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Fisiologia degli scambi
gassosi durante circolazione
extracorporea
2009, Milano
Luciano Gattinoni, MD, FRCP
Università di Milano
Fondazione IRCCS- “Ospedale Maggiore
Policlinico, Mangiagalli, Regina Elena”
Milan, Italy
Oxygenation assessment:
the basicsthe basics
Oxygenation
• Tension
• Content• Content
• Assessment
Oxygenation
• Tension
• Content• Content
• Assessment
The basic Physiology
Partial pressure (Tension)
Activity of the unbounded O2molecules
In arterial blood PaO2In venous blood PvO2In alveoli PAO2
PAO2 = FIO2 * 713 – PACO2/RQ
Oxygenation
• Tension
• Content• Content
• Assessment
Ox
yg
en S
atu
rati
on
(%
)
92
94
96
98
100
102
54 pts
PaO2 (mmHg)
0 50 100 150 200 250 300
Ox
yg
en S
atu
rati
on
(%
)
80
82
84
86
88
90
r2 = 0.8973
p < 0.0001
54 pts
Maximal binding capacity of hemoglobin
1 mole Hb (64500 gr/M)
4 moles of oxygen (4 x 22.414 L at 0°C and 760 mmHg)
binds
4 moles of oxygen (4 x 22.414 L at 0°C and 760 mmHg)
Therefore
89656 mL/64500 gr = 1.39 mLO2/grHb
The basic Physiology
Content
total amount of bounded and unbounded O2 molecules
In arterial bloodIn arterial blood
CaO2 = PaO2 x 0.003 + 1.39 x Hb x SataO2
In venous blood
CvO2 = PvO2 x 0.003 + 1.39 x Hb x SatvO2
In lung capillaries (Hp Sat=100%)
CcO2 = PAO2 x 0.003 + 1.39 x Hb x 1
Oxygen Transport (DO2)
DO2 = CaO2 x Qt
normally
1000 mL/L = 200 mL/Lx 5 L1000 mL/L = 200 mL/Lx 5 L
VO2 ≈ 1/4 - 1/5 of DO2
Venous O2 saturation ≈ 0.75 = 1- VO2/DO2
Oxygenation
• Tension
• Content• Content
• Assessment
– PaO2/FiO2
– Right to left shunt
– Oxygenation Index (OI)
Anatomical shunt compartment
Gasless tissue
CvO2 CaO2
CvO2
VCO2CcO2
Right to Left Shunt
(CcO2 – CaO2)
(CcO2 – CvO2)
CaO2 x Qt = CcO2 x (Qt-Qs)+CvO2 x Qs
Shunt =
Oxygenation Index = (FIO2 * Mean Airway Pressure) / PaO2
Oxygenation Index
Oxygenation index and severity of lung dysfunction
2–7 Normal or mild pulmonary dysfunction2–7 Normal or mild pulmonary dysfunction
8–9 Moderate pulmonary dysfunction
≥ 10 Severe pulmonary dysfunction
≥ 30 Need for ECMO
Fiser et al. J Heart Lung Transplant 2001;20:631–636.
Oxy
gen
atio
n I
ndex
40
45
50
55
PaO2 60 mmHg
PaO2 50 mmHg
MAP 25 cmH2O
As an example…
67
6071
63
56
50
Oxygen fraction (%)
50 60 70 80 90 100 110
Oxy
gen
atio
n I
ndex
20
25
30
35
100
86
75
67
83
71
P/F ratio
Carbon dioxide assessment:
the basicsthe basics
Carbon dioxide
• Tension
• Content• Content
• Assessment
Carbon dioxide
• Tension
• Content• Content
• Assessment
The basic Physiology
Partial pressure (tension)
Activity of the unbounded CO2molecules
In arterial blood PaCO2In venous blood PvCO2
In alveoli PACO2 ETCO2
Carbon dioxide
• Tension
• Content• Content
• Assessment
Contents
Total CO2 = sCO2 + HCO3- + CO3= + PrNHCOO- + NaCO3-
Simplifying
Total CO = 0.03 x PaCO + HCO3-Total CO2 = 0.03 x PaCO2 + HCO3-
i.e.
Total CO2 = 0.03 x PaCO2 x (1 + 10pH-pK)
Remember
1 mMol/L = 2.24 mL%
40
60
80
BE 0
BE -5
BE -10
BE -15
BE -20
con
ten
t(m
L%
)
20 40 60 80 100 120
20
CO
2co
nte
nt
PCO2 (mmHg)
Carbon dioxide
• Tension
• Content• Content
• Assessment
Dead Space derivation
VA*PACO2 = VCO2
(VA+VDalv)*PETCO2 = VCO2
(VA+VDalv+VDanat)*PECO2 = VCO2
Alveolar PCO2 = Arterial PCO2
It is assumed that:
Physiological Dead
Space
(PaCO2 – PECO2)
PaCO2
Alveolar Dead Space
(PaCO2 – PETCO2)
PaCO2
Shunt effect
PvCO2 PaCO2
VCO2PcCO2
PcCO2=PACO2
PvCO2
Greater the shunt, greater the difference between
alveolar and arterial CO2
PCO2cascade
PACO2
Ventilated/
perfused lung
Alveolar
VD/VT
PETCO2
Anatomic
VD/VT
PECO2
PvCO2 PaCO2
PvCO2
VCO2PcCO2
perfused lung VD/VT VD/VT
Artificial Lung
• Determinants of oxygenation
• Determinants of Decarboxylation• Determinants of Decarboxylation
• The performance of the membrane
lung
Artificial Lung
• Determinants of oxygenation
• Determinants of Decarboxylation• Determinants of Decarboxylation
• The performance of the membrane
lung
The oxygen charged by the
artificial lung depends,
for a given input saturation, for a given input saturation,
on the blood flow in the
device
Performance
Oxygenator
Input:
37°C
Hb 15 gr/dLHb 15 gr/dL
Sat IN 70%
Bovine blood
Remember that:
The output blood is fully oxygenated,
even at low extracorporeal gas flow
Oxygen transfer is greater with lowerOxygen transfer is greater with lower
input saturation
Oxygen transfer increases linearly with
extracorporeal blood flow
Artificial Lung
• Determinants of oxygenation
• Determinants of Decarboxylation• Determinants of Decarboxylation
• The performance of the membrane
lung
In the venous blood the CO2
content is ≈ 45-50 mL%.
