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Wake Forest University ECMO Exam Scott Copus BS RRT by WesleyL


									                          Wake Forest University ECMO Exam - 2004

Scott Copus, BS, RRT
Wake Forest University Baptist Medical Center

1) The goal of ECMO use for respiratory failure is to:
   a) allow time for the reactive nature of the pulmonary vasculature to subside or decrease in intensity
   b) allow time for parenchymal lung processes to heal
   c) provide adequate oxygenation and ventilation without barotrauma and oxygen toxicity
   d) all of the above

2) Oxygen crosses the oxygenator’s membrane more easily than CO2.
   a) True
   b) False

3) CO2 exchange in the membrane oxygenator is dependent upon what three items?
   a) Relative concentrations of CO2 on either side of the membrane.
   b) Blood flow through the membrane oxygenator.
   c) Surface area of the membrane oxygenator.
   d) Gas flow rate through the membrane oxygenator.

4) Oxygen transfer in the membrane oxygenator is dependent all of the following EXCEPT:
   a) Blood flow rate through the membrane oxygenator
   b) Blood path thickness
   c) Membrane surface area
   d) Sweep gas flow rate

5) Turning up the sweep gas flow rate will increase oxygen transfer.
   a) True
   b) False

6) The following factors influence oxygenation on VA ECMO with no native lung function (circle all that
   a) Pump flow rate
   b) Hemoglobin concentration
   c) Pulmonary blood flow
   d) Ventilator FiO2

7) The following factors influence oxygenation on VV ECMO with no native lung function:
   a) Pump flow rate
   b) Recirculation
   c) Cardiac output
   d) All of the above

8) When assessing a patient’s oxygenation status on VV ECMO, which of the following is the best
   indicator of adequacy of oxygenation?
   a) Patient arterial saturation
   b) Patient PaO2
   c) Pre membrane saturation
   d) all of the above

Page 1 of 7                         ECMO Sample Test 05                             March 2006
                           Wake Forest University ECMO Exam - 2004

9) The roller pump uses ______ to pull blood into the biohead and direct it through the circuit.
   a) Positive displacement
   b) Afterload
   c) Constrained vortex
   d) Preload

10) Advantages of the roller pump include:
    a) Low hemolysis
    b) Traps air
    c) Constant flow with variable pre load
    d) Reduced likelihood of cavitation

11) The oxygenator membrane is made of what material?
    a) Polycarbonate
    b) Silicon rubber
    c) Tygon
    d) Polyvinyl chloride

12) Why are heat exchangers used in ECMO made of stainless steel?
    a) Reduced corrosion
    b) Less expensive
    c) Superior heating characteristics
    d) More durable

13) An increase in the transmembrane pressure across the membrane usually signifies:
    a) A kinked arterial cannula
    b) Reduced gas exchange
    c) A blood leak
    d) Clots in the membrane

14) In VA ECMO, a circuit venous saturation monitor can help determine:
    a) Amount of recirculation
    b) Adequacy of oxygen delivery
    c) Direct measure of oxygen utilization
    d) Membrane function

15) The ACT might be prolonged in all of the following circumstances except:
    a) Active patient diuresis
    b) Oliguria
    c) Thrombocytopenia
    d) DIC

16) Low levels of AT III in a patient on ECMO bypass may lead to:
    a) Bleeding
    b) Thrombocytopenia
    c) Hemolysis
    d) Heparin resistance

17) The ACT or “activated clotting time” is:
    a) A bedside test of “true” clotting time
    b) Equivalent to the PT
    c) A bedside test of clotting function using an accelerant to obtain a quick result
    d) An unreliable test of clotting function

Page 2 of 7                          ECMO Sample Test 05                              March 2006
                           Wake Forest University ECMO Exam - 2004

18) A heparin bolus is given to the patient prior to ECMO cannulation in order to:
    a) Prevent clotting of the ECMO cannula during the procedure
    b) Calibrate the bedside ACT machine
    c) Act as an antifibrinolytic on pre-existing clots

19) Amicar (aminocaproic acid) is used in the ECMO patient to:
    a) Prevent clotting
    b) Potentiate the action of heparin
    c) Prevent lysis of pre-existing clots
    d) Prevent thrombocytopenia

20) Cryoprecipitate is the blood product of choice for a patient on ECMO to treat:
    a) Low fibrinogen levels
    b) Factor depletion
    c) Hypovolemia
    d) AT III deficiency

21) Platelets should be transfused:
    a) On the venous side of the circuit
    b) Every 8 hours around the clock
    c) When the PTT is prolonged
    d) Post oxygenator

22) Bleeding on ECMO may be treated in the following manner:
    a) Decrease ACT goals to 180 - 200 or lower.
    b) Use of aminocaproic acid (Amicar).
    c) Give inotropes to increase blood pressure.
    d) Correction of coagulation studies.

