Episode 5: Cardiogenic shock and ECMO with Brendan Riordan

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.

Some pearls

  1. 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.
  2. “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.
  3. 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.
  4. A PA catheter is more useful for weaning ECMO than during the period of full support.
  5. 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.



2 thoughts on “Episode 5: Cardiogenic shock and ECMO with Brendan Riordan”

  1. Great episode. Couple thoughts…
    There are non-heparin bound oxygenators, but the benefit of using these is negligible.
    You have to consider the flow from Impella and ECMO circuit to account for a total flow. There most likely wouldn’t be a need to flow ~4.0lpm from the Impella and ECMO. The Impella should usually flow around 2lpm for decompression only. The ECMO flow should handle perfusion needs.
    The Impella can then be used as a bridge from ECMO once oxygenation is no longer an issue.
    You should do a more in depth episode on VV-ECMO!

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