BASIC CRITICAL CARE OF THE PATIENT. Hannelisa Callisen PA C February 2017

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "BASIC CRITICAL CARE OF THE PATIENT. Hannelisa Callisen PA C February 2017"

Transcription

1 BASIC CRITICAL CARE OF THE PATIENT Hannelisa Callisen PA C February 2017

2 Disclosures Industry: None ECMO is off label

3 Objectives ECMO initiation selection, cannulation Physiology : Review of DO2 on ECMO Monitoring on ECMO Bedside management of the ECMO patient Complications 2 ICU patients

4 FIRST.. WHAT IS ECMO? Image credit: S. Conrad

5 42F to ED w/ SOB PMH: Obesity, Pre diabetes Admitted last night for acute hypoxic respiratory failure Intubated, paralyzed On low dose pressors BAL: +H1N1 PIP 40 Vt 210 PEEP 14 RR 32 ABG ph 7.15 paco2 66 pao2 52 SaO2 76 HCO3 19

6 To Cannulate? CURRENT SITUATION: ARDS w/ significant hypercapnia & hypoxia affecting DO2 and end organ function, on maximal vent settings Does she meet criteria? When is the right time to cannulate? What is the likelihood of recovery? PIP 40 Vt 210 PEEP 12 RR 32 ABG ph 7.15 paco2 66 pao2 52 SaO2 76 HCO3 19

7 To Cannulate? SELECTION CRITERIA

8 To Cannulate? SELECTION CRITERIA? Are these specific gas exchange parameters useful?why 7 days of aggressive ventilation?how definite are these contraindications Brodie NEJM 2011

9 To Cannulate? INDICATIONS? Are these specific gas exchange parameters useful GENERAL CRITERIA: Reversible (or transplantable) disease Refractory to maximal conventional therapy High risk of mortality

10 To Cannulate? TIMING TO ECMO?Why 7 days of aggressive ventilation Timing to cannulation / transfer is difficult to discern Trajectory of illness is most important factor Ferguson ND ICM 2012 Rescue therapies for ARDS Moerer. Curr Opin 2016

11 To Cannulate? TIMING TO ECMO?Why 7 days of aggressive ventilation Domico M, Ped Crit Care Med 2012 Nance, J of Ped Surg 2009

12 To Cannulate? CONTRAINDICATIONS?How definite are these contraindications ECMO IS A BRIDGE THERAPY Goal: Buy time for disease process to resolve Avoid injury from other therapies Consider end point & ability to recover and overcome potential complications of ECMO therapy (early) ELSO Guidelines for acute resp failure

13 To Cannulate? PRE ECMO PREDICTORS RESP Score ECMOnet Score Pre ECMO SOFA Score?helpful

14 Rationale for VV ECMO ARDS continues to have high mortality VILI may develop and worsen lung disease ECMO: Puts less dependence on ventilator, reduces transpulmonary pressures Allows DO2 and VO2 to be better controlled and manipulated (even if SaO2 NOT improved) May improve hemodynamics & CO

15 RATIONALE FOR ECMO Improve Cellular Oxygenation DO2 normally 4 5 times that of VO2 Resting VO2: 3 5mL/kg/min for adults DO2 (ml/min) = CO (L/min) x CaO2 (ml O2 / L blood) [1.34 Hgb SaO2] + [0.003 PaO2] OER = VO2 / DO2 [Normal~25%] CO (L/min) x CaO2 CvO2 (ml O2 / L blood) = VO2 (ml/min) Cells determined by tissue metabolic rate

16 RATIONALE FOR ECMO Improve Cellular Oxygenation DO2 normally 4 5 times that of VO2 Resting VO2: 3 5mL/kg/min for adults OER = VO2 / DO2 [Normal~25%] If DO2:VO2 is < 2:1 Anaerobic Metabolism ILLNESS SvO2 < 50 60% DO2crit ~4mL/kg/min Monitoring DO2 in the crit ill Huang. Chest 2005 O2 delivery and consumption, macrocirc perpective Nichols. Crit Care Clin 2010

17 VV ECMO NO cardiac support NO in pulmonary blood flow Configura on Usually PARTIAL pulmonary support Based on ECBF : CO Ratio ECMO flow Venous Admixture Outlet / Return Native Lung Function Recirculation Patient Cardiac Output VV perfusate mixes with mixed venous blood return, bypassed by ECMO Venous Admixture Inlet / Drainage Venous Return mixed Cells Bypassed Venous Flow

18 VV ECMO Cannulation SINGLE SITE CANNULATION DUAL SITE CANNULATION ECMO in CP disease in adults Abrams. JACC 2014

19 ECMO CIRCUIT Cannula Biggest, shortest cannula = least resistance to flow Appropriate cannula selection is critical! ECMO for adult resp failure Turner. Resp Care 2013

20 ECMO CIRCUIT Tubing PVC TUBING Neonates: 1/4 inch Peds: 3/8 inch Adults: 3/8 1/2 inch TUBING SIZE SV (ml/rpm) PRIME VOLUME MAX ART FLOW MAX VEN FLOW 1/4 inch 13ml 9.65ml/ft 3 LPM 1.3 LPM 3/8 inch 27ml 21.71ml/ft 8 LPM 4 :PM Biocompatible surface coating

21 ECMO CIRCUIT Pump CENTRIFUGAL PUMP Non occlusive pump Pre load sensitive Afterload dependent (must overcome positive resistance) Flow RPM Impeller design Magnetically coupled to motor NO Direct relationship between RPM and Flow Flowmeter is necessary

