Utilizacion del ECMO en el distress respiratorio. Presentacion de sesiones cientificas del departamento de cirugia cardiaca de la clinica universidad de navarra
ECMO provides cardiopulmonary support by oxygenating blood and supporting circulation outside the body. The history of ECMO began in the 1930s with experiments in extracorporeal circulation and progressed to successful use in humans in the 1950s. Indications for ECMO include cardiac and pulmonary failure. Contraindications include advanced organ failure or inability to anticoagulate. Cannulation techniques include central cannulation through major blood vessels or peripheral cannulation through the neck or groin.
This document provides an overview of extracorporeal membrane oxygenation (ECMO) in 3 parts. It discusses the history and evolution of ECMO from its origins in the 1950s to more modern applications. ECMO can be used in veno-venous or veno-arterial modes, with veno-venous providing oxygenation support for lung failure and veno-arterial providing both oxygenation and circulatory support. The document outlines common indications for ECMO and considerations for cannulation approaches and placements. It also previews topics that will be covered in more depth in the second part such as monitoring, complications, and guidelines.
- ECMO is a form of extracorporeal life support that involves removing blood from the body, oxygenating it using an artificial lung, then returning it to circulate oxygenated blood through the body.
- It was first developed in the 1950s and saw its first successful use in 1971. It is now commonly used to support patients with severe cardiac and/or respiratory failure.
- There are two main types - venoarterial (VA) ECMO which supports cardiac function and venovenous (VV) ECMO which supports respiratory function. Indications, complications, and outcomes were discussed.
1. The document describes a case of a 28-year-old female with cyanotic congenital heart disease who underwent an arterial switch operation with integrated ECMO support.
2. ECMO is a form of extracorporeal life support used for both cardiac and respiratory failure in adults. It involves pumping blood out of the body to an artificial lung for gas exchange before returning it to circulation.
3. The key components of an ECMO circuit include a blood pump, membrane oxygenator, tubing, heat exchanger, and monitoring equipment. Proper anticoagulation and flow rates are important for safety and effectiveness.
This document provides an overview of extracorporeal membrane oxygenation (ECMO) including its definition, history, components, configurations, physiology, indications, and complications. ECMO temporarily replaces or supports the cardiopulmonary system by extracting blood, oxygenating it through an artificial lung, then returning it to circulation. Key points include:
- ECMO was developed in the 1960s-70s and can support heart and/or lung function for weeks.
- The circuit includes cannulae, a pump, oxygenator, and controller. Configurations include venovenous (lung support) and venoarterial (heart and lung support).
- ECMO settings impact oxygen delivery and carbon dioxide
This document discusses extracorporeal membrane oxygenation (ECMO) as a treatment for severe acute respiratory distress syndrome (ARDS). It provides details on:
1. How ECMO works by using an external circuit to oxygenate blood and remove carbon dioxide before returning it to the body.
2. The types of ECMO (veno-venous and veno-arterial) and their indications.
3. The process of ECMO, including patient care focused on end organ perfusion to prevent further injury and improve function.
4. Complications of ECMO like bleeding, infections, and mechanical issues.
5. Considerations for when to initiate ECMO based on oxygenation levels
ECMO, DEFINITION, ETIOLOGY, INDICATION, CONTRAINDICATION, TYPES OF ECMO, VENOVENOUS ECMO, VENO ARTERIAL ECMO, NURSING CARE OF PATIENT ON ECMO, WEANING FROM ECMO,
ECMO can be considered for partial or full cardiopulmonary support in cases of potentially reversible post-traumatic cardiopulmonary failure. Those with respiratory failure should be candidates for VV ECMO, while those with refractory cardiac dysfunction should receive VA ECMO. ECMO can improve oxygenation and circulation to limit complications like metabolic acidosis. Indications include severe lung injury from trauma leading to ARDS. Contraindications include unrecoverable injury or advanced organ dysfunction. While outcomes are best at high-volume centers, ECMO may allow time for injury recovery or organ donation in severe trauma.
