2017 ECMO in the adult patient (core critical care)

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IntraAbdominal Hypertension Manu Malbrain and Jan De Waele ISBN 9780521149396Clinical Information Systems in Critical Care Cecilia Morrison, Matthew R. Jones and Julie BrackenISBN 9780521156745Delirium in Critical Care, Second Edition Valerie Page and E. Wesley Ely ISBN 9781107433656IntraAbdominal Hypertension Manu Malbrain and Jan De Waele ISBN 9780521149396Clinical Information Systems in Critical Care Cecilia Morrison, Matthew R. Jones and Julie BrackenISBN 9780521156745Delirium in Critical Care, Second Edition Valerie Page and E. Wesley Ely ISBN 9781107433656IntraAbdominal Hypertension Manu Malbrain and Jan De Waele ISBN 9780521149396Clinical Information Systems in Critical Care Cecilia Morrison, Matthew R. Jones and Julie BrackenISBN 9780521156745Delirium in Critical Care, Second Edition Valerie Page and E. Wesley Ely ISBN 9781107433656 E C M O I N T H E A D U LT P A T I E N T C O R E C R IT IC A L C A R E SeriesEditor DrAlainVuylsteke PapworthHospital Cambridge,UK Othertitlesintheseries Intra-AbdominalHypertensionManuMalbrainandJanDeWaeleISBN9780521149396 ClinicalInformationSystemsinCriticalCareCeciliaMorrison,MatthewR JonesandJulieBracken ISBN9780521156745 DeliriuminCriticalCare,SecondEditionValeriePageandE WesleyElyISBN9781107433656 E C M O I N T HE A D U LT PAT I E N T AlainVuylsteke,BSc,MA,MD,FRCA,FFICM ConsultantinIntensiveCareandClinicalDirector PapworthHospitalCambridge,UK DanielBrodie,MD AssociateProfessorofMedicine ColumbiaUniversityCollegeofPhysiciansandSurgeons NewYork-PresbyterianHospital NewYork,NY,USA AlainCombes,MD,PhD ProfessorofIntensiveCareMedicine UniversityofParis,PierreetMarieCurie SeniorIntensivistattheServicedeRéanimationMédicaleInstitutdeCardiologie HôpitalPitié-Salpêtrière Paris,France Jo-anneFowles,RGN LeadECMONurse PapworthHospital Cambridge,UK GilesPeek,MD,FRCSCTh,FFICM ProfessorandChiefofPediatricCardiacSurgery ECMODirector TheChildren’sHospitalofMontefiore NewYork,NY,USA UniversityPrintingHouse,CambridgeCB28BS,UnitedKingdom CambridgeUniversityPressispartoftheUniversityofCambridge ItfurtherstheUniversity’smissionbydisseminatingknowledgeinthepursuitofeducation,learningandresearchatthehighest internationallevelsofexcellence www.cambridge.org Informationonthistitle:www.cambridge.org/9781107681248 ©AlainVuylsteke,DanielBrodie,AlainCombes,Jo-anneFowles,GilesPeek2017 Thispublicationisincopyright Subjecttostatutoryexceptionandtotheprovisionsofrelevantcollectivelicensingagreements,no reproductionofanypartmaytakeplacewithoutthewrittenpermissionofCambridgeUniversityPress Firstpublished2017 PrintedintheUnitedKingdombyTJInternationalLtd,Padstow,Cornwall AcataloguerecordforthispublicationisavailablefromtheBritishLibrary ISBN978-1-107-68124-8Paperback CambridgeUniversityPresshasnoresponsibilityforthepersistenceoraccuracyofURLsforexternalorthird-partyinternetwebsites referredtointhispublication,anddoesnotguaranteethatanycontentonsuchwebsitesis,orwillremain,accurateorappropriate Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateandup-to-dateinformationwhichisinaccordwithaccepted standardsandpracticeatthetimeofpublication Althoughcasehistoriesaredrawnfromactualcases,everyefforthasbeenmadeto disguisetheidentitiesoftheindividualsinvolved Nevertheless,theauthors,editorsandpublisherscanmakenowarrantiesthatthe