Table Of ContentTable of Contents
Dedication .............
V
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Preface to the 5th Edition ............................................................................................... xvii
I. Extracorporeal Life Support: General Principles
1. The ffistory and ofExtracorporea] Support..•.....•••..............••••....•.•..1
Support: Earliest Beginnings ......................................................... 1
.,nr",," of ECMO ~~~~.. ~ .... ~~ .... ~~....~ .....,. .. ~ .......".".......~ ...........*._.".. *••• ~"~ .. ¥ ..... ,, ....... ** •• ~~ .... * ••6
Perseverance: and Growing Indications in Adult ECMO ................... 9
2. The
A Conversation with Dr. Jay Zwischen berger. ......................................................22
3. Evolution and ffistory Global ELSO .................................................................. 25
................................................................................................ 26
ELSO .......................................................................................... 27
South and West Asian ELSO .............................................................................. 28
References............................................................................................................ 29
4. The Physiology of Extracorporeal Life Support .....................................................31
Cardiopulmonary Physiology ............................................................................... 31
Cardiopulmonary Pathophysiology ......................................................................33
Cardiopulmonary Pathophysiology during ECMO
The ECMO Circuit. ............................................................................................. 34
Modes and .............................................................36
5. The Circuit ........................................................................................ 49
t>..............................................'"
49
lastl.cmlrs ..................................................................................... 51
ECLS Circuit Components ...................................................................................52
Table ofContents
Commercial Centrifugal Pumps .......................................................................... 60
Gas Exchange Devices .........................................................................................6 3
Commercial Gas Exchange Devices ..................................................................... 65
Gas Exchanger Related Complications ........................................................ ,...... 70
Heat Exchange and Heat Regulation .................................................................... 71
Heat Exchanger Related Complications ............................................................... 72
Circuit Priming .....................................................................................................73
Circuit Monitoring ................................................................................................ 73
Summary ............................................................................................................... 75
References.................... .............. ............................ ...............................................76
6. Adverse Effects ofECLS: The Blood Biomaterial Interaction................•.............81
Introduction........................................................................................................... 81
Nonnal Hemostasis ........................................................................ ..................... 82
Activation of the Coagulation Pathway ................................................................ 82
Activation of the Fibrinolytic Pathway ................................................................. 83
Developmental Hemostasis ................................... ................................................ 83
Coagulation Pathway Activation and Inflammatory Response ........................... 84
Activation of the Coagulation System during ECLS ............................................ 87
Activation of the Innate Immune System .............................................................. 87
Endothelial Function in Hemostasis and Circuit Modifications .......................... 88
References ............................................................................................................ 90
7. Anticoagulation and Disorders of Hemostasis........................................................ 93
Introduction....................................... .................................................................... 93
Anticoagulation ..................................................................................................... 93
Anticoagulation Monitoring ..................................................................................9 5
Anticoagulation Laboratory Schedule and Blood Product Replacement... .......... 98
Hemorrhagic and Thrombotic Complications ..................................................... 99
Conclusions.......................................................................................................... 99
References .......................................................................................................... 100
8. Transfusion Management during Extracorporeal Support ................................ 105
Blood Product Transfusion during Extracorporeal Support ............................... 105
Use of Coagulation Factor Replacement ............................................................ III
References ........................................................................................................... 117
ll. Extracorporeal Life Support: Neonatal Respiratory Disease
9. Neonatal Respiratory Diseases .............................................................................. 123
Introduction......................................................................................................... 123
Congenital Diaphragmatic Hernia (CDH) .......................................................... 123
Meconium Aspiration Syndrome (MAS) ............................................................ 123
Persistent Pulmonary Hypertension of the Newborn .......................................... 126
Pneumonia/Sepsis ............................................................................................... 127
Surfactant Deficiency - Hyaline Membrane Disease ........................................ 128
Surfactant Deficiency - Tenn Infants in Respiratory Failure ...................... ...... 129
References.......................................................................................................... 130
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Table o/Contents
10. Congenital Diaphragmatic Hernia ECMO .................................................. 133
133
Diagnosis ........................................................................................................... .
134
Mechanical Ventilation ..................................................................................... .
Inhaled Oxide ........................................................................................... 1
Sildenafil ............................................................................................................. 135
lmervelluons .............................................................................................. 136
Management Adjuncts ........................................................................................ 137
ECMO ................................................................................................................. 137
Summary ............................................................................................................ .
