Extracorporeal Membrane Oxygenation

Presented by Group B Intensive Care Unit SQUH,OMAN

What is an ECMO?• ECMO is the use of extracorporeal circulation and gas exchange to provide temporary life support in patients with reversible pulmonary or cardiac failure.

GOALS •Ensure the body has enough oxygen. •ECMO does not heal the heart or lungs but gives them time to rest and recover.•The ventilator settings can be decreased to levels that will not damage the lungs.•Able to decrease other drugs that support the heart.

How ECMO Works ?•Pumping a steady amount of blood through the ECMO machine each minute -SWEEP GAS

ECMO Indications• Neonatal

• Congenital Diaphragmatic Hernia• Meconium aspiration• ARDS• Pneumonia and sepsis• Pulmonary HTN

• VV ECMO in Peds and Adults• Pneumonia and sepsis• ARDS• Aspiration Pneumonia• Drowning & Trauma• Respiratory Failure

• VA ECMO Pedia & Adults• Cardiomyopathy• Sepsis• Perioperative Cardiac Surgery• Poisoning• Post Cardiac Arrest

ECMO Contraindications

•Age: <34 weeks gestational age, > 75 years old• Severe chronic organ failures, e.g. cirrhosis, ESRD,

hepatic failure• <2000gms for paediatrics•Coagulopathy that is ongoing/uncorrectable • Severe neurologic insult or asphyxia

Who comprises the ideal team?

• Two intensivists (ECMO intensivist) and/or cardiothoracic surgeons: cannulation• One Medical Officer: monitor cannula position by ECHO• One Medical Officer: clinical management• Perfusionist: ECMO priming and maintenance• Respiratory Therapist: lung protective management, ventilator settings• Nurses:

• Senior CCN/OT Scrub Nurse: assists in the procedure.• 2nd Senior CCN/OT Circulating Nurse: supports clinical management.• 3rd RN/ICU nurse: ONGOING CARE FOR ECMO PATIENT

• Radiologic Technician

What are the Common Types of ECMO?

• VA ECMO is mainly used in people with heart problems or blood pressure problems. A catheter takes blood from the superior vena cava, runs it through the ECMO machine, and then replaces the blood, under pressure, to arterial circulation, usually via the aorta. This method supports both the heart and the lungs.

• VV ECMO is used for patients who need mainly lung support. In this case, the blood is taken from a major vein and returned to another major vein after oxygenation

CENTRAL VA ECMO: cannula into the ascending aorta or subclavian artery

Nursing Considerations:•

Nursing Actions•Maintain strict infection control. No alcohol swabs or

chlorhexidine wash. Only USE BETADINE •Restrict access to essential personnel.•Remove unnecessary invasive lines.• Ensure that all required invasive access are present,

eg. NGT, core temp probe.• Secure ET tube to maintain access during procedure

maintaining the sterile field.

• Ensure crash trolley in close proximity• Insert fecal management system, ensure fecal

softeners as prescribed.•Prepare and position patient. Place appropriate

mattress on bed.•Clip hair on the proposed site with electric razor. •Move the bed so the ECHO machine, ECMO trolley

and sterile field can be positioned

Nursing Actions

• Collaborate with the members of the ECMO management team about the necessary equipment and materials to be prepared.• Ensure liberal supply of gauze.• Be aware that it is the responsibility of the ECMO intensivist

to dress and secure ECMO cannula.• Ensure that baseline ECMO observations and pump settings

are monitored, liaised with the perfusionist.

Cannulation

• Ensure contact numbers of the on call perfusionist and ECMO intensivist is updated and noted.• Ensure four tubing clamps are readily available.• Liaised with respiratory therapist and ECMO

intensivist about the rescue ventilation orders for emergencies.