Theoretically from 0.5 L of
blood it is possible to clear the
metabolic CO2 production
Carbon dioxide transfer as a function of blood input pCO2, at different blood flow rates
Kolobow et al Trans. Am. Soc. Artif. Intern. Organs. 1977. 23: 17-21
Kolobow et al Trans. Am. Soc. Artif. Intern. Organs. 1977. 23: 17-21
Performance
Oxygenator
Input:
37°C
Bovine blood
PCO2 45 mmHg
Artificial Lung Performances(11 pts)
Day 1 Day 10
Blood Flow 1 L 2 L
Gas Flow 1.5 L 2.5 L
Input PO2 47 ± 12 mmHg 31 ± 10 mmHgInput PO2 47 ± 12 mmHg 31 ± 10 mmHg
Output PO2 530 ± 80 mmHg 479 ± 80 mmHg
Input PCO2 52.8 ± 8 mmHg 47.7 ± 8 mmHg
Output PCO2 35.4 ± 7 mmHg 29.0 ± 7 mmHg
∆PCO2 17.4 mmHg 18.7 mmHg
Input SatO2 76 ± 8 57 ± 7
CO2 clearance increases with:
Gas flow (primarily)
The logarithm of Blood Flow
Input PCO2
While in natural lung…While in natural lung…
15
20
60
80
100
% DP40 ∆∆∆∆P5
Content/Tension relationship
49
54
( mL/100mL whole blood)
∆∆∆∆C5∆∆∆∆C5
0
5
10
0 20 40 60 80 100 120 140
0
20
40
60%
(mmHg)PO2
DP40 ∆∆∆∆P5
PCO2
35 40 45 503034
39
44
40 40 4580
OXYGENATION
FiO2 =1.0 250 mL min-1
CO REMOVAL
VO2
250
mL min-1
Sata 98%
PaO2 110 mmHgHb 15 g
Satv 82%
PvO2 47 mmHg
7000 mL min-1
PBF
CO2 REMOVAL
VA 9500 mL min-1
VCO2
200
mL min-1
CO2 cont 34 mL
PaCO2 15 mmHg
PvO2 47 mmHg
CO2 cont 52 mL
PvCO2 43 mmHg
1100 mL min-1
PBF
Gattinoni et al., European Advances in Intensive Care, 1983; 21: 97-117
5000
6000
7000
8000
9000
1 104
60
70
80
90
100
110
120
VE
PaCO2V
E (
mL
*min
-1)
Pa
CO
2 (mm
Hg
)
gas flow 10 l/min EC onset
0
1000
2000
3000
4000
5000
0
10
20
30
40
50
60
0 6 12 18 24 30 36 42 48 54 60 66 72
VE
(m
L*m
in (m
mH
g)
Time (h)
Oxygen transfer in artificial and natural lung:
Interaction
The model
Limits of oxygenation in V-V bypass
Consequences of loss of hypoxic
vasoconstriction
Oxygen transfer in artificial and natural lung:
Interaction
The model
Limits of oxygenation in V-V bypass
Consequences of loss of hypoxic
vasoconstriction
Lu
ng
End-capillary blood
Intrapulmonary
shunt
Art
eria
lblo
od
Mixed-venousNatural Lung
Post
lung
O2 natural lung
O2 ECMO
Art
ific
ial
Lu
ng
Pre
lung
Art
eria
l
Body Tissues
VO2
Time course to
equilibrium
Shunt 40%
Art
eri
al O
xyg
en
Sa
tura
tio
n (
%)
94
96
98
100
Mix
ed
Ve
no
us O
xyg
en
Sa
tura
tio
n (
%)
90
95
100QECMO/Qtot 70% QECMO/Qtot 70%
Arterial Oxygen Saturation (%) Mixed Venous Oxygen Saturation (%)
Shunt 40%
STEP
1 2 3 4 5 6 7
Art
eri
al O
xyg
en
Sa
tura
tio
n (
%)
80
82
84
86
88
90
92
94
STEP
1 2 3 4 5 6 7
Mix
ed
Ve
no
us O