22 ECMO CIRCUIT Oxygenator MICROPOUROUS HOLLOW FIBER Polymethylpentene Gas inside fibers, blood on outside Low pressure drop across membrane Very small nano pore size Rare plasma leakage High gas permeability Rated flow Maquet.com

23 ECMO CIRCUIT Heat Exchanger Integrated in hollow fiber membrane lungs External water bath warms blood Bath temp usually set C above 37 C

24 ECMO CIRCUIT Gas Blender Connected to oxygenator Mixes air and oxygen O2 Dial for FiO2 (0 100%) Connects to 30 70PSI inlet Air Gas flow = Sweep 2 dials 0 10 LPM

25 Cannulated for VV ECMO using fem fem approach Sedated, paralyzed 42F w/ ARDS on VV ECMO ABG BP: 78/50 (60) on Norepinephrine HR: 100 CVP: 16 SWEEP FiO2 ph 7.29 paco2 42 pao2 59 SaO2 88 HCO3 17 Lactate 4.1 FLOW: RPM:

26 42F w/ ARDS on VV ECMO What is most concerning? What are we missing here? What do we address first? vent?? ABG BP: 78/50 (60) on Norepinephrine HR: 100 CVP: 16 SWEEP FiO2 ph 7.29 paco2 42 pao2 58 SaO2 87 HCO3 17 Lactate 4.1 FLOW: RPM:

27 42F w/ ARDS on VV ECMO

28 PATIENT A B C Vitals / Pressures / Waveforms SpO2 RR HR BP CVP Physical Exam IMAGING MEDS LABS CO VO2 CANNULAS TUBING FLOWS PRESSURES OXYGEN ATOR PUMP CaO2 ECMO VENTILATOR INTERACTION GAS EXCHANGE FiO 2 PEEP RR V T PIP

29 Oxygen Delivery ON VV ECMO DO2 = CaO2 CO native cardiac function

30 VV Air/O2 Blender MO V A Motor Pump S inlet O2 MO FiO2 MO Dynamics Blood Flow Rate membrane oxygenated blood For Best Ratio: Effec ve ECBF Recircula on CO true S V O2 Lung Function Ventilator Settings lung oxygenated blood

31 Blood Viscosity Blender / O2 Blood Flow : CO Ratio?OK OK MO Dynamics Membrane thickness Membrane Surface Area Diffusion capacity OK OK Lung Function MINIMAL, but that is OK! True SvO2 LOW: due to shock, VO2 Recirculation Fraction HIGH: Due to PTX Cells Oxygen Delivery Adequate CO NO: Obstructive shock due to PTX & high PIP Hemoglobin?OK NEEDS CHEST TUBE!

32 Mechanical Ventilation ON VV ECMO

33 38M w/ NIMCP Code Blue PEA ARREST Admitted 1 day ago w/ decompensated HF Hx of dilated CMP (non ischemic, previous viral) CPR ROSC Ends up on high dose inotropes Hypoxic & Acidemic ABG ph 7.20 paco2 36 pao2 50 SaO2 86 HCO3 12 Lactate 11? VA ECMO

34 38M w/ NIMCP Code Blue? VA ECMO INDICATIONS CONTRAINDICATIONS CONSIDERATIONS

35 38M w/ NIMCP Code Blue ECMO in CP disease in adults Abrams. JACC 2014

36 Outcomes FOR VA ECMO

37 VA ECMO Configura on Inlet / Drainage in pulmonary blood flow ECMO flow Outlet / Return Cardiac bypass support (partial to sub total) Total CO = Native CO + ECBF Native Lung Function Native Cardiac Output Arterial oxygenation: Dependent on sample location (in relation to mixing cloud) Mixture of ECLS perfusate and natively oxygenated blood in aorta Venous Return mixed Mixing Cloud Cells

38 VA ECMO Peripheral Cannulation ECMO in CP disease in adults Abrams. JACC 2014

39 DO2 = C Nat O2 CO Nat + C ECMO O2 ECBF VA V A S V O2 Lung Function Ventilator Settings lung oxygenated blood Ratio Native CO : ECBF membrane oxygenated blood S V O2 MO FiO2 MO Dynamics Native CO + ECBF

40 38M w/ Card Shock on VA ECMO What to do with inotropes? How to approach hypoxia? What is an acceptable SaO2? How to manage ventilator?

41 38M w/ Card Shock on VA ECMO With most inotropes off:

42 LV Distention ON PERIPHERAL VA ECMO Risk of LV thrombosis Pulmonary Edema LV Failure

43 CHEST TUBE now in place 42F w/ ARDS on VV ECMO BP: 110/50(70) HR: 120 CVP: 11 SaO2: 83% What SaO2 is acceptable? If DO2 inadequate, how can it be improved?

