Ecmo

RECOMENDACIONES RECOMENDACIONES PARA EL TRATAMIENTO TRATAMIENTO MEDIANTE OXIGENACIÓN DE MEBRANA EXTRACORPÓREA (E.C.M.O.) EN EL PERIOPERATORIO PERIOPERATORIO DEL TRASPLANTE PULMONAR SERVICIO DE ANESTESIOLOGÍA Y REANIMA RE ANIMACIÓN CIÓN COMPLEJO HOSPITALARIO HOSPITALARIO UNIVERSITARIO UNIVERSITARIO DE A CORUÑA DICIEMBRE DE 201

 Apartado

Página

Introducción e indicaciones

2

Contraindicaciones

5

 Algoritmo para para la implantación implantación del ECMO ECMO en la disfunción disfunción injerto pulmonar pulmonar

6

Conceptos claves del ECMO Configuraciones Configuraciones del ECMO !"" # "A$

%

Compon ponente entess de del si siste stema # fifisio siolog&a g&a de del in interc tercam am'i 'io o ga gaseo seoso en EC ECMO

(2

Consideraciones antes de la instauración del ECMO

(5

Canulación

(%

Inicio del ECMO por primera ve)

2*

 Anticoagulación+  Anticoagulación+ fluidos+ fluidos+ sedación # anti'ioterapia anti'ioterapia

2%

Papel de la ecocardiograf&a ecocardiograf &a en el ECMO

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Controles rutinarios propuestos para el paciente en ECMO

,*

-uración del soporte -estete del ECMO

,5

Complicaciones

,.

/u&a rápida de solución de pro'lemas urgentes

*%

Pro'lemas cl&nicos durante el ECMO+ causas e intervenciones

50

1i'liograf&a

52

 Aneo (3 4ista de de compro'ación compro'ación de tareas en le le paciente con ECMO ECMO

5,

 Aneo 23 Prue'as Prue'as # controles de enfermer&a

5*

 Aneo ,3 canulación canulación segn tcnica tcnica de 7eldinger 7eldinger

55

 Aneo *3 8a'la 8a'la de anticoagulación anticoagulación

56

 Aneo 53 Actuación Actuación ante una 9emorragia 9emorragia en e paciente paciente con ECMO ECMO

5%

 Aneo 63 Protocolo Protocolo de actuación actuación ante la 9emólisis 9emólisis

5.

 Aneo %3 Cam'io Cam'io del circuito circuito

5:

 Aneo .3 Adición Adición de un segundo segundo oigenador oigenador

6(

 Aneo :3 -eaireamiento -eaireamiento de emergencia emergencia

62

1

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ECMO PARA EL TRASPLANTE TRASPLANTE PULMONAR INTRODUCCIÓN E INDICACIONES! 4a disfunción primaria del injerto !-PI$ es una complicación preco) # grave del trasplante de pulmón !8P$+ ;ue ocurre entre un (0a de un incremento de resistencias vasculares pulmonares+ disminución de la compli complianc ance+ e+ increm increment ento o de la permea permea'il 'ilida idad d capilar capilar++ edema edema alveol alveoloo intercam'io de gases a travs de los pulmones nativos # una recirculación m&nima a travs del circuito ECMO+ los puntos importantes a tener en cuenta son ;ue el O 2 arterial final se determina por la relación entre el flujo de la 'om'a ECMO # el gasto card&aco del paciente Por lo tanto+ a pesar de una pO 2  de *00adirse 2 ciclos por minuto a una presión meseta de

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ANTICOAGULACIÓNQ ANTICOAGULACIÓNQ LUIDOSQ SEDACIÓN Y ANTIBIOTERAPIA!

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4os pacientes no anticoagulados # sin pro'lemas de 9emostasia reci'irán 'olo

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P"%%%-% $* %"%- ; &"*:*4 $* 5*%*

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Monitori)ación de parámetros de infección cada 2* 9oras3 leucocitos #

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Iniciar de forma preco) la nutrición enteral durante las primeras 6 9oras tras

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A*/% ! D*#"*#+*% $* *+*"3*#! El em'olismo de gas en el circuito es una complicación rara !más frecuente en el ECMO pediátrico$ pero mu# severa+ ;ue necesita del clampaje # drenaje inmediato del sistema -e'ido a la gran presión negativa ;ue generan las centr&fugas en la rama de drenaje+ esta región es especialmente vulnera'le vulnera'le a la entrada de aire 4as v&as de entrada de aire son3 4as coneiones+ llaves o los tu'os da>ados en las cánulas de drenaje o 4a movili)ación !retirada$ de una cánula de drenaje multiperforada en la ;ue se o epongan orificios al aire o `n acodamiento del circuito+ ;ue produ)ca cavitación o O'strucción del orificio de salida del gas fresco del oigenador+ ;ue presurice la mem'rana # provo;ue su rotura En caso de em'olismo de gas+ se pierde flujo 7e necesita reiniciar la ventilación mecánica de emergencia # clampar el circuito 4as consecuencias para el paciente dependen de la cantidad de gas # del tipo de ECMO !"" o "A$ En caso de entrada de aire+ la ma#or&a se acumula en las primeras porciones 9asta el oigenador -e'emos entonces reali)ar una deaireación del circuito3 Clampar do'lemente el circuito !el primero en la rama de retorno # luego la de drenaje$ < # apagar la 'om'a `na `na 'olsa 'olsa reserv reservori orio o vac&a vac&a se coloca coloca en el puert puerto o superi superior or del lado lado arteri arterial al del del < oigenador oigenador # se a're el puerto para permitir la salida de aire < 4a ca'e)a de la 'om'a se saca de la má;uina El clamp del lado de drenaje se retira+ permitiendo ;ue la sangre del paciente flu#a 9acia la 'om'a # el aire 9acia el puerto a'ierto del oigenador  `na ve) la 'om'a est deaireada+ se coloca un clamp en el circuito distal a la 'om'a # < se une una 'olsa llena de l&;uido a la coneión del circuito en la )ona 2+ permitiendo deairear el circuito distal metiendo l&;uido # sacando aire a travs de los tu'os 9acia el oigenador oigenador xo siempre se consigue deairear completamente el oigenador !so're todo la parte arterial$ `na ve) eliminado el gas de las tu'uladuras # 'om'as+ # más de ¥ del oigenador+ la < ca'e)a de a 'om'a se une a la 'om'a # se enciende a (000a cantidad de aire ser  epelido por la 'om'a El puerto de acceso de la parte arterial del oigenador se cierra # el clamp de la rama < de retorno se li'era El flujo se va aumentando paulatinamente 7i el aire permanece en el oigenador+ se recomienda un cam'io completo del circuito+ < tras una per&odo de recuperación del paciente

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