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What is ECLS?
Extracorporeal Life Support (ECMO)

Oxygenating blood outside of the body; a form of by-pass

It's not a treatment/therapy, but it's a supportive measure while the underlying process heals
What are some neonate/infant conditions that may benefit from ECLS?
MAS, CDH, persistant sepsis, pulmonary hypertension, pneumonia, heart defects

(anything that can cause inadequate oxygenation)
What are some pediatric conditions that may benefits from ELCS?
ARDS, ALI, cardiac conditions, aspiration injury, waiting for heart transplant..
Exclusions to using ELCS?
needs to be greater than 32 weeks gestation and greater than 2 kg; can't be on vent greater than 10 days (because it's a chronic condition then)
What is the Oxygen Index?
(MAP x FiO2 x 100)/PaO2
Normals for Oxygen Index?

Mortality Risk?
Normal Oxygen Index is less then 30

If greater than 40, 80% mortality rate
What is V-A ECLS?
*Has 2 cannulas

Bloo is drained from the right atrium to the ECMO machine, warmed, and then returns to the body via a second cannula into the carotid artery
What does V-A ECLS support?
Supports lungs AND heart
What is V-V ECLS?
*Has 1 cannula

Blood leaves the body and returns through 1 vein (same cannula)
What does V-V ECLS support?
ONLY supports lung function
What are some complications of ECLS?
*It's invasion, so infections could occur.
*Intracranial hemorrhage (neo/infants)
*Blood clots in tubing
*Air into ECMO circuit
What are some outcomes of ECLS?
*Gives body time to heal
*avg. duration is 4-6 days
*Hospital survival rate is 76% (depends on underlying cause)
*Higher survival rates in neonates
*Peds survival rate 51%
What is Nitric Oxide?
colorless, odorless toxic gas produced by our body

How does NO work?
Diffuses across the alveolar-capillary membrane and attaches to hemoglobin

What are some indications for iNO?
*FDA approvded iNO for Hypoxic Resp. assocation with pulmonary hypertension in neonates greater than 34 weeks

*PPHN (persistant pulmonary hypertension of a newborn)

In Peds/adults--ARDS, ALI
What is the recommended dosage range for iNO?
5-80 ppm

Optimal doage range: 20-30 ppm
How do you administer iNO?
The INOVent system

separate from ventilator; added to the vent. circuit
What is NO2?
Nitric dioxide--very toxic byproduct of NO
OSHA guidelines for NO2?
Keep NO2 at less than 5 ppm

Greater than 10ppm can cause death!
What is MetHB?

Nitric oxide plus hemoglobin

Nitric oxide binds to hemoglobin 280x's faster than CO2
What percentage do you want to keep MetHB at?
Keep at less than 5%
Outcomes of using iNO?
*Improves oxygenation
*Decreased V/Q mismatch
*Decreased shunting
*Decreased PVR
*Maybe won't need ECMO
*Better outcomes if delivered with HFOV
How do you wean off iNO?
(iNO doesn't usually last over 5 days)

1.  Wean ppm down to lowest effective does (goal is to get to less than 5 ppm; 1 ppm is ideal)
2.  Then wean FiO2 (down to 50% at least)
3.  Then wean PEEP if on high levels
What do you have to do before discontinuing iNO?
Have to be hyperoxygenated by 20% for about 30 min. before; otherwise will have rebound hypoxemia
Properties of helium?
Helium has low density and can pass easily through constricted airways
Heliox mixtures?
Number 1 indication for Heliox?
Severe asthma/bronchospasm
Other indications for Heliox?
Upper airway obstructions
Smoke inhalation
Post extubation-stridor
Limitations of using Heliox?
If pt. needs high FiO2s, will dilute mixture; need special flowmeters

(can also deliver with non-rebreather, but need to use conversion factor)
Outcomes of using Heliox?
*Oxygen goes into airways better; improves gas exchange
*Decreased WOB
*Decreased PIP, if on vent.
*Less air trapping
*Improved peak flow in asthmatics
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