쉐도잉 연습: Introduction to ECMO Part 3 - V-A ECMO - 영상으로 영어 말하기 배우기
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Veno-arterial ECMO is a bit like Veno-Venous ECMO, except you return the non-pulsatile blood flow into a high pressure system.
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Oh, and the blood is travelling in the wrong direction.
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My name is Ken Hoffman.
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I'm an intensivist at the Alfred Hospital in Melbourne.
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This is the third video in our introduction to ECMO series, aimed at new staff joining our team.
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It will cover the principles of Veno-arterial or VA ECMO,
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the indications, complications and considerations for liberation from VA ECMO support.
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To start with, the circuit itself for VA ECMO is very similar to VV ECMO.
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The major difference is that blood is returned to an artery under high pressure.
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In this way, we can consider the ECMO pump being an artificial heart pumping non-pulsatile blood in parallel around the body.
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The circuit starts with an access cannula in the right atrium or vena cava which removes venous blood from the body.
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As this blood will return to the arterial circulation without going through the lungs, it must pass through a membrane oxygenator for gas exchange.
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It will then be returned back under high pressure to the arterial circulation, usually via the common femoral artery.
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The returning blood travels in the opposite direction through the arterial system, back towards the heart.
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If the heart is still able to contract and eject some blood, this blood will mix with the ECMO blood somewhere in the proximal aorta.
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This combination of a native pulsatile circulation and an artificial retrograde non-pulsatile circulation will be important when considering some specific complications later.
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One specific difference with a VA ECMO circuit is the requirement for a backflow cannula.
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As the large return cannula will sit in the common femoral artery, this can occlude blood flow to the leg.
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To prevent leg ischemia, a smaller cannula is placed in the superficial femoral artery
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which is connected into the ECMO circuit and allows downstream perfusion of the leg with oxygenated ECMO blood.
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To titrate the amount of VA ECMO flow, we rely on clinical parameters such as mean arterial pressure,
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lactate, urine output and peripheral perfusion.
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Turning up the fresh gas flow doesn't really change the oxygen delivery.
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So if the patient needs more support, the ECMO circuit flow should be increased.
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It is important to remember that with VA ECMO, the fresh gas flow should never be turned to zero,
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as this would result in deoxygenated blood being returned into the arterial circulation.
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To summarise, VA ECMO can provide cardiac support by pumping oxygenated blood into the arterial circulation.
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It can also be used for respiratory support as the returned blood is fully oxygenated.
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In terms of the indications for VA ECMO, it is used as support for severe heart failure.
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It is important to remember that VA ECMO doesn't actually fix anything.
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Instead, it provides time so the patient can be bridged to recovery, bridged to a durable left ventricular assist device, or transplantation.
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This is why VA ECMO is still a niche support modality.
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A lot of the complexity comes from decision-making about how and when to liberate the patient from VA ECMO support.
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The next thing to talk about are complications.
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These can be divided into the common ECMO complications of bleeding,
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thrombosis, infection and hemolysis and specific VA ECMO complications.
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The specific VA ECMO complications to discuss are differential hypoxia,
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left ventricular distension, leg ischemia and cardiac arrest on VA ECMO support.
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Differential hypoxia occurs as a result of mixing between the forward flowing native cardiac output and retrograde flow from the ECMO circuit.
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If the native lungs are poorly oxygenating the native cardiac output, then hypoxic blood will be pumped into the aorta.
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The relative proportions of native cardiac output to ECMO flow will determine where the mixing point will be in the aortic arch.
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If native heart function improves but the lungs still have respiratory failure, increasing amounts of hypoxic blood will enter the arterial circulation,
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which will disproportionately affect the upper parts of the body.
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In order to detect this, the arterial line is routinely inserted in the right radial artery
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and the pulse oximeter should be placed on the right hand or right ear lobe.
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This will confirm if the blood in the first branch of the aortic root, which is the brachiocephalic trunk,
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is delivering adequately oxygenated blood to the right subclavian artery and more importantly, the right common carotid artery.
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When differential hypoxia occurs the focus should be on trying to
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improve the native lung function to increase oxygenation of the native cardiac output.
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Other options include reducing inotropy to decrease the native cardiac output,
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increasing ECMO flow to move the mixing point proximally or reconfiguring to return sites other than the femoral vessels.
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Rarely fancy ECMO modes are required such as VAV or even separate VA and VV ECMO circuits.
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Next complication to talk about is left ventricular distension.
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This occurs
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when the left ventricle is unable to generate enough tension for
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the aortic valve to open during systole due to the pathology affecting the ventricle plus the increased afterload from retrograde ecmine flow.