informationcontainedhereinistotallyfreefromerror,notleastbecauseclinicalstandardsareconstantlychangingthroughresearchand regulation Theauthors,editorsandpublishersthereforedisclaimallliabilityfordirectorconsequentialdamagesresultingfromtheuseof materialcontainedinthisbook Readersarestronglyadvisedtopaycarefulattentiontoinformationprovidedbythemanufacturerofany drugsorequipmentthattheyplantouse Contents Notefromtheauthors Listofabbreviations Apatienttestimony:IsurvivedECMO AbriefhistoryofECMO AnECMOservice TheECMOcircuit MonitoringthepatientonECMO Caseselection Cannulationanddecannulation Coagulation,bloodandECMO Managementofthepatientonveno-venousECMO:generalprinciples Managementofthepatientonveno-arterialECMO:generalprinciples 10 Patienttransfer 11 LiberationfromECMO 12 SpecificsofintensivecaremanagementforthepatientonECMO 13 ExtracorporealcarbondioxideremovalorECCO2R 14 ECMOtosupportorgandonation 15 ECMOregistriesandresearch Appendix:ThefutureofECMO Index Notefromtheauthors ThisbookisaboutECMOintheadultpatient Theadultpatientcanbedefinedinmanywaysbutwe have arbitrarily chosen someone older than 16 years and, more importantly in relation to the discussed technology,heavierthan20kg We would like to acknowledge the contributions of: Dr Mindaugus Balciunas, UK; Dr Richard Porter,UK;DrMathieuSchmidt,France;andDrMartinBesser,UK Abbreviations ACT activatedcoagulationtime AKI acutekidneyinjury anti-Xa anti-factorXa APR activatedprothrombintimeratio aPTT activatedprothrombintime ARDS acuterespiratorydistresssyndrome CO2 carbondioxide CPR cardiopulmonaryresuscitation CT computedtomography DCD donationaftercardiacdeath ECCO2R Appendix:ThefutureofECMO Itisimpossibletopredictthefuture! In 1980, no one could have predicted how ubiquitous the mobile phone would be or how ECMO wouldbeusedtosupportanever-increasingnumberofpatients The immediate future of ECMO, or the now, is about limiting its complications by improving the designofcircuitsandcannula,andsharingpracticeandexperiencebetweenclinicians Key elements of ECMO support are an understanding of which patients should be supported and theirmanagementwhiletheyaresupported,andtoacknowledgethatsomepatientswillnotbenefitfrom supportonECMO ECMOsupportisoftenthelastoption,andprogressshouldaimatunderstandinghowtopreventand treatthoseconditionsleadingtothissupportbeingrequired TheECMOtechnicianwillcontinuetostrivetoimproveECMO,whiletheECMOclinicians’ aim willbetofindwhatisneededtoavoidECMO! Index acanthocytosis,135 accidentalhypothermia,90 acetaminophen,185 activatedcoagulationtime(ACT),125 activatedprothrombintime(aPTT),127 activatedprothrombintimeratio(APR),127,129 acutekidneyinjury(AKI),172,173 acutelunginjury,73 acutemechanicaldefect,86 acuterespiratorydistresssyndrome(ARDS),6 acuterespiratoryfailure,72 age,71,74 airembolism,115,116,177 airentrainment,37,49,58 airtransferofpatient,163 albumin,183 aminocaproicacid,138 amiodarone,187 anaemia,121,136 antibiotics,180 antibodies,131,132 anticoagulants,121–123 anticoagulation,88,89 assessment,51 ECCO2R,201 monitoringof,123–129 needof,120 renalreplacementtherapy,177 antiepileptics,187 antithrombin,122,123,126,128 anti-Xalevels,126,128 arrhythmias,83,115 arterialcannulas,103,106,107,117 arterialpressurewaveform,64 arterio-venousECCO2R,198–199 artificiallung,41 aseptictechnique,96,109,115 assays,120 asthma,70 AvalonElite®,108 barotrauma,148 benchmarking,23 betaadrenergicreceptorantagonists,79 