{"id":965,"date":"2016-07-08T18:09:50","date_gmt":"2016-07-08T18:09:50","guid":{"rendered":"http:\/\/hfhpulm.com\/info\/?p=965"},"modified":"2017-01-03T15:51:03","modified_gmt":"2017-01-03T15:51:03","slug":"ecmo-reference-sheet","status":"publish","type":"post","link":"https:\/\/hfhpulm.com\/info\/?p=965","title":{"rendered":"ECMO reference sheet"},"content":{"rendered":"

Fellow\u2019s Reference for ECMO-related Queries<\/strong><\/p>\n

Prepared by Alvey, Abu-Sayf, Al-Jasmi, Razvi, Abrencillo<\/p>\n

FullPDF<\/a><\/p>\n

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<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Problem<\/th>\nSymptoms\/Signs<\/th>\nDifferential<\/th>\nPossible Solutions<\/th>\nWho to involve<\/th>\n<\/tr>\n
Decreasing Patient PO2<\/strong>.Think of:Increase O2 consumption, decrease O2 delivery, decrease exchange <\/p>\n

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As a general rule an arterial Sats of 85% patients on VV ECMO is acceptable if the patient is perfusing<\/strong> (no worsening organ dysfunction, not forming lactate)<\/em><\/td>\n

CyanosisAcidosisLethargyPoor perfusion<\/p>\n

Worsening PO2 and O2sat on ABG<\/p>\n

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Patient looks well<\/p>\n

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Problems related to Increase O2 consumption: <\/strong>Seizures, Sepsis, AgitationProblems related ECMO: <\/strong><\/p>\n

Inadequate blood flow, Sweeper gas line malfunction, Oxygenator failing, FiO2 of sweep gas low<\/p>\n

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Problems related to the Native lung: <\/strong>Pneumothorax, ET tube malfunction, pleural effusion, hypervolemia, increased shunting<\/p>\n

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Problems related to CO: <\/strong><\/p>\n

Abdominal compartment, decreased CO, Pericardial tamponade, Suspected cardiac shunt vs valvular defect, acute right heart failure,<\/p>\n

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O2 carrying capacity:<\/strong><\/p>\n

Anemia,\u00a0 Methemoglobinemia (from NO or Nitroprusside)<\/p>\n

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Recirculation:<\/strong><\/p>\n

Most common in Jugular-Femoral and Femoral-Femoral VV circuit .Least common in Femoral- Jugular VV circuit<\/p>\n

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Improved CO (Hemodynamics is improved therefore pushing more blood to the recovering lung)<\/td>\n

Treat underlying cause <\/p>\n

Increase the flow, Replace or fix the line, Replace the oxygenator, Increase FiO2<\/p>\n

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know the native lung parameters and compliance before the acute event, resting lung strategy may worsen hypoxemia and increase shunting and pulm pressures<\/em><\/p>\n

Diuresis, reintubation, increasing PEEP or FiO2, extreme caution on invasive procedures<\/p>\n

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\u00a0<\/em><\/p>\n

Review the last echo and the Arterial line parameters before the event<\/em><\/p>\n

Consider repeating Echo and vasopressors, consider possible conversion to VA ECMO<\/p>\n

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Although the cardiac literature asks for Hb > 10, there is no data to support against or for transfusion with Hb < 7.0 unless it is a method to increase CO.<\/em><\/p>\n

Transfusion of prbc, methylene blue<\/p>\n

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Consider switching circuit or even adding another venous line.<\/p>\n

AVLON catheter might be considered.<\/p>\n

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Consider ECMO weaning<\/td>\n

Fellow\/Primary team with RT to make medical decision involving increasing vent supportCall Perfusion and CTS for gas, recirculation and oxygenator problem<\/p>\n

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Before placing any tubes (catastrophic bleed), if stable, please contact CT surgery. If unstable, call CVICU, team to help out<\/strong><\/p>\n

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Call CT surgery if lines needed to be added or changed<\/td>\n<\/tr>\n

PO2 is increasing<\/strong><\/td>\nCyanosisAcidosisPoor perfusionHemodynamic instability<\/p>\n

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Patient is looking well<\/td>\n

