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Canadian Journal of Cardiology

Medical Optimization and Liberation of Adult Patients From VA-ECMO

Published:November 04, 2019DOI:https://doi.org/10.1016/j.cjca.2019.10.038

      Abstract

      Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be an efficacious cardiopulmonary support for adults as rescue from refractory cardiogenic shock. It is best employed as a bridging strategy to recovery or alternative support rather than sustained, long-term mechanical circulatory support. The purpose of this paper is to discuss strategies to optimize patient management on VA-ECMO and approaches to promote successful separation from support. Rapid medical optimization will assist in reducing the time on VA-ECMO, thereby improving the likelihood of patient salvage. Suitably trained physicians and personnel, guided by structured protocols, can promote excellence in team care and provision of consistent management. Focusing on anticoagulation, careful neurologic monitoring, prevention of leg ischemia, awareness of differential hypoxemia, optimizing mechanical ventilation, identifying and timely intervention for left-ventricular distension (LVD), along with a strategic weaning algorithm, can prevent significant morbidity and mortality. LVD physiology, diagnosis, and risk factors are reviewed. Indications for LV decompression, along with medical and mechanical management options, are elucidated.

      Résumé

      L’oxygénation extracorporelle veino-artérielle par membrane (ECMO-VA) est une méthode d’assistance cardiopulmonaire qui peut se révéler une méthode de sauvetage efficace chez les adultes ayant subi un choc cardiogénique réfractaire. Elle est de préférence employée comme stratégie de transition jusqu’au rétablissement ou comme soutien de rechange à une assistance circulatoire mécanique soutenue à long terme. Le présent article traite des stratégies d’optimisation de la prise en charge des patients par ECMO-VA et des approches favorisant la réussite de l’arrêt de l’assistance. Une optimisation médicale rapide contribue également à réduire la durée de l’ECMO-VA, ce qui améliore les chances du patient de s’en sortir. Des médecins et du personnel ayant suivi une formation appropriée, guidés par des protocoles structurés, peuvent favoriser l’excellence de l’équipe soignante et la prestation de soins uniformisés. Grâce à une prise en charge axée sur l’anticoagulation, une surveillance neurologique attentive, la prévention de l’ischémie des membres inférieurs, la surveillance de l’hypoxémie différentielle, l’optimisation de la ventilation artificielle et la détection précoce de toute distension du ventricule gauche suivie d’une intervention rapide, ainsi qu’à un algorithme de sevrage stratégique, il est possible de réduire considérablement la morbidité et la mortalité. La physiologie, le diagnostic et les facteurs de risque de la distension du ventricule gauche sont passés en revue. Les indications quant à la décompression ventriculaire gauche ainsi que les options pour la prise en charge médicale et mécanique sont élucidées.
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