This document discusses extracorporeal membrane oxygenation (ECMO) in adults. It describes the different types of ECMO (veno-arterial, veno-venous, arterio-venous), how the ECMO circuit works to facilitate gas exchange outside the body, clinical indications for its use including acute respiratory failure and cardiac support, complications, and transfusion guidelines for ECMO patients.
This document provides an overview of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for adults. It discusses how VA-ECMO can support patients with refractory cardiopulmonary failure for weeks. It describes the hemodynamics of cardiogenic shock and how VA-ECMO impacts pressure-volume loops. It outlines strategies to reduce pulmonary congestion on VA-ECMO and lists contraindications and predictors of mortality. It also discusses the use of ECMO for cardiac arrest (ECPR) and criteria for its use for refractory ventricular tachycardia or cardiogenic shock.
ECMO (extracorporeal membrane oxygenation) is a technique that uses pumps and a artificial lung to support heart and lung function. It can be used to support failing organs while allowing time for recovery or as a bridge to transplant. The history of ECMO began in the 1950s with the development of cardiopulmonary bypass and its use has expanded to support both children and adults with heart and lung failure. While intensive, ECMO can save lives that would otherwise be lost to critical illness.
This document discusses the use of ECMO (extracorporeal membrane oxygenation) after cardiac surgery. It outlines the indications for ECMO, including post-cardiotomy cardiogenic shock. Different cannulation strategies and their considerations are described. Monitoring patients on ECMO includes ensuring adequate oxygen delivery and preventing complications like bleeding, leg ischemia, and pulmonary edema. Myocardial stunning can lead to left ventricular overdistention, so decompression may be needed. Improving contractility may cause the harlequin phenomenon if lungs are not well ventilated. Outcome data shows a prevalence of 0.5-2.6% for post-cardiac surgery ECMO with in-hospital survival rates of
ECMO is a form of extracorporeal life support that involves removing blood from the body, oxygenating it using an artificial lung, then returning it to circulate in the body. It can be used for both cardiac and respiratory support for neonates and involves different configurations depending on whether support is needed for the heart, lungs, or both. Indications for ECMO include meconium aspiration syndrome, congenital diaphragmatic hernia, respiratory distress syndrome, and persistent pulmonary hypertension among others. Outcomes have improved over time with advances in technology and experience with the procedure.
Veno-arterial extracorporeal membrane oxygenation (VA ECMO) provides both respiratory and circulatory support for patients with heart and lung failure. It works by draining venous blood, oxygenating it, and returning it to the arterial system. The document discusses cannulation techniques and considerations for VA ECMO, as well as physiological effects and important monitoring parameters to optimize patient care and outcomes.
This document provides an overview of extracorporeal membrane oxygenation (ECMO), including its history, principles, components, indications, and complications. Some key points:
- ECMO is a form of extracorporeal life support that oxygenates blood and removes carbon dioxide outside of the body, then returns the blood to the patient. It has been used since the 1950s and is now standard treatment for some cardiac and respiratory conditions.
- The basic ECMO circuit includes a blood pump, membrane oxygenator, heat exchanger, cannulas, and tubing. There are various configurations depending on whether it is used for respiratory (VV ECMO) or cardiac (VA ECMO) support.
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This document discusses extracorporeal membrane oxygenation (ECMO), which provides prolonged cardiopulmonary support. There are two main types of ECMO: venovenous (VV) ECMO, which provides respiratory support, and venoarterial (VA) ECMO, which provides both respiratory and hemodynamic support. The document outlines patient selection criteria and outcomes, complications, techniques for initiation and maintenance of ECMO, and considerations for weaning from and discontinuing ECMO support.