Problems related to O2 consumption\/delivery: <\/strong>Sepsis with peripheral shunting, tissue death with decreased O2 consumption, central shunting\u00a0<\/strong>Problems related increasing ECMO flow secondary to decrease CO: <\/strong><\/p>\n

MI, cardiac stunning, cardiac tamponade (air,fluid), Lung (air,fluid), hypovolemia<\/p>\n

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Improving native lung compliance (better TV, lower pressures)<\/p>\n

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Cardiac stunned with adequate VA flow<\/td>\n

Treat the underlying reason, monitor clinically for fasciitis, gangrene or worsening sepsis, central shunt is hard to treatTreat underlying cause, increase ECMO flow, consider converting to VA, administer volume or blood<\/p>\n

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Consider lowering FiO2 on the ECMO and start weaning<\/p>\n

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Continue ECMO Full support<\/td>\n

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Before placing any tubes (catastrophic bleed), if stable, please contact CT surgery. If unstable, call CVICU, team to help out<\/strong><\/p>\n

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Decreasing CO2<\/strong><\/td>\nPatient is apneic and alkalotic <\/p>\n

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Patient tachypneic<\/td>\n

CO2 in sweep gas too lowSweep gas flow too high <\/p>\n

Overventilation<\/p>\n

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Improving lung function<\/p>\n

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CO2 in sweep gas is too high or Sweep gas flow too low<\/p>\n

(acidemia with compensatory tachypnea)<\/p>\n

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Underventilation<\/p>\n

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Increase CO2 in sweepDecrease flow <\/p>\n

Adjust vent settings to decrease MV<\/p>\n

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Check compliance on vent and ABG while on 100% FiO2 (Cilley Test) on vent to assess lung recovery \u00e0 consider weaning<\/p>\n

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Decrease CO2 in sweep gas or Increase gas flow<\/p>\n

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Ensure ETT in position<\/p>\n

Adjust vent to increase MV<\/td>\n

Call Perfusion to adjust CO2 in the blender or to change the flowCall RT for Vent changes<\/td>\n<\/tr>\n
Increasing PCO2<\/strong><\/td>\nTachypnea, acidosis, agitation, hypertension<\/td>\nOxygenator failureCO2 in sweep gas too high or Sweep gas flow too low <\/p>\n

Patient agitated<\/p>\n

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Increased metabolic activity<\/p>\n

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ETT positioning problem and\/or Increasing airway pressures in ventilator<\/p>\n

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Look at oxygenation, delta P across membrane (prob clot if high)Decrease CO2 in sweep gas or decrease gas flowAddress source of agitation<\/p>\n

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look for signs of sepsis, overfeeding<\/p>\n

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Adjust ET and\/or look for pneumothorax, hemothorax, effusion<\/td>\n

Call Perfusion to adjust CO2 in the blender or to change the flowCall RT for Vent changes<\/td>\n<\/tr>\n
Coagulation problems \u2013 difficulty maintaining PTT<\/strong><\/td>\nToo High <\/p>\n

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Too Low<\/td>\n

Error in lab testing, lab was drawn incorrectly, error in heparin dosingDecrease in coagulation factors <\/p>\n

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DIC<\/p>\n

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Lab error, collection error, dosing error<\/p>\n

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Recent transfusion of blood products<\/p>\n

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Heparin resistance<\/td>\n

Double check heparin dose, location lab was drawn, etc.Assess for Vit K deficiency, liver dysfunction, consumptive coagulopathy <\/p>\n

r\/o sepsis, r\/o circuit coagulopathy (diagnosis of exclusion)<\/p>\n

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Double check heparin dose, location lab was drawn, etc.<\/p>\n

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Recheck PTT after completion of transfusion<\/p>\n

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Assess for\u00a0 antithrombin deficiency (esp in malnutrition, liver\/renal failure) and supplement with FFP or factor concentrate; look for drug interactions<\/p>\n