Shift Checks• Power• Flow Mode (liters per minute)• Mode• Alarms• Hand crank• Emergency Checks• Battery Check• Circuit Assessment• Cannula Assessment• ECMO checks

Nursing Assessments• Routine Assessments:

• HR, SaO2, SBP, MAP

• Hourly Assessments:• Neuro-vascular observation• Urine output• Core temperature• EtC02• Ventilator observations

• Regular Assessments:• CVP• Neurological assessments• Sedation level

Pressure area care and positioning:

•Restriction in mobility; ensure appropriate mattress. Once a day pressure care, preferably in day shift.•Log rolled. One RN ensures circuit and cannula safety and directs turning.

Mouth, eye and catheter care

•Use swabs; no toothbrushes.•No shaving with wet razor; use clippers.•Don’t do routine tracheal and mouth suctioning.•Do not dislodge clots covering wound and insertion sites.•No venipuncture.

Dressing the cannula• Only if there is significant exudates or if not intact or

secured.• Do not remove lower adhesion tape and stitching. Do

dressing of cannula site first before, the replacing adhesion tapes.• Required two nurses for dressing. Dressing changes

preferable in day shift.• Pull the dressing off towards the insertion site. • If there is ongoing oozing, calcium/sorbalgon alginate

dressing can be applied.

Blood Works and Diagnostics• Ensure current crossmatch PRBCs are available.• Daily U/E, Mg and LFT.• CBC BD and as prn. PLATELET COUNT• Daily blood cultures during spike of fever or ideally beginning at 5th

day of therapy.• Pre and post oxygenator ABG c/o perfusionist. • ACT every 2 hours x 24 hours.• APTT every 6 hours, target 55-75 s or as specified by intensivist.

Weaning• Be knowledgeable of the signs for weaning:• Improving oxygenation• Reduced CO2 retention• Improving chest xray• Blood flow unchanged in ECMO• Stable ABG > 6 hours without oxygenator support

• Note clotting and platelet levels before decannulation procedure.• Discontinue heparin infusion 2-4 hours or as ordered prior to

decannulation.

Decannulation• Ensure two medical staff are involved in the removal of the cannulas,

while a third medical staff clinically manage the patient.• Coordinate with perfusionist and respiratory technician about the plans. • Ensure that direct pressure is applied on the insertion site for at least 20

minutes and the ECMO intensivist will remain with the patient until hemostasis achieved.• Coordinate with intensivist about the need for sedation and pain

medication before the procedure.• Carry out successive Doppler assessment of the decannulated limbs

after catheter removal.

Preventing and Managing Complications

• Patient Related:• Bleeding• Hemolysis• Recirculation• Infection

• Circuit Related:• Clot formation• Plasma Leak• Oxygenator Failure• Heat Exchanger

Failure• Tubing, Connector

Cracks and Blood Leakage

• Emergencies:• Pump Failure• Decannulation• Air Embolism • Cardiac Arrest

Bleeding

• Hourly cannula site assessment.•Monitor clotting time, Hb, platelets.• Ensure access sites are stabilized. Do not dislodge clots

directly from wounds or insertion sites. •Maintain enteral feeding if tolerated; ulcer prophylaxis.• Report blood loss.• Ensure current crossmatched PRBC.• Give blood products as ordered.

Hemolysis• Monitor the lab results( CBC, U/E and urine)• Hourly assessment for movement(kinking) of the access cannula• Hourly assessment of the temperature of the heat exchanger

Recirculation• Monitor the SPO2 and ABG values• Colour of RETURNED BLOOD • Ensure catheter security during patient movement.

Infection• Prevent high risk of nosocomial infection.• Closely watched for signs of infection

Circuit Related Complications• Clot formation Maintain anti-coagulation as prescribed • Plasma Leak,ALARMS • Oxygenator Failure• Heat Exchanged Failure• Tubing Cracks or blood leakage

ECMO Emergencies• Pump failure- power check• Decannulation- reinsertion• Air embolism- trendlenberg position• Cardiac Arrest- VA ECMO-No Chest compressionVV ECMO-chest compression