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Quick Tip for Families in Intensive Care: My Dad was on VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenation) for Cardiac Arrest & He Got De-Cannulated! Was it Too Early? He Has Deteriorated.

If you want to know when is the right time to decannulate someone from VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenation) for heart failure, stay tuned! I’ve got news for you.

My name is Patrik Hutzel from intensivecarehotline.com, and I have another quick tip for families in intensive care.

So currently, we are working with one of our members, we have a membership for families of critically ill patients in intensive care, who has their 51-year-old dad in ICU, and they had them on VA ECMO for heart failure.

Now, VA ECMO, just for explanation, is a bypass machine that can take over the function of the heart for a period of time, which is what happened in this particular situation. Our member’s dad had a cardiac arrest and ended up on ECMO to provide the cardiac and lung support while his heart was recovering.

So, he was on ECMO for about 3 weeks, and they had taken him off to an Impella, which basically a machine that can also take over the function of the left ventricle for a period of time. It’s less support than ECMO, but there’s still support needed for the heart because the heart had a cardiac arrest, and it’s not fully recovered yet that’s why this particular patient went from VA-ECMO to Impella.

Now, the question is, was that too early? And especially since ejection fraction, which refers to the contractility or the pump function of the heart, was around 20 to 25%. The patient was not on inotropes, not on vasopressors whilst on ECMO. But now, let’s look at the clinical status after he’s come off VA-ECMO, and I will read that out and explain as we go along.

“Patient remains critically ill following VA ECMO decannulation and Impella 5.5 placement. Postop day 1 status post bilateral groin decannulation of VA ECMO and left-sided Impella insertion with patch angioplasty of the right common femoral artery, primary repair of SFA (superficial femoral artery) antegrade access, and primary repair of left common femoral artery access as well as over-sewing of left common femoral vein.”

This is when ECMO decannulation was taken out. The veins and the arteries had to be sutured to stop bleeding.

“Patient’s cardiac function is being supported with Impella 5.5, along with vasopressors/inotropes with norepinephrine 0.03 mcg/kg/min, vasopressin 0.06 units/min, and epinephrine 0.025 mcg/kg/min to maintain MAP (mean arterial blood pressure) goal of 70-80 and to wean as tolerated. He is also continued with the antiarrhythmic therapy with amiodarone and lidocaine (0.5 mg/min) per the cardiovascular team.”

Now, let’s just stop there for a moment.

So, when this patient was on VA ECMO, he also had amiodarone and lidocaine simply because he had a cardiac arrest and he had VT (ventricular tachycardia) and VF (ventricular fibrillation) arrest, which means he was in an irregular heart rhythm. Amiodarone and lidocaine prevent arrhythmias, but he was not on vasopressor as an inotrope such as norepinephrine, vasopressin and epinephrine. So, from that perspective alone, you could argue it was too early to take out VA ECMO.

The challenge here is that you can only leave a patient on VA ECMO for so long because there’s a huge infection risk, there’s a huge clotting risk. There’s a number of risks attached to ECMO, and therefore, they had to make a call.

Now, let’s continue with the report.

“Blood transfusions are needed to maintain hemoglobin >8 g/dL. His most recent hemoglobin level is 7.8 and 6.8 on yesterday, which must be addressed.” So, i.e., he needs another blood transfusion.

“To further investigate for any active bleeding, especially following ECMO decannulation and vascular repair, bilateral groins are soft and JP drain output bilaterally has been appropriate per the vascular team. They need to monitor output via the bilateral groin JP (Jackson-Pratt) drains every 4 hours and as necessary for any significant increase in JP drain output indicating further or worsening bleeding and intervene promptly.

He is with ongoing anticoagulation using heparin (tapered down to 500u/hr) per the Impella device protocol and antiplatelet therapy (aspirin 81 mg daily and ticagrelor 90 mg BID) for stent protection.” This gentleman also has a cardiac stent, PTCA (percutaneous transluminal coronary angioplasty). “His platelets improved to 144, and INR (International Normalized Ratio), PT (Prothrombin Time), and fibrinogen levels are normal. PTT (Partial Thromboplastin Time) at 37, monitoring trends.

They need to balance anticoagulation with bleeding risk, particularly your dad, this is our member, your dad being a high-risk patient post-ECMO decannulation/vascular repair.

Renal function continues to be impaired, BUN/Blood Urea Nitrogen (59) and creatinine (2.72) significantly increased, estimated Glomerular Filtration Rate (EGFR) dropped to >27, though urine output has improved to 700 mL in the last 24 hours. CRRT (continuous renal replacement therapy), also known as hemodialysis, is currently held. He is also with increased potassium/hyperkalemia (5.5 – 5.7) episodes and is being corrected. To recheck potassium levels as persistent hyperkalemia may lead to life-threatening complications such as heart arrhythmias. For close monitoring of renal function with a potential need to restart CRRT if kidney function does not improve. To further monitor and renal team to address.

