EXTRACORPOREAL MEMBRANE

OXYGENATION
(ECMO)
PERFUSION PERSEPCTIVE

D i s a m p a i k a n pada Z o o m i n a r

28 Agustus 2022

Ibnu Soa S.Kep Ners

Ikatan Perfusionist Indonesia

Nama : Ibnu sofa

TTL : Batang 8 April 1985
Alamat : jl. Intisari RT 03 RW 09 No
3 Kalisari Jakarta Timur
No HP : 085642501626
Email : [email protected]
1. Ecmo definition
2. Ecmo Indication
3. Type of ecmo
4. Step by step ecmo
5. Monitoring during ecmo
6. Ecmo problems
7. Build up ECMO team

ECMO DI iNDONESIA “the DREAMS COME TRUE”

Covid 19 (2020-2021)
Jumlah kasus: 44
Hidup :14 hidup off ecmo
Hidup keluar RS : 11
Meninggal :30
ECMO definition

Schematic depiction of components of extracorporeal membrane oxygenator circuit as used for

ECPR. Components include venous cannula, a pump, an oxygenator, and an arterial cannula. ECPR indicates
extracorporeal cardiopulmonary resuscitation

Important …

• Anatomy • Anatomy • Anatomy

• Physiology • Physiology • Physiology

Vascular Cardiac Lung

ECMO INDICATION??

E C M O IS A BRIDGE…

 Recovery
 Decision
 Transplant
 Bridge to bridge

Type ecmo
VA ECMO VV-ECMO

V-A V-V
Cannulation
Cardiac output 60% CO
Flow ecmo
1:1 2:1
Flow o2 blender
<80% 80-100%
Fio2
Gradual decrease flow Gradual decrese
Weanning oxygenation ecmo support
harlequine resirculation
Troubleshooting
ECMO STEP BY STEP

RUNNING

PREPARATION WEANING
ECMO STEP BY STEP
1. SETTING  Consumable, Disposible, Machine, Emeegency Kits

(Oxygenator, Circuit, Centrifugal Pump, HE, Cannula)

1. PRIMING  Blood, Clear, Crystalloyd , Colloid, Heparine

CANNULATION : Strategy, Heparine 50 Ui/Kg

3. INITIATING  Unclamp , Increase Flow, Sweap Gas, Baseline Value,

4. RUNNING  General Management, Troubleshooting

5. WEANNING  Strategy, Bedside Trial Off,

6. DECANULATION

Preparation... ECMO Machine &disposible

1.Cannulae 2.Circuit
3.Centrifugal
4. pump
5. Pump console
6.Oxygenator
7.Heater
8.Pressure monitoring
9.Handcrank
10. Back up disposible
Preparation... ECMO PRIMING

1. CRYSTALLOID
2. NaHCO3 10-15 Meq
3. 100 ML ALBUMIN 25 %
4. HEPARINE 1 U/ML OF PRIME
5. CACL 250 MG
6. IF BLOOD PRIMING (I UNIT PRC ) ADD 1 UNIT
FFP

EMERGENCY ECMO??
Preparation... Cannulation

1. Strategy
Perifer
- Open/Cut down
- Seldinger
Central
2. Heparine 50 Ui/Kg
3. PRC 1000 ml
4. Positioning
5. Team: Surgeon, Ners, Perfusionist
6. Monitoring kits hemodynamic
7. Emergency troly
RUNNING ECMO

1.. Monitoring ecmo display

2. Monitoring ECMO circuits

P1 P2 P3

3.Monitoring ECMO Pressure

p1 p2 p3 Problem

↑ ↓ ↓ Hipovolum, pneumothorak, posisi /

(-30  -100) (max 300) (max 250) kinking kanul vena,

↓ ↓ ↓ Pump failure

↓ ↑ ↓ Oksigenator failure

↓ ↑ ↑ Kanul arteri kinking, hipertensi

3.Monitoring Daily & Laboratory
Date/Time Goal Result Date/Time Freq
Blood Gases: Patient Arterial /6 hrs
ECMO Day ...
ECMO pre /12 hrs
Systolic > 90 mmHg
ECMO post /12 hrs
MAP > 65 mmHg
Lactate /12 hrs
CVP 8 – 12 mmHg
Na, K, iCa, Glucose /12 hrs
Temp 0C 35.5-37.0 0C