23) What indicators are used to monitor the adequacy of handcranking a roller pump on VA bypass?
    a) Monitor pre-membrane pressure
    b) Patient SaO2 and circuit SvO2
    c) Visual readout on the pump

24) List the three topical measures which can be used to control minor bleeding from the cannulation site.
    a) Direct pressure
    b) Topical thrombin
    c) Silver nitrate
    d) Gelfoam

25) What are the signs of a tension pneumothorax on VA ECMO?
    a) Increasing patient PaO2
    b) Decreasing SvO2
    c) Decreased venous return
    d) Wide pulse pressure

26) The following are signs of a failing membrane oxygenator EXCEPT:
    a) Decreased oxygen and carbon dioxide transfer.
    b) DIC
    c) Increased pre and post-oxygenator pressure
    d) Increased pre-oxygenator pressure and decreased post-oxygenator pressure

Page 3 of 7                         ECMO Sample Test 05                              March 2006
                           Wake Forest University ECMO Exam - 2004

27) Veno-venous ECMO in the pediatric ECMO population is limited to patients with a weight less than 4
    a) True
    b) False

28) Which of the following would be an appropriate response to bleeding in a pediatric ECMO patient?
    a) lower the target ACT range
    b) stop the heparin drip and increase pump flow to prevent clot formation
    c) correct coagulopathies
    d) all of the above

29) Direct cannulation of heart during cardiac ECLS carries the risk of:
    a) Decannulation after several days due to tissue fatigue.
    b) Inability to perform adequate pulmonary toiletry due to immobility of the patient.
    c) Misinterpretation of high membrane pressures.
    d) Higher incidence of infection.

30) Patients being placed on ECLS directly from conventional cardiopulmonary bypass will usually have:
    a) Elevated PT/PTT
    b) Low hematocrit and low platelet counts
    c) Prolonged ACTs and low fibrinogen level
    d) All the above

31) Cryoprecipitate when given to the ECLS patient:
    a) Will cause the ACTs to drop rapidly
    b) Must be given post-membrane and flushed very well
    c) Will raise the fibrinogen level with less volume compared to FFP
    d) All the above

32) Pump flow rate for the cardiac ECLS patient is determined by:
    a) Calculating 120 cc/kg
    b) Filling pressures of the heart
    c) Degree of contractility of the heart
    d) Underlying reason for cardiac ECLS

33) Cardiac tamponade in the post-operative cardiac ECLS patient may be indicated by:
    a) Loss of venous return even when pump flow is reduced slightly
    b) Rise in filling pressures with loss of venous return
    c) Rise in heart rate and filling pressures
    d) All the above

34) Oxygen delivery for the adult VA ECLS patient is increased by:
    a) Increasing the sweep (oxygenator) gas flow
    b) Increasing the ECLS pump flow.
    c) Increasing the ventilator rate.
    d) Increasing the heparin rate.

35) What is an appropriate intervention to decrease the PaCO2 for adult ECLS patients?
    a) Decrease the ventilator rate.
    b) Increase the ventilator FiO2.
    c) Increase the sweep (oxygenator) gas flow.
    d) Decrease the sweep (oxygenator) gas flow.

Page 4 of 7                         ECMO Sample Test 05                               March 2006
                           Wake Forest University ECMO Exam - 2004

36) During VA ECLS the arterial pressure wave:
    a) Is unchanged.
    b) Increases as ECLS flow increases.
    c) Dampens as ECLS flow increases.
    d) Is not important.

37) Why is the circuit venous saturation higher during VV ECLS?
    a) VV ECLS patients hearts are working harder.
    b) VV ECLS patients are always on a ventilator.
    c) There is a certain amount of recirculation that occurs with VV ECLS.
    d) VV ECLS patients may be obese.

38) Management of VA ECLS patients with a femoral artery cannula is likely to include:
    a) Frequent assessment of pedal pulses of the extremity with the cannula.
    b) Frequent assessment of the color and warmth of the foot distal to the cannula.
    c) Placement of a distal arterial cannulae to improve perfusion of the extremity.
    d) All of the above.