xyg
en
Sa
tura
tio
n (
%)
60
65
70
75
80
85
QECMO/Qtot 10%
QECMO/Qtot 10%
Time course to
equilibrium
Shunt 60%
Art
eri
al O
xyg
en
Sa
tura
tio
n (
%)
92
94
96
98
Mix
ed
Ve
no
us O
xyg
en
Sa
tura
tio
n (
%)
85
90
95QECMO/Qtot 70% QECMO/Qtot 70%
Arterial Oxygen Saturation (%) Mixed Venous Oxygen Saturation (%)
STEP
1 2 3 4 5 6 7
Art
eri
al O
xyg
en
Sa
tura
tio
n (
%)
76
78
80
82
84
86
88
90
92
STEP
1 2 3 4 5 6 7
Mix
ed
Ve
no
us O
xyg
en
Sa
tura
tio
n (
%)
60
65
70
75
80
85
QECMO/Qtot 10% QECMO/Qtot 10%
Shunt 60%
The equilibrium is reached when O2
from artificial lung plus O2 from
natural lung equals O2 consumed by2
tissues
VO2 = O2ECMO + O2NATURAL LUNG
Art
eria
l O
xyg
en S
atu
rati
on
(%
)
88
90
92
94
96
(mL
/min
)
340
360
380
400
420
ECMO
mathematical model
Shunt 50%
ECMO blood flow 50%
CO 9 L/min
Hb 11 gr/dL
VO2 250 mL/min
STEP
1 2 3 4 5 6 7
Art
eria
l O
xyg
en S
atu
rati
on
(%
)
78
80
82
84
86
88
VO
2 (
mL
/min
)
240
260
280
300
320
340
O2
tran
sfer
Oxygen transfer in artificial and natural lung:
Interaction
The model
Limits of oxygenation in V-V bypass
Consequences of loss of hypoxic
vasoconstriction
Steady stateA
rter
ial
Ox
yg
en S
atu
rati
on
(%
)
90
95
100
ECMO
mathematical model
ECMO Blood Flow (%CO)
10 20 30 40 50 60 70
Art
eria
l O
xyg
en S
atu
rati
on
(%
)
75
80
85
90
Shunt 60%
Shunt 50%
Shunt 40%
Oxygen transfer in artificial and natural lung:
Interaction
The model
Limits of oxygenation in V-V bypass
Consequences of loss of hypoxic
vasoconstriction
Anatomical shunt compartment
Gasless tissue
Fu
ncti
on
al
sh
un
t
0.4
0.6
0.8
1.0
Fu
ncti
on
al
sh
un
t
0.4
0.6
0.8
1.0
Anatomical shunt compartment
0.0 0.2 0.4 0.6 0.8 1.0
Fu
ncti
on
al
sh
un
t
0.0
0.2
0.4
Anatomical shunt compartment
0.0 0.2 0.4 0.6 0.8 1.0
Fu
ncti
on
al
sh
un
t
0.0
0.2
0.4
A B
Cressoni M. et al. Crit Care Med. 2008 Mar;36(3):669-75.
200
300
400
200
300
400
PaO
2/F
IO2
(mm
Hg
)
PaO
2/F
IO2
(mm
Hg
)Anatomical shunt compartment
0.0 0.2 0.4 0.6 0.8 1.0
0
100
Anatomical shunt compartment
0.0 0.2 0.4 0.6 0.8 1.0
0
100
A B
PaO
PaO
Cressoni M. et al. Crit Care Med. 2008 Mar;36(3):669-75.
Hypoxic vasoconstriction
maintains oxygenation at
different degrees of
anatomical shunt
QS
QT
=Gr. non aerated tissue
Lung Total Weight (gr.)K x
=Perfusion/ gr. non aerated tissue
K
Perfusion Ratio
=Perfusion/ gr. Tot.
K
Assumptions: 1) Edema near homogeneously distributed
2) Qs perfuses only the non aerated tissueHU > -100
HU > -300
Cressoni M. et al. Crit Care Med. 2008 Mar;36(3):669-75.