bleeding Seehaemorrhage bloodcountabnormalities,131–134 bloodfilms,changesto,134 bloodflow throughthecircuit,51 veno-venousECMO,146 bloodgasmonitoring,49 bloodproducttransfusion,131 bloodpump,38–41 bloodsamples,120 bonemarrowbiopsy,134 braininjury,75 bridgeconfigurationintubing,37 bubbleoxygenators,1,2 bupropion,79 calciumchannelantagonists,79 cannulas circuitconfiguration,112 comparisons,105 dislodgement,53 doublelumen,105,108 fixation,111,195 insertion,109 length,103 mainfeatures,101 materials,102 pressuremonitoring,59 pumpflowand,40 shape,103–104 sidearms,105 sideholes,104,108 surfacecoating,102 veno-arterialECMO,103,106,107,117 veno-venousECMO,103,104,108 cannulation,96,Seealsodecannulation angleof,110 complications,114 insertionchecklists,97 locationofprocedure,100 personnelinvolved,96 technique,109–112 carbohydrates,191 carbondioxideremoval,45,SeealsoECCO2R cardiacarrest,81,84,85 cardiacdiseases,22,78–90 acutemechanicaldefect,86 arrhythmias,83,115 ECMObridge,86 eCPR,81–85 pulmonaryembolism,88 reversibility,80–81 cardiopulmonarybypass,3,5,7,15,87,89,168 cardiopulmonaryresuscitation(CPR),91 eCPR,81–85 cardioversion,83 caseselection Seepatientselection caspofungin,186 catabolism,188,190 cavitation,115 centrifugalpumps,38–41 pressuremonitoring,48 cerebralhaemorrhage,72,76 Cesartrial,3,6,72,77 chestphysiotherapy,194 chronicobstructivepulmonarydisease,71 chronicthromboembolichypertension,89 clottingfactors,122,124,128 coagulationcascade,124 competencies assessment,9 doctors,12 ECMOspecialist,13 contamination,water,45 continuousperitonealdialysis,175 continuousveno-venoushaemodialysis,176 continuousveno-venoushemodiafiltration,176 continuousveno-venoushemofiltration,176 controlleddonors,205,206 cyclosporine,187 cysticfibrosis,71 decannulation,96 arterialcannula,117 checklists,98 venouscannula,115–117 dexmedetomidine,185 diazepam,184 digoxin,79 directthrombininhibitors,123 distallimbischaemia,199,200 doctors,10,12 arbitrationrole,21 cannulation,96 ECMOtrainingtopics,11 patienttransfer,160 doublelumencannulas,105,108 drainagecannula,114 drugavailability,changes,183–184 drugintoxication,78,91 durationofventilation,72,76 ECCO2R,197–198 arterio-venous,198–199 circuitmonitoring,201 complications,200 veno-venous,199 echocardiography,66 ECMO Seealsoveno-venousECMO developmentalmilestones,1,2 firstpatients,4 firsttrial,4 futureof,209 intensivecaremanagement,171–195 nextgenerationv2.0,6 organdonation,204–206 paediatric,5,19,178 predictionscores,92 survivalafter,x weaningpatientfrom,165–169 whennottouse,92 ECMOcircuit,12,25–31,Seealsocannulas cannulaconfiguration,112 components,32–46 diagramillustrating,35 gasandelectricsupplies,19 maintenance,55 monitoring,46–53 perfusionistroleand,15 RRTconnectionto,175 selection,53 trainingin,9 ECMOcoordinator,10,14 ECMOdirector,10,15 ECMOservice,6 co-locatedclinicalservices,18 infrastructure,17–21 keyteammembers,10 organisationof,21–23 staffing,9–17 ECMOspecialists,10,13 eCPR,81–85 electrolyteplasmalevels,191 emphysema,69,71 end-of-lifecare,168 enteralnutrition,189–190 complicationsfrom,192 ethics,78,205,206 extracorporeallifesupport,1 ExtracorporealLifeSupportOrganization(ELSO),5,207 extracorporealmembraneoxygenation SeeECMO FactorXa,124 anti-Xalevels,126,128 femoralartery,112 fentanyl,183,184,185 fibrinolysis,138 finances,22 flecainide,79 fluidbalance,150,156 optimisation,174 fluoroscopy,99,101,109,111 