Neonates with Respiratory Failure ........ 151
151
u","",,,,,,,.. Selection Criteria ,..~~~**~...,.*~~.... ~,. ......... *~ .... ~~~~.~.~~* ..........6~ ... * ............... ~.~~~ .. ,. .. "~~"'.e.... ~ ..... B .. ~*~ 151
1
Contraindications
Weight kg ...................................................................................................... 154
Gestational Age wks ................................................................................... 154
iemorrtlage ..................................................................................... 155
Chromosome Abnormalities ............................................................................... 156
Pre-ECMO
157
12. ECLS Cannulation for Neonates with Respiratory Failure ............................... 159
.................................................................................................................. 159
vv-
or VA ........................................................................................... 160
Choice ofCannula and Vessel ........................................................................... 160
Cannulation Technique ....................................................................................... 161
Post Cannulation
liJ.,u"i'>H15
167
13. Congenital Comorbidities among Respiratory Neonatal ECLS Patients •......•. 169
Background ........................................................................................................ 169
Congenital Anomalies ........................................................................................ 169
Malignancies ...................................................................................................... .
173
llU'",",..Ull" ............................................................................................................
.......................................................................................................... 175
Errors of Metabolism .............................................................................. 176
Abnormalities ........................................................................................ 176
Conclusion .......................................................................................................... 177
178
14. Medical Management ofthe Neonate with Respiratory on 183
and ...................................................................... 183
Respiratory......................................................................................................... 184
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Table ofContents
Cardiovascular .................................................................................................... 186
Infection .............................................................................................................. 187
ECMO Circuit Considerations in the Neonatal Patient .................................... .
Hematologic ....................................................................................................... 190
Neurologic 191
Summary ............................................................................................................ 194
195
15.
Cardiovascular .................................................................................................. .
Neurologica1....................................................................................................... 204
Fluid
JJu,Jt.....""v.L'-VJUu,u
XXIl
Table ojContents
ExtracorporeaJ Support: Pediatric Respiratory Disease
18. Pediatric Respiratory Diseases Predisposing to
£.t'L,JU;:h........'..........'...................." ...!,.:1 ...
for KeSPlratC)ry "'1T~TV,rt
Failure
Asthmaticus
The Inununocompromised ..................................................................................233
MediastmallH'L;);)<O;)
uillionary Hemorrhage .................................................................................. ..
Peri operative Support for
.......................................................
Air ................................................................................................ 234
Preoperative Rehabilitation ............
<;:t''l1~t,...1''V Support of Patients Congenital Heart L'L:'"'''"'''''
Prolonged Respiratory ECLS ..............................................................................235
References ........................................................................................................... 23 7
Contraindications in Children with Respiratory Failure .......... 239
239
:ontramlOlC'ltIODS ................................................................................................242
244
244
20. ECLS Cannulation for Children with Respiratory Failure ................................247
Preferred Routes
Technique ........................................................................................................... 248
Complications .....................................................................................................252
254
21. Comorbidities Pediatric Patients with Respiratory Failure .................. 255
."ULIULU"i!:;
Hospital
n.HULU.\V...
Prediction of Mortality Risk Prior to Initiation........................................ 261
Conclusion ..........................................................................................................262
References...........................................................................................................263
22. Management ofthe Pediatric Respiratory Patient on ECMO ..............267
Introduction.........................................................................................................267
Mima.gclnelnt .......................................................................................... 268
...."1'1'''nT
276
lLA..d.V1.\J .........................................................................................
xxiii
Table ofContents
Diagnostic Tools in ECMO ................................................................................. 277
Other Interventions ............................................................................................ 278
Complications .................................................................................................... 278
Followup ............................................................................................................ 278
Conclusion ......................................................................................................... 278
References .......................................................................................................... 279
23. Nursing Management ofthe Child with Respiratory Failure on ECLS .......•... 283
Introduction......................................................................................................... 283
Daily Assessment ................................................................................................ 283
Daily Patient Care .............................................................................................. 284
Wound Care ......................................................................................................... 286
Daily Activities ...................................................................................................287
Conclusion ......................................................................................................... 288
References.......................................................................................................... 289
24. Weaning and Decannulation of Children with Respiratory Failure on ECLS..291
Strategies for Withdrawal of ECLS Support. ...................................................... 291
Withdrawal ofECLS Support as Palliative Withdrawal ofCare ........................292
Weaning Support and Trialing ............................................................................ .292
Technique for Decannulation ofPatients on Venovenous ECLS ........................ 293
Continuing Venous Access after Decannu1ation ................................................ 294
Approaches to Inadvertent Decannulation ............. ............................................ 294
References........................................................................................................... 296
25. Outcomes, Complications, & Followup of Children with Respiratory Failure 297
Introduction .................................................................... ..................................... 297
Outcomes ............................................................................................................ 297
Long-term Outcomes ......................................................................................... 299
ECMO Complications ........................................................................................ 300
References.......................................................................................................... 304
IV. Extracorporeal Life Support: Neonatal and Pediatric Cardiac Disease
26. Neonatal and Pediatric Cardiovascular Diseases Predisposing to ECLS ..........307
Introduction......................................................................................................... 307
Indications and Outcomes .................................................................................. 308
ECMO in Patients with Functionally Univentricu1ar Circulation ..................... .312
Outcome and Risk Factors for Death ..................................................................313
Conclusions........................................................................................................ 314
References...........................................................................................................315
27. Extracorporeal Cardiopulmonary Resuscitation in ChHdren ..•.........................321
Introduction ......................................................................................................... 321
ECPR Definition ................................................................................................. 321
ECMO for Failed CPR ........................................................................................ 321
ECPR Utilization and Epidemiology ................................................................. .322
Survival to Hospital Discharge after ECPR ....................................................... .322
Patient Selection for ECPR .................................................................................323
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Table ofContents
MfmagerneIlt Strategies ..................................................................................... .