Perfusion ratio
and its change
depend on
(R2 0.83)
1) Size of the “bad” lung
2) Global perfusion
3) Hypoxic stimulus
(PsO2 = PvO20.38 x PAO2
0.42)
Perfusion Ratio
(PsO2 = PvO2 x PAO2 )
Decreasing the size
(recruitment)
Decreasing the CO
Perfusion ratio ↑
Perfusion ratio ↓
AS AVERAGE – It does not change
PV
R M
AX
(%
)
60
80
100
Hypoxic vasoconstriction
Theoretical modelPsO2 = PvO2
0.38 x PAO20.42
PVR max (%) = 100 x (PsO2-2.616)/(6.683 x 10-5 + PsO2
-2.61)
PvO2
0 20 40 60 80 100
PV
R M
AX
(%
)
0
20
40
FiO2 40%FiO2 60%FiO2 80%FiO2 100%
Therefore don’t be surprised
if providing 3-4 L ECMO
fully oxygenated blood flow,
arterial PaO2 and saturationarterial PaO2 and saturation
change minimally, since
functional shunt tends to
increase
Decarboxylation: interaction with
spontaneous and mechanical breathing
Control of breathing using an
extracorporeal membrane lung
The lung rest concept
Kolobow T, Gattinoni et al., Anesthesiology, 1977; 46: 138-141
Kolobow et al Trans. Am. Soc. Artif. Intern. Organs. 1977. 23: 17-21
This happens also in
spontaneously breathing menspontaneously breathing men
during CO2 removal
Alveolar ventilation as a function of CO2 elimination
Gattinoni et al Anest. e Rianim. 1977. 18(4): 396-406
Gattinoni et al Anest. e Rianim. 1977. 18(4): 396-406
Control of intermittent positive pressure breathing
(IPPB) by extracorporeal removal of carbon dioxide
Gattinoni et al., Br. J. Anesth., 1978; 50: 753
Corso Teorico-Pratico
Trattamento
dell’Insufficienza Respiratoria Acuta
mediante Supporto Extracorporeo
Centro di Simulazione
Fondazione IRCCS Policlinico, Mangiagalli e Regina Elena
Milano
2009
Il circuito extracorporeo:
Tipologie possibili
Giorgio IottiAnestesia e Rianimazione 2
Pavia
Sistema Respiratorio
Pump Failure
Lung Failure
Scambiatore di Gas
Pompa
Insp
Esp
INSUFFICIENZA RESPIRATORIA
PUMP FAILURE - IPERCAPNICA
Inquadramento Diagnostico Fisiopatologico
INSUFFICIENZA RESPIRATORIA
PUMP FAILURE - IPERCAPNICA LUNG FAILURE - IPOSSIEMICA
Inquadramento Diagnostico Fisiopatologico
• The syndrome did not respond to usual and ordinary methods of respiratory and ordinary methods of respiratory therapy
• The syndrome did not respond to usual and ordinary methods of respiratory and ordinary methods of respiratory therapy
• Positive end-expiratory pressure (PEEP) was most helpful in combating atelectasys and hypoxemia
CPT
Vtidal
FRC
VolumiPolmonari
StartStart
Plim
Ptidal
EEP
PressioniAlveolari
CPT
Vtidal
FRC
VolumiPolmonari
StartStart
Plim
Ptidal
EEP
PressioniAlveolari
CPT
Vtidal
FRC
VolumiPolmonari
↓ VtStart ↓ VtStart
Plim
Ptidal
EEP
PressioniAlveolari
CPT
Vtidal
FRC
VolumiPolmonari
↓ VtStart ↑ Freq.↓ VtStart
Plim
Ptidal
EEP
PressioniAlveolari
↑ Freq.
INSUFFICIENZA RESPIRATORIA
PUMP FAILURE - IPERCAPNICA LUNG FAILURE - IPOSSIEMICA
• Ossigeno• Ventilazione protettiva• Ventilazione protettiva• ↓ spazio morto• Pronazione• Manovre di reclutamento• iNO• Attività resp. spontanea
UTILIZZO OTTIMALE / MASSIMALE
DELL’ORGANO MALATO
Il gioco qualche volta non funziona…
• Anche con tutti i trucchi, le acrobazie e le precauzioni che abbiamo imparato, talvolta la sola POMPA ARTIFICIALEtalvolta la sola POMPA ARTIFICIALEnon basta:
– Severa IPERCAPNIA
–Pericolosa IPOSSIEMIA
INSUFFICIENZA RESPIRATORIA
PUMP FAILURE - IPERCAPNICA LUNG FAILURE - IPOSSIEMICA
• Ossigeno• Ventilazione protettiva• Ventilazione protettiva• ↓ spazio morto• Pronazione• Manovre di reclutamento• iNO• Attività resp. spontanea
UTILIZZO OTTIMALE / MASSIMALE
DELL’ORGANO MALATOSOSTITUZIONE con
ORGANO ARTIFICIALE
INSUFFICIENZA RESPIRATORIA
PUMP FAILURE - IPERCAPNICA LUNG FAILURE - IPOSSIEMICA
Supporto Respiratorio Extracorporeo
• Prelevo del sangue
• Lo tratto con uno scambiatore di gas Extra Corporeo a MembranaExtra Corporeo a Membrana
� Rimozione di CO2 (CO2R) ECCO2R
� + Ossigenazione (O) ECMO
• Reinfondo il sangue trattato
va ECMO
Rimozione di CO2
Ossigenazione
Assist. Cardiaca
JAMA 1979; 242:2193-6
Extracorporeal membrane oxygenation in severe acute respiratory
failure. A randomized prospective study.
Zapol WM, Snider MT, Hill JD, Fallat RJ, Bartlett RH, Edmunds LH,
Morris AH, Peirce EC 2nd, Thomas AN, Proctor HJ, Drinker PA, Pratt
PC, Bagniewski A, Miller RG Jr.
Nine medical centers collaborated in a prospective randomized study to
evaluate prolonged extracorporeal membrane oxygenation (ECMO) as a
therapy for severe acute respiratory failure (ARF). Ninety adult patients were therapy for severe acute respiratory failure (ARF). Ninety adult patients were
selected by common criteria of arterial hypoxemia and treated with either
conventional mechanical ventilation (48 patients) or mechanical ventilation
supplemented with partial venoarterial bypass (42 patients). Four patients in
each group survived. The majority of patients suffered acute bacterial or viral
pneumonia (57%). All nine patients with pulmonary embolism and six
patients with posttraumatic acute respiratory failure died. The majority of
patients died of progressive reduction of transpulmonary gas exchange and
decreased compliance due to diffuse pulmonary inflammation, necrosis, and
fibrosis. We conclude that ECMO can support respiratory gas exchange but
did not increase the probability of long-term survival in patients with severe
ARF.
