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55 Cards in this Set
- Front
- Back
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meconium aspiration syndrome -2 forms of lung pathology |
1. atelectasis 2. emphysema resulting from "ball-valve" effect |
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2 strong stimulators of pulmonary vascular spasm: |
1. hypoxemia 2. acidosis |
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Describe cycle of PPHN |
1. Hypoxemia 2. pulmonary vasoconstriction 2. pulmonary hypertension 4. r- l shunting |
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Pre vs Post Ductal Sats |
Pre- measured at right hand/ temporal artery Post- lower extremeties ( or left hand depending on location of PDA) * > 15% diff indicates shunting at the ductal level - there is no diff in sats when shunting at PFO |
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NON-ECMO therapies to be trailed for the pediatric patient prior to ECMO |
-permissive hypercapnia (PaC02 to 70 with pH>= 7.28) -permissive hypoxemia (Sats tolerance of 80% with HCT >=45) -peep trial (to 15 cm H20) -ino -hfov |
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Advantages of VA ECMO |
-one surgical site -not dependent on cardiac function -excellent oxygenation at low flows -excellent support of heart and lungs |
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Disadvantages of VA ECMO |
-particles, bubbles, air to arterial system -ligation of carotid artery -blood entering cerebral tree is highly oxygenated and under high pressure increasing risk of ICH - > risk of ischemic lung injury due to decreased pulmonary blood flow |
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What is a cardiac advantage of VA ECMO? |
Not dependent on cardiac function |
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What are some cardiac disadvantages of VA ECMO? |
-dec pulmonary blood flow -dec physiological pulsitility -dec o2 to the coronary arteries -inc left ventricular after load |
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Advantages of VV ECMO |
-avoids cannulation and ligation of the carotid artery -Hyperoxygenated blood enters the PA and may help dec PAP and echo run time -dec risk of ischemic lung injury -dec risk of neurologic injury -dec risk of emboli to systemic circulation -possible percutaneous cannulation |
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Disadvantages of VV ECMO (5) |
-2 Cannulation sites in > 16 kg patients -higher flows are required to achieve adequate oxygenation -dependent on cardiac function -still requires IJV ligation -recirculation |
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What is Recirculation on VV ECMO? |
-oxygenated blood from the circuit being drained back to the circuit |
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What is the ideal recirculation? |
- < or = 20 to 30% -svo2 of 75% is ideal |
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What Factors Effect Recirculation? (4) |
(PCCR) 1. Pump Flow 2. Catheter Placement 3. Cardiac Output 4. RA Volume |
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What cannula is used for the single site cannulation for VV ECMO and when? |
- Origen Double Lumen Cannula -used unless the patient is > than 16 kg |
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What is the Primary Goal of ECMO. |
to rest the lungs |
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Patient Selection Guidelines (NEONATAL) |
- weight> 2 kg and gestational age> 34 weeks -reversible lung disease -AaDo2> 610 and OI> 25 for at least 8 hours despite max therapy -conv vent< 10 days EXCLUDES: -no lethal cardiac heart defects or irreversible cardiac failure -no IVH> 11 -no lethal chromosomal abnormalities /coagulopathy -absense of prolonged asphyxia |
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Patient Selection Guidelines (PEDIATRIC) |
-reversible lung disease -failure with non-ECMO therapies -AaD02>350 for 8 hours, PIP limit 40, inability to wean Fi02 to 65% within 8 hours -refactory Barotrauma (uncontrolled/persistent air leaks) EXCLUDES: -severe CNS disease or hemorrhagic CNS disorder -recent GI bleeding -terminal stage of lethal condition -mechanic vent > 10 days |
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How do we control Co2 with the pump? |
- Increase sweep gas to decrease c02 and vice versa * we no longer add c02 to the pump |
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What things determine the output from the roller head pump? |
-size of the tubing -size of the roller head -RPMs of the roller head -occlusion of rollers against tubing |
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What material is the raceway made off? |
- super tygon tubing |
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What is the oxygenator made of ? |
-the quadroxD is a hollow fiber oxygenator made of polymethylpentene (PMP) |
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What are 2 indicators of oxygenator failure? |
1. Increased c02 on pump ABG 2. Decreased P02 on pump ABG |
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What are possible causes of oxygenator failure? |
- congenital defect - pressure drop across membrane of > 300 mmHG - subjecting it to post oxygenator pressures > 450 mmHG - clots - water vapor |
