The Scientific World Journal / 2014 / Article / Tab 5

Review Article

Monitoring of the Adult Patient on Venoarterial Extracorporeal Membrane Oxygenation

Table 5

Summary of monitoring in VA ECMO.

Monitor forTreatment

RhythmDysrhythmias such as ventricular fibrillation that may prevent ventricular ejectionAntiarrhythmics
Cardioversion
Pacing
Ablation

MAPHypotension (MAP = CO × SVR)
 (i) Inadequate VA ECMO flow
 (ii) Inadequate SVR
   
(i) See “Flow” below
(ii) Start vasoconstrictor

PulsatilityLack of pulsatility on arterial waveform caused by
  (i) poor myocardial function
  (ii) excessive VA ECMO support
  (iii) Inadequate preload
  (iv) RV failure
May result in
  (i) thrombus
  (ii) myocardial ischemia
  (iii) pulmonary edema (assess CXR, wedge)
If poor myocardial function, consider:
 decreasing VA ECMO flow
 starting or increasing inotrope
 starting or increasing vasodilator
 IABP
 myocardial decompression

Flow (liters/min)Low flows (assuming centrifugal pump)
 (i) Inadequate preload
  (a) Hypovolemia (may see hemolysis,
    chattering)
  (b) Mechanical obstructive
 (ii) Excessive afterload (thrombus, kink, SVR)
 (iii) Inadequate RPM
   
(i) Volume: crystalloid/colloid/transfusion
  Release of mechanical obstruction
(ii) Exchange oxygenator, relieve cannula kink,
vasodilator to decrease SVR
(iii) Increase RPM

   
   
   
   
   
   
   
Gas exchange
Inadequate PaO2 inadequate or excessive CO2 elimination
 (i) VA ECMO settings
  (a) FDO2   
  (b) VA ECMO flow
  (c) Sweep gas flow rate
  (i) If hypoxemia, increase FDO2 or flow.
  If hypercarbia, increase sweep. If
  hypocarbia, decrease sweep or add CO2.
 (ii) Oxygenator function
  (a) Pre- and postmembrane pressures
  (b) Pre- and postoxygenator gases
(ii) Increased and inadequate arterialization
  of postoxygenator gases suggest oxygenator
  malfunction
 (iii) Upper body hypoxemia (femoral-femoral
 cannulation)
(iii) Increase pulmonary venous O2 content
 Adjust ventilator settings
 Treat etiology of pulmonary dysfunction
 Increase VA ECMO flow
 Change to axillary/carotid cannulation
 VA-V ECMO
 VV ECMO

Oxygen delivery: SvO2 and lactateDecreased SvO2 and increasing lactate suggest inadequate oxygen delivery (DO2 = CO × CaO2)
 (i) VA ECMO flow
 (ii) Hemoglobin
 (iii) SaO2  
Excessive oxygen consumption (ER = VO2/DO2)
 (i) Febrile
 (ii) Shivering
   
   
(i) Increase VA ECMO flow
(ii) Transfuse
(iii) Ensure adequate gas exchange

(i) Antipyretics
(ii) Consider agents such as meperidine or
dexmedetomidine

Distal limb ischemiaLoss of pulses
Cyanosis and coolness of limb
Femoral-femoral cannulation:
DP or PT anterograde perfusion catheter

AnticoagulationAdequate heparinization by PTT

TemperatureNormothermia unless therapeutic hypothermia

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