Infant with Congenital Diaphragmatic Hernia, Pre and Post-operative Care — VA ECMO Decannulation Readiness — Clinical Pathway: Inpatient and ICU

Infant with Congenital Diaphragmatic Hernia Clinical Pathway, Pre and Post-operative Care — Inpatient and ICU

VA ECMO Decannulation Readiness

Respiratory Status
  • Minimum TV 4 mL/kg
  • No significant pleural effusions
  • Improved edema
Pulmonary Hypertension
  • Resolved shunting when ECMO flow weaned, if PDA open
  • Low flow Echo with cardiology attending
Low Flow
  • Goal
    • Hemodynamic stability without acidosis, hypoxemia, ductal shunting and/or evidence of right heart compromise on Echo
  • Preparation
    • Coordinate trial time with entire team, including neonatal surgical attending/fellow, neonatal attending and fellow, neonatal surgical APP, bedside RN, respiratory therapist, and attending Echo cardiologist
    • Ensure adequate access, infusions running to patient, dopamine and epinephrine primed
    • Discuss appropriate ventilator settings with clinical team +/- iNO
  • ECMO Flow Challenge
    • Consider low flow trial ~20 mL/kg/min if there is concern for clot burden in circuit otherwise, consider clamp trial for maximum of 10-15 mins
    • Monitor BP, Transcutaneous CO2 monitoring (TCOM), and oxygen saturations continuously
    • Obtain iSTAT ABG at 5-10 mins
    • If impaired oxygenation and/or ventilation, consider the administration of vecuronium and assess response
  • Successful Wean Trial Parameters
    • PIP < 26
    • MAP ≤ 15
    • FiO2 < 50%
    • CO2 < 55 mmHg
    • TV > 4 mL/kg
    • No ductal shunting
    • Dopamine ≤ 5 mcg/kg/min