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How does the oxygenator work? |
- Gas exchange occurs by diffusion across a semi-permeable membrane with no direct contact between blood and gas. |
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What is the max blood and gas flow rate across the Quadrox D oxygenator? |
Max blood flow- 7 lpm Min blood flow- 0.5 lpm Gas flow rate is 15 lpm |
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When should a "shunt" be placed when using the Quadrox D oxygenator? |
-blood flow rates of < 500cc/min |
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If the gas outlet port was occluded what would be the first thing to happen? |
Foaming of the oxygenator. (supersaturation) |
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What is drawn at the Pre-Bladder? |
-SV02, Labs |
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What is done at the Bladder site? |
-infuse PRBCs only and other volume. -monitor bladder pressure -return for CRRT |
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What is given post-bladder? |
-Meds and Heparin gtt |
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What is done post race way? |
set occlusion? |
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What is drawn and infused post-oxygenator? |
-draw pump ABGs -infusion of certain blood products: (FFP, Cryo, Platelets) -CRRT connection here |
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Calculate Cardiac output. What is the formula for neonates? |
Cardiac output VA pediatric 100 cc/kg VA( neonates) 200cc/kg *kg *% = % of bypass
VV 100-140cc/kg* kg* % = % of bypass |
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Formula for AaDO2 and OI |
AaD02= (713*Fi02)-PaC02/0.8-PaO2 OI= MAP*Fi02*100/Pa02 |
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Formula for 02 content |
CO * ( Sats * Hgb* 1.34) + ( P02*0.0031) |
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Oxygen Delivery (OD) is based on what two values? |
02 content and CO |
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Heparin acts on Antithrombin III to.... |
Heparin acts on Antithrombin III to prevent the conversion of Prothrombin to Thrombin |
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What is the normal ACT range for healthy neonates? |
90-150 |
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What is the ACT range for non-bleeding pt on ECMO? |
200-220 |
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What is the ACT range for bleeding patients on ECMO? |
180-200 |
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What is the dosage for initial Heparin bolus? When is this given? |
50 units/kg. When the vessels are isolated. |
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What do you do when 30 min have passed and the vessels have not been isolated? |
Draw ACT. |
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What things could effect Heparin requirements? |
-urine output -blood transfusions -platelet transfusions -abnormal coags -CRRT |
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What response is needed for ACT greater than 300? or unusual results? |
-Recheck ACT -Change stopcock -Decrease drip to 0.1cc/hr and notify ECMO physician on service |
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What are the typical effects of ECMO on the pt's K and NA? |
-K is lost -Na is retained |
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What is done if patient is to be taken off bypass? |
1. cross clamp pt 2. emergency vent settings 3. Disconnect 02 to oxygenator 4. Move all drips to patient. |
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If patient has been off ECMO > 10 min, what should happen after ECMO is restarted? |
Recheck ACT |
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What are the 3 most common places for clot formation? |
-Bladder -Corners of oxygenator -Bridge |
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What are the 2 places bubbles are most commonly trapped in the circuit? |
-bladder -top of the oxygenator |
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Describe the order for clamping and unclamping when cross clamping... |
Going ON- Unclamp arterial then venous lines, close the stopcock bridge. Going OFF- Open the stopcock bridge, clamp the venous/ arterial lines |
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Signs and Symptoms of PDA |
-pulmonary edema -decrease UOP -poor perfusion -acidosis |
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If the pt is on 70 to 80% bypass the pts Pa02 depends greatly on what? |
ECMO flow *Remember in VA -NEED more 0s....INCREASE the FLOW!! |
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What is considered "idle" for VA ECMO and what should your pump FI02 and Sweep be set at? |
-Idle is a flow rate decreased to 80-90 cc/min. Once 100cc/min reached, decrease Fi02 to 60% and sweep no > than 1 ppm. |
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Describe "capping off" |
-Vent settings are increased per physician orders -02 line is removed from circuit and placed over the vent at the bottom of the oxygenator -pt can then be capped off if tolerates -monitor blood gases (30 min post cap off, then Q2) -successful capping off, time to decannulate -if unsuccessful, reconnect 02 line to circuit blender. |