vv ECMO
Rimozione di CO2
Ossigenazione
Kolobow T, Zapol W, Pierce J (1969) Trans Am Soc Artif Intern Organs 15:172-7
Anesth Analg 57: 470: 1978
av ECLA
(ILA Novalung)
Rimozione di CO2
A confronto
va ECMO
Rimozione di CO2
Ossigenazione
Assist. Cardiaca
vaECMO respiratoria: problemi
• Fortissima dipendenza dal supporto extracorporeo
• Ridotta perfusione polmonare• Ridotta perfusione polmonare
• Scarsa ossigenazione del sangue in uscita da VS (coronarie, tronchi sovraortici)
• Problemi di perfusione distale della zona dipendente dall’arteria incannulata
• Embolizzazione sistemica
av ECLA
(ILA Novalung)
Rimozione di CO2
avECLA: vantaggi
• Bassa richiesta di tecnologia
– Semplicità
– Investimenti ridotti
– Facile trasportabilità– Facile trasportabilità
• Comunque necessari:
– Misuratore flusso extracorporea
– Flussimetro di precisione
– Hemochron (ACT)
avECLA: problemi
• Notevole aumento della richiesta di prestazione cardiaca (shunt a-v)
• Dipendenza dalle condizioni emodinamiche del paziente
• Ridotta perfusione distale della zona dipendente dall’arteria incannulatadall’arteria incannulata
• Dispersione di calore (scambiatore di calore assente)
• Facilità di passaggio di gas nella camera ematica dell’ossigenatore (pressione transmembrana!!)
• Facilità di apposizioni trombotiche dell’ossigenatore (flusso relativamente basso)
• Scarsa capacità di ossigenazione
avECLA: problemi
• Scarsa capacità di ossigenazione
• Se bisogna passare allo step successivo (vvECMO), abbiamo fatto un grosso buco in un’arteria!
vv ECMO
Rimozione di CO2
Ossigenazione
vvECMO: limiti
• Capacità di ossigenazione: non consente un supporto totale
• Assistenza cardiaca: nessuna, se non • Assistenza cardiaca: nessuna, se non indiretta
Decapnizzatori
• vvECMO a bassissimo flusso
• Nessuna ossigenazione
• CO2 removal molto limitato• CO2 removal molto limitato
• Circuiteria da CRRT
– non eparinata
– Pompa sangue ?
– Concepita per uso discontinuo
– Cambi, tempo e impegno, costi
Conclusioni
• A voi le conclusioni sulla “ECMO respiratoria” più appropriata oggirespiratoria” più appropriata oggi
La gestione del ventilatore ed
interazione con il bypass
Giuseppe Foti
Istituto Anestesia e RianimazioneIstituto Anestesia e Rianimazione
Università di Milano-Bicocca
dir. Prof. A. Pesenti
Ospedale S. Gerardo Monza
…….ma adesso che sono in bypass,
il ventilatore
serve ancora ?
VENTILAZIONE OSSIGENAZIONE
Cosa succede alla partenza della
CEC
Rimozione > 70% VCO2Rimozione > 70% VCO2
PCO2 !!
ATTENZIONE SHIFT pH e
PCO2 !!
• � subito
– FR (sempre)
– TV (se necessario)– TV (se necessario)
– I/E (attenzione)
• Guided by:
– EndTidalCO2
– EGA
• entro 10’
Se non serve più ventilare, perché
tengo il ventilatore ?
• Malgrado �ECBF la PaO2 può essere �
• ECBF/C.O.
• � SvO2 � �Vasocostrizione ipossica
PO2 e PAP
PAPPAP
�������� Flusso CECFlusso CEC�������� SvOSvO22
SvOSvO22
Se non serve più ventilare, perché
tengo il ventilatore ?
• Per Ossigenare
Come
• Tenendo aperto il polmone
FR = 30
Paw = [(30*1) + (15*1)] / 2 = 22.5
30
Attenzione ai cambi bruschi di
Pmedia
FR = 15
Paw = [(30*1) + (15*2)] / 3 = 20
30
1” 1”
15
30
1” 2”
15
30
Attenzione ai cambi bruschi di
Pmedia
Attenzione ai cambi bruschi di
Pmedia
• Evitare immediatamente la sovradistensione
• Ridurre Pplat < 30
• TV < 6 ml/Kg
NO GOOD BETTER
Perché/Come contrastare i bruschi
cambi Pmedia ?
Perché/Come contrastare i bruschi
cambi Pmedia ?
• Dereclutamento
(Plasmorrea/Capillary Leak)
• ���� PEEP
• Evitando ���� I/E
Strategie Ventilatorie in ECMO
(una guerra di religione)
Recruiter Non Recruiter
High survival in adult patients with ARDS treated by High survival in adult patients with ARDS treated by extracorporeal membrane oxygenation, extracorporeal membrane oxygenation, minimal minimal sedation, and pressure supported ventilationsedation, and pressure supported ventilation
Linden V et al. Linden V et al. ICM 2000; 26: 1630ICM 2000; 26: 1630
�� 17 patients17 patients
�� LIS 3.5LIS 3.5�� LIS 3.5LIS 3.5
�� PaOPaO22/FiO/FiO22 46 mmHg46 mmHg
�� Length of bypass 3Length of bypass 3--52 days52 days
��((conventionalconventional VV or VA 9/17)VV or VA 9/17)
�� PEEP 10 PSV 15PEEP 10 PSV 15
�� Survival Rate 76 %Survival Rate 76 %
lung rest settings were :
- peak inspiratory pressure 20–25,
- positive endexpiratory pressure 10–15,
- rate 10,
- FiO2 0・3.
