EXTRA CORPOREAL MEMBRANE OXYGENATION

Transcription

1 EXTRA CORPOREAL MEMBRANE OXYGENATION Basic Overview and Case Study Bob Hayes, Chief Perfusionist Enloe Medical Center Jenny Humphries, RN, BSN, MBA, CFRN Chief Flight Nurse, Enloe FlightCare Normal Cardiopulmonary Circulation What Are Our Options When Normal Fails? Pre-Hospital.. Hospital.. 1

2 Cardiopulmonary Bypass VS. ECMO/ECLS Cardiopulmonary Bypass Cardiopulmonary Bypass 2

3 ECMO ECMO is instituted in an emergency or urgent situation for the management of life threatening pulmonary or cardiac failure (or both), after failure of other treatment modalities ECMO is used for temporary support Organ recovery Bridge to definitive treatment VAD Transplant ECMO IS NOT CURATIVE Types of ECMO Veno-Arterial vs Veno-Venous 3

4 VA ECMO-CARDIAC SUPPORT Veno-Arterial Provides cardiac support to assist systemic circulation Requires arterial and venous cannulation Bypasses pulmonary circulation/decreases pulmonary artery pressures Could be used in RV failure Lower perfusion rates are needed Higher Pa02 is achieved ECMO circuit parallel to heart/lungs VA CANNULATION Veno-Venous VV ECMO-RESPIRATORY SUPPORT Does not provide cardiac support to assist systemic circulation Requires only venous cannulation Maintains pulmonary blood flow No RV failure support Higher perfusion rates are needed Lower Pa02 achieved ECMO circuit in series to heart/lungs 4

5 VV CANNULATION VA ECMO INDICATIONS CARDIAC FAILURE - Post-cardiotomy - Unable to get patient off cardiopulmonary bypass following cardiac surgery - High Risk Cardiac Cath Lab Procedures - Severe cardiac failure due to almost any other cause - Acute coronary syndrome with cardiogenic shock - Can improve chance of survival with better neuro outcomes - Decompensated cardiomyopathy - Profound cardiac depression from OVERDOSE or spesis VV ECMO INDICATIONS RESPIRATORY FAILURE - Adult respiratory distress syndrome (ARDS)- numerous causes - Pneumonia - H1N1 - Trauma - Primary graft failure following lung transplantation 5

6 TEAM EFFORT TO INITIATE AND MANAGE ECMO - ECMO Physician - Patient selection - Cannula placement - Initiates ECMO order set (once stable on support) - Manages patient care while on ECMO - Perfusionist - Manages the ECMO circuit and machinery - Bedside RN - Works alongside perfusionist to manage patient on ECMO - Physician Assistant/Surgical Tech - Assists with cannulation and connecting to ECMO circuit - OR, Cath Lab, ICU/CCU, ER - Anesthesiologist/Respiratory Therapist - Ventilator Management - Responsible for emergency ventilator settings Case Study D.J. 22 y/o Male Background: Arrived ER via 1308, per medics report- last normal Took a sip of methadone this AM. S.O. found him just before 1300 foaming at the mouth. Hypotensive, tachycardic and hypoxic Narcan2 mg IV (1 14) to (34 6) Arrives to ER in respiratory distress and still hypoxic- 68% on O2 Med Alert, BiPap, intubation, central line, art line, labs, numerous meds. To 1600 for ECMO cannulation 6

7 Differentials: Bronch to R/O plug.. Found pick frothy blood tinged sputum consistent with alveolar hemorrhage Bedside US bilateral lower extremities R/O DVT s- no evidence of DVT Echo- hyperdynamic heart, no effusion 1.0 FiO2, PEEP +15 ARDS ventilation without improvement ECMO for 84 hours Outcome D/C UC Davis day 15 post event EnloeER day 18 post event for staple removal. How Do We Move These Patients? 7

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10 Transport Perfusionist/Nurse/Pilot Crew Devices/Duties ECMO- Perfusionist Ventilator Monitor- including pressure lines IV Pumps (5-7) Blood Transfusion if needed Chest Tubes IABP (Perfusion and Medical Crew) Just because nothing bad happened doesn t mean it was the right thing to do. 10

11 11/6/2017 ECMO Sim Additional Crew members Additional Perfusionists Coming Soon. Ground Sim Conclusion Re: ECMO Transport Questions? 11