39) You are caring for a 55 year old patient on VA ECLS after open-heart surgery. The patient has chest
    cannulae. Care is likely to include:
    a) Turning the patient prone every 6 hours.
    b) Close monitoring of chest tube output and the chest dressing for bleeding.
    c) Hold all blood transfusions as the patient may be a transplant candidate.
    d) Administering more heparin than usual.

40) The severe respiratory compromise present in CDH is due to all of the following except:
    a) Pulmonary hypertension
    b) Increased smooth muscle of pulmonary arterial bed
    c) Compression of the lung by the abdominal contents
    d) Lung hypoplasia
    e) Prematurity

41) Hyperventilation induced hypocapnia has no adverse outcomes.
    a) True
    b) False

42) The goal of permissive hypercapnia is:
    a) Hyperventilation with an associated decrease in PaCO2
    b) Oxygen saturation of 100% in the left hand
    c) Increased minute ventilation
    d) Oxygen saturation of at least 90% in the right hand

43) Special precautions taken in the nursing care of ECMO patients include: (circle all correct responses).
    a) Avoidance of IV starts and venipuncture
    b) Avoid nasal suctioning
    c) Constant presence of trained ECMO staff at the bedside
    d) All of the above

Page 5 of 7                         ECMO Sample Test 05                              March 2006
                           Wake Forest University ECMO Exam - 2004

44) A 12 year old patient with pneumonia has been on VA bypass for 36 hours. Pump flow is 100
    cc/kg/min. Blood pressure and perfusion are adequate. Edema is moderate. Urine output is 0.5
    cc/kg/hr with normal renal function studies. Management of the this patient would include (circle all
    correct responses):
    a) Restricting fluids
    b) Starting lasix
    c) Giving volume
    d) Starting hemofiltration

45) You are caring for a. one year old with pneumonia on VV bypass. Pump flow is 100 cc/kg/min.
    Sweep gas flow is 60% FiO2, 1.O LPM. Ventilator settings are PIP 24 PEEP 6 Rate 15 FiO2 .3. An
    ABG drawn from the radial arterial line reveals pH 7.26, PaCO2 62, PaO2 75, HCO3 22.4 and mixed
    venous saturation 81%. The most appropriate action would be to:
    a) Increase bypass flow
    b) Increase the FiO2 of the sweep gas
    c) Increase the sweep gas flow
    d) Increase the ventilator rate

46) A newborn has been placed on VA bypass for overwhelming sepsis. ECMO pump flow at hour 6 is
    120 cc/kg min. Blood gases and the mixed venous saturation have been within accepted parameters.
    You note that the mean arterial blood pressure has fallen below 35 mmHg and the CVP has fallen to
    2 mmHg. The best response would be to (circle all correct responses):
    a) Give volume
    b) Start dopamine
    c) Continue to monitor the blood pressure
    d) Increase ECMO pump flow

47) The systolic BP in a neonate is consistently > 90 mmHg on day 1 of VA ECMO. Appropriate actions
    include: (circle all correct responses).
    a) Increasing the pump flow
    b) Lowering the bed
    c) Starting antihypertensive therapy
    d) Increasing sedation

48) Your patient has been on VV bypass for 10 hours and has become acidotic with a narrowed pulse
    pressure. Pump flow is 120 cc/kg/min. The pre-oxygenator circuit pressure is 420 mmHg. Ventilator
    settings are FiO2 .5, PIP 28, PEEP 7, rate 30, A dopamine drip is infusing at 15 mcg/kg/min. An
    appropriate action would be to:
    a) Start a dobutamine drip
    b) Start a bicarbonate drip
    c) Increase ECMO pump flow
    d) Prepare for conversion to VA bypass

49) ACTs will be prolonged in the following situations except for:
    a) Increased urine production
    b) Decreased platelet count
    c) Decreased urine production
    d) High heparin infusion rates

Page 6 of 7                          ECMO Sample Test 05                              March 2006
                         Wake Forest University ECMO Exam - 2004

50) The circuit pressures in the VA ECMO patient you are caring for are rising. Both the pre and post
    circuit pressures are 50 mmHg higher than they were at the start of your shift. ECMO pump flow has
    not changed. Possible causes of this situation are (circle all correct responses):
    a) Patient agitation
    b) Kink in the arterial catheter
    c) Kink pre-oxygenator
    d) Clot in the heat exchanger

Page 7 of 7                        ECMO Sample Test 05                            March 2006

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