Recruiter strategy
� PAW
� B.F.
Non Recruiter strategy
� PAW
� B.F.
Non Recruiter strategy
• Low PEEP (5-10)
• LPS
– PSV
• High Blood Flow• High Blood Flow
– II° drainage cannula
• NO PNX
•• PulmonaryPulmonary HypertensionHypertension
–– VV--A bypass?A bypass?
� B.F.
Reclutamento e PAP
PAP
PVCPVC
RMs = 70 cmH2ORMs = 70 cmH2O
Non Recruiter strategy
In 33 patients (49%), a secondaccesscannula was needed to augmentcannula was needed to augmentECMO support.
Recruiter strategy
• RMs
• PEEP Titration
• SIGH
•• PNX ?PNX ?•• PNX ?PNX ?
%
Opening and closing pressures
30
40
50
Opening
pressure
Closing
pressure
Paw > 35 cmH2O
to fully recruit
Paw [cmH2O]
0 5 10 15 20 25 30 35 40 45 500
10
20 pressure
Crotti et al. Am J Respir Crit Care Med 2001
Modern PEEP TitrationModern PEEP Titration
10 1215
7
10
Spo2 e RM’s
• � � Problema risolto !Era un’atelettasia
• � e poi � � Ripeto e � PEEP
•± �� Pressione Rm’s
oppure aspetto
Quante RM’s ?
• Pochissime se uso SIGH
• In Controllata e Assistita
• Che pressione ? � quella di reclutamento• Che pressione ? � quella di reclutamento
• A chi ? � A quelli che reclutano
Sigh (1 ogni 3 min)
Effects of periodic lung recruitment maneuvers on gas exchange and
respiratory mechanics in mechanically ventilated ARDS patients.G. Foti, M.Cereda, M.E. Sparacino, L. De Marchi,F. Villa, A. Pesenti Intensive Care Med (2000) 26: 501-507
Pressione di reclutamento
Sigh (1 ogni 3 min)
↑Oxygenation
↓↓↓↓ Qva/Qt
SIGH
Monitoraggio
reclutamento
Monitoraggio
reclutamento• EGA
– P/F
– PaO2 al 100%
– Shunt– Shunt
– Rapporto B.F./C.O.
• Meccanica respiratoria
– Cpl, FRC
• Imaging
– Rx
– TC
Monitoraggio reclutamento
durante V-A bypass
• Quale sangue proviene dai polmoni ?
• Incannula la radiale dx• Incannula la radiale dx
– Se attività cardiaca
– Sangue proveniente dal polmone naturale
Oh..oh…c’è un PNX
• Presto mettiamo drenaggio toracico
• Aspettiamo e convertiamoci
Oh..oh…c’è un PNX
• Non mi convertirò mai!
– Dg percutaneo
– Guidato scopia– Guidato scopia
– Identificazione eco
• Bene, non sbolla più
• Tiriamolo via
•• Non rimuovete le frecce Non rimuovete le frecce
durante CEC (durante CEC (…augh…augh))
Identificazione Ecografica PNX
Sono passate ormai 2
settimane…dobbiamo fare la tracheo.
• Se proprio non se ne può fare a meno
• Percutanea meglio che chirurgica
• Fantoni meglio delle altre
– Attenzione al tracheoscopio rigido– Attenzione al tracheoscopio rigido
– Tecnica con fibroscopia flessibile
– Mantenete Paw con il tubino
– Sospendere/ridurre eparina
When a ALI/ARDS pts. can be When a ALI/ARDS pts. can be
weaned to PSV from CMV ?weaned to PSV from CMV ?
n.s.181±67218±68PaO2/FiO2
pFailureFailure22%
SuccessSuccess78%
PaO2 > 80
PEEP < 15
< .0520.2 ±19.29.2 ±13.5Days from
Tube
< .050.70 ±0.090.52 ±0.10Vd/Vt
< .0530 ±1642 ± 15Cst,rs
(ml/cmH2O)
Cereda M, Foti G. et al. Crit Care Med 2000 Vol.28 n° 5; 1269-1275
BENEFICI Respiro Spontaneo in ARDS
spontaneous breathing controlled ventilation, NMBA
Set: BIPAP+PSV, Pmax = 35-40cmH2O
Ti = 3-5 s.
RRBIPAP = 0.5-1 b.p.m.
ECMO per favorire il passaggio
al respiro assistito
• Quando è terminata fase iperacuta
– No capillary leak
• Per favorire reclutamento alveolare• Per favorire reclutamento alveolare
• Per accelerare il weaning
• Dottore..dottore..la frequenza respiratoria �– Aumenta PSV..mmm..no anzi
– Sedalo un pochino…..mmm….,aspetta
– Aumenta gas flow !
E se facessimo a meno del ventilatore ?del ventilatore ?
