See...I dont write everyone off Hern..

[Hernandez]

No way they gonna spin her with systolics in the 60's on 5 pressors. If she was on VA ECMO SURE, too unstable for transport to our other facility which has it. i dont remember her ph off hand but it was >7....very reassuring....

Y'all bicarb gtt her?

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[VentdependenT]

We did. Started for the CCB OD

 

[bigtuna]

No way they gonna spin her with systolics in the 60's on 5 pressors. If she was on VA ECMO SURE, too unstable for transport to our other facility which has it. i dont remember her ph off hand but it was >7....very reassuring....

FYI....VA ecmo won't help you with high CO and refractory vasodilatory shock. That's why it's no good for sepsis either

 

[Bostonredsox]

Her pressure was too low to tolerate cvvhd? Most of my shock pts that are too hypotensive and on too many pressors for HD get shipped for cvvhd and seem to tolerate it well. Though if we're doing it for refractory acidosis a 24 hour dialysis treatment isn't exactly going to improve the acidemia quickly which was the entire point of dialyzing so I guess that makes sense.

 

[Bostonredsox]

FYI....VA ecmo won't help you with high CO and refractory vasodilatory shock. That's why it's no good for sepsis either

Glad you brought that up. My understanding is systemic vasodilation with high cardiac output, IE septic Shock, did not improve with VA ecmo. Not 100% on the physiology of it though.

 

[Hernandez]

Her pressure was too low to tolerate cvvhd? Most of my shock pts that are too hypotensive and on too many pressors for HD get shipped for cvvhd and seem to tolerate it well. Though if we're doing it for refractory acidosis a 24 hour dialysis treatment isn't exactly going to improve the acidemia quickly which was the entire point of dialyzing so I guess that makes sense.

If CVVHD was already running then became that unstable, I might continue, but even I wouldn't start with a systolic of 60

 

[VentdependenT]

Shows how much i know about VA ECMO, but ive seen many dead people kept alive with it. Virtually nobody dies on the cath or cardiothoracic tables because of this salvage machine

 

[bigtuna]

VA ecmo will take between about 4 and 7 lpm of venous blood, oxygenate it, and pump it into the arterial system. If you already have a high CO, it wont add anything and wont increase vascular tone. Its useful for lv failure primarily but also situations such as PE with refractory shock, PAH with ards.

 

[Bostonredsox]

VA ecmo will take between about 4 and 7 lpm of venous blood, oxygenate it, and pump it into the arterial system. If you already have a high CO, it wont add anything and wont increase vascular tone. Its useful for lv failure primarily but also situations such as PE with refractory shock, PAH with ards.

Ah. So it essentially treats refractory hypoxemia with a direct conduit to the arterial system with freshly oxygenated blood. I see why it wouldn't help in high CO septics with hyperdynamic LV function

 

[bigtuna]

Ah. So it essentially treats refractory hypoxemia with a direct conduit to the arterial system with freshly oxygenated blood. I see why it wouldn't help in high CO septics with hyperdynamic LV function

Not quite.

Venovenous ecmo is adequate to treat refractory hypoxemia if cardiac output is normal - fully oxygenate venous blood and then return it to the right side of the heart where it is pumped by the normal heart through the lungs and then out to the systemic circulation.

VA ecmo is fundamentally for pump failure.

VA ecmo is required for refractory hypoxemia if cardiac output also stinks - like the example of a pt with PAH and ARDS. If the right heart is already bad, VV-ecmo is usually not the way to go.

Neither type of ecmo will help you with vasodilatory shock.


BTW...CVVHD doesn't drop your pressure much if you're not hypovolemic. I doubt it would change the hemodynamics much in the pt that OD'ed on CCB.

 

[Bostonredsox]

Not quite.

Venovenous ecmo is adequate to treat refractory hypoxemia if cardiac output is normal - fully oxygenate venous blood and then return it to the right side of the heart where it is pumped by the normal heart through the lungs and then out to the systemic circulation.

VA ecmo is fundamentally for pump failure.

VA ecmo is required for refractory hypoxemia if cardiac output also stinks - like the example of a pt with PAH and ARDS. If the right heart is already bad, VV-ecmo is usually not the way to go.Neither type of ecmo will help you with vasodilatory shock.


BTW...CVVHD doesn't drop your pressure much if you're not hypovolemic. I doubt it would change the hemodynamics much in the pt that OD'ed on CCB.

makes sense. Your bypassing the LV with VA ecmo so poor CO and poor LV function are no longer an issue. Is it more tedious to setup and monitor then VV ecmo?