Mg /12 hrs
Patient pH 7.35-7.45
Urea, Creatinine /12 hrs
Patient paCO2 mmHg 35-45 mmHg
LFT(SGOT/SGPT/Albumin/Bil,) /12 hrs
Patient paO2 mmHg >50 mmHg
SvO2 > 60% >65%
CBC (Hb, Ht, L, Plat) /12 hrs
Hematocrit % 32-37% or 42-45%
(single vent) ACT /12 hrs

Coags (PT, APTT, Fibrinogen) /12 hrs

Platelet count mm3 >80.000 –
120.000mm3 AT3 once

D-Dimers 3 days
PT, APTT 1.5 – 2 times control
CRP 3 days
Fibrinogen g/i >150 mg/dl
Cultures (Blood and BAL) 3 days
Antithrombin units/ml 60% - 120% unit/ml
Chest X Ray 24 hrs
Standard heparin titrasi
Echo 24 hrs
IU/kg/hour
ACT sec Titrasi Pupils 24hrs

SatO2 > 80% Physician name and signature Bambang W/Vidya GR

Weaning ECMO
VV ecmo

Weaning ECMO
VA ecmo

1. The patient phenotype is compatible with recovery;

2. End-organ function is recovering;
3. Pa02/Fi02 > 100;
4. Vasopressors and inotropes are at reasonably low levels
(for instance norepinephrine ≤ 4 µg/min or dobutamine <
5 mcg/kg/min)

3-part approach to weaning

1. Daily weaning study,
2. Bedside assessment for decannulation, and
3. Final assessment
VA ECMO WEANING-BRIDGING

VA ecmo weaning - PCRTO

General problem VV & VA ecmo
• Bleeding • Pump failure
• Haemolysis • Oxygenator failure
• Air embolism • Increase CO2 post oxy
• Decrease PaO2 post oxy
• Increse transmembrane pressure
(delta pressure /P2-P3)
• Maksure Algoritm oxy failure

Anticoagulation protocol
(infusion of iv heparin 6 hours after implant, 10-15 UI/kg/

Parameters Goal of values

Parameters Goal of values
PTT 40- ‐ 45 sec
PTT 50- ‐ 55 sec
Platlets Transfusion if <30
Platlets > 30 x10.9/L If bleeding x10.9/L
AT III > 80%
AT III > 80%
ACT ≈200 sec
ACT 160- ‐ 180 sec

Parameters Surveillance time If Bleeding

PT-APTT Every 6 hours/day same

INR-AT III-FDP-
fibrinogen
Count of platlets Once a day Re-control transfusion

ROTEM/aggregometry Once a week On bleeding

32
PADUA
VV Ecmo Problem:
1. Resirculation

Causes: Estimating Recirculation

1. Cannula configuration and Saturation(%) =
positioning (SpreO2 – SvO2)/(SpostO2 – SvO2)
2. Pump speed, cannula size, and x100;
extracorporeal blood flow
3. Changes in intra-thoracic, intra-
cardiac, and intra-abdominal
pressures

Recirculation (%) = (SpreO2 – SvO2)/(SpostO2 – SvO2) x100;

Example;
Agd pre oxy sat 75%
Agd post oxy 100%
Agd mix vein 63%

(75-63)/ (100-63 )x 100

12/37 x 100

32,4%
2. Hypoxia / Hypercarbia
Check!! Management
• Increase pump flow
• Pump flow is > 2/3 pt cardiac
output (e.g. CO 6l = 4l pump • Increase ventilation
flow) • Cool pt to 35deg
• 100% 02 to oxygenator • Muscle relaxants
• Check Oxygenator :outflow • Correct anaemia
pO2>150mmHg

VA ECMO Problems:

1. Pump flow : pre load after load

dependent
2. Differential circulation & Differential
hypoxemia VAV ecmo
3. Left heart statis  unloading LV
4. Limb ischemia  distal perfusion
A. Differential circulation and B. VA-V
hypoxemia

A & B LV unloading C. Distal perfusion

ECMO TEAM

Cardiac Surgeoan
Perfusionist
Pasien ECMO Scrub ners
Intensivist
Cardiologist/Respiratorist
Intensive Ners/Icu

Preparation For ECMO Team

1. Checklist
2. Standards and
Guidelines
3. Protocols
4. Training/ Simulation
E C M O IS A BRIDGE…

Thank You

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Excellent is about doing your best