44 Lung Function Oxygen Delivery Adequate CO Blood Flow : CO Ratio Hemoglobin Blood Viscosity Blender / O2 MO Dynamics Membrane thickness Membrane Surface Area Diffusion capacity True SvO2 Recirculation Fraction Cells

45 VV ECBF DETERMINANTS AND LIMITATIONS Effective

46 Recirculation CAUSES 1. RPM 2. Cannula Positioning 3. Venous Chamber Compliance 4. Low CO

47 38M w/ Card Shock on VA ECMO Inotropes increased to arterial pulsatility (native CO) Ventilator Settings decreased (FiO2 50%, PEEP 5) BP: 72/60 (64) SaO2: 80%

48 Differential Hypoxia ON PERIPHERAL VA ECMO C. Lotz Circulation 2014

49 VV & VA side by side IN SERIES Cells Cells IN PARALLEL

50 Complications, Considerations Bleeding, Hemolysis, Thrombosis Renal Failure Pharmacy Neurocognitive Limb perfusion Nursing care Team Cost

51 Complications, Considerations Lim ECLS physiological concepts and clinical outcomes. J of Card Failure 2016

52 Final Thoughts ECMO: Physiology is complex! Needs meticulous consideration of risks, potential for recovery (or transplant), & co morbidities Is resource intensive & costly Best practiced at experienced, high volume centers w/ well trained team members (that means everyone involved)

53 PATIENT A B C Vitals / Pressures / Waveforms SpO2 RR HR BP CVP Physical Exam IMAGING MEDS LABS CO VO2 CANNULAS TUBING FLOWS PRESSURES OXYGEN ATOR PUMP CaO2 ECMO VENTILATOR INTERACTION GAS EXCHANGE FiO 2 PEEP RR V T PIP

54 THANK YOU

ECLS Registry Form Extracorporeal Life Support Organization (ELSO)

ECLS Registry Form Extracorporeal Life Support Organization (ELSO) ECLS Registry Form Extracorporeal Life Support Organization (ELSO) Center ID: Center name: Run No (for this patient) Unique ID: Birth Date/Time Sex: (M, F) Race: (Asian, Black, Hispanic, White, Other)

More information

CASE PRESENTATION VV ECMO

CASE PRESENTATION VV ECMO CASE PRESENTATION VV ECMO Joshua Huelster, MD Fellow in Critical Care Medicine Department of Pulmonary and Critical Care Medicine Hennepin County Medical Center Disclosure There are no conflicts of interest

More information

ECMO for Refractory Septic Shock Prof. Alain Combes

ECMO for Refractory Septic Shock Prof. Alain Combes ECMO for Refractory Septic Shock Prof. Alain Combes Service de Réanimation ican, Institute of Cardiometabolism and Nutrition Hôpital Pitié-Salpêtrière, AP-HP, Paris Université Pierre et Marie Curie, Paris

More information

Introduction. Invasive Hemodynamic Monitoring. Determinants of Cardiovascular Function. Cardiovascular System. Hemodynamic Monitoring

Introduction. Invasive Hemodynamic Monitoring. Determinants of Cardiovascular Function. Cardiovascular System. Hemodynamic Monitoring Introduction Invasive Hemodynamic Monitoring Audis Bethea, Pharm.D. Assistant Professor Therapeutics IV January 21, 2004 Hemodynamic monitoring is necessary to assess and manage shock Information obtained

More information

Extracorporeal Membrane Oxygenation (ECMO)

Extracorporeal Membrane Oxygenation (ECMO) Extracorporeal Membrane Oxygenation (ECMO) Policy Number: Original Effective Date: MM.12.006 05/16/2006 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 01/01/2017 Section: Other/Miscellaneous

More information

PEEP recruitment maneuver

PEEP recruitment maneuver Robert M. Rodriguez, MD FAAEM Clinical Professor of Medicine and Emergency Medicine, UCSF Case 1: 40 yo Male restrained driver high speed MVA P 140, RR 40 labored, BP 100/70, O 2 sat 70 Chest wheeze, crackles

More information

Extracorporeal Membrane Oxygenation (ECMO)

Extracorporeal Membrane Oxygenation (ECMO) Extracorporeal Membrane Oxygenation (ECMO) Policy Number: Original Effective Date: MM.12.006 05/16/2006 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 11/01/2014 Section: Other/Miscellaneous

More information

Ventilator ECMO Interactions

Ventilator ECMO Interactions Ventilator ECMO Interactions Lorenzo Del Sorbo, MD CCCF Toronto, October 2 nd 2017 Disclosure Relevant relationships with commercial entities: none Potential for conflicts within this presentation: none

More information

ECMO Primer A View to the Future

ECMO Primer A View to the Future ECMO Primer A View to the Future Todd J. Kilbaugh Assistant Professor of Anesthesiology, Critical Care Medicine, and Pediatrics Director of The ECMO Center at the Children s Hospital of Philadelphia Disclosures

More information

ECLS as Bridge to Transplant

ECLS as Bridge to Transplant ECLS as Bridge to Transplant Marcelo Cypel MD, MSc Assistant Professor of Surgery Division of Thoracic Surgery Toronto General Hospital University of Toronto Application of ECLS Bridge to lung recovery

More information

Prepared by : Bayan Kaddourah RN,MHM. GICU Clinical Instructor

Prepared by : Bayan Kaddourah RN,MHM. GICU Clinical Instructor Mechanical Ventilation Prepared by : Bayan Kaddourah RN,MHM. GICU Clinical Instructor 1 Definition Is a supportive therapy to facilitate gas exchange. Most ventilatory support requires an artificial airway.