This document provides an overview of ECMO (extracorporeal membrane oxygenation) and E-CPR (extracorporeal cardiopulmonary resuscitation) at SCGH. It describes what ECMO is, the inclusion/exclusion criteria for its use, the equipment and staff required, and differences between a conventional and ECMO resuscitation. Key points include: ECMO provides temporary cardiac and/or respiratory support for patients failing maximal medical therapy; there are two types - VV and VA; VA ECMO/E-CPR is performed in the ED for cardiac arrest and provides both respiratory and hemodynamic support; and an ECMO resuscitation requires rapid cannulation and connection to an EC
This document discusses extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). ECMO provides cardiopulmonary support for critically ill patients, while CRRT manages fluid overload and acute kidney injury. The document outlines some of the technical considerations for combining ECMO and CRRT treatment, including using separate circuits or incorporating CRRT into the ECMO circuit. Some benefits of the combined treatment are managing fluid overload, electrolyte imbalances, and removing inflammatory cytokines. Early initiation of CRRT is recommended to improve outcomes in ECMO patients. Complications can include bleeding risks from anticoagulation and electrolyte disturbances.
1. basic aspects of physiology during ecmo supportNahas N
This document provides an overview of physiology during ECMO support. It discusses:
1) The basic principles of veno-arterial and veno-venous ECMO, which replace both heart and lung function or only lung function, respectively.
2) Oxygenation and carbon dioxide removal processes during ECMO, which rely on membrane gas exchange and blood flow/sweep gas flow rates.
3) Hemodynamic impacts that depend on the type of ECMO (veno-venous is neutral while veno-arterial reduces preload and increases afterload).
1. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are important life support therapies used in intensive care units.
2. ECMO uses an external circuit to oxygenate blood and remove carbon dioxide, functioning as a bridge to recovery, transplant, or decision. CRRT slowly removes waste and fluid from the blood of patients with kidney failure or injury.
3. The document discusses the principles, indications, techniques, and complications of ECMO and CRRT, highlighting their roles in supporting critically ill patients with cardiac, respiratory, or renal issues.
ECMO is a form of extracorporeal life support used for patients with severe cardiac or respiratory failure. It works by removing blood from the body, oxygenating it, and returning it. The document discusses the history and development of ECMO, components of the ECMO circuit, modes of ECMO including veno-venous and veno-arterial, indications and contraindications for its use, complications, and criteria for weaning patients off of ECMO support.
This document provides an overview of extracorporeal membrane oxygenation (ECMO), including its history, modes, components, indications, contraindications, and complications. ECMO is an effective technique for providing emergency circulatory and respiratory support. It works by draining venous blood, oxygenating it through an artificial lung, and returning it to the circulation. There are two main modes - venoarterial (VA) ECMO which supports both heart and lung function, and venovenous (VV) ECMO which only supports lung function. Proper anticoagulation, volume management, and treatment of potential complications like bleeding, infection and circuit failures are important for safe ECMO management.
This document discusses extracorporeal membrane oxygenation (ECMO), including its indications, types (veno-arterial and veno-venous), management strategies, and the experience with ECMO at Heart Hospital. ECMO can be used as a bridge to recovery, decision-making, surgery, long-term devices like LVADs, or transplant. It involves draining blood from the body, removing carbon dioxide and adding oxygen through an external oxygenator before returning the blood. Management involves anticoagulation and monitoring various patient parameters. Complications can include bleeding, infection, and organ dysfunction. Criteria and protocols are discussed for weaning patients off ECMO support.
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
This document provides an overview of extracorporeal membrane oxygenation (ECMO), including its history, principles, components, indications, contraindications, mechanisms, and complications. ECMO is a form of extracorporeal life support that oxygenates a patient's blood and removes carbon dioxide before returning it to circulation. It is used as a bridge to recovery, decision, or transplant for patients with severe cardiac or respiratory failure. The document describes the various ECMO circuits and cannulation methods, as well as guidelines for initiation and monitoring of ECMO.
