(精编)【体外膜肺ECMO精品课件】 Management of Infants requiring ECMO教学课件.ppt

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Weaning of ECMO Assess pulmonary status Compliance - Vt with set Pmax, PEEP Typical maximal vent setting Pmax 30 RR 35-40 FiO2 50% HFOV Pulmonary hypertension Cardiac echo pre-post ductal saturations Recovery and Decannulation Adequate gas exchange PIP 30 PEEP7 Rate 35-40 FiO250% Adequate cardiac output and BP Cardiac echo Weaning of ECMO Assess hemodynamics Ventricular funcion Organ perfusion BP Weaning of ECMO - VA ECMO flows weaned Minimum ECMO flow 100 ml/min Risk for clot formation inceases with lower flows (absolute flow rate) Frequent assessment of activated clotting time (ACT) is needed Ventilator settings at maximum Pmax to give desired Vt Assessment of gas exchange via SaO2 and ABG Additional preload frequently needed Additional Ca VA ECMO Clamp Out Cannula - clamped Bridge - Opened Stagnant blood Tubing and cannula distal to the bridge Intermittent flow in the cannula needed every 5-10 minutes Future Management Issues Hypothermia Extracorporeal CPR Follow up High incidence of late hearing loss Routine late screening recommended ECPR - Extraporporeal Cardioulmonary Resuscitation CPR is not a contraindication for ECMO End organ perfusion may be better post CPR in infants treated with ECMO Pediatr Crit Care Med 2004;5:440-446 Case VA ECMO for Sepsis Infants ABG 7.34 / 40 / 350 / 19 Post oxygenator 7.34 / 40 / 450 / 19 Preoxygenator 7.30 / 46 / 20 / 19 CXR - “White out” Systemic oxygen delivery is: Low - pvO2 is low, SvO2 is low Cardiac output is: Low - paO2 in infant is similar to the post oxygenator paO2 Case VA ECMO for Sepsis Infants ABG 7.36 / 40 / 52 / 24 Post oxygenator 7.39 / 36 / 450 / 24 Preoxygenator 7.30 / 44 / 40 / 24 Systemic oxygen delivery is: High - PvO2 is high, SvO2 is high Cardiac output is: Good - large gradient between infant ABG and post oxygenator gas Mixing of LV and ECMO output * * * * * * * * * * * * * * * * *