More information

ECMO for Severe Hypoxemic Respiratory Failure: Pro-Con Debate. Carolyn Calfee, MD MAS Mark Eisner, MD MPH

ECMO for Severe Hypoxemic Respiratory Failure: Pro-Con Debate. Carolyn Calfee, MD MAS Mark Eisner, MD MPH ECMO for Severe Hypoxemic Respiratory Failure: Pro-Con Debate Carolyn Calfee, MD MAS Mark Eisner, MD MPH June 3, 2010 Case Presentation Setting: Community hospital, November 2009 29 year old woman with

More information

Extracorporeal Life Support Organization (ELSO) Guidelines for Pediatric Respiratory Failure

Extracorporeal Life Support Organization (ELSO) Guidelines for Pediatric Respiratory Failure Extracorporeal Life Support Organization (ELSO) Guidelines for Pediatric Respiratory Failure Introduction This pediatric respiratory failure guideline is a supplement to ELSO s General Guidelines for all

More information

Mechanical ventilation induced or exacerbated right ventricular failure

Mechanical ventilation induced or exacerbated right ventricular failure Mechanical ventilation induced or exacerbated right ventricular failure Toronto 2016 Jesse Hall MD Professor of Medicine, Anesthesia & Critical Care University of Chicago Faculty Disclosures Dr. Hall

More information

10/16/2017. Review the indications for ECMO in patients with. Respiratory failure Cardiac failure Cardiorespiratory failure

10/16/2017. Review the indications for ECMO in patients with. Respiratory failure Cardiac failure Cardiorespiratory failure Review the indications for ECMO in patients with Respiratory failure Cardiac failure Cardiorespiratory failure 1 Extracorporeal membrane lung and/or cardiac support. A support therapy, in no way definitive.

More information

Echo assessment of patients with an ECMO device

Echo assessment of patients with an ECMO device Echo assessment of patients with an ECMO device Evangelos Leontiadis Cardiologist 1st Cardiology Dept. Onassis Cardiac Surgery Center Athens, Greece Gibbon HLM 1953 Goldstein DJ et al, NEJM 1998; 339:1522

More information

Rounds in the ICU. Eran Segal, MD Director General ICU Sheba Medical Center

Rounds in the ICU. Eran Segal, MD Director General ICU Sheba Medical Center Rounds in the ICU Eran Segal, MD Director General ICU Sheba Medical Center Real Clinical cases (including our mistakes) Emphasis on hemodynamic monitoring Usually no single correct answer We will conduct

More information

ARDS: The Evidence. Topics. New definition Breaths: Little or Big? Wet or Dry? Moving or Still? Upside down or Right side up?

ARDS: The Evidence. Topics. New definition Breaths: Little or Big? Wet or Dry? Moving or Still? Upside down or Right side up? ARDS: The Evidence Todd M Bull MD Professor of Medicine Division of Pulmonary Sciences and Critical Care Division of Cardiology Director Pulmonary Vascular Disease Center Director Center for Lungs and

More information

5. What is the cause of this patient s metabolic acidosis? LACTIC ACIDOSIS SECONDARY TO ANEMIC HYPOXIA (HIGH CO LEVEL)

5. What is the cause of this patient s metabolic acidosis? LACTIC ACIDOSIS SECONDARY TO ANEMIC HYPOXIA (HIGH CO LEVEL) Self-Assessment RSPT 2350: Module F - ABG Analysis 1. You are called to the ER to do an ABG on a 40 year old female who is C/O dyspnea but seems confused and disoriented. The ABG on an FiO 2 of.21 show:

More information

PATIENT SELECTION FOR ACUTE APPLICATION OF ECMO, ECCOR, ETC.

PATIENT SELECTION FOR ACUTE APPLICATION OF ECMO, ECCOR, ETC. PATIENT SELECTION FOR ACUTE APPLICATION OF ECMO, ECCOR, ETC. J. CHRISTOPHER FARMER, MD PROFESSOR OF MEDICINE CHAIR OF CRITICAL CARE MEDICINE MAYO CLINIC PHOENIX, AZ Dr. Chris Farmer is a critical care

More information

Application of Lung Protective Ventilation MUST Begin Immediately After Intubation

Application of Lung Protective Ventilation MUST Begin Immediately After Intubation Conflict of Interest Disclosure Robert M Kacmarek Managing Severe Hypoxemia!" 9-28-17 FOCUS Bob Kacmarek PhD, RRT Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts I disclose

More information

DO 2 > VO 2. The amount of oxygen delivered is a product of cardiac output (L/min) and the amount of oxygen in the arterial blood (ml/dl).

DO 2 > VO 2. The amount of oxygen delivered is a product of cardiac output (L/min) and the amount of oxygen in the arterial blood (ml/dl). Shock (Part 1): Review and Diagnostic Approach Jeffrey M. Todd, DVM, DACVECC University of Minnesota, St. Paul, MN Overview Shock is the clinical presentation of inadequate oxygen utilization, typically

More information

The Association Between Oxygenation Thresholds and Mortality During Extracorporeal Life Support

The Association Between Oxygenation Thresholds and Mortality During Extracorporeal Life Support The Association Between Oxygenation Thresholds and Mortality During Extracorporeal Life Support Laveena Munshi, MD, MSc November 1, 2016 Critical Care Canada Forum Interdepartmental Division of Critical

More information

Capnography: The Most Vital of Vital Signs. Tom Ahrens, PhD, RN, FAAN Research Scientist, Barnes-Jewish Hospital, St. Louis, MO May, 2017

Capnography: The Most Vital of Vital Signs. Tom Ahrens, PhD, RN, FAAN Research Scientist, Barnes-Jewish Hospital, St. Louis, MO May, 2017 Capnography: The Most Vital of Vital Signs Tom Ahrens, PhD, RN, FAAN Research Scientist, Barnes-Jewish Hospital, St. Louis, MO May, 2017 Assessing Ventilation and Blood Flow with Capnography Capnography