Veno-Arterial Ecmo (VA-ECMO) & Their basicGunalan M.M
VA ECMO stands for Venoarterial Extracorporeal Membrane Oxygenation. It's a life-saving medical procedure used in critical situations where the heart and lungs are unable to function adequately. VA ECMO involves diverting blood from the body, oxygenating it outside the body, and then returning it to the arterial system, effectively bypassing the heart and lungs. This allows time for the organs to rest and heal, supporting patients with severe cardiac or respiratory failure.
This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.
This document provides an overview of extracorporeal membrane oxygenation (ECMO). It describes what ECMO is, the differences between conventional cardiopulmonary bypass and ECMO, the types of ECMO circuits, ECMO flow calculations, cannulation techniques, indications for ECMO in neonates, pediatrics and adults, management of ECMO, and complications. The key points covered are: ECMO can provide both cardiac and respiratory support for longer durations than cardiopulmonary bypass; the two main types are venovenous and venoarterial ECMO; cannulation sites include femoral, axillary and internal jugular vessels; and indications and management vary between age groups.
This document discusses ECMO cannulation and potential pitfalls. It begins by outlining the personnel and equipment needed for ECMO, including pumps, oxygenators, and cannulas. It then describes the types of ECMO (VA and VV) and considerations for cannula choice and placement. Key steps in cannulation like imaging, vessel access and cannula fixation are covered. Management of the ECMO circuit and potential complications are also reviewed. Specifically, protocols for bleeding management, cannulation failures and malpositions are outlined to minimize risks. Overall, the document provides guidance on safely establishing ECMO support through cannulation and ongoing management.
VenovenousECMO physiology f extracorporeal life support where an external ar...bae sungjin
A form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed. This blood then re-enters the patient circulation.
1) The document provides information about extracorporeal membrane oxygenation (ECMO), including definitions, equipment, procedures, types (veno-venous and veno-arterial), management, and complications.
2) ECMO is a form of extracorporeal life support that involves removing blood from the body, oxygenating it in an artificial lung, and returning it to the circulation to support patients with severe heart and lung failure.
3) There are two main types - veno-venous ECMO which supports only the lungs, and veno-arterial ECMO which supports both the heart and lungs.
- Hemoptysis is the expectoration of blood from the respiratory tract below the level of the vocal cords. It can range from blood-streaked sputum to gross blood. It is classified as minor (<20mL/day), moderate (20-100mL/day), or massive (100-600mL/day).
- The bronchial arteries, which arise from the aorta, are responsible for 95% of hemoptysis cases as they have higher systemic pressure. The pulmonary arteries have lower pressure and carry only a small portion of cardiac output.
- Common causes of hemoptysis include tuberculosis, bronchiectasis, mycetoma, lung abscess, mitral stenosis, and
A 58-year-old male presented with cardiogenic shock after an anterolateral STEMI. He was started on VA ECMO support due to refractory shock and cardiac arrest. The patient developed left ventricular distension on ECMO due to non-ejection of the left ventricle. Potential causes were addressed with less invasive measures first, like reducing afterload and improving contractility, before considering more invasive interventions like an LV vent. Signs of potential cardiac recovery on ECMO include improved hemodynamics, echocardiogram findings, and reduced inotrope requirements. A trial reduction of ECMO flow can be done if these criteria are met to assess ability to wean from support.
Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a life-saving therapy for severe respiratory failure. It involves using an external circuit to oxygenate and remove carbon dioxide from the blood, providing temporary support to the lungs. This allows the patient's lungs to rest and recover while maintaining oxygen delivery to the body. VV ECMO can be a bridge to recovery or lung transplantation for patients with acute respiratory distress syndrome (ARDS), pneumonia, or other conditions causing respiratory failure. It requires specialized equipment and expertise for cannulation, management, and monitoring.
