An ECMO in OMAN: FB Discussion

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Editor’s Note:

I saw this discussion on the Perfusion.com Group FB page, and thought it merited a post here on ‘Surfes– to demonstrate how effective new media communication can be in real time.

Please feel free to add to the discussion 🙂

Frank

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Post H1N1 with Bi lateral Pneumonia pt. On VV ecmo, today completes 15th day of support. X-ray showed no improvement.. Since two days we noticed a fibrin deposits at the Oxy inlet. Today was very obvious. Oxy performance getting affected. Post Oxy blood gases: Po2 162 Pco2 53..
What do you suggest, to stop the ecmo support or continue support and changing the oxygenator!!

  • Nusrat Rizvi How is renal function ?
  • Saleh Al Harthy Was good.. Little hematuria shows up
  • Muraa Pascaline Cont ECMO support, change oxygenator, consider change of Rx.
    23 hrs · Like · 3
  • Saleh Al Harthy The decision gonna be finalized by ICU drs.
  • Kapil Ravindra Dere Please do preoxygenator blood gas and post oxygenator blood gas with coagulation studies
    23 hrs · Like · 2
  • Saleh Al Harthy All done.. Coagulation profile is acceptable aPTT is 70
  • Kapil Ravindra Dere Please specify pt pre oxy abg and post oxy abg
  • Pat Phillips Need to do a TEG. And change oxygenator.
    23 hrs · Like · 3
  • Saleh Al Harthy Pre Oxy gases: po2 is 34 & pco2 is 67
  • Saleh Al Harthy Svo2 is 67
  • Pat Phillips What is cerebral oximetry showing.
    23 hrs · Like · 1
  • Kapil Ravindra Dere Problem is not about weaning but pt general condition is poor xray chest reveals atlectasis
    23 hrs · Like · 2
  • Saleh Al Harthy Unfortunately, it’s not available in ICU, however the pupil reacts to light. ++
    23 hrs · Like · 1
  • Kapil Ravindra Dere U can also think of oxygenator change out
    23 hrs · Like · 2
  • Kapil Ravindra Dere Because respiratory issues are more
  • David Park Oxygenation change out… hopefully neurological and all major organs are intact.
    Are you trying recoup the lungs to keep lungs for atlectasis.. increase peep pressure 6-8.. pressure control on ventilator? Alot of suction of the ET.. maybe bronchoscopy the lungs for secretion and mucus plug.. good luck
    22 hrs · Like · 1
  • Saleh Al Harthy Hello David, fortunately we are on all what you stated. Neurological status seems intact. He is moving in between.
    However, cerebral intact is not fully sure.
  • KV Nagendra sir , as u said patient having a little hematuria (with good out put) , APTT 70, pupil reacting ++, and neurologically intact. . PT age also 30 . so i think u continue the same VV support by changing OXY.
    22 hrs · Like · 3
  • Saleh Al Harthy How do u know that pt is 30 ?? I didn’t mention the age
    22 hrs · Like · 1
  • Nusrat Rizvi Boss as u mention in xray chest no any improvement even after 12 days so what is the use of V V ecmo at this stage any how it would be a multideciplinary decision
    22 hrs · Like · 1
  • KV Nagendra PT details is there on X ray
    22 hrs · Like · 1
  • Pat Phillips San diego and Portland have had survivors after 30 days. Patient age is a huge factor. Just need to support organs till lungs recover. Change Oxy perfuse organs use the tools god and science gave us like the TEG and Cerebral oximetry and give the patient a chance.
    22 hrs · Like · 3
  • Mathias Allegaert Definetely change the MO. Our longest support on ecmo was 47 days with positive outcome.
    21 hrs · Like · 1
  • Francis Langlois have you tried burping the membrane, sometimes humidity and water deposit on fibers can lower efficacy of gas exchanges, especially on long lasting ecmos. Is transmembrane pressure drop higher than it used to be or is that not relevant anymore with new oxygenators?
    21 hrs · Like · 1
  • Saleh Al Harthy We daily burping the Oxy, pressure drop is 65
  • Francis Langlois VV ecmos can be long, in the end its multidisciplinary and familly decision… wouldn’t really know what else to tell you. Sorry.
  • Saleh Al Harthy Thanks for interactions let’s hope for good
  • Brian White With VV ECMO, pressure drops of 10mmHg per 1 liter of flow is the average seen. I don’t know what your flows are, but I promise you 65mmHG is too much!! Also, with hematuria present, the choice of cannula(s) may be affecting flow vs RPMs. If hematuria is seen, larger cannulas maybe needed. You didn’t specify cannula sizes, or whether you are using an Avalon or two separate cannulas.
    20 hrs · Like · 2
  • Muhammad Usman Ali change the oxygenator
    20 hrs · Like · 1
  • Pat Phillips Higher RPM is probably caused by the fibrin strands and high membrane pressures. fix the problem and take the time to let the patient rest.
    20 hrs · Like · 3
  • Yasmin Suarez I think it’s a doctor and family decision.
  • Saleh Al HarthyBrian, we using Maquet bioline coated, 17 F for outflow and 21 for inflow. We had no issue while flowing up to 5L
    Hematuria most probably from blood transfusion. As we gave so far more than 4 units. Pressure drop of the Oxy is pretty high bcz of fibri
    See More
    20 hrs · Like · 1
  • Maya L Gopal you can change the oxy and continue with ecmo.closely monitor the act levels
    20 hrs · Like · 1
  • Saleh Al Harthy To judge that oxygenator is failed by post Oxy Po2 or Osat? In this case Osat post membrane is 98%
  • Mehmet Hadi çağlayan Hawe much FIO2
  • Brian White I have never let a quadrox go over 50mmHg without changing it. Consequently, I have also seen lung improvement in younger patients after 2 weeks on VV ECMO.
    19 hrs · Like · 1
  • Mavi Nehir Hii saleh. FIO2 so change the face. sweep (flash) Are you doing?
    19 hrs · Like · 1
  • Mavi Nehir We have a similar situation in the past week we meet.
    19 hrs · Like · 1
  • Mavi Nehir H1N1 cases of ecmo surah leave average 27 days. you have received from patients and the blood gas you receive from input-output oxygenator PO2 and PCO2 values I’d appreciate if you write
    19 hrs · Like · 1
  • Mavi Nehir continue support and changing the oxygenator.
    19 hrs · Like · 2
  • Sean Rider 15 days is not a long time in the realm of VV ECMO. We’ve had survivors at 5-6 weeks.
    18 hrs · Like · 1
  • Mavi Nehir Hi sean Rider. I discovered that my observation I’ve seen in patients on ECMO is very difficult to give a time for the blockage of the oxygenator. This situation can change for all patients. 58 days vv ecmo patient I’m following in everything, although we had to change the oxygenatör blocked four times and we… Goodbye
    18 hrs · Like · 2
  • Sean Rider yes oxy’s can fail at any time. We just change them. We actually change the whole circuit from cannula to cannula. But if the patient is neurologically intact, we typically continue forward. Aggressive fluid management is critical too utilizing continuous hemodialysis.
    18 hrs · Like · 2
  • Mavi Nehir Certainly you’re right sometimes life-saving hemodialysis is going on. We follow our patients are usually awake is happening … thank you for the share.
    18 hrs · Like · 1
  • Gary Sherriff We had great success with these cases, by putting them on aspirin. Your oxygenation should improve and oxy’s might last a little longer.
    16 hrs · Like · 1
  • Saleh Al Harthy So most of suggest to continue the ecmo. Well thanks for share
    14 hrs · Like · 1
  • Meg Rhame Huyck Following this post.
  • Saleh Al Harthy Oxygenator got changed, as per ICU drs, to continue the ecmo support. Today’s x ray showed vey bad outcome.
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Saleh Al Harthy ABG taken before 3 hrs