He continues on PRVC (Pressure Regulated Volume Control) ventilation with stable settings, FiO2 (fraction of inspired oxygen) 40%, set rate: 16, PEEP (positive end expiratory pressure) 5, tidal volume: 400 ml. Inhaled nitric oxide is being weaned, with plans for Daily Sedation Interruption (DSI) and Spontaneous Breathing Trial (SBT) once off nitric oxide.”

Now, here is another big change. The patient did not need any nitric oxide while he was on VA ECMO, now he needs nitric oxygen. That is also a big game changer. What are indications for nitric oxide? Usually, it’s pulmonary hypertension, i.e. there is high pressures in the lungs. That can happen if the heart is failing, especially if the right heart is failing. But that’s also a sign that weaning off VA ECMO might have been a little bit premature.

Let’s continue in the report.

“Infection control remains a priority, with cefepime continued for his Klebsiella-associated pneumonia and close monitoring of persistent leukocytosis, his WBC (white blood cell) is now at 19.01 and with recent episodes of spikes of fever (38.4 °C). They need to further investigate and do septic workup. Take all blood cultures, urine, sputum, wound, and central line sites to target infection with targeted antibiotics, antivirals, and antifungals. They need to be aggressive with this and involve the Infectious Disease team.

Neurologically, he is sedated with dexmedetomidine (Precedex) at 0.2 mcg/kg/hr with GCS (Glasgow coma scale) of 4, not obeying commands. To monitor further if weaning is possible.

Fluid balance in the last 24 hours, he is with fluid intake of 6230 ml, with urine output of 1290 ml, and a significant net positive fluid balance of 4940 ml. Per notes from the cardiologist, he reviewed the chest x ray and noted with minimal vascular congestion. Careful monitoring and targeted diuresis with Furosemide/Lasix or CRRT resumption are needed to prevent overall fluid overload which could compromise cardiac and pulmonary function.” So, fluid balance of around nearly 5L positive is huge and could impact on cardiac function as well, so that needs to be monitored. I presume they will be starting CRRT (Continuous Renal Replacement Therapy) again soon to manage a very positive fluid balance.

“Enteral nutrition at 60 mL/hr is in place and to monitor for tolerance, and albumin supplementation may be considered for hypoalbuminemia (low albumin)

It is important to maintain interdisciplinary collaboration with cardiology, nephrology, hematology, infectious disease, nutritionist, and neurology to promptly address the complex critical needs of your dad. “

Also, left ventricular ejection fraction is estimated at 25%. Once again, what’s ejection fraction? It refers to the contractility or pump function of the heart. There is a dilated left ventricle with severe segmental left ventricular systolic dysfunction, EF 20-25%. Akinesis of the apical wall segments. Otherwise, mild hypokinesis. Impella catheter is visualized crossing the aortic valve into the left ventricle.

Other things that need to be looked at in a situation like that is mixed venous blood gases, also known as SvO2, and in this situation it’s very low, around 45-48%. Normal mixed venous gas should be above 60%, that indicates a reduced oxygen delivery, which indicates that the ECMO decannulation was possibly too early. Pulmonary artery pressures (PA) are also high with 60/30 mmHg, and CVP (central venous pressures) also remain high above 15 mmHg.

What also needs to be looked at in a situation like that is cardiac output, cardiac index, which relates directly to mixed venous gas saturation (SvO2). If the organs aren’t perfused, mixed venous gas is decreased, which is clearly what’s happening here, especially when patients are still on inotropes and vasopressors to support a blood pressure.

So, I really hope that helps you understand what’s happening with VA ECMO decannulation, especially when it goes on to an Impella or an LVAD (left ventricular assist device). I hope that helps you understand some of the dynamics and mechanics around it.

I have worked in critical care nursing for 25 years in three different countries where I’ve worked as a nurse manager for over 5 years. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy.

You can verify that on our testimonial section at intensivecarehotline.com and you can verify it at intensivecarehotline.com on our podcast section where we have some client interviews. We share with our audience how we help them save their loved ones’ lives in intensive care with our consulting and advocacy.

We have helped hundreds and hundreds of members and clients over the years to improve their lives instantly when they have a loved one critically ill in intensive care. You can join the growing list of members and clients by giving us a call here at intensivecarehotline.com and we can show you very quickly how we can help. Our advice is absolutely life-changing. Once again, that is all documented and verified by our clients. It is absolutely life-changing.

That’s one of the reasons why I do one on one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. I also talk to doctors and nurses directly with you or on your behalf, or I can set you up with the right questions to ask. When I talk to doctors and nurses directly, I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com, and I will talk to you in a few days.

Take care for now.