Ebook ECMO in the adult patient - Core critical care: Part 2

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(BQ) Part 2 book ECMO in the adult patient - Core critical care has contents: ECMO registries and research, ECMO to support organ donation, specifics of intensive care management for the patient on ECMO, patient transfer, liberation from ECMO,... and other contents. Chapter8 Managementofthepatientonveno-venous ECMO:generalprinciples ◈ Introduction Veno-venousECMOallowsgasexchangeandisusedtosupportfailinglungs Thecardiovascularsystem remainsintact,andtheheartcontinuestopumpthebloodaroundthepatient’sbody Asimplifiedviewofveno-venousECMOisthatthebloodistakenfromandreturnedtothevenous system Ifthebloodiscirculatedthroughafunctioningoxygenator,gasexchangewillhappen Ifthereis nooxygenator(ornogasflowthroughtheoxygenator),thebloodwilljustreturninthesamestateasit drained(perhapsabitcoolerifnoheatexchangerisinplace) Thewhole-bloodvolume(includingthe proportionthatwentthroughtheECMOcircuit)ispumpedbytheheartthroughthelungsandcirculation Veno-venousECMOisusuallyinstitutedinthecontextofsevereacuterespiratoryfailure Itsupports oxygenation and CO2 removal and allows the implementation of safer ventilation strategies This is inaccuratelyreferredtoas‘protective’ventilation(anypositive-pressureventilationisdeemedtocause damagetothelung)andcouldbecalledthe‘least-damaginglungventilation’ Veno-venous ECMO can be continued for as long as appropriate; investigations are directed at confirmingtheunderlyingdiagnosisandensuringspecifictherapyisadministered Patientssupportedwithveno-venousECMOfrequentlyhaveadditionalnon-pulmonaryorganfailure andrequireahighlevelofcriticalcaresupport(e.g acuterenalfailure) The day-to-day management of patients on veno-venous ECMO includes all that is common to criticallyillpatientsplussomespecificelements Thischapterdescribesthosespecificelements LocallyagreedprotocolsforthecareofECMOpatientsshouldbeincorporatedintotraining Monitoringofthepatientonveno-venousECMOhasbeendescribedinChapter4 Stabilizationonveno-venousECMO InsertionofECMOcannulasshouldideallytakeplaceinanoperatingroom Avarietyofconfigurations can be used It is often striking how rapidly ventilation and other support can be modified after venovenousECMOsupporthasbeenstarted Lung ventilation can be adapted immediately after veno-venous ECMO has been established The aim is to institute a less-damaging mechanical ventilation with lower levels of pressure Multiple publications are available, but most clinicians would agree to aim for a standard setting (Table 8.1) Veno-venous ECMO circuits are very efficient at exchanging CO2 While unproven, it makes sense to decrease the patient PaCO2 progressively to avoid extreme vasoactive responses This can easily be achievedbyinitiatingveno-venousECMOwithalowgassweep through the oxygenator (e g L/min) that is progressively increased (e.g within the first hour) A low gas sweep will usually not affect oxygenationastransferofO2willbelimitedbyotherfactors(aslongasthedeliveredfractionofO2 in the sweep gas is 100%) In veno-venous ECMO, the inspired fraction of O2 in the sweep gas should alwaysbe100% Asexplainedinpreviouschapters,oxygenationinpatientssupportedwithveno-venous ECMOisdependentonthebloodflowinthecircuitinrelationtothepatient’scardiacoutput Table8.1Exampleofstandardventilationsettingswhileonveno-venousECMO Peakairwaypressure
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