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Category: Critical Care Medicine-Pulmonary Disorders--->Lung Transplantation, Complications, and VV ECMO
Page: 2

Question 6# Print Question

A 35-year-old female patient is admitted to the hospital with pneumonia. She was recently diagnosed with end-stage renal disease and is on maintenance dialysis through a tunneled right subclavian dialysis catheter. Hospital course is complicated by respiratory failure and acute respiratory distress syndrome requiring mechanical ventilation. Due to progressive hypoxia, VV ECMO is instituted via bilateral femoral cannulas. Mechanical ventilation is reduced to resting ventilation with a low FiO2 , tidal volume, and respiratory rate. Twelve hours later the patient has a drop in arterial oxygen saturation from her baseline of 94% to 82%. The oxygen saturation of blood drawn from the femoral venous line, which is pre-oxygenator, has increased during the same time from 65% to 80%.

What is the most appropriate next step in management?

A. Increase pump speed
B. Radiographic evaluation of the cannulas
C. Change oxygenator
D. Add an additional parallel ECMO circuit

Question 7# Print Question

A 22-year-old male is admitted to the ICU with acute respiratory distress syndrome secondary to pneumonia. The clinical course is complicated by progressive hypoxemia, which does not improve with prone ventilation. VV ECMO is instituted with a 31 Fr right internal jugular double-lumen cannula, and the pump flow is at 4.5 L/min. The patient has a HR of 90/min, BP of 110/70 mm Hg with a norepinephrine infusion at 0.05 µg/kg/min, and a SpO2 of 90%. One hour later, the ECMO specialist mentions of “chugging” in the drainage circuit with low inlet pressures. The ECMO flow has reduced to 3 L/min. There is a drop in SpO2 to 84%, and the norepinephrine requirement has increased to 0.1 µg/kg/min. An arterial blood sample sent to the critical care laboratory reveals:

  • pH of 7.30
  • PaCO2 of 35
  • PaO2 of 49
  • HCO3 of 19
  • hematocrit of 42%
  • lactate 4.2

The most appropriate next step in management is to:

A. Start epinephrine to improve cardiac contractility
B. Increase pump speed to increase ECMO flow
C. Urgent blood transfusion
D. Administer a 500 mL fluid bolus

Question 8# Print Question

A 42-year-old female is admitted to the ICU after a motor vehicle accident. She develops ARDS secondary to lung contusions and is initiated on VV ECMO. The clinical course is complicated by worsening acute kidney injury. The latest laboratory workup reveals acidosis with a pH of 7.18 and hyperkalemia of 6.5 mEq/L. Sodium bicarbonate, calcium gluconate, and insulin-dextrose are administered. Although adding on a continuous renal replacement therapy circuit to the ECMO circuit, the patient develops a short run of ventricular tachycardia, which quickly degenerates into asystole.

What is the immediate next step in managing this patient?

A. Initiate chest compressions
B. Administer epinephrine only and avoid chest compressions
C. Urgent conversion to VA ECMO
D. Defibrillation with 200 J

Category: Critical Care Medicine-Pulmonary Disorders--->Lung Transplantation, Complications, and VV ECMO
Page: 2 of 2