folicacid,136 fondaparinux,122,123 fractionatedheparin,122 frailty,71,74 freehaemoglobin,51 furosemide,187 gastrointestinalbleeding,137 gentamicin,184,185 glucose,191 glutaminesupplementation,191 glyceryltrinitrate,112 H1N1pandemic,3,6,20 haematologysupport,119 haemofiltration,175 haemoglobin,free,51 haemoglobinopathy,136 haemolysis,115,121,135 haemophilia,125 haemorrhage,114,115,137–140 cerebral,72,76 ECCO2R,200 intracranial,137 managementof,139 pulmonary,137 riskof,120 tracheostomyriskand,151,156 harlequinsyndrome,65 hearttransplantation,86 heatexchangers,45 heparin,1,2,187 cannulationand,112 coatings,34,102,120 fractionated,122 monitoring,125–129 thrombocytopenia,132,200 unfractionated,121,126 higharterialbloodpressure,173 highfrequencyoscillatoryventilation,148 HIV/AIDS,71 hydralazine,187 hypothermia,accidental,90 hypoxaemia,73,147 immunethrombocytopenia,133 immunoglobulins,134,136 immunosuppression,70 impellers,38 inotropes,143,157 insulin,187 intensivecaremanagement,171–195 intensivecareunit,17,58 InternationalECMONetwork(ECMONet),207 internationalregistry,23,207 intra-aorticballoonpump,157 intracranialhaemorrhage,137 intravascularpressures,58 irreversibility,respiratorydiseases,77 ischaemia,distallimb,199,200 isolationfacilities,19 jugularvein,109 leastdamaginglungventilation,4,141 levetiracetam,187 lipaemia,121 lipids,191 lipophilicdrugs,183,186 liverfailure,91 lorazepam,184 lowflowalarms,52 lowmolecularweightheparin(LMWH),122 lumbarpuncture,138 lungfibrosis,71 lungtransplantation,6,77,198 magneticallylevitatedpumps,38 majorbleeding,137,139 mattresssuture,116 Mayo-Gibbonpump-oxygenator,2 mechanicalventilation veno-arterialECMO,154 veno-venousECMO,142,148–150 membraneoxygenators,2,5,41 schematics,42 meropenem,184,186 metabolicresponse,188 midazolam,183,184 minorbleeding,137,139 M-numberformalism,106 monitoring Seealsopatientmonitoring ECMOcircuit,46–53 morphine,185 Murrayscore,72,73 NationalRespiratoryECMOservice,71 negativepressuremonitoring,49 neuraminidaseinhibitors,186 neuromonitoring,59 nicardipine,187 nitricoxide,152,173 nosocomialinfections,179–180 NovaportTwincannula,108 nurses,10,14,193 nutrition,187–192 obesity,75 operatingtheatre,100 organdonation,90,169,204–206 deadbraindonors,204 non-heart-beatingdonors,205 oseltamivir,186 oxygenation veno-arterialECMO,155 veno-venousECMO,145–146 oxygenators,27,41–45,Seealsomembraneoxygenators bubble,1,2 failure,49 Mayo-Gibbonpump,2 monitoring,47,49 secondoxygenator,44,145 paediatricECMO,5,19,178 paralysis,171 parenteralnutrition,190 patientmonitoring,58–67 anticoagulation,123–129 veno-arterialECMO,63–67 veno-venousECMO,46,60–62 patientselection,12,68 cardiacdiseases,78–90 ECMOpredictionscores,92 otherdiseases,90–92 respiratorydiseases,69–78 whennottouseECMO,92 patienttransfer,159–164 byair,163 careduring,162 planning,159 peakinspiratorypressure,149 pentasaccharides,123 pepticulceration,188 perfusionists,10,15 peripheralveno-arterialconfiguration,65,80,86 cannulas,104,107 personalprotectionequipment,20 pharmacists,10 pharmacokinetics,181,184 pharmacology,181–187 phenobarbital,187 phenytoin,187 physiotherapy,194 piperacillin,186 plasmapheresis,178 plateletcount,131,139 pneumonia,70,179,181 polymethylpentene,43 polyurethane,102 polyvinylchloride,34 positiveend-expiratorypressure(PEEP),73,149 post-oxygenatorpressure,48 pre-centrifugalpumppressure,48 predictionscores,92 prednisolone,133 