#ecmo #vvecmo #heartlungmachine #vaecmo
CPB diverts blood flow away from the heart to an external circuit that oxygenates and returns the blood. It was first successfully used in 1953 to correct an atrial septal defect. The CPB circuit includes cannulas, a reservoir, oxygenator, heat exchanger, pump, and filters. It aims to replace heart and lung function during surgery. Key responsibilities of the anesthesiologist during CPB include acid-base management, anticoagulation, cardioplegia delivery, and cerebral protection.
This document summarizes New Zealand's national adult ECMO service based in Auckland City Hospital. ECMO uses an extracorporeal circuit to support the lungs and/or heart for extended periods. The national service began in 1993 and established a mobile ECMO retrieval team in 2005 to place and transport patients on ECMO anywhere in New Zealand. The mobile ECMO system was designed to be lightweight and portable to transport patients by road, fixed wing aircraft, or helicopter. During the 2009 H1N1 influenza pandemic, the service experienced a surge in ECMO cases and transports across New Zealand.
Similar to Ecmo en el distress respiratorio agudo otra herramienta para el intensivista (20)
Este documento describe los cursos de especialización de postgrado en enfermería ofrecidos por la Clínica Universidad de Navarra (CUN). Presenta siete cursos de especialización en áreas como oncohematología, psiquiatría, cuidados intensivos, cardiología y quirúrgica, con el objetivo de capacitar a los enfermeros con conocimientos especializados. Explica las metodologías docentes activas utilizadas y proporciona más información sobre los cursos.
Este documento resume la investigación actual sobre la válvula tricúspide. Describe que la insuficiencia tricúspide funcional es más compleja de lo que se pensaba, involucrando cambios en la forma y función del anillo valvular. También destaca la falta de consenso sobre cuándo reparar quirúrgicamente la válvula tricúspide.
El documento describe la regurgitación tricúspide en contexto. Explica la anatomía, las causas, la fisiopatología y la evaluación de la regurgitación tricúspide, incluidos los mecanismos, la cuantificación mediante ecocardiografía y la resonancia magnética. También analiza los factores de riesgo asociados con un grado postoperatorio más alto de regurgitación tricúspide y las indicaciones quirúrgicas.
Este documento resume la historia y uso del dispositivo ECMO (oxigenación por membrana extracorpórea) como una forma de asistencia cardiopulmonar barata y efectiva en situaciones de crisis. Describe brevemente el desarrollo del ECMO desde sus orígenes en la década de 1970 y sus usos actuales como puente hacia la decisión, el trasplante o la recuperación. Finalmente, presenta algunos resultados del uso del ECMO que muestran tasas de supervivencia del 50% en pacientes críticos.
Este documento presenta una guía sobre cómo realizar una búsqueda bibliográfica efectiva. Explica las principales bases de datos y estrategias de búsqueda, incluyendo el modelo PICO. Detalla los pasos para formular una pregunta de investigación, seleccionar palabras clave apropiadas y utilizar operadores lógicos para obtener resultados relevantes. Además, enfatiza la importancia de documentar la búsqueda realizada.
El documento habla sobre los fundamentos y metodología de la investigación cuantitativa. Explica los diferentes tipos de diseños de investigación como descriptivos, correlacionales y experimentales. También cubre temas como tipos de muestreo, métodos de recogida de datos, análisis estadístico y consideraciones éticas.
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Estrategias de afrontamiento ante el maltrato verbal y conductual al personal de enfermeria. Curso impartido para enfermería de la Clínica Universidad de Navarra
Este documento resume las novedades en reanimación cardiopulmonar avanzada de 2010, incluyendo énfasis en compresiones torácicas continuas y de alta calidad, desfibrilación precoz, uso de adrenalina y amiodarona, y tratamiento post-reanimación como hipotermia terapéutica. También cubre puntos clave como reconocimiento temprano de parada cardiaca, llamada al 500, relación compresión-ventilación de 30:2, y causas potencialmente reversibles como hipoxia, hipovolemia e hip
El documento describe la importancia de la educación sanitaria del paciente y su familia para mejorar la adherencia al tratamiento y la seguridad de la medicación. Explica que la educación del paciente debe proporcionar conocimientos sobre el nombre, indicaciones, dosis y efectos del medicamento, así como instrucciones sobre omisiones de dosis e interacciones con otros fármacos. También destaca la necesidad de evaluar factores como la accesibilidad del sistema de salud y la comunicación médico-paciente que pueden afectar a la adherencia.
