VA ECMO stands for Venoarterial Extracorporeal Membrane Oxygenation. It's a life-saving medical procedure used in critical situations where the heart and lungs are unable to function adequately. VA ECMO involves diverting blood from the body, oxygenating it outside the body, and then returning it to the arterial system, effectively bypassing the heart and lungs. This allows time for the organs to rest and heal, supporting patients with severe cardiac or respiratory failure.

1. UNDERSTANDING BASICS OF VA-ECMO

2. TABLE OF CONTENT
➢ Introduction of VA-ECMO
➢ Indications of VA-ECMO
➢ Cannulation sites of VA-ECMO
➢ Management of VA-ECMO
➢ Complications of VA-ECMO
➢ Outcomes of VA-ECMO
➢ Weaning protocol of VA-ECMO

3. INTRODUCTION OF VA-ECMO
DEFINITION
Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) is a life-
saving medical intervention used in critically ill patients with severe
cardiac or respiratory failure. It involves the temporary extracorporeal
support of both the heart and lungs by routing blood from a large vein
(usually the femoral vein) through an oxygenator that adds oxygen and
removes carbon dioxide before returning it to a large artery (usually the
femoral artery) to circulate throughout the body. VA ECMO serves as a
bridge to recovery by providing temporary support while allowing the heart
and lungs to rest and heal.

4. INDICATIONS OF VA-ECMO
➔ VA ECMO is used to provide both respiratory and cardiac support.
➔ Cardiac conditions with low cardiac output (cardiac index < 2L/min/m)
and hypotension (systolic blood pressure <90 mmHg) despite
inotropic and intra-aortic balloon pump support.
➔ Cardiogenic shock secondary to either acute coronary syndrome,
refractory cardiac arrhythmia, sepsis leading to cardiac depression,
myocarditis, pulmonary embolism, drug toxicity, cardiac trauma,
anaphylaxis, acute decompensated heart failure, septic shock; where
cardiac activity is compromised and unable to pump out the adequate

5. CONT….
➔ Postoperative heart failure: Inability to wean from cardiopulmonary
bypass after cardiac surgery; ECMO is very useful post-operatively
to provide rest for the heart and helps in recovery after the surgery.
➔ Post heart transplant: after heart or lung-heart transplantation in
cases of primary graft failure
➔ Bridge to long-term VAD support or bridge to heart/lung transplant.
➔ Periprocedural for high-risk cardiac interventions

6. CANNULATIONS SITES OF VA-ECMO
PERIPHERAL CANNULATION CENTRAL CANNULATION
1.Femoral vein-femoral artery aorta - right atrium
2.femoral vein-axillary artery aorta-bicaval
3.IJV-carotid artery
4.IJV-axillary artery

7. PATIENTS MANAGEMENT IN VA-ECMO
1) Initial assessment
2) Cannulation & initiation
3) Hemodynamic monitoring
4) Ventilator management
5) Anticoagulation management
6) Fluid management
7) Organ support
8) Complication management
9) Weaning & decannulation
10)rehabilitation

8. COMPLICATION OF VA-ECMO
1. Bleeding
2. Thrombosis
3. Infection
4. Hemolysis
5. Circuit malfunction
6. Organ dysfunction
7. Vascular complication
8. Metabolic distrubances
9. Complication related to immobilization
10.Psychosocial complication

9. OUTCOMES OF VA-ECMO
1. Survival
2. Recovery of organ function
3. Neurological outcomes
4. Quality of life
5. Long-term survival & morbidity

10. WEANING PROTOCOL OF VA-ECMO
➔ The initial cause of cardiogenic shock must have resolved or been
corrected prior to weaning from VA ECMO. Depending on the initial
cause of VA ECMO initiation, the weaning process will start at
different times for different disease processes. Every patient will have
a different weaning strategy and an individual plan.
➔ To begin a weaning trial, the patient should have MAP >70 with or
without inotropic or device support, low vasopressor/inotropic support,
oxygen saturation greater than 95%, central venous oxygen
concentration greater than 70%, normal ventilation and oxygenation
of the patient's lungs with improving chest Xrays, echocardiographic
data with an ejection fraction greater than 25% to 30%.
➔ Weaning is started by reducing the overall pump flow on the ECMO
circuit.

11. CONT…
➔ The patient will need to have inotropic drugs at reasonable levels for
support. The patient may also have an aortic balloon pump or a left
ventricular device in place for added support. Weaning attempts can
still be started with these mentioned drugs/devices in place. Some
centers recommend weaning ECMO before removing the left
ventricular support device.
➔ When the pump is slowly titrated down, the patient will start to
develop more pre-load, and the heart can be monitored for how well
the left ventricle can eject

12. CONT….
➔ Each time the ECMO flow level is decreased, the cardiac function
should be continuously monitored using echocardiography.
Noninvasive cardiac function monitoring can be used, or a pulmonary
artery catheter can be placed to monitor second to second cardiac
function changes.
➔ Strict attention to the ventilator settings and respiratory support must
always be accounted for. Pulmonary blood flow will significantly
increase, thus changing your PEEP and tidal volume settings.

13. CONT….
➔ The maximum flow rate on the majority of ECMO machines is around 6
liters per minute. When weaning VA ECMO, we recommend weaning at
increments of 0.5 liters per minute to 1.0 liter per minute changes when
decreasing the flow rates. Flow rates should not drop below 2.0 to 2.5 l/min
as this will cause clotting in the cannulas and circuit.
➔ Each time a decrease in flow rate is made, this rate should be maintained
for at least 60 minutes to monitor the patient's decompensation. If the
patient shows any signs of failure to have adequate cardiac output, signs of
inadequate tissue perfusion, increasing blood lactate levels, or any
echocardiographic findings of ventricular demise should prompt the
physician to place the patient back on full support and monitor the patient
for recovery of their cardiac function on full ECMO support.

14. CONT….
➔ When weaning from VA ECMO, the patient may show signs of stability with a
left ventricular ejection fraction greater than 25% with a normal cardiac index
greater than 2.5 L/min. These are good signs for ECMO weaning.
➔ If the patient shows signs of hemodynamic instability or signs of distress at any
time, the patient should be changed to full ECMO support. When monitoring
with a transesophageal echo or transthoracic echo when weaning, we need to
look for signs of rising left or right-sided filling pressures, progressive
ventricular dilation, worsening or new signs of mitral or tricuspid regurgitation,
any sign of hypoxia or hypercarbia on arterial blood gas, any sign of ventilator
changes with elevated peak pressures or plateau pressures. Also, look for
signs of increasing vasopressors support when the patient has signs of
hypotension with a map less than 60

15. CONT…
➔ Once the patient has completed weaning from the ECMO circuit, the
heparin infusion can be stopped, and the pump flow on the ECMO
machine will be raised. This is performed to avoid any clot
accumulation. Some institutions will administer a positive inotrope at
this time to help facilitate cardiac output after the cannulas have been
clamped. If the patient is deemed liberated/weaned from ECMO
support at this time, the patient can be decannulated with the removal
of the cannulas. This could be performed at the bedside if the
percutaneous placement of the cannulas was performed. If central
cannulation or surgical cutdown were performed, the cannulas would
need to be removed in the operating room.

16. CONT….
➔ Once the patient has been completely weaned from ECMO, the
patient will need continuous monitoring of their cardiac output, oxygen
saturation levels, lactic acid levels, pH, urine output, and vent settings
to confirm the patient can maintain perfusion of their organs.
➔ After liberating the patient from ECMO support, patients sometimes
have signs of an inflammatory response requiring an increase in their
inotropic support. This is not uncommon when weaning from ECMO

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