ECMO in Previous ",n"""'''"''''''
ECMO for ACHD
Stabilization ................................................................................. .
1-'ft>",r"'1"",fn'l>
Support ........................................................................................ 340
I-'Pf·llU,pr,.1"n,p
Mechanical Support beyond Perioperative
Low Output Syndrome ......................................................................... 340
to Transplantation .................................................................................... 341
ULl~.I-.n~'LI""..AU'LI Support
Cardiac
,"-"WlHILU<U,lVLl
347
,"-"WlLU"ll(n,lVLl ...............................................................................................
Transthoracic Cannulation ................................................................................. 348
Venting ............................................................................................................... 350
Not Venting 1
Troubleshooting .................................................................................................. 351
Conclusion ......................................................................................................... 354
References...........................................................................................................355
Comorbidities and in Pediatric Patients for Cardiac •••••...•.357
Background .........................................................................................................357
Preexisting
Acquired ...................................................................................... 361
References.......................................................................................................... 364
Medical Management ofNeonates & Children with Cardiovascular Disease •.367
Introduction.........................................................................................................367
Utilization ECLS
xxv
Table a/Contents
Management of Common Issues for Cardiac Patient ....................... 368
Cardiovascular Assessment and Monitoring ..................................................... 370
Ventilator M~magelneJ[lt
Other Organ System to the Cardiac ECLS Patient ...... 372
Support
",u,"',v"",,,,a,
Conclusion ......................................................................................................... 374
33. Nursing Management of Children with Cardiovascular Disease ..................... 379
Introduction........................................................................................................ 379
Prevention of Infection ...................................................................................... 380
Neurologic Considerations ................................................................................. 381
Rehabilitation......................................................................................................382
Integumentary Considerations ............................................................................382
Nursing in Rapid
Family
-':H'''\nrl,rt
34. Weaning Pediatric Cardiac ECMO.......................................................................387
Introduction.........................................................................................................387
When to Attempt Weaning ..................................................................................387
Predictors of Successful Weaning ...................................................................... 389
Weaning Trial ................................................................................................... ..
Speed of Weaning .............................................................................................. 390
for ........................................................................... 390
Decannulation .................................................................................................... 390
Failure to
Conclusion ..........................................................................................................393
394
35. Outcomes/Complications/Followup of with Cardiovascular Disease 395
Longt;:r-tl~rm Survival
Early Neurological Outcome
LOJl1ge:r-u~rm Neurodevelopmental Outcome ......................................................397
Long-term Quality ofLife (QOL)
FoUowup ............................................................................................................ 398
References........................................................................................................... 401
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Table ofContents
Extracorporeal Support: Adult Respiratory Disease
36. Adult Respiratory Diseases Predisposing to ECLS. ............................................ 405
M,magernelltApproaches to Respiratory ........ ..405
Syndrome (ARDS) ............................ .406
hCltlocardllOlloca()llV in Acute
,-nn"\"v,Pfn'
Immunosuppressed ...................................................................................407
ofARDS ............................................................................................. 409
Lung Biopsy ............................................................................................. 4
411
37. Indications & Contraindications in Adults with Respiratory Failure .............. 415
15
424
38. ECLS Cannulation for Adults with Respiratory Failure ................................. ..
LTJ.~U~~'''' for Adult Respiratory
Aspects for Adult Respiratory Failure
,"""UUL'..,al
References...........................................................................................................436
39. Comorbidities among Patients with ......,....",'1........, Failure ....................... 439
Comorbidities
Comorbidities lOemUlOO
Impact ofComorbidities on Outcome
Specific Common Comorbidities and Their with ECLS ................. .442
Summary............................................................................................................ 444
1.I'",.n.,_i-.... Failure on ECLS ........... 449
1r"1L1
Prone I:'matlClnIrlg
Bronchoscopy .................................................................................................... 450
Airway 450
Tracheostomy 1
Awake 1
Cardiovascular Vasopressors and 1
xxvii
