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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.
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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.
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Careful management of patients having
Cardiac Support: Emphasis on Venoarterial ECMO
Section snippets
Key points
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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Cited by (17)
Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation With and Without Intra-Aortic Balloon Pump
2022, Journal of Cardiothoracic and Vascular AnesthesiaRewarming from accidental hypothermia enhances whole blood clotting properties in a murine model
2020, Thrombosis ResearchCitation Excerpt :Presumably, the activity of coagulants released during platelet degranulation was inhibited when the body temperature was low, but was reactivated during rewarming. For the treatment of severe cases of accidental hypothermia in emergency medicine, extracorporeal membrane oxygenation (ECMO) is utilized [23,24]. However, since the foreign surface in the ECMO devices activates platelets and the clotting system, this treatment always has a risk of coagulation disorder [25,26].
Critical Care of the Adult Patient With Cystic Fibrosis
2019, ChestCitation Excerpt :Further studies are required to validate the benefit of these ventilator modes in comparison with conventional ventilator support modes. Extracorporeal membrane oxygenation (ECMO) is being used increasingly as a bridge to recovery or transplant in numerous conditions.23 A query of the Extracorporeal Life Support Organization data from 1998 to 2013 found reports of ECMO use in 73 patients with CF, with an associated rate of survival to discharge of 52%.24
Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting
2020, Air Medical JournalCitation Excerpt :A recent platelet count, prothrombin time, international normalized ratio, and fibrinogen should be reviewed before transport for any concerns of disseminated intravascular coagulation. Platelets should be transfused if less than 100 × 103/µL with active bleeding, fresh frozen plasma administered for an international normalized ratio over 1.6, and cryoprecipitate given, if available, for a fibrinogen less than 100 mg/dL.22 Considerations for transfusion and bleeding on ECMO are listed in Table 2.
Effects of Extracorporeal Membrane Oxygenation on the Coagulation System
2024, Journal of Visualized Experiments
Conflicts of Interest: The authors have no conflicts to disclose.