More information

Practical issues in ScvO2 monitoring

Practical issues in ScvO2 monitoring Practical issues in ScvO2 monitoring Prof. Jan Bakker MD PhD Chair dept of Intensive Care jan.bakker@erasmusmc.nl 1 Supply-Demand 2 TO 2 = Hb x SaO 2 x CO x ζ OXYGEN DEMAND OXYGEN SUPPLY 3 Oxygen Extraction

More information

Extracorporeal Life Support Organization (ELSO) General Guidelines for all ECLS Cases August, 2017

Extracorporeal Life Support Organization (ELSO) General Guidelines for all ECLS Cases August, 2017 Extracorporeal Life Support Organization (ELSO) Introduction General Guidelines for all ECLS Cases August, 2017 This guideline describes prolonged extracorporeal life support (ECLS, ECMO), applicable to

More information

Assist Devices in STEMI- Intra-aortic Balloon Pump

Assist Devices in STEMI- Intra-aortic Balloon Pump Assist Devices in STEMI- Intra-aortic Balloon Pump Ioannis Iakovou, MD, PhD Onassis Cardiac Surgery Center Athens, Greece Cardiogenic shock 5-10% of pts after a heart attack 60000-70000 pts in Europe/year

More information

Obligatory joke. The case for why it matters. Sepsis: More is more. Goal-Directed Fluid Resuscitation 6/1/2013

Obligatory joke. The case for why it matters. Sepsis: More is more. Goal-Directed Fluid Resuscitation 6/1/2013 Obligatory joke Keep your eye on the food. Goal-Directed Fluid Resuscitation Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care University of California, San Francisco The

More information

Goal Directed Perfusion: theory, clinical results, and key rules

Goal Directed Perfusion: theory, clinical results, and key rules Goal Directed Perfusion: theory, clinical results, and key rules M. Ranucci Director of Clinical Research Dept of Cardiothoracic and Vascular Anesthesia and Intensive Care IRCCS Policlinico S.Donato Ranuuci,

More information

Extracorporeal Life Support Organization (ELSO) Guidelines for Adult Respiratory Failure August, 2017

Extracorporeal Life Support Organization (ELSO) Guidelines for Adult Respiratory Failure August, 2017 Introduction Extracorporeal Life Support Organization (ELSO) Guidelines for Adult Respiratory Failure August, 2017 This guideline describes prolonged extracorporeal life support (ECLS, ECMO), applicable

More information

ECMO & Renal Failure Epidemeology Renal failure & effect on out come

ECMO & Renal Failure Epidemeology Renal failure & effect on out come ECMO Induced Renal Issues Transient renal dysfunction Improvement in renal function ECMO & Renal Failure Epidemeology Renal failure & effect on out come With or Without RRT Renal replacement Therapy Utilizes

More information

Which mechanical assistance for cardiogenic shock?

Which mechanical assistance for cardiogenic shock? Which mechanical assistance for cardiogenic shock? Alain Combes, MD, PhD, Hôpital Pitié-Salpêtrière, AP-HP Inserm UMRS 1166, ican, Institute of Cardiometabolism and Nutrition Pierre et Marie Curie Sorbonne

More information

Evolution of ECLS. 04/22/2016 Updated. AllinaHealthSystem. Minneapolis ECMO Early history. ELSO Member Centers

Evolution of ECLS. 04/22/2016 Updated. AllinaHealthSystem. Minneapolis ECMO Early history. ELSO Member Centers Evolution of ECLS Minneapolis 2016 Boston Children s Hospital Surgical Staff 1965 ECMO Early history Lab, 4 days ECC First cardiac case First newborn case(esperanza) 1965 1971 1972 1975 1980 First sucessful

More information

Recognizing the Need to Support A Failing Right Ventricular Role of Mechanical Support

Recognizing the Need to Support A Failing Right Ventricular Role of Mechanical Support Recognizing the Need to Support A Failing Right Ventricular Role of Mechanical Support Mahir Elder, MD, FACC,SCAI Medical Direct of PERT program Medical Director of Endovascular medicine Clinical Professor

More information

FloTrac Sensor and Edwards PreSep Central Venous Oximetry Catheter Case Presentations

FloTrac Sensor and Edwards PreSep Central Venous Oximetry Catheter Case Presentations Edwards FloTrac Sensor & Edwards Vigileo Monitor FloTrac Sensor and Edwards PreSep Central Venous Oximetry Catheter Case Presentations 1 Topics System Configuration FloTrac Sensor and PreSep Catheter Thoracotomy

More information

CENTRAL ECMO WHEN AND HOW? RANJIT JOHN, MD UNIVERSITY OF MINESOTA

CENTRAL ECMO WHEN AND HOW? RANJIT JOHN, MD UNIVERSITY OF MINESOTA CENTRAL ECMO WHEN AND HOW? RANJIT JOHN, MD UNIVERSITY OF MINESOTA Background How to do Case reports When to do Managing complications Post operative management strategies CASE PRESENTATION 46 year old

More information

NUTRITION SUPPORT DURING EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) IN CRITICALLY ILL ADULT PATIENTS. Haley Murrell, March 19, 2015

NUTRITION SUPPORT DURING EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) IN CRITICALLY ILL ADULT PATIENTS. Haley Murrell, March 19, 2015 NUTRITION SUPPORT DURING EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) IN CRITICALLY ILL ADULT PATIENTS Haley Murrell, March 19, 2015 Objectives Provide an overview of Extracorporeal Membrane Oxygenation

More information

Part 2 of park s Ventilator and ARDS slides for syllabus

Part 2 of park s Ventilator and ARDS slides for syllabus Part 2 of park s Ventilator and ARDS slides for syllabus Early Neuromuscular Blockade Question 4 The early use of cis-atracurium in severe ARDS is: A. Contraindicated in patients with diabetes B. Associated

More information

Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.