Material didactico del curso "Diagnóstico de bacteriemia. Hemocultivos" que impartió el Servicio de Microbiología de la Clínica Universidad de Navarra.
Este documento resume los resultados de un estudio sobre los factores de riesgo asociados al fallo primario (precoz) del injerto tras un trasplante cardíaco. Algunos de los hallazgos principales son:
1) Los receptores con diabetes, requerimiento previo de inotrópicos y elevación de la presión pulmonar tenían un mayor riesgo de fallo primario del injerto.
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El documento habla sobre la visión de la Organización Nacional de Trasplantes de España respecto al trasplante cardiaco y la donación de órganos. La ONT promueve una estrategia de autosuficiencia en la que cada país debe esforzarse por satisfacer las necesidades de sus pacientes mediante la obtención de recursos dentro del propio país y la cooperación regional o internacional regulada cuando sea necesario.
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This document discusses surgical treatment of atrial fibrillation, specifically left atrial isolation surgery. It provides an overview of the techniques, clinical issues, and results of surgical ablation studies. Surgical ablation has been shown to have better outcomes than percutaneous approaches in eliminating atrial fibrillation and reducing thromboembolic events. Removing the left atrial appendage surgically may further reduce embolic risk compared to rate or rhythm control alone by eliminating the main site of clot formation.
As a leading rheumatologist in Chandigarh, Dr. Aseem specializes in the diagnosis and management of a wide range of rheumatic conditions, including but not limited to:
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Treatment Approaches
Dr. Aseem Goyal adopts a holistic and patient-centered approach to treatment. Depending on the specific condition and its severity, treatment options may include:
Medications
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Regenerative Medicine in Chronic Pain ManagementReza Aminnejad
Regenerative technologies are the future of medicine. The current clinical strategy focuses primarily on treating the symptoms but regenerative medicine seeks to replace tissue or organs that have been damaged by age, disease, trauma, or congenital issues.
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Hemodialysis: Chapter 11, Venous Catheter - Basics, Insertion, Use and Care -...NephroTube - Dr.Gawad
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Definition of mental health nursing, terminology, classification of mental disorder, ICD-10, Indian Classification, Personality development, defense mechanism, etiology of bio psychosocial factors,
Factors influencing growth & development:
Growth & development depend upon multiple factors or determinants. They influence directly or indirectly by promoting or hindering the process.
The determinants can be grouped as Heredity & environment..
Heredity or genetic factors are also related to sex, race, & nationality. Environment includes both pre natal & post natal factors.
These simplified lecture slides by Dr Sidra Arshad offer a concise look at the cardiovascular effects of heart failure:
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This Presentation provides information on hyperlipidemic drugs. It begins with an introduction to hyperlipidemia and its causes. It then discusses various drug classes for treating hyperlipidemia, including their mechanisms of action, effects on lipid levels, pharmacokinetics, therapeutic uses, adverse effects and interactions. The major drug classes discussed are HMG-CoA reductase inhibitors (statins), bile acid sequestrants, fibrates, and niacin. For each class, specific drugs are highlighted and their properties compared.
THE MANAGEMENT OF PENILE CANCER. PowerPointBright Chipili
This PowerPoint includes all the relevant information and science about penile cancer and its management. Information is based on Campbell 12th edition and EAU 2024 updated guidelines.
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CASE PRESENTATION ON CEREBROVASCULAR ACCIDENT (ACUTE ISCHEMIC STROKE) WITH HE...Bhavana
This is a case presentation of a 70 year old female patient who was admitted in the hospital with the chief complaints of right sided upper limb and lower limb weakness and with mouth deviation towards the left, and nausea and fever.
