56: Pressors, Fluid, or Flow – Optimizing ECMO Physiology

A post arrest patient just got initiated on ECMO.  Do you give fluids, add pressors, or increase flow?  Marc Dickstein, an anesthesiologist from Columbia University and an expert in the physiology of ECMO, talks with Zack about how to manage these patients, what diagnostics we need and how to optimize your use of the machine.  This talk is a must for everyone starting ECPR in their departments.

Photo: Marc Dickstein

Marc's ECMO physiology website Harvi

Marc's ASAIO article on ECMO physiology –

Dickstein ML. The Starling Relationship and Veno-Arterial ECMO: Ventricular Distension Explained. ASAIO J. 2018 Jul/Aug;64(4):497-501. doi: 10.1097/MAT.0000000000000660. PubMed PMID: 29076945.

Zack's recent Resus Editorial on Impella

Shinar Z. Is the "Unprotected Heart" a clinical myth? Use of IABP, Impella,
and ECMO in the acute cardiac patient. Resuscitation. 2019 May 21. pii:
S0300-9572(19)30173-X. doi: 10.1016/j.resuscitation.2019.05.005. [Epub ahead of
print] PubMed PMID: 31125528

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John Stokes
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John Stokes

Great episode and love the discussion. Wanted to add a simple point that I didn’t hear mentioned. It may have not been mentioned because it is obvious to everyone. Lots of discussion about whether the aortic valve is opening and adjusting flow, pre-load, after-load to get the valve opening. Remember the simplest, real-time way to assess whether the valve is opening is your right radial or axillary arterial line. The patient needs it anyway. If you have a pulsatile waveform on that arterial line, the valve is opening. If you don’t have a pulsatile waveform, the valve isn’t opening. Additionally,… Read more »

Marc Dickstein
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Marc Dickstein

Great comments. Spot on! What you mention is so important, it’s worth repeating: No pulsatility on the a-line means there’s no ejection. But if there is pulsatility (ie ejection), you still need to determine the filling pressure required for the LV to eject; could be reasonable (pcwp in the teens) or it could be unacceptably high. No way of knowing that from the a-line waveform. And a distended ventricle won’t recover, and acute pulmonary edema really complicates management!