Heart Surgery in America: Wednesday 1.1
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24 Hours… of ECMO
Getting Started …
24 hours to the finish line, and all you can do is just hope you don’t trip and fall. That pretty much sums up this ECMO run. Just trust your feet, and don’t lose sight of the goal…
If you are in the middle of your otherwise hustle and bustle filled life, a day in the midweek- leaves little consequential impact on you, your psyche, or anything else for that matter- other than time clock numbers and your paycheck. Fridays are a little more important because that’s when you can set your motor back to idle- and chill out for the weekend.
However, (and it’s a big however…) once in awhile life does rev down a bit, and becomes more like a slow motion syrup.
And that is the case today… Even though your own pace hasn’t changed, everything else around you has started to rotate a little slower, and the interplay between you and your surroundings has become a little more dramatic.
This game is on, and the edge of the sword has come into play…
Friday: 7:00 pm Getting to the PICU…
It’s already been a long day, just waiting for MY day to begin (a 24 hour shift from Friday evening to Sat night). I had been thinking about this patient and the family for most of it, and the decision that had been taken to render a mid-course correction of an ECMO run on a semi-adult sized child.
I had some butterflies, not because I’m a rookie or scared or anything so un-brave as that. More to the point, it is that ECMO waters are almost always unpredictable and uncharted. The only dependable thing is the trust you have in yourself and the colleagues surrounding you. The only thing I trust when it comes to equipment, is that each piece has it’s breaking point.
The one thing I know for sure about us here in this unit, is that we just don’t (break).
Not today.
Not on this run…
So I called my 13 year old daughter on my way in, and told her about what was going on at work, in 13 year old language of course- which is almost always more honest (black & white) than the gray-scale ambiguity coming from most adults.
She got it, and even though she was far away, she cared for both me and was sad for our young patient. She reminded me that I was the best at what I do (cuz that’s what Dad’s tell their little girls from day 1 of course) and she cracked me up with her humor.
I laughed so hard- and for a second wasn’t so worried about some unknowable storm on some unseen horizon.
I really needed that to get my perspective back. Thanks Maria 🙂
8:00 pm A Quick Review …
(Click Image to Enlarge)
The patient had just gotten back from the cardiac cath lab. Original cannulation for the ECMO was via IJ and Carotid, but our CVP had bumped to 22-22. As well the LA pressures were 20 ish (down from 40 or so when we first got the patient), but still too high.
Big time inotropic support to offest what seemed like the perfect storm of Sepsis, Infectious Mononucleosis, and the Epstein–Barr virus (EBV).
The plan was to do an atrial septostomy to create an ASD– float an additional percutaneous venous catheter up from the right femoral vein to IVC and across the septum to the LA. The anticipated result was to unload both sides of the heart and decrease cardiac chamber pressures.
Obviously the physics, physiology, planning, and medical dynamics regarding this approach are far more sophisticated and in-depth than the scope of this post, but the goal here is to paint a comprehensible picture, recognize the fluidity of the clinical environment, and avoid turning it into a case review presentation.
We used a Quadrox oxygenator, an adult circuit as the BSA was 2.06 M2 (85 Kg), and threw in a “kydney” to ultrafiltrate some serious volume as the patient was + 4 liters from onset of ECMO.
While we had managed reasonable flows (1.8 CI) prior to the cath lab visit, our venous return was rate limiting (bladder pressure around -7 mmHg ).
After the “fix” our flows were the same, but venous return much improved (bladder pressure around + 38 mmHg ), venous saturations in the high 70’s, CVP down to 12, PA pressures close to normal.
