6. radiologic imaging in ecmo #beach2019 (nieboer)
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This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.
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6. radiologic imaging in ecmo #beach2019 (nieboer)
- 1. - 3rd Beach Course - The Radiology of ECMO Koenraad Nieboer MD FESER Emergency & Intensive Care Radiology UZ Brussel
- 2. Speaker - GE Healthcare Disclosure
- 3. 1) Pré ECMO imaging 2) Per ECMO imaging 3) Imaging findings / canula positions 4) Haemodynamic changes important for CT imaging 5) Complications Learning objectives
- 5. Pré ECMO Imaging Important for decision making Baseline Before or soon after cannulation if possible Involve Radiology at an early stage where possible Done at the refferring centre if possible
- 6. Pré ECMO Imaging Reasons not to start with ECMO:
- 7. Pré ECMO Imaging Compare for evolution Case: F 35y EW: Abdominal pain Vomiting One day post PS AKI + Sepsis Chest X-ray + CT
- 8. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 1: EW 3:31 am
- 9. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 2: ICU 3:31 am 11:04 am
- 10. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 3: ICU 3:31 am 11:04 am 1:44 pm
- 11. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 4: ICU 3:31 am 11:04 am 1:44 pm 3:06 pm
- 12. Pré ECMO Imaging Compare for evolution Case: F 35y Chest X-ray 5: ICU Decision for ECMO 5:02 pm
- 13. Per ECMO imaging
- 14. Per ECMO imaging Imaging modalities Imaging protocol
- 15. Per ECMO imaging Imaging modalities X-ray Ultrasound CT scan
- 16. Per ECMO imaging Imaging modalities X-ray: Mobile DX X-ray device > Image on device! Ultrasound CT scan - Check lines and tubes / canulas - Extent of consolidations - Follow up of effusions - Pneumothorax
- 17. Per ECMO imaging Imaging modalities X-ray: Mobile DX X-ray device > Image on device! Ultrasound CT scan - Check lines and tubes - Extent of consolidations - Follow up of effusions - Pneumothorax Measurement on X-ray device screen
- 18. Per ECMO imaging Imaging modalities X-ray: Mobile DX X-ray device > Image on device! Ultrasound CT scan - Check lines and tubes - Extent of consolidations - Follow up of effusions - Pneumothorax Immediate adjustment and control
- 19. Per ECMO imaging Imaging modalities X-ray: Mobile DX X-ray device > Image on device! Ultrasound CT scan - Check lines and tubes - Extent of consolidations - Follow up of effusions - Pneumothorax Companion view
- 20. Per ECMO imaging Imaging modalities X-ray Ultrasound: - ∆ effusions – consolidation CT scan - Abdominal organ evaluation - Intraperitoneal free fluid - US guided interventions - Mobile / portable and good equiped - But: Operator and patient dependent!
- 21. Per ECMO imaging Imaging modalities X-ray Ultrasound CT scan: - Clinically driven - Transport - Communication - Examination Planning - Patiënt positioning - Iodinated contrast access: CVC / peripheral https://intensiveblog.com/on-the-move-ecmo-transport/
- 22. Imaging findings / canula positions
- 23. Imaging findings / Canula positions ARDS VV ECMO > VA ECMO
- 24. Imaging findings / Canula positions ARDS: Acute Respiratory Distress Syndrome “Berlin definition” (2011): ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance. ALI: Acute Lung Injury = obsolete DAD: Diffuse Alveolar Damage = the histopathologic pattern
- 25. Imaging findings / Canula positions ARDS: Acute Respiratory Distress Syndrome “Berlin definition”: Key components: - Acute onset over 1 week or less - Bilateral opacities consistent with pulmonary edema on Chest X-ray or CT - Reduced oxygenation (PF ratio < 300mmHg, min 5cmH2O PEEP (or CPAP) ) - Exclusion of Cardiac failure or Fluid overload
- 26. Imaging findings: ARDS chest X-ray
- 27. Imaging findings: ARDS CT scan
- 28. Imaging findings / Canula positions ARDS: Acute Respiratory Distress Syndrome Clinical and Radiological Mimics Hydrostatic pulmonary edema Pneumonia Aspiration Diffuse alveolar hemorrhage Acute hypersensitivity pneumonitis Organising pneumonia Acute eosinophilic pneumonia Acute fibrinous organising pneumonia Radiol Clin N Am 54(2016) 1119-32