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This is exacerbated by any aortic valve regurgitation.
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When left ventricular distension occurs,
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the forward flow through the lungs is impaired and can result in pulmonary edema and pulmonary hemorrhage.
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Rarely, stagnant blood in the left ventricle can clot.
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Signs of left ventricular distension include a loss of arterial line pulsatility, a chest x-ray with pulmonary edema
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or an echo with a dilated poorly functioning left ventricle with an aortic valve that is not opening.
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Management of left ventricular distension involves increasing left ventricular ejection with inotropes,
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reducing peripheral resistance and lowering mean arterial pressure targets and fluid removal to reduce the main systemic filling pressure.
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If these interventions don't work, the left ventricle needs to be decompressed.
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Usually, this is with a left ventricular vent cannula, which is joined into the access part of the ECMO circuit and drains the left ventricle with negative pressure.
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The complication of leg ischemia has already been discussed.
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It is prevented with insertion of a backflow cannula in the superficial femoral artery.
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The leg still requires regular vascular observation by monitoring non-pulsatile Doppler flow as the backflow cannula can develop thrombosis.
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The last complication to discuss is cardiac arrest on VA ECMO.
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This is detected by a loss of pulsatility on the arterial line and an ECG that is not in a perfusing rhythm.
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When this occurs, chest compressions are not required.
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Instead, attempt to increase the VA ECMO flow to provide support whilst trying to restore a perfusing rhythm.
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The reason restoring a perfusing rhythm is important is that stagnant blood in the left ventricle may clot.
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Large clots in the left ventricle are unsurvivable.
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and even small clots may result in embolic complications with restoration of cardiac output.
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The final thing to discuss is liberation from VA ECMO support.
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As already mentioned, if there is no cardiac recovery, then ECMO is a bridge to another treatment,
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such as a durable left ventricular assist device or transplantation.
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If there is cardiac recovery, then an echo-guided weaning study is performed.
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This examines cardiac function with progressively reducing VA ECMO flow to determine
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if the heart is able to cope without VA ECMO support.
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If the weaning study is passed,
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the VA ECMO is removed in the operating theatre as the large arterial cannulation site requires some stitches to control bleeding.
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In summary, VA ECMO is used for cardiac support when the heart is unable to pump sufficient blood to maintain organ function.
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Complications occur related to the ECMO circuit including the VA specific complications of differential hypoxia and left ventricular distension.
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Liberation from VA ECMO is complicated as it is used either
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as a bridge to recovery guided by an echo weaning study
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or as a bridge to a durable left ventricular assist device or transplantation.
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If you would like to read more about our ECMO protocols, they are freely available at ecmo.icu.
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Thank you for listening.
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If you enjoyed this video, please hit the like button.
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If you would like to see more videos like this, please subscribe to our channel.
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맥락 및 배경
이 비디오에서는 VA ECMO에 대한 소개가 이루어지며, 발표자는 멜버른의 앨프리드 병원에서 근무하는 중환자 전문의인 Ken Hoffman입니다. VA ECMO는 심장과 폐의 기능을 보조하여 환자가 회복할 수 있도록 도움을 주는 복잡한 기계적 장치로, 특히 중증 심부전 환자에게 사용됩니다. 이 콘텐츠는 영어 학습자들이 영어 발음 교정과 의학 관련 용어를 개선하는 데 도움이 될 것입니다.
일상 대화를 위한 5가지 주요 문구
- Veno-arterial ECMO는 비슷하지만 정맥에서 동맥으로 혈액을 되돌립니다.
- ECMO 펌프는 인공 심장처럼 작동하여 비펄스 방식으로 혈액을 순환시킵니다.
- 환자의 상태에 따라 ECMO 흐름을 조절해야 합니다.
- VA ECMO는 시간을 제공하여 회복으로 다리를 잃지 않도록 도와줍니다.
- 복합적인 결정 과정이 환자를 ECMO 지원에서 해방하는 시점에 영향을 미칩니다.
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화자가 가장 많이 쓰는 문형을 영상 속 실제 표현과 함께 정리했습니다.
| 문형 | 영상 속 표현 |
|---|---|
| 수동태 be + 과거분사 — 누가 하는지보다 무슨 일이 일어나는지에 초점 | is returned · be returned · is placed |
| 관계절 who / which + 절 — 사람이나 사물에 대한 추가 정보 | root, which is · cannula, which is |
쉐도잉이란? 영어 실력을 빠르게 키우는 과학적 방법
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