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RN and Pharmacy for additional blood draws\/ work-up and for dosing error respectivelyIf circuit is cause\u00a0 \u2013 call Perfusion and CT surgery for a circuit change<\/td>\n<\/tr>\n
Bleeding<\/strong><\/td>\nVisible bleeding, expanding hematoma, drop in Hgb, MAPs decreased, signs of hypoperfusion<\/td>\nCoagulopathy: iatrogenic from anticoags vs consumptic (DIC vs circuit).Bleeding from surgical site <\/p>\n

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hypertension<\/td>\n

Decrease heparin dosing Assess for sepsis, circuit coagulopathy (diagnosis of exclusion)Hold pressure. Consider Amicar, FFP, platelets <\/p>\n

control BP<\/td>\n

Call CT surgery.Coordinate with CVICU team for threshold of transfusion<\/td>\n<\/tr>\n
Hemolysis<\/strong><\/td>\nPlasma free hemoglobin \u00a0\u00a0\u00a0> 50 mg\/dl, Tea colored urine<\/td>\nPump Over occluded, clots in patient, clots or kinks in system, centrifugal pump issue<\/td>\nChange pump and inspect for clots in kinks in circuit, hemofilter or patient<\/td>\nCT surgery and Perfusion to help with possibly changing lines or pumps respectively<\/td>\n<\/tr>\n
Hypertension<\/strong><\/td>\nIncreased BP<\/td>\nFluid overload, pain, agitation, idiopathic, improved Cardiac Output(VA ECMO), high pump flow(VA ECMO), steroid use<\/td>\nDiuretics\/CVVHD, treat pain, sedatives, anxiolytics, Anti HTN meds, Decreased ECMO flow<\/td>\nMICU team<\/td>\n<\/tr>\n
Hypotension<\/strong><\/td>\nDecrease BP<\/td>\nMassive HemorrhageHypovolemia, capillary leak syndrome, sepsis <\/p>\n

Low pump flow<\/td>\n

Emergency!!!<\/strong> Supportive resuscitationTreat underlying cause <\/p>\n

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Increase pump flow if adequate arterial volume<\/td>\n

For massive bleeding CVICU to be involved STAT and CT surgery to be involved immediately<\/td>\n<\/tr>\n
Arterial line tracing flat<\/strong> (loss of pulsatility)<\/td>\nVA ecmo: patient well perfusedVA ecmo: patient not perfusing <\/p>\n

VV ecmo: not good<\/td>\n

Too much ecmo support or profound depression of COCode or precode situation <\/p>\n

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Code or precode situation<\/td>\n

Maybe appropriate if \u201cresting\u201d the myocardiumNO chest compression <\/p>\n

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ACLS<\/td>\n

If patient is sick, all services should be notified and critical care team at bedside<\/td>\n<\/tr>\n
Decreased Urine Output<\/strong><\/td>\nOliguria\/anuria<\/td>\nHypotension, Hypovolemia, decreased CO, ATN<\/td>\nTreat underlying cause, might need to augment CO (watch out for hypoxia i.e. more de-oxgenated blood pushed to sick lung), consider HD<\/td>\nMICU team in coordination with CT surgery if planning to place a dialysis catheter<\/td>\n<\/tr>\n
Seizure<\/strong><\/td>\nRepetitive involuntary movements, Increased BP, Decreased SVO2, Cyanosis, Hypoxia<\/td>\nIschemic brain injury, Cerebral edema, Infarction, Intracranial hemorrhage<\/td>\nAnticonvulsants, treat the underlying cause. Must rule out brain bleed<\/td>\nMICU team<\/td>\n<\/tr>\n
Oxygenator Failure<\/strong>\u00a0<\/strong><\/td>\nLow pump atrial PO2, Decreased PCO2 clearanceIncreased pressure gradient across membrane (normal delta P = 20 to 40mmHg). Leads to hemolysis, elevated fibrin split products, worsening thrombocytopenia <\/td>\nLow FiO2, high PaCO2, Sweep gas line to oxygenator is loose, disconnected or crackedOxygenator Clotting off, air in the top of oxygenator or blood leaking from the exhaust gas port due to membrane leak or complete rupture <\/p>\n

Oxygen rated flow\/Efficiency exceeded<\/p>\n

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Increase FiO2 and check oxygen tank, increase sweep Gas if not at maximum, reattach gas line to oxygenatorReplace oxygenator <\/p>\n