Images have been removed from the PowerPoint slides in this handout due to copyright restrictions. Arterial Blood Gas Interpretation Routine Assessment Inspection Palpation Auscultation Labs Na 135-145 K 3.5-5.3 Chloride 95-105 CO2 22-31 BUN 10-26 Creat.5-1.2 Glu 80-120 Arterial Blood Gases WBC 5-10K

More information

Optimize vent weaning and SBT outcomes. Identify underlying causes for SBT failures. Role SBT and weaning protocol have in respiratory care

Optimize vent weaning and SBT outcomes. Identify underlying causes for SBT failures. Role SBT and weaning protocol have in respiratory care Optimize vent weaning and SBT outcomes Identify underlying causes for SBT failures Role SBT and weaning protocol have in respiratory care Lower risk of developing complications Lower risk of VAP, other

More information

ARDS AND ECLS DEPARTMENT OF CRITICAL CARE JOSHUA HUELSTER, MD ABBOTT NORTHWESTERN HOSPITAL

ARDS AND ECLS DEPARTMENT OF CRITICAL CARE JOSHUA HUELSTER, MD ABBOTT NORTHWESTERN HOSPITAL ARDS AND ECLS JOSHUA HUELSTER, MD DEPARTMENT OF CRITICAL CARE ABBOTT NORTHWESTERN HOSPITAL DISCLOSURES I have no financial disclosures I have no conflicts of interest I have my own biases (we all do) OBJECTIVES

More information

Introduction to Cardiopulmonary Bypass. Syllabus for TSDA Boot Camp Ron Angona, Perfusionist University of Rochester Medical Center

Introduction to Cardiopulmonary Bypass. Syllabus for TSDA Boot Camp Ron Angona, Perfusionist University of Rochester Medical Center Introduction to Cardiopulmonary Bypass Syllabus for TSDA Boot Camp Ron Angona, Perfusionist University of Rochester Medical Center Why CPB To facilitate a surgical intervention Provide a motionless field

More information

Chapter 21. Flail Chest. Mosby items and derived items 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 21. Flail Chest. Mosby items and derived items 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 21 Flail Chest 1 Figure 21-1. Flail chest. Double fractures of three or more adjacent ribs produce instability of the chest wall and paradoxical motion of the thorax. Inset, Atelectasis, a common

More information

Sepsis. From EMS to ER to ICU. What we need to be doing

Sepsis. From EMS to ER to ICU. What we need to be doing Sepsis From EMS to ER to ICU What we need to be doing NEHAL BHATT, MD ATHENS PULMONARY, CRITICAL CARE AND SLEEP Objectives 1. Define the changes to the definition of Sepsis 2. Describe the assessment,

More information

Disclosures. Extra-Corporeal Membrane Oxygenation During Cardio- Pulmonary Resuscitation ECPR April 22, 2016 ECG. Case. Case. Case Summary 4/22/2016

Disclosures. Extra-Corporeal Membrane Oxygenation During Cardio- Pulmonary Resuscitation ECPR April 22, 2016 ECG. Case. Case. Case Summary 4/22/2016 Extra-Corporeal Membrane Oxygenation During Cardio- Pulmonary Resuscitation ECPR April 22, 2016 Nothing to disclose. Disclosures Ivan J Chavez MD Case ECG History 60 y/o male No prior history of CAD In

More information

IN THE NAME OF GOD SHOCK MANAGMENT OMID MORADI MOGHADDAM,MD,FCCM IUMS ASSISTANT PROFESSOR

IN THE NAME OF GOD SHOCK MANAGMENT OMID MORADI MOGHADDAM,MD,FCCM IUMS ASSISTANT PROFESSOR IN THE NAME OF GOD SHOCK MANAGMENT OMID MORADI MOGHADDAM,MD,FCCM IUMS ASSISTANT PROFESSOR The ability to evaluate and manage a critically ill patient is one of the most important skills any intensivist

More information

Interesting Capnography Cases

Interesting Capnography Cases Interesting Capnography Cases Mike McEvoy, PhD, NRP, RN, CCRN Cardiac Surgical ICU RN & Chair Resuscitation Committee Albany Medical Center EMS Coordinator Saratoga County, NY www.mikemcevoy.com Outline

More information

Surviving Sepsis Campaign. Guidelines for Management of Severe Sepsis/Septic Shock. An Overview

Surviving Sepsis Campaign. Guidelines for Management of Severe Sepsis/Septic Shock. An Overview Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock An Overview Mechanical Ventilation of Sepsis-Induced ALI/ARDS ARDSnet Mechanical Ventilation Protocol Results: Mortality

More information

Capnography 101. James A Temple BA, NRP, CCP

Capnography 101. James A Temple BA, NRP, CCP Capnography 101 James A Temple BA, NRP, CCP Expected Outcomes 1. Gain a working knowledge of the physiology and science behind End-Tidal CO2. 2.Relate End-Tidal CO2 to ventilation, perfusion, and metabolism.

More information

Effects of mechanical ventilation on organ function. Masterclass ICU nurses

Effects of mechanical ventilation on organ function. Masterclass ICU nurses Effects of mechanical ventilation on organ function Masterclass ICU nurses Case Male, 60 - No PMH - L 1.74 m and W 85 kg Pneumococcal pneumonia Stable hemodynamics - No AKI MV in prone position (PEEP 16

More information

Goal-directed vs Flow-guidedresponsive

Goal-directed vs Flow-guidedresponsive Goal-directed vs Flow-guidedresponsive therapy S Magder Department of Critical Care, McGill University Health Centre Flow-directed vs goal directed strategy for management of hemodynamics S Magder Curr

More information

An early warning indicator of tissue hypoxia.

