ECMO AND THE ADULT PATIENT:NURSING CONSIDERATIONS

Jason Lippy, RN

Paula Minor, RN

University of Maryland Medical Center

March 2012

What is ECMO?

Extra Corporeal Membrane Oxygenation

Blood is drained from the venous system Oxygenated through an artificial lung,

removing carbon dioxide Returned to the patient

Goal of ECMO

Ensure oxygen supply meets/exceeds the patient’s demands

Prevent end organ dysfunction and tissue death.

Rest heart and/or lungs Allow time for healing

ECMO FLOWBlood Flow

1. Deoxygenated Blood Drained from Venous Circulation

2. Blood Pump

Centrimag

Rotaflow

3. Membrane Oxygenator/

Heat Exchanger (Quadrox)

Hollow fiber

polymethylpentene

4. Oxygenated Blood Returned

to the Patient

5. Pressure monitor

1

23

4

5

Venovenous (VV) ECMO Blood is drained FROM and returned TO the

venous circulation Does NOT provide hemodynamic support Goal is to rest the lungs Allow time for healing

Venoarterial (VA) ECMO Provides pulmonary and hemodynamic

support Heart and lungs are bypassed Venous/drainage and arterial/return Nonpulsatile

Multidisciplinary Team Critical Care Physician and/or Surgeon Attending Physician / Nurse Practitioner Bedside RN / Resource RN ECMO Specialist (RN, RT or Perfusionist) Respiratory Therapist

Communication is the Key!!!

Pre-ECMO Management

Documentation Consent, Orders, Current Type X

Bedside ECMO,open chest & code cart, back-up ECMO (on unit),

central line cart PRBC, heparin, NS, sedation, narcotics

Pre-Procedure Are New Lines Needed? Wound Care Consult (Specialty Bed) Gastric Tube /Small Bowel Tube Placement Baseline Neuro, pulse, ECG, labs

VV ECMO: Two Site Cannulation

1 Drainage, 1 Return Internal Jugular Vein Femoral Vein or Saphenous

Vein

Cannulation Dressings

Cannula Positions

Single Site Cannulation

One double lumen catheter is inserted through the right IJ into the right atrium

Blood is drained and returned through separate lumens in the same cannula

www.avalonlabs.com

ECMO Considerations Based on Systems

Neurologic

Management / Goals Brain Injury Sedation Vacation RASS 0 to -2 by Day 3 Pain Cluster Care

ECMO Considerations CNS insult prior to ECMO Watch for signs of Intraventricular

Hemorrhage/Infarct First 72 hours difficult sedation

titration Propofol (watch Triglycerides) Precedex (brady) Narcotics

Cardiovascular

Management / Goals Sinus rhythm MAP appropriate for

age and condition Pulses (VV ECMO) Extremities

ECMO Considerations Chattering Volume Deficit ECMO Flow Pulmonary HTN Right sided heart

failure Vasoactive use

Respiratory

Management / Goals Minimal Vent Settings Pulmonary Toilet Frequent

Repositioning

ECMO Considerations Daily Chest X-ray CO2 control ETCo2 monitor gradient “Red Rubber” suction Specialty mattress Prone

Respiratory

ABG

Patient &Arterial side of oxygenator

VBG Venous side of oxygenator

RECIRCULATION!!!

Heme Issues Appropriate HGb for the appropriate situation

Remember blood can be bad Heparin bonded cannula Centrifugal pumps less damage Anticoagulation

ACT (Hourly initially the your call)○ Target 160-180

Anti Xa (q 6 hours when stable q 12)○ Target 0.3-0.7

Platelet >50,000Daily TEG Analysis, Plasma Free Hgb, LDH

22Hemoscope TEG-Based GuidelinesTEG® Value Clinical Cause

Suggested Treatment

R between 7 - 10 min clotting factors x 1 FFP or 4 ml/kg

R between 11-14 min clotting factors x 2 FFP or 8 ml/kg

R greater than 14 min clotting factorsx 4 FFP or 16

ml/kg

MA between 49 -54 mm platelet function0.3mcg/kg

DDAVPMA between 41 -48 mm platelet function x5 platelet units

MA at 40 mm or less platelet function x10 platelet units

Angle less than 45° fibrinogen level .06 u/kg cryoLY30 at 7.5% or greater,

C.I. less than 3.0 Primary fibrinolysisantifibrinolytic of

choiceLY30 at 7.5% or greater,

C.I. greater than 3.0 Secondary fibrinolysisanticoagulant of

choiceLY30 less than 7.5%, C.I.

greater than 3.0 Prothrombotic stateanticoagulant of

choice

Gastrointestinal

Management / Goals Small bowel feeding Daily Stool Gastritis Prophylaxis

ECMO Considerations Bleeding Ischemia Hyper-bilirubinemia

not always hemolysis

Renal

Management / Goals Even Fluid Balance Renal protection therapy

Good CI Good MBP

ECMO Considerations SCUF -Hemo concentrator CRRT (prisma flex) Hyperosmomolar /

hyperoncotic pH control

Skin Frequent Repositioning Specialty Mattress Aseptic Technique No New Sticks Wound Care Consult Edema

Patient and family support Must define prognosis Help MD understand family expectations Should define end-points Team communication

Intra Hospital Transport …Don’t Do It !!

Group Effort Trial Run – scout the path Transport Team

The Future of ECMO

ReferencesAllen, S., Holena, D., McCunn, M., Kohl, B., & Sarani, B. (2011). A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ecmo) in critically ill adult patients. Journal of Intensive Care Medicine (Sage Publications Inc.), 26(1), 13-26. Retrieved from EBSCOhost.

Bojar, R.M. (2011). Manual of Perioperative Care in Adult Cardiac Surgery Fifth Edition. Hoboken, NJ: Wiley-Blackwell.

Gay, S., Ankney, N., Cochran, J., & Highland, K. (2005). Critical care challenges in the adult ECMO patient. Dimensions of Critical Care Nursing, 24(4), 157-164. Retrieved from EBSCOhost.

Peterson, K., & Brown, M. (1990). Extracorporeal membrane oxygenation in adults: a nursing challenge. Focus on Critical Care, 17(1), 40-49. Retrieved from EBSCOhost.

Santiago, M., Sanchez, A., Lopez-Herce, J., Perez, R., Del Castillo, J., Urbano, J., & Carrillo, A. (2009). The use of continuous renal replacement therapy in series with extracorporeal membrane oxygenation. Kidney International, 76(12), 1289-1292. Retrieved from EBSCOhost.

Scott, L., Boudreaux, K., Thaljeh, F., Grier, L., & Conrad, S. (2004). Early enteral feedings in adults receiving venovenous extracorporeal membrane oxygenation. JPEN Journal of Parenteral & Enteral Nutrition, 28(5), 295-300. Retrieved from EBSCOhost.

Short B.L., Williams, L (2010) ECMO Specialist Training Manual, Third Edition. Michigan: Extracorporeal Life Support Organization

ReferencesSievert, A., Uber, W., Laws, S., & Cochran, J. (2011). Improvement in long-term ecmo by detailed monitoring of anticoagulation: a case report. Perfusion, 26(1), 59-64. doi:10.1177/0267659110385513

Van Meurs K, Lally KP, Peek G, Zwischenberger JB (2005) ECMO: Extracorporeal Cardiopulmonary Support in Critical Care, Third Edition. Michigan: Extracorporeal Life Support Organization