2/87 Survival
in Intubated in Intubated
because of Pneumonia
Ventilazione Diversamente
Invasiva (DIV)
1 Week
CEC
P/F 64
PEEP 15
GB 280
Plt 19.000
P/F 104
PEEP 10
GB 1050
Plt 33.000
Start
CEC
Pediatric ECMO Management: Pulmonary
• Optimal ventilator settings vary
• Limit peak pressures to 30 cm H2OH2O
• Delivered tidal volumes 4-6 cc/kg
• Rate 5-10 breaths/minute
• PEEP 12-15 cm H2O
• Inspiratory time longer
• Goal FiO2 0.21
Federico Pappalardo, MD
Department of Cardiothoracic and Vascular Anesthesia and Intensive Care
Università Vita e Salute San Raffaele Hospital, Milano
� Hemorrhagic complications 54% (37/68)
• ECMO cannulation site 22%
• GI bleeding 10%
• Respiratory tract 10%• Respiratory tract 10%
• Intracranial hemorrhage 9%
• Genital bleeding 9%
� Median amount of blood administered per patient 1880 mL
� NO thromboembolic complications ???
Overall adult ECLS SurvivalOverall adult ECLS Survival
Respiratory 53%
Cardiac 32%
ELSO Registry (100 centers)
Cardiac 32%
eCPR 37%
THROMBIN GENERATION/EFFECTS
XaXVIIIa, , PLCa++
Tissue Factor(TF:VIIa)
*
IXa
IX
Contact(XIIa)
Prothrombin
PT fragment 1.2
Va, Ca++
THROMBIN
, PL
FPAXIII
FV, FVIII, FXI FXIa, FVa/FVIIIa
Platelets
BTG, PF4
activation/consumption
*TFPI
bradykinin
APC
FVi, FVIIIi
Thrombomodulin*
Protein C
ATIII
ATIII
ATIII
ATIII
*
PT fragment 1.2
Fibrin (M)Fibrinogen
Fibrin (Ps)
Fibrin (Pi)
XIIIa
tPA*
EC
Plasminogen PLASMIN
D-dimer
FSP
Platelet GP1bPAP complexes
-2-antiplasmin
PAI1
tPA:PAI1*
TAT
ATIII
Injury of vessels wallleads to contact between blood and subendothelial cells
Tissue factor (TF) isexposed and binds toFVIIa or FVII whichis subsequently converted to FVIIa
1. Initiation phase
FXa binds to FVa on thecell surface
The complex between TF and FVIIa activates FIX and FX
The FXa/FVa complexconverts small amountsof prothrombin intothrombin
The small amount ofthrombin generatedactivates FVIII, FV, FXIand platelets locally.FXIa converts FIX to FIXa
2. Amplification phase
Activated plateletsbind FVa, FVIIIaand FIXa
The FVIIIa/FIXa complexactivates FX on thesurfaces of activatedplatelets
FXa in association withFVa converts largeamounts of prothrombininto thrombin creating a “thrombin burst”.
3. Propagation phase
The “thrombin burst”leads to the formationof a stable fibrin clot.
ASA, Dipyridamol, Clopidogrel
Heparin
Coumadin
PAT
aPTT
INR
TEG
• Haemostasis starts with the interaction between TF
and FVIIa on the surface of subendothelial cells.
• The small amount of thrombin generated during the amplification phase activates platelets locally on whose surface the subsequent reactions take place.whose surface the subsequent reactions take place.
• The resulting thrombin burst results in the formation of a stable clot.
Activation Balance
Inappropriate
Site
Inappropriate
Amount
Inappropriate Control
ThrombosisDVT/PTE
MIStroke
Bleeding
Transfusion
Inappropriate Control
� Contact activation : interface of blood with nonendothelial surface
� Pericardial activation : mediated by trasfusion of pericardial bloodpericardial blood
� Mechanical consumption : shear forces imposed by circuit’s component
� Pulsatile, axial or centrifugal device
� Cannulation (apical, atrial)
� Coagulation disease (anti-phospholipid antibodies,..)
� Heart disease (acute infarction, icmp, myocarditis,
Anticoagulation ManagementAnticoagulation Management
� Heart disease (acute infarction, icmp, myocarditis,
dcmp)
� Cardiac rhythm (fibrillation)
� Age (children)
Anticoagulation management
safe
Anticoagulation ManagementAnticoagulation Management
Anticoagulation management
low costs simple
Heparin activates platelets directly-GP IIb/IIIa activated-P-selectin expressed
+ Platelet Activated
Platelet
HeparinP-selectin
GP IIb/IIIa
Low concentrations of heparin increase the affinity of thrombin for fibrin.
Fibrin
ThrombinThrombin
ThrombinHeparin
+Thrombin
Heparin can induce
Heparin inactivated by Platelet Factor 4 (PF4)
FibrinHeparin can induce an immune response in the form of HIT/HITTS and lead to thrombocytopenia and thrombosis
Anti-bodies
Platelet
Factor 4+Heparin
Fibrin
2
1
Thrombin2
1
Thrombin
2
1
ThrombinHeparin
Heparin cannot bind clot-bound thrombin
P P
P
P
P
Heparin binds to plasma proteins and cells
PP
Cell
PPCell
PP
Heparin exhibitsa nonlinear
dose-response.