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Check manufacture rated oxygenator flow and decrease blood flow if indicated<\/td>\n

Involve Perfusion for replacement of oxygenator or increase change gas setting<\/td>\n<\/tr>\n
Low Flow<\/strong><\/td>\nNegative pressure alarm(Bladder or venous line pressure alarm) <\/p>\n

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Positive pressure alarm<\/p>\n

(oxygenator alarm)<\/td>\n

Venous\/Cephalic catheter malposition or kinked, clot in the systemIntravascular volume depletion <\/p>\n

Inadequate venous return due to patient condition(pericardial tamponade, pneumothorax, increase IA pressure)<\/p>\n

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Pressure alarm limit set too low, pressure transducer malfunction,<\/p>\n

flow is adjusted too high<\/p>\n

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Malposition and kinks in the tubing\/cannula, Clot in oxygenator system, clot in art line filter, wrong alarm setting, alarm malfunction<\/td>\n

Catheter needs to be repositioned, check for clotsConsider fluid bolus <\/p>\n

Address the underlying issue. Can bolus in the meantime<\/p>\n

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Adjustment of alarms, flush transducer, lower flows<\/p>\n

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Remove kinks, check cannula position, inspect for clots and replace as needed, check alarm settings<\/td>\n

Call CT surgery for readjustmentBefore placing any tubes (catastrophic bleed), if stable, please contact CT surgery. If unstable, call CVICU, team to help out<\/strong> <\/p>\n

Call Perfusion for alarms and flow adjustments<\/p>\n

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Exchanger water heater<\/strong><\/td>\nBlood in water line <\/p>\n

Water dripping<\/p>\n

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Temperature alarm:<\/p>\n

Consider if patient is cold or Hot ( patient will usually follow the temp set it ECMO)<\/p>\n

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Crack in heat exchanger water\/blood sealLeak<\/p>\n

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Temp set wrong, heater pump malfunction, large amount of cold water adder to reservoir, tem adjusted, water level low, consider new fevers<\/p>\n

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Emergency!!! <\/strong>\u00a0turn off the heater immediately, replace the heat exchangerChange circuit<\/p>\n

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Check set temperature, replacement of water heater, add water to heater, check exhaust fan, check connections and plugs of water heating unit<\/p>\n

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Involve Perfusion as soon as possible if blood is in the water line<\/td>\n<\/tr>\n
Air in Circuit<\/strong><\/td>\nPreoxygenator(air in venous line)Oxygenator <\/p>\n

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Post-Oxygenator<\/p>\n

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\u00a0<\/strong><\/p>\n

Arterial Line<\/td>\n

Open\/Cracked stopcocks, connectors in venous linesAir from IV infusion, air leak (venous line oxygenator, bladder), priming problem <\/p>\n

Air from IV infusion lines, leak from venous line passing through oxygenator, gas outlet obstruction<\/p>\n

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Massive air pumped from venous side<\/td>\n

Air aspiration from bladder, top of oxygenatorAir aspiration (risk of embolism), oxygenator replacement, monitor for recurrence <\/p>\n

Aspirate, stop airleak, replace oxygenator, calmp ECMO if risk of air reaching the patient<\/p>\n

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VA ECMO Emergency!!!<\/strong> arterial line needs to be manually kinked to stop air flow into arterial system<\/td>\n

Any Air in the system, Perfusion needs to be involved<\/td>\n<\/tr>\n
Pump Failure<\/strong><\/td>\nPump without power, Pump shutting offoverheated pump<\/p>\n

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Pump rotating but no flow<\/p>\n

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Unplugged, battery malfunction, specific switches off, unsecured lids, alarms and knobs not in proper settingWet connections <\/p>\n

Malfunction, inadequate seal<\/td>\n

Check connections, use portable power supply, hand cranking , reset the system, check for air and switchesCheck connections <\/p>\n

Adjust occlusion\/seal<\/td>\n

Involve Perfusion\u00a0 STAT<\/td>\n<\/tr>\n
Negative Pressure Monitor Failure <\/strong>at the bladder box (venous blood reservoir)<\/td>\nCavitation (space free of fluid) as pump turns
\nPump not stopping when venous line clampedNo alarmsBlood on floor<\/td>\n		Obstruction just after bladder (kicks or clots), malfunction of bladder or pressure transducer <\/p>\n