All the information you need to know about Hypothyroidism - Introduction,
Etiology, clinical manifestations, complications, pathophysiology,
diagnosis, treatment, precautions.
A medical treatment that uses high doses of radiation to kill cancer cells or shrink tumors by damaging their DNA. When the DNA is damaged, cancer cells can no longer divide and grow, and they eventually die.
These lecture slides, by Dr Sidra Arshad, offer a simplified description of the physiology of insulin and glucagon.
Learning objectives:
1. Describe the synthesis and release of insulin
2. Explain the mechanism of action of insulin
3. Discuss the metabolic functions of insulin
4. Elucidate the effects of insulin on adipose tissue, skeletal muscle, and liver
5. Enlist the factors which stimulate and inhibit the release of insulin
6. Explain the mechanism of action of glucagon
7. Discuss the metabolic functions of glucagon
8. Elucidate the role of insulin and glucagon in glucose homeostasis during the fasting and fed states
9. Discuss the role of other hormones in the glucose homeostasis
10. Differentiate between the types of diabetes mellitus
11. Explain the pathophysiology of the features of diabetes mellitus
12. Discuss the complications of diabetes mellitus
13. Explain the rationale of oral hypoglycemic drugs
14. Describe the features of hyperinsulinemia
Study Resources:
1. Chapter 79, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 24, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 39, Berne and Levy Physiology, 7th edition
4. Chapter 19, Human Physiology, From Cells to Systems by Lauralee Sherwood, 9th edition
5. Chapter 3, Endocrine and Reproductive Physiology, Bruce A. White and Susan P. Porterfield, 4th edition
6. Insulin and Insulin Resistance, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1204764/
7. Complications of diabetes mellitus,
https://pdb101.rcsb.org/global-health/diabetes-mellitus/monitoring/complications
Co-Chairs, Stephen Salloway, MD, MS, and Sharon J. Sha, MD, MS, prepared useful Practice Aids pertaining to Alzheimer's disease for this CME/MOC/NCPD/AAPA activity titled “Preparing Your Practice for the New Era of Amyloid-Targeting Therapies in Alzheimer's Disease: Expert Insights on Key Evidence, Administrative and Clinical Considerations, and Best Practices for Individualized, Patient-Centered Care.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/AAPA information, and to apply for credit, please visit us at https://bit.ly/3twjpAt. CME/MOC/NCPD/AAPA credit will be available until June 19, 2025.
9. ¢ ELSO registry from 1986–2006
¢ 1,473 patients with severe respiratory
failure
l 50% survived to hospital discharge
¢ Median age was 34 years.
¢ Most patients (78%) supported with
venovenous ECMO
10. ¢ Multivariate logistic regression model
¢ Pre-ECMO factors associated with increased
odds of death were
l Increasing age
l Decreased weight
l Days on mechanical ventilation before ECMO
l Arterial blood pH < 7.18
l Hispanic and Asian race vs. white race
l ECMO VA vs. ECMO VV
26. ¢ UK, 2001-2006
¢ ECMO provided only at the Glenfield
Hospital, Leicester
¢ Entry criteria:
l Adult patients (18-65 years)
l Severe, but potentially reversible ARDS
l Murray score ≥3.0, or
l Uncompensated hypercapnia: pH <7.20
The CESAR trial
27. ¢ Primary outcome measure
l Death or severe disability 6 months
l Severe disability defined as being both
"confined to bed" and "unable to wash
or dress oneself“
¢ Secondary outcomes
l Death at 6 months, at hospital
discharge
l HRQL, costs…
31. ¢ Time from
randomization
to death
¢ Log rank
p = 0.03
32. ECMO : potential indications
• Refractory hypoxemia: PaO2/FiO2 < 50, persistent *
Despite: FiO2 > 80 %, PEEP (≤ 20 cmH2O)
targeting Pplat = 32 cmH2O, prone position +/- NOi
• Plateau Pressure ≥ 35 cmH2O
despite reducing PEEP to 5 cmH2O
AND reducing Vt to 4 ml/kg providing that pH ≥ 7,15
* : Should also account for disease’s type and evolution
33. Where to perform ECMO?
• Experienced centers:
• With Heart surgeons, intensivists, perfusionists, nurses….