An early warning indicator of tissue hypoxia. An early warning indicator of tissue hypoxia. Continuous ScvO2 monitoring with the PreSep oximetry catheter Are your vital signs telling you everything? Valuable time may be lost before traditional vital

More information

UNUSUAL INDICATIONS FOR ECMO

UNUSUAL INDICATIONS FOR ECMO DISCLOSURE UNUSUAL INDICATIONS FOR ECMO DAVE WILLIAMS D.O. INTENSIVIST AT ABBOTT NORTHWESTERN HOSPITAL There are no conflicts of interest or relevant financial interests in making this presentation and

More information

Modern Left Ventricular Assist Devices (LVAD) : An Intro, Complications, and Emergencies

Modern Left Ventricular Assist Devices (LVAD) : An Intro, Complications, and Emergencies Modern Left Ventricular Assist Devices (LVAD) : An Intro, Complications, and Emergencies ERIC T. ROME D.O. HEART FAILURE, MECHANICAL ASSISTANCE AND TRANSPLANTATION CVI Left Ventricular Assist Device An

More information

Hemodynamic Monitoring and Circulatory Assist Devices

Hemodynamic Monitoring and Circulatory Assist Devices Hemodynamic Monitoring and Circulatory Assist Devices Speaker: Jana Ogden Learning Unit 2: Hemodynamic Monitoring and Circulatory Assist Devices Hemodynamic monitoring refers to the measurement of pressure,

More information

ENDPOINTS OF RESUSCITATION

ENDPOINTS OF RESUSCITATION ENDPOINTS OF RESUSCITATION Fred Pieracci, MD, MPH Acute Care Surgeon Denver Health Medical Center Assistant Professor of Surgery University of Colorado Health Science Center OUTLINE Recognition and characterization

More information

Basics of Cardiopulmonary Exercise Test Interpretation. Robert Kempainen, MD Hennepin County Medical Center

Basics of Cardiopulmonary Exercise Test Interpretation. Robert Kempainen, MD Hennepin County Medical Center Basics of Cardiopulmonary Exercise Test Interpretation Robert Kempainen, MD Hennepin County Medical Center None Conflicts of Interest Objectives Explain what normally limits exercise Summarize basic protocol

More information

Wet Lungs Dry lungs Impact on Outcome in ARDS. Charlie Phillips MD Division of PCCM OHSU 2009

Wet Lungs Dry lungs Impact on Outcome in ARDS. Charlie Phillips MD Division of PCCM OHSU 2009 Wet Lungs Dry lungs Impact on Outcome in ARDS Charlie Phillips MD Division of PCCM OHSU 2009 Today s talk Pathophysiology of ARDS The case for dry Targeting EVLW Disclosures Advisor for Pulsion Medical

More information

Mechanical circulatory support in cardiogenic shock The Cardiologist s view ACCA Masterclass 2017

Mechanical circulatory support in cardiogenic shock The Cardiologist s view ACCA Masterclass 2017 Mechanical circulatory support in cardiogenic shock The Cardiologist s view ACCA Masterclass 2017 Pascal Vranckx MD, PhD. Medical director Cardiac Critical Care Services Hartcentrum Hasselt Belgium Disclosure

More information

Noninvasive Ventilation: Non-COPD Applications

Noninvasive Ventilation: Non-COPD Applications Noninvasive Ventilation: Non-COPD Applications NONINVASIVE MECHANICAL VENTILATION Why Noninvasive Ventilation? Avoids upper A respiratory airway trauma system lacerations, protective hemorrhage strategy

More information

Sepsis Update: Focus on Early Recognition and Intervention. Disclosures

Sepsis Update: Focus on Early Recognition and Intervention. Disclosures Sepsis Update: Focus on Early Recognition and Intervention Jessie Roske, MD October 2017 Disclosures I have no actual or potential conflict of interest in relation to this program/presentation. I will

More information

What is sepsis? RECOGNITION. Sepsis I Know It When I See It 9/21/2017

What is sepsis? RECOGNITION. Sepsis I Know It When I See It 9/21/2017 Sepsis I Know It When I See It September 15, 2017 Matthew Exline, MD MPH Medical Director, Medical ICU What is sepsis? I shall not today attempt further to define the kinds of material [b]ut I know it

More information

CRRT Fundamentals Pre- and Post- Test. AKI & CRRT Conference 2018

CRRT Fundamentals Pre- and Post- Test. AKI & CRRT Conference 2018 CRRT Fundamentals Pre- and Post- Test AKI & CRRT Conference 2018 Question 1 Which ONE of the following statements regarding solute clearance in CRRT is MOST correct? A. Convective and diffusive solute

More information

Case Scenario 3: Shock and Sepsis

Case Scenario 3: Shock and Sepsis Name: Molly Boyle 1. Define the term shock (Lewis textbook): Shock is a syndrome characterized by decreased perfusion and impaired metabolism. Shock can have a number of causes that result in damage to

More information

In-hospital Care of the Post-Cardiac Arrest Patient. David A. Pearson, MD, FACEP, FAAEM Associate Program Director Department of Emergency Medicine

