Elsevier

Critical Care Clinics

Volume 33, Issue 4, October 2017, Pages 777-794
Critical Care Clinics

Cardiac Support: Emphasis on Venoarterial ECMO

https://doi.org/10.1016/j.ccc.2017.06.002Get rights and content

Section snippets

Key points

  • Venoarterial extracorporeal membrane oxygenation (ECMO) can be used as a bridge to recovery or definitive therapy for several conditions, including cardiogenic shock, pulmonary embolism, intoxication or poisoning, and hypothermia.

  • Important considerations when developing a cannulation strategy for venoarterial ECMO include cardiac and pulmonary function, need for mobilization, anticipated duration of support, and the urgency of the time to cannulation.

  • Careful management of patients having

What is venoarterial extracorporeal membrane oxygenation and how does it differ from venovenous extracorporeal membrane oxygenation?

The basic components of any ECMO circuit include a cannula to drain blood from the venous system (inflow cannula), a pump, an oxygenator, and a cannula to return blood to the body (outflow cannula). In addition to these essential components, most ECMO circuits contain a console where pump speed can be adjusted, a heat exchanger, various ports for blood sampling and medication infusion, a saturation sensor on the inflow cannula, and a flow sensor on the outflow cannula. The inflow cannula

General Considerations

Initiation of extracorporeal support is a complex, resource-intensive undertaking that requires careful consideration and should only be performed at centers with sufficient resources to care for this patient population. Appropriate patient selection is of paramount importance. Given the lack of robust data supporting its efficacy, the cost, and the potential for complications, ECMO support should only be initiated in those patients with an appropriate indication who cannot be managed with more

The decision has been made to proceed with extracorporeal membrane oxygenation. How is the optimal cannulation strategy determined?

Once the decision to initiate VA ECMO is made, the cannulation strategy must be determined. Several factors must be considered when determining the optimal cannulation strategy, including the urgency of the situation, the underlying cardiac issue (right, left, or biventricular heart failure), pulmonary status, the size of arterial vessels, the need for mobilization, and the anticipated duration of support. Consideration must also be given to the size of the cannulas to ensure that flows

Venoarteriovenous Extracorporeal Membrane Oxygenation

As briefly mentioned earlier, upper body hypoxemia can complicate the care of patients who are peripherally cannulated for VA ECMO, particularly those with femoral arterial cannulas. If a patient recovers ventricular function while still experiencing significant pulmonary dysfunction, the native cardiac output will pump poorly oxygenated blood to the coronary arteries and brain while well-oxygenated blood from the ECMO outflow cannula only reaches the lower half of the body. This phenomenon is

Determine the Degree of Support Required

The primary goal of ECMO support is to maintain adequate oxygen delivery to end organs.

Delivery of oxygen depends on cardiac output, the hemoglobin concentration, and arterial oxygen saturation. In ECMO patients, all of these variables can be manipulated to ensure adequate tissue perfusion. Recall that, in ECMO patients, the functional cardiac output is a combination of the native cardiac output and the ECMO flow. The optimal amount of ECMO support varies depending on native cardiac function.

Summary

VA ECMO can provide robust, highly customizable cardiac and pulmonary support for several conditions. It is likely that use of this powerful tool will continue to expand, so it is prudent for clinicians to familiarize themselves with its components and basic management strategies.

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    Conflicts of Interest: The authors have no conflicts to disclose.

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