• All experienced in the management of ECMO devices
• ECMO programs should include a
mobile ECMO retrieval team
• Available 24H/7D
• Nationwide or regional EMCO networks necessary
34. ECMO configuration for
acute respiratory failure
Should always be venovenous…
…Except in the case of severe
associated cardiogenic shock
35. Peripheral VA ECMO is not
indicated for ARF because…
¢ Flow competition in the aorta
l Heart vs. ECMO pump
¢ If pulmonary function is impaired
l The “Harlequin” syndrome
• “Blue head”: deoxygenated blood directed
to the upper part of the body
• “Red legs”: hyperoxygenated blood in the
lower part of the body
¢ Not possible to rest the lungs
l Vt, Pplat and FiO2 cannot be reduced
36. Peripheral VA ECMO is not
indicated for ARF because…
¢ VA ECMO increases LV afterload
l Risk of myocardial damage/stunning
¢ Complications associated with the
arterial line in VA femoro-femoral ECMO
l Leg ischemia
l Arterial embolism
l Massive arterial hemorrhage
38. Blood oxygenation objectives
in VV ECMO
¢ SaO2 >86-88%
¢ May be difficult to obtain more…
l Because of blood recirculation
l Even if FiO2 set at 100% on the
machine
¢ CO2 elimination much easier
39. RECIRCULATION:
The major limitation of VV ECMO
¢ Factors increasing Recirculation
l Proximity of venous catheter tips
l Low cardiac output
l Hypovolemia and decreased RA
blood content
l Increased pump flow
40. How to optimize blood oxygenation?
¢ Minimize recirculation
l Cannulas adequately (re)positionned
l Fluid loading to correct hypovolemia
l Adjust pump flow
¢ ECMO flow objective:
l Pump flow: the major determinant of oxygenation
• >5 - 6 l/min or >3 L/m² or >70% of CO
l USE LARGE DRAINAGE CANNULAS!!!
¢ Other parameters
l Red cells transfusion: Hb >10 g/dl
45. Conclusion
¢ For the most severe forms of acute respiratory
failure, ECMO:
l Replaces pulmonary function
l Allows ultraprotective MV settings
l Should allow facilitated lung healing
¢ Only experienced centers should run these programs
l With a mobile ECMO retrieval team available 24H/7D
¢ Still a controversy on the use of ECMO
l Need for a confirmation trial
46. La Pitié: Louis XIX, 1656…
To 2010…
La Chapelle Institut de Cardiologie
48. EOLIA: ECMO to rescue Lung Injury
in severe ARDS
¢ Multicenter international randomized controlled trial
¢ Best care possible in the ECMO arm
l ECMO initiated asap for every patient randomized
• Using the most recent ECMO technology
• CardioHelp, from Maquet
l Inclusion of some non-ECMO centers with a mobile
ECMO rescue team available from the referral center
in less than 1 hour
• Transport of randomized patients to the referral center
UNDER ECMO
• ECMO managed only in highly experienced centers
l “Highly protective” MV
• Plateau pressure limited to ≤ 20 cm H2O
49. EOLIA: ECMO to rescue Lung Injury
in severe ARDS
¢ Best care possible in the control arm
l MV protocolized using the
“high PEEP – high recruitment” strategy of
the EXPRESS trial
l To limit plateau pressure <28-30 cm H2O
• Vt limited to 6 ml/kg IBW
l “Ethical” cross-over option to ECMO if the
patient develops refractory hypoxemia