 

[bigtuna]

makes sense. Your bypassing the LV with VA ecmo so poor CO and poor LV function are no longer an issue. Is it more tedious to setup and monitor then VV ecmo?

Oh yeah - something about garden hose size arterial canulas and full anticoagulation. Complication rate from VV much lower.

 

[VentdependenT]

Oh yeah - something about garden hose size arterial canulas and full anticoagulation. Complication rate from VV much lower.

people lose their canulated leg all da time.

 

[pseudoknot]

Also had suspected CCB od on 30yr old maxed on 5 pressors with systolics hangin in high 60's for like 10 HOURS.

This may be of interest. Blog post about a case series of CCB ODs. Some treated with spectacular doses of conventional pressors (100 mcg/min norepinephrine and epi). As always there is no max dose for pressors...

http://www.thepoisonreview.com/2013...-therapy-in-calcium-channel-blocker-overdose/

 

[Hernandez]

This may be of interest. Blog post about a case series of CCB ODs. Some treated with spectacular doses of conventional pressors (100 mcg/min norepinephrine and epi). As always there is no max dose for pressors...

http://www.thepoisonreview.com/2013...-therapy-in-calcium-channel-blocker-overdose/

Good link, I'd forgotten about insulin gtt, I've only seen 3 CCB od's, 2 were mild and didn't require much, the other was co-ingestion with a beta-blocker, that dude was asystolic & pacer dependent for days.

 

[jdh71]

Good link, I'd forgotten about insulin gtt, I've only seen 3 CCB od's, 2 were mild and didn't require much, the other was co-ingestion with a beta-blocker, that dude was asystolic & pacer dependent for days.

Insulin gtt became my main weapon after working with one of the tox gurus here where I'm doing fellowship.

The first time a nurse is asked to do it, she might threaten to quit. Heh. I thought I had a mutiny at the U on one patient last year when I ordered it up. Luckily my favorite charge was on and I showed her the information and she talked the nurse off the ledge. We'd "maxed" the norepinephrine with clear history of OD gor many, many things incling BBs and CCBs without any other evidence for other etiologies of hypotension and I was like, "I'm done messing around here".

 

[Stitch]

people lose their canulated leg all da time.

If the arterial cannula is in the femoral artery, it's worth putting in a booster cannula distally. But in general I hate canulating the leg for arterial return for this reason. Better to go neck/carotid.

Not quite.

Venovenous ecmo is adequate to treat refractory hypoxemia if cardiac output is normal - fully oxygenate venous blood and then return it to the right side of the heart where it is pumped by the normal heart through the lungs and then out to the systemic circulation.

VA ecmo is fundamentally for pump failure.

VA ecmo is required for refractory hypoxemia if cardiac output also stinks - like the example of a pt with PAH and ARDS. If the right heart is already bad, VV-ecmo is usually not the way to go.

Neither type of ecmo will help you with vasodilatory shock.


BTW...CVVHD doesn't drop your pressure much if you're not hypovolemic. I doubt it would change the hemodynamics much in the pt that OD'ed on CCB.

I generally agree, but we've successfully used it in a teenager with vasodilatory shock. Just used two venous cannulas (neck and fem) and cranked up the flow to 6 L. There was a French report of success using this method, but I can't find it at the moment. We also able to get some response from vasopressin and phenylephrine drips (which we almost never do in peds). Of course if your issue is dysoxia/inability to use the O2 delivered, then you're hosed.

And you'd be surprised what offloading the RV can do in certain RV failure situations. Some will go VV rather than VA and just draining off the pressure can make a big difference.

 

[bigtuna]

If the arterial cannula is in the femoral artery, it's worth putting in a booster cannula distally. But in general I hate canulating the leg for arterial return for this reason. Better to go neck/carotid.



I generally agree, but we've successfully used it in a teenager with vasodilatory shock. Just used two venous cannulas (neck and fem) and cranked up the flow to 6 L. There was a French report of success using this method, but I can't find it at the moment. We also able to get some response from vasopressin and phenylephrine drips (which we almost never do in peds). Of course if your issue is dysoxia/inability to use the O2 delivered, then you're hosed.

And you'd be surprised what offloading the RV can do in certain RV failure situations. Some will go VV rather than VA and just draining off the pressure can make a big difference.

This doesnt seem correct to me - remember that there is no net change in cardiac output with VV ecmo. All of the blood that comes out goes right back in to the right side of the heart - no net change. I can't imagine VV ecmo having any effect on vasodilatory shock at all.