Cardiothoracic critical care PA Brendan Riordan (@concernecus) shows us his initial approach to the patient in cardiogenic shock, including initiating mechanical support, managing ECMO (plus Impella), and eventual weaning and discontinuation of support.
Anticoagulation on VA ECMO can be titrated to bleeding risk, with a balance between bleeding and circuit longevity—the latter being more than an inconvenience, as changing the circuit in a patient fully dependent on the pump is fraught. Anti-Xa levels are more reliable than the PTT. In a patient with HIT, you may be able to treat through it with bivalirudin, as the heparin-bonded circuit usually cannot be switched out.
“Hypoxemia” on VA ECMO is either regional hypoxemia/North-South syndrome/harlequin syndrome, or oxygenator failure. Rule out the latter by checking a post-oxygenator ABG or just looking to ensure the outflow blood is bright red. Rule in the former by evaluating the ABG or SpO2 from the right upper extremity.
Preemptively placing an anterograde perfusion catheter in the femoral artery is not absolutely mandatory, but is probably simpler and perhaps safer than placing one reactively.
A PA catheter is more useful for weaning ECMO than during the period of full support.
Readiness for weaning is evaluated by recognition of improving cardiac pulsatility, followed by a trial of weaning down pump flow, and finally decannulation in the OR. Consider leaving the Impella if there are any lingering concerns.
A 5-minute episode describing three hyper-simple, generally safe recipes for the initial strategy of mechanical ventilation after intubating a COVID-19 patient.
Caveat: this is intended for trained clinicians, such as emergency medicine providers, who already have a general understanding of safe and sound life support practices. It glosses over a great deal and is not meant as a primer for trainees.
Intensivist and passionate slayer of venous congestion Philippe Rola (@thinkingcc) shows us how to deresuscitate the septic patient, with guidance from his handy ultrasound.
Fluid overload is harmful and should be actively reduced, even in a patient in active shock; it will not harm them.
The VEXUS exam is a good method for stratifying fluid overload by severity, i.e. severe (and harmful) versus mild (and relatively benign).
The IVC, CVP, or hepatic vein doppler offer similar information, and are all effective means of assessing central venous pressure, the first and most important step in evaluating for venous congestion. The portal vein doppler offers the most additional diagnostic yield on top of this. Renal vascular doppler acts mostly as a “tiebreaker” when these other studies are equivocal.
No one study or datapoint tells the whole story in these patients. Gather data from as many sources as possible to form the clearest picture.
Our apologies for the section of missing audio and slightly below-par audio quality in this one.