Equipment or wrong alarm threshold<\/p>\n

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Leak in bladder<\/td>\n

Inspect for obstruction prior to pump,\u00a0 change bladder, re-zero pressures, inspect pressure transducer lines, Change bladder <\/td>\nAsk nurse to inspect for clots close to the bladder. Call Perfusion\u00a0 to inspect bladder, lines and pressure settings<\/td>\n<\/tr>\n
Pump Failure<\/strong><\/td>\nPump without powerPump shutting off<\/p>\n

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overheated pump<\/p>\n

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Pump rotating but no flow<\/p>\n

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Unplugged, battery malfunction, specific switches not onUnsecured lids, alarms and knobs not in proper setting <\/p>\n

Wet connections<\/p>\n

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Malfunction, inadequate seal<\/td>\n

Check connections, use portable power supply, hand crankingReset the system, check for air and switches <\/p>\n

Check connections<\/p>\n

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Adjust occlusion\/seal<\/td>\n

Involve Perfusion\u00a0 STAT<\/td>\n<\/tr>\n
Negative Pressure Monitor Failure <\/strong>at the bladder box (venous blood reservoir)<\/td>\nCavitation (space free of fluid) as pump turns
\nPump not stopping when venous line clampedNo alarmsBlood on floor<\/td>\n		Obstruction just after bladder (kicks or clots), malfunction of bladder or pressure transducer <\/p>\n

Equipment or wrong alarm threshold<\/p>\n

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Leak in bladder<\/td>\n

Inspect for obstruction prior to pump,\u00a0 change bladder, re-zero pressures, inspect pressure transducer lines, Change bladder <\/td>\nAsk nurse to inspect for clots close to the bladder. Call Perfusion\u00a0 to inspect bladder, lines and pressure settings<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

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Glossary of Terms<\/p>\n

Sweep gas: determines CO2 elimination. CO2 elimination is dependent Fresh gas flow rate but independent on blood flow rate<\/p>\n

Flow rate: determines oxygenation. Oxygenation is dependent on blood flow rate but not fresh gas flow rate<\/p>\n

Bladder Chamber: a reservoir for blood before the pump used to catch air and help provide constant volume to the pump<\/p>\n

Centrifugal pump: imparts centrifugal force to fluid\/blood causing increase in pressure and kinetic energy radially. This ultimately cause displacement of fluid which creates a suction effect<\/p>\n

Oxygenator: \u201cexternal lungs\u201d; this is where gas exchange happens. The system is usually divided to pre and post oxygenator<\/p>\n

Oxygen rated flow: manufacturer-set-predicted PaO2 on post oxygenator blood at a given flow and hemoglobin<\/p>\n

Delta P: Pressure gradient across the oxygenator (pre and post).<\/p>\n

Re-circulation: blood that goes around the circuit and not delivered to patient<\/p>\n

Chattering: Low amplitude shaking of tubes representing high variation in flow<\/p>\n

Cavitation: intermittent collapse of the vessel which may lead to hemolysis<\/p>\n

Cilley Test: Increase FiO2 to 1.0 with no other changes. Positive test is rapid increase to SaO2 100%<\/p>\n

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 <\/p>\n","protected":false},"excerpt":{"rendered":"

Fellow’s Reference for ECMO-related Queries Prepared by Alvey, Abu-Sayf, Al-Jasmi, Razvi, Abrencillo FullPDF  <\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[9],"tags":[],"class_list":["post-965","post","type-post","status-publish","format-standard","hentry","category-micu"],"modified_by":"Jennings","_links":{"self":[{"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=\/wp\/v2\/posts\/965","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=965"}],"version-history":[{"count":13,"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=\/wp\/v2\/posts\/965\/revisions"}],"predecessor-version":[{"id":1031,"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=\/wp\/v2\/posts\/965\/revisions\/1031"}],"wp:attachment":[{"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=965"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=965"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hfhpulm.com\/info\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=965"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}