- 29. Imaging findings: ARDS vs Acute Pulmonary Edema Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 33582
- 30. Imaging findings: Canula positions ARDS VV ECMO > VA ECMO: Canula positions Echocardiography: initial placement confirmation X-ray series: reaffirmation canula position use bonelandmarks and carina CT scan: clinically driven problems
- 31. Imaging findings / Canula positions: VV ECMO
- 32. Imaging findings / Canula positions: VV ECMO
- 33. Imaging findings / Canula positions: VV ECMO
- 34. Imaging findings / Canula positions: Central VA ECMO
- 35. Imaging findings / Canula positions: Periferal VA ECMO
- 36. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
- 37. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
- 38. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
- 39. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
- 40. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
- 41. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
- 42. Imaging findings / Canula positions: Follow Up Courtesy: Dr Bobby Agrawal
- 43. Haemodynamic changes important for CT imaging
- 44. Haemodynamic changes important for CT imaging More pronounced in VA ECMO compared to VV ECMO VV ECMO: Larger “vascular” volume Right Atrial / Inferior caval vein siphon effect
- 45. Haemodynamic changes important for CT imaging: VV ECMO
- 46. Haemodynamic changes important for CT imaging: VV ECMO
- 47. Haemodynamic changes important for CT imaging More pronounced in VA ECMO compared to VV ECMO VA ECMO: Retrograde aortic flow > inconsistent flow from heart and EC circuit Other factors also cause heterogeneous enhancement: Native ejection fraction Flow rate Total amount of contrast medium administered Scan delay time Cannulation (central vs peripheral)
- 48. Haemodynamic changes important for CT imaging: VA ECMO
- 49. Haemodynamic changes important for CT imaging: VA ECMO
- 50. Haemodynamic changes important for CT imaging: VA ECMO KJR 2014; 15(3) Aortic Pseudolesions
- 51. Haemodynamic changes important for CT imaging: VA ECMO AJNR 2017;38:773-76 Pseudothrombosis
- 52. Haemodynamic changes important for CT imaging: VA ECMO Aortic Stasis • Inadequate flow can lead to stasis thrombus forming in the LV, LVOT and ascending aorta proximal to the arterial cannula • High density thrombus is easily seen on non-contrast enhanced CT Insights Imaging 2014; 5:731
- 53. Haemodynamic changes important for CT imaging Optimizing CT for pulmonary emboli Poor RV function will predispose to pulmonary arterial thrombosis Venous cannula will siphon off contrast media before opacifying the pulmonary trunc and arteries Can reduce flow to 500 cc/min or discontinue flow for 10-15 sec to allow normal pulmonary circulation and prevent siphon effect (Risk for thrombosis)
- 54. Haemodynamic changes important for CT imaging Optimizing CT for pulmonary emboli: Repeat scan if necessary! Poor RV function will predispose to pulmonary arterial thrombosis Venous cannula will siphon off contrast media before opacifying the pulmonary trunc and arteries Can reduce flow to 0,5 l/min or discontinue flow for 10-15 sec to allow normal pulmonary circulation and prevent siphon effect (Risk for thrombosis) Courtesy: Dr Bobby Agrawal
- 55. Complications
- 56. Complications CNS: Ischemic infarction (hypoexemia, acidosis, hypotension) Hemorrhage (anticoagulatio related) Thoracic: Canula migration Effusions Pneumothorax Pulmonary embolism / Hemorrhage Others: Hemorrhage: intra / retroperitoneal / adrenal gland Hepatic infarction Arterial occlusions Deep venous thrombosis
- 61. Take to your Work: • Pré ECMO = Baseline for Follow Up • Always compare imaging with prior exam • CT = Communication and Planning • Involve your (ICU) Radiologist • Be aware of haemodynamic changes in CT • Be aware of complications
- 62. Thank you for your attention! Koenraad.nieboer@uzbrussel.be