ECMO

1. Pediatric ECMO
DR. SANJOY SEN GUPTA

4. ECMO
VENOVENOUS VENOARTERIAL
1. End-of-case ECMO
2. E-CPR
3. Failing maximal medical therapy

22. MANAGEMENT OF CHILDREN ON
ECMO
• Ventilator management-
fractional inspired oxygen concentration of
40%; tidal volume of 6 to 8 ml/kg; a
respiratory rate of 20 per minute and a
positive end expiratory pressure of 6-8 cm
H2O

24. • Coagulation management -
• Activated Coagulation Time -180 -240 s
• Activated partial thromboplastin time of 50 -
70s
• Prothrombin time of 18-24 s
• An internationalized normal ratio of 1.5- 2.0
• Platelet count more than 50000/micro litre.

25. • Nutrition-
After 4 hours of institution of ECMO; Enteral
feeding through nasogastric

26. • INOTROPE- dopamine, dobutamine,
milrinone, adrenaline, noradranline,
vasopressin -> to maintain
heart rate between 100 and 150 bpm
mean arterial pressure of 30-50 mm/Hg
right atrial pressure of 8 -10 mm Hg
urine output of 1 ml/kg/min

27. ECMO flows -
• At the initiation of ECMO –
the flows between 100 and 150 ml/kg/min
The arterial (aortic) line pressure of less than
200 mm Hg MAY BE ACCEPTED.

28. Sedation
• Fentanyl
• Rocuronium

29. Monitoring
• Heart rate
• mean arterial pressure
• urine output
• SpO2
• Temperature
• arterial blood gas analysis
• NIRS
• abdominal girth
• peripheral pulses
• ECMO flows
• arterial line pressure
• amount of hemofiltration.

30. INVESTIGATIONS
• 12 HOURLY ECHOCARDIOGRAM
• DAILY CHEST SKIAGRAM
• DAILY BLOOD INVEATIGATIONS

31. WEANING CHILDREN FROM ECMO
• Stable heart rate and rhythm
• Hemodynamically stable on optimal
• No active bleeding
• Arterial blood gases within acceptable limits
• Lactate less than 4.0 mmol/L
• Chest x ray - within normal limits
• Normal breath sounds with minimal added sounds and
no evidence of lower respiratory tract infection
• Hematocrit between 30-35%
• No end organ dysfunction

32. COMPLICATIONS
• Bleeding
• Risk factors-
1- exploration before ECMO
2-higher RACHS SCORE
3-longer BYPASS time
4- low threshold for ANY invasive
intervention

36. MANAGEMENT OF BLEEDING
• CAUSE ?
• TRANSFUSE
• ACT ?
• ANTI-FIBRINOLYSE
• STOP HEPARIN- DESPERATE MEASURE
• CALL OF ECMO

37. SITE OF BLEEDING
• CANNUALTION SITE
• SURGICAL SITE
• CHEST DRAIN SITE
• MUCOUS MEMBRANE
• GASTROINTESTINAL
• NEUROLOGICAL

38. OTHER COMPLICATIONS
INFECTION- CONCERNS ISSUES
1. DURATION OF ECMO
2. CONFUSION DUE TO LYMPHOPENIA
3. VIGILANCE vs. routine SURVEILLANCE

39. • TEMPERATURE MANAGEMENT
-USE OF HEAT EXCHANGER
-HEAT DISSIPATION
- NEED OF COOLING

40. NEUROLOGIC INJURY
• LOWER AGE
• CHD
• NEED OF SCREENING
• NEED OF MONITORING

41. SEDATION
• TREND TO DECREASE USE
• ENSURING DURING CANNUALTION
• HIGHER DOSING FOR DESIRED EFFECT

42. FLUID BALNCE
• INTERSTITIAL EDEMA
• HEMOFILTRATION
• FIRST TWO DAYS CUMMULATIVE FLUID
BALANCE

43. PROCEDURES ON ECMO
• 1. VENIPUNCTURE
• 2. LIVER TRANSPLANT
• 3. TRACHEOSTOMY.

48. THANK YOU