pre-oxygenatorpressure,47 pressureflowtables,105 pressuremonitoring,47–49,59 pressuresores,193 pronepositioning,151 prophylacticantibiotics,181 propofol,185 propranolol,184 protamine,122,123,127 proteins,190 pulmonaryembolism,88 pulmonaryhaemorrhage,137 pumpafterload,40 pumppreload,40 pump-oxygenators,2 pumps centrifugal,38–41 intra-aorticballoon,157 pressuremonitoring,48 requirementfor,25,26 ranitidine,187 recirculationinveno-venousECMO,61,145 recombinantfactorVIIa,139 redcelltransfusion,144 rehabilitation,194 renalfunction,172–178,184 renalreplacementtherapy(RRT),172 anticoagulationwith,177 indicationsfor,174 methodsof,175–177 nutritionand,190,192 reperfusionlines,60,105,107,111,156 RESPscores,92 respiratorydiseases,22,69–78,141 ECCO2Rsupport,197 irreversibility,77 reversibility,70 specificsconsiderations,71–77 ventilator-associatedlunginjury,148 returncannula,114 returnofspontaneouscirculation,81 reversibility cardiacdiseases,80–81 respiratorydiseases,70 revolutionsperminute,40 rhesusnegativewomen,131 SAVEscores,92 sedation,171 Seldingertechnique,96 sepsis,178–181,191 sicklecelldisease,136 sideportsintubing,36 sidearmsincannulas,105 sideholesincannulas,104,108 stafftraining,9,13 staffing,9–17 surfaceareaofmembrane,43 survival-to-discharge,83 sweepgas,45,143,148,165,197 tachypnea,150 theophylline,186 thrombin,126 directinhibitors,123 thrombocytopenia,131 heparin-induced,132,200 othercauses,133 thromboelastography,128 thrombosis,88 ECCO2Rand,198,200 veno-arterialECMO,63 thromboticthrombocytopeniapurpura,134 tidalvolume,149 trachealextubation,151 tracheostomy,151,156 tranexamicacid,138 transferequipment,161–162 transferteam,16,160 transmembranepressure,49,50 transplantation,70,90 heart,86 lung,6,77,198 transthoracicpressure,149 tricyclicantidepressants,79 tubing,32–38 ultrasound,111,112 incannulation,97 uncontrolleddonors,205 unfractionatedheparin,121,126 valsalvamanoeuvre,116 vancomycin,184,185 vasculitis,70 vasoactivedrugs,143 veno-arterialECMO,7,26,30,34,92,153–157 arterialpressurewaveform,64 cannulas,106,107 cardiacrecoveryproblemswith,80 mechanicalventilation,154 oxygenationduring,155 patientmonitoring,63–67 peripheralconfiguration,65,80,86 pumpafterload,40 pumpflowand,41 stabilisationon,154 weaningpatientfrom,168 veno-venousECCO2R,199 veno-venousECMO,25,31,141–142 cannulas,103,104,108 cannulasremoval,115–117 cerebralhaemorrhage,72,76 fluidbalance,150 mechanicalventilation,142,148–150 oxygenationduring,145–146 patientmonitoring,46,60–62 stabilisationon,142–145 standardventilationsettings,143 weaningpatientfrom,165–168 ventilator-associatedlunginjury,148 ventricularassistdevice,86 ventricularvents,157 visualinspectionoftheECMO,53 voriconazole,186 waterdrills,9 ... Table2.2Specializedtopicstobecovered in the trainingofan ECMO clinician Typesof ECMO Riskandpotentialbenefitsof ECMO Indicationandcontraindicationfor ECMO Pathophysiologyof the patient on ECMO ECMOequipment(includingcircuits)... Staffwhohaveundergonespecialisttrainingandhaveexpert knowledgeof the managementof the ECMO patient and the ECMO circuit Willsupport the ECMO coordinator in day-to-daycoordination of the service Attendingnurses... areavailabletoteach the basicsof ECMO Cliniciansinvolved in ECMO arealwayswillingtohelpeach other Adult intensivecareskillsarecentralto the safedeliveryof ECMO, andall the basicsofintensive
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