Heparin dose
AC
T
�UFH continues to dominate ECMO anticoagulation:
• rapidly acting
• easily reversible
• inexpensive
• widely available
• well tollerated by pediatrics and adults
• needs cofactor AT, produce inhibition of factor Xa, thrombin and TF • needs cofactor AT, produce inhibition of factor Xa, thrombin and TF
• thrombin bound to clot or surface of the circuit is not inhibited by AT-UFH complex
Bound thrombin activate clotting and thrombin generation
GREATER UFH NEEDS
4000
5000 D-Dimer ( ng / ml )
Increased Heparin to
Preserve Haemostasis• High Heparin had
reduced:
– Prothrombin activation
� β−Thromboglobulin
Despotis et al Thromb Hemostasis 1996;76:902-8
2000
3000
Control High Hep
� The effectiveness of anticoagulation worsens with the duration of ECMO (6 days freedom from thromboembolic events)
� Management of ECMO anticoagulation partially derived from the experiences of CPB
� The popular range for the ACT with UFH during ECMO is 180 to
220 sec220 sec
� aPTT is a valuable tool to assess anticoagulation in situation that do not require high heparin dosing such as ECMO
� In very ill patients requiring continuous infusion of UFH the ACT can not delineate between low and moderate level of anticoagulation compared with aPTT
Dosage of Acetylsalicylacide
Low dosage:Thromboxane A2 (platelet)-> reduction of aggregation
High dosage:Prostacyclin (endothelium)
Dosage of Acetylsalicylacide
Prostacyclin (endothelium)-> increasing aggregation
High dosage:Prostaglandin (stomac)
-> increasing GI-bleeding
0
50
100
150
200
250
300
350
400
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
400
500
600
Platelets and shockPlatelets and shock
0
100
200
300
400
500
600
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
0
100
200
300
400
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Grafic 1.: LVAD and RHF
Grafic 2.: LVAD survival
Grafic 3.: TAH survival
Platelets and shockPlatelets and shock
“Platelet transfusion represents a major part of
management of ECMO patients”
“Recurrent platelet dysfunction on ECMO”
“Frequent platelets transfusions even with
normal platelet count” normal platelet count”
“The more critically ill the patient, the more likely
platelets have been given”
LABORATORY TESTING
• Antigen assays- ELISA detects antibodies
reactive against the PF4/Heparin complex
- High sensitivity (90-98%)- High negative predictive
value
• Activation/Functional assays
- SRA (Serotonin release assay)
- Platelet aggregation assay
- Detect the presence of antibodies that activate platelets in the presence of heparin
- High sensitivity (>95%)
- High negative predictive valuevalue
- Moderate positive predictive value
- The magnitude of a positive ELISA can be diagnostically useful
- High negative predictive value
- Moderate positive predictive value
- The magnitude of a positive ELISA can be diagnostically useful
The presence of HIT antibodies does not necessarily predict the development of clinical HIT!!
There is no single laboratory test that perfectly correlates
with a clinical diagnosis of HIT, because there is currently no
test with 100% sensitivity and specificity for the detection of
pathogenic HIT antibodies
LABORATORY TESTING
pathogenic HIT antibodies
Do
STOP heparin
Switch to alternate anticoagulantSwitch to alternate anticoagulant
Don’t Do
No warfarin (Vit K if warfarin given)
No prophylactic platelets
Dx
HIT antibodies
Ultrasound for lower-limb DVT
COO-
+H3N
Lepirudin Bivalirudin Argatroban
+H3N
BIVALENT DTI UNIVALENT DTI
DTIDTI
Lepirudin Bivalirudin Argatroban
RENAL ENZIMATIC>RENAL HEPATICElimination
Binding
Effect on INR
Immunogenicity
REVERSIBLE REVERSIBLEIRREVERSIBLE
+ ++ ++++
+++ + -
�Reversible binding to thrombin - BIVALENT DTI�Blocks activation by thrombin of fibrinogen, Fact. V,VIII,XIII and platelets�Cleaved by circulating proteases� Half-life 25-30’
Bivalirudin Bivalirudin
� Half-life 25-30’� Proteolytic clevage by thrombin (80%)� Removal by haemofiltration� AVOID STASIS
Set upSet up
� Albumin in priming
� Consider UF in presence of lung injury and/or capillary leak syndrome
� Heparin bolus 1000 UI after cannulation, then check for bleeding
If bleeding <50 cc/h � start heparin infusion to a target
ACT 180-200, aPTT 60 sec
If bleeding on heparin > 50 ml/h � stopIf bleeding on heparin > 50 ml/h � stop
� 2 UI/mL of heparin in the priming� Weaning ACT >200
ECMO circuit changeECMO circuit change
� Plasma leak
� Hemolysis likely if:
• Pressure > 300 mmHg on arterial cannula
• Negative pressure > 200 on the venous cannula
• LDH>1000 mg/dL and FHb >40 mg/dL in two samples within 24h• LDH>1000 mg/dL and FHb >40 mg/dL in two samples within 24h
� Thrombi Check HIT
� Thrombocytopenia
� Sistematically every 8-10 days
WeaningWeaning
� Always keep 0.5L flow (risk of thrombosis)
� If flow is stopped for definitive evaluation
(30 min. observation)
give heparin 10000 UI before lines clamping
� Recirculation
Figure 1.: RVAD Impeller after 33 days of support Figure 2.: RVAD Impeller after 3 days of low flow support