  • 1 hr · Like · 1
  • KV Nagendra will hope good
  • Brian White Sweep? FiO2 through blender of ECMO? SpO2 on patient probe (and where is it located?) ventilator settings?
  • Saleh Al HarthySweep 9L
    Fio2 100
    Pt’s sat 85 placed on forefinger

    Peep 8
  • Brian WhiteI have had a similar situation in the past. I don’t know how closely our situations are but: I had a young pt that developed fibrotic lungs after H1N1. Very similar blood gas to yours, expect lower SPO2. We discovered that the dysfunction in the patients lungs was causing a reverse V/Q motion (ie greater O2 exhaled that inhaled). We reversed the I:E ratio on the ventilation and great increased the inspiration time to 2.5-3 seconds. This helped to mitigate the reverse loss of oxygen through the lungs. Secondly, we lowered the FiO2 on the ventilator slowly over time to 50%, while allowing the PO2 to drop, and only keeping the SPO2 probe on the patient 70% or greater. Doing this over a number of weeks we were able to allow for recruitment on one of the lungs enough to weak the patient off of ECMO. This was done all while drying the patient with CRRT and doing bronchoscopies every other day. Take from that what you will, but “Red Book” put out by ELSO specifically indicates that PO2 is not a primary number to follow for guiding VV ECMO care. I hope this patient can recover from what sounds like a very difficult situation.
    56 mins · Like · 4
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