
imagin
g
ECHO
Intervention
Adjust ECMO setting
Adjust ventilator, inotropes, drugs, transfusion
RRT
ICU physician
ECMO MACHINE INTERDEPENDENT
FLOW
ECMO
RPM PRESSURE
INLET
Monitoring Pressure ECMO
p1 p2 p3 Problem
↑ ↓ ↓
Hypovolume, pneumothorak,
(-30 100) (160 130) (140 120)
kinking venouse cannula
↓ ↓ ↓ Pump failure
↓ ↑ ↓ Oksigenator failure
↓ ↑ ↑ Kinking arterial cannula, hypertention
Monitoring of complication and organ
dysfunction
Organ Method of monitoring intervention
Central nervous system Pupil diameter and reaction If bleeding consider to stop ECLS
NIRS Keep Na 130-135
Head US Keep CO2 35-45
CT scan head
Mannitol
Cardiovascular Pulse pressure, CRT, IBP monitor Tamponade evacuate
Echocardiography LCOS primer treat with flow, inotrope, anti PH,
vasopressor
LCOS LV distension -> LA vent, impella
anemia, hypovolemia PRC, 5% Albumin
Respiratory Auscultation, Cxray, Lung US, Pneumothorax WSD
Sppreox increase SaO2 decrease ARDS lung protective strategy; HFOV
Sign of recirculation of VV ECMO
Gastrointestinal and renal Abdomen distended. Bloody stool Consider NEC NPO
Oliguria, uremia
AKI RRT
Limb Physical examination of 4 DVT; ALI
extremities, DUS
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As per example
L in the literature
A Edwards L Todd
N M. Patient
management :
Neonatal and
pediatric cardiac
ECLS. In :
Brogan TV etal.
Eds. The
extracorporeal
life support the
ELSO red book
5th ed. ISBN
3.Monitoring Daily &
Laboratory
Date/Time Goal Result
Date/Time
Blood Gases: Patient Arterial
Freq
/6 hrs
ECMO Day ...
ECMO pre /12 hrs
Systolic > 90 mmHg
ECMO post /12 hrs
MAP > 65 mmHg
Lactate /12 hrs
CVP 8 – 12 mmHg
Na, K, iCa, Glucose /12 hrs
Temp C0 35.5-37.0 0C
Mg /12 hrs
Patient pH 7.35-7.45
Urea, Creatinine /12 hrs
Patient paCO2 mmHg 35-45 mmHg
LFT(SGOT/SGPT/Albumin/Bil,) /12 hrs
Patient paO2 mmHg >50 mmHg
SvO2 > 60% >65%
CBC (Hb, Ht, L, Plat) /12 hrs
Hematocrit % 32-37% or 42-45%
(single vent) ACT /12 hrs
Coags (PT, APTT, Fibrinogen) /12 hrs
Platelet count mm3 >80.000 – 120.000mm3
AT3 once
D-Dimers 3 days
PT, APTT 1.5 – 2 times control
CRP 3 days
Fibrinogen g/i >150 mg/dl
Cultures (Blood and BAL) 3 days
Antithrombin units/ml 60% - 120% unit/ml
Chest X Ray 24 hrs
Standard heparin titrasi
IU/kg/hour Echo 24 hrs
ACT sec Titrasi Pupils 24hrs
SatO2 > 80% Physician name and signature Bambang W/Vidya GR
Management of anticoagulant
Exposure of blood to the nonbiologic
surfaces of an extracorporeal circuit initiates a
complex inflammatory response involving both the
coagulation and the inflammatory response pathways
(Figure 6-3). This response leads to capillary leak which
can cause temporary dysfunction
of every organ.
Annich GM, Barbaro R, Cornell TT, etal. Adverse Effects of Extracorporeal Life Support: The Blood Biomaterial Interaction. In: Brogan TV etal
eds. The extracorporeal life support the ELSO red book 5th ed. ISBN 978-0-9656756-5-9
https://www.stepwards.com/?
page_id=866#ACTIVATED_PARTIAL_THROMBOPLASTIN_TIME_aPTTPARTIAL_THROMBOPLASTIN_TIME_PTT
Summary
Monitoring all aspect of ECMO is an effort to maintain patient’s safety
Monitoring device categorized into patient related device and Ecmo
related device monitoring. The conclusion must be weigh
comprehensively so that the better result can be achieved
VV and VA ECMO have it’s own characteristic that we should recognize
The best application of daily ECMO contingency plan provide the best
directed therapy
ECMO / ECLS is a life support, therapy of the primary disease entity is
compulsory