In-hospital Care of the Post-Cardiac Arrest Patient. David A. Pearson, MD, FACEP, FAAEM Associate Program Director Department of Emergency Medicine In-hospital Care of the Post-Cardiac Arrest Patient David A. Pearson, MD, FACEP, FAAEM Associate Program Director Department of Emergency Medicine Disclosures I have no financial interest, arrangement,

More information

Saving Lives with Capnography

Saving Lives with Capnography Saving Lives with Capnography Mike McEvoy, PhD, NRP, RN, CCRN Cardiac Surgical ICU RN & Chair Resuscitation Committee Albany Medical Center EMS Coordinator Saratoga County, NY www.mikemcevoy.com CO 2 In

More information

Acute heart failure: ECMO Cardiology & Vascular Medicine 2012

Acute heart failure: ECMO Cardiology & Vascular Medicine 2012 Acute heart failure: ECMO Cardiology & Vascular Medicine 2012 Lucia Jewbali cardiologist-intensivist 14 beds/8 ICU beds Acute coronary syndromes Heart failure/ Cardiogenic shock Post cardiotomy Heart

More information

Sample Case Study. The patient was a 77-year-old female who arrived to the emergency room on

Sample Case Study. The patient was a 77-year-old female who arrived to the emergency room on Sample Case Study The patient was a 77-year-old female who arrived to the emergency room on February 25 th with a chief complaint of shortness of breath and a deteriorating pulmonary status along with

More information

Extracorporeal Life Support Organization (ELSO)

Extracorporeal Life Support Organization (ELSO) Extracorporeal Life Support Organization (ELSO) ELSO Registry Data Definitions 2/1/2018 For all comments, questions and concerns please email Peter Rycus at prycus@elso.org 1 Preface This document is intended

More information

Best of Pulmonary Jennifer R. Hucks, MD University of South Carolina School of Medicine

Best of Pulmonary Jennifer R. Hucks, MD University of South Carolina School of Medicine Best of Pulmonary 2012-2013 Jennifer R. Hucks, MD University of South Carolina School of Medicine Topics ARDS- Berlin Definition Prone Positioning For ARDS Lung Protective Ventilation In Patients Without

More information

The Case for ECCO 2 R

The Case for ECCO 2 R The Case for ECCO 2 R Extracorporeal CO 2 Removal in Acute Respiratory Failure Disclaimer The information in this presentation is provided by ALung Technologies for the purpose of educating health care

More information

Nurse Driven Fluid Optimization Using Dynamic Assessments

Nurse Driven Fluid Optimization Using Dynamic Assessments Nurse Driven Fluid Optimization Using Dynamic Assessments 2016 1 WHAT WE BELIEVE We believe that clinicians make vital fluid and drug decisions every day with limited and inconclusive information Cheetah

More information

Jennifer A. Brown The Cleveland Clinic School of Perfusion Cleveland, Ohio

Jennifer A. Brown The Cleveland Clinic School of Perfusion Cleveland, Ohio Biventricular Heart Failure Advanced Treatment Options at The Cleveland Clinic Jennifer A. Brown The Cleveland Clinic School of Perfusion Cleveland, Ohio I have no disclosures. Examine respiratory and

More information

1. When a patient fails to ventilate or oxygenate adequately, the problem is caused by pathophysiological factors such as hyperventilation.

1. When a patient fails to ventilate or oxygenate adequately, the problem is caused by pathophysiological factors such as hyperventilation. Chapter 1: Principles of Mechanical Ventilation TRUE/FALSE 1. When a patient fails to ventilate or oxygenate adequately, the problem is caused by pathophysiological factors such as hyperventilation. F

More information

to optimize mechanical ventilation

to optimize mechanical ventilation ILLUSTRATION BY ROY SCOTT Using ABGs to optimize mechanical ventilation Three case studies illustrate how arterial blood gas analyses can guide appropriate ventilator strategy. By Jin Xiong Lian, BSN,

More information

9/13/2015. Laboratory. HPI and PE

9/13/2015. Laboratory. HPI and PE Critical Care HPI and PE 74 yo male confused SBP 90/20 MAP50, P 122, RR 34 Ox1 w/o nuchal rigidity S1S2 wo m RLL reduced breath sounds Skin warm dry Laboratory» WBC 15,600 Hgb 8.4 HCt 23%, Plts 95000,

More information

Fluid Resuscitation in Critically Ill Patients with Acute Kidney Injury (AKI)

Fluid Resuscitation in Critically Ill Patients with Acute Kidney Injury (AKI) Fluid Resuscitation in Critically Ill Patients with Acute Kidney Injury (AKI) Robert W. Schrier, MD University of Colorado School of Medicine Denver, Colorado USA Prevalence of acute renal failure in Intensive

More information

Case - Advanced HF and Shock (INTERMACS 1)

Case - Advanced HF and Shock (INTERMACS 1) Case - Advanced HF and Shock (INTERMACS 1) Navin K. Kapur, MD, FACC, FSCAI, FAHA Associate Professor, Department of Medicine Interventional Cardiology & Advanced Heart Failure Programs Executive Director,

More information

Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium

Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium MARIA E. MANDICH MD Fairbanks Memorial Hospital Emergency Department Attending Physician Interior Region EMS Council Medical Director

More information

Nothing to Disclose. Severe Pulmonary Hypertension

Nothing to Disclose. Severe Pulmonary Hypertension Severe Ronald Pearl, MD, PhD Professor and Chair Department of Anesthesiology Stanford University Rpearl@stanford.edu Nothing to Disclose 65 year old female Elective knee surgery NYHA Class 3 Aortic stenosis

More information