Extracorporeal membrane oxygen nursing care and management

1. EXTRACORPOREAL
MEMBRANE OXYGENATION
By:
Jobince Thomas
CRN
king Saud university hospital
Riyadh/KSA

2. AIMS & OBJECTIVES
• Introduction
• History
• Modes of ECMO
• Circuit & Components
• Indications
• Contraindications
• Mechanisms
• Complications
• Outcome

3. What is ECMO??
• Ecmo is an effective technique to provide emergency
mechanical circulatory support for patients with
reversable cardiac / respiratory failure.

4. GOAL OF ECMO
• Ensure oxygen supply meets/exceeds patient demand
• Prevent end organ dysfunction and tissue damage
• Rest heart/lung
• Allow time for healing

5. PHYSIOLOGY:
• Draining venous blood ,
achieving gas exchange by
removing Co2 and adding
O2 through an artificial lung
and returning blood to the
circulation via VV or VA
mode
BLOOD
DRIANAGE
BLOOD
REINFUSION
BLOOD
TREATMENT
Add O2 and
Remove
CO2

6. HISTORY

8. 1972
Long-term ECMO :- first successfully used in 1972 in an adult patient with post-
traumatic respiratory failure

10. ECMO configuration(Types)
• VA ECMO
(Veno-Arterial)
• VV-ECMO
(Veno-Venous)

11. VA ECMO(Veno-Arterial)
1. Heart and lung functions are
replaced totally/ partially.
2. Provide pulmonary and
hemodynamic support
3. Venous /drainage and arterial/return

12. Clinical Indications for VA-ECMO
1. Low cardiac index < 2L/min
2. hypotension despite inotropic support and an IABP
3. Cardiogenic Shock or Severe cardiac failure
• ACS
• Refractory arrhythmia’s
• Sepsis with profound myocardial dysfunction
• Drug overdose/toxicity with profound myocardial
dysfunction
• Myocarditis
• Pulmonary Embolism
• Cardiac Trauma
• Acute Anaphylaxis

13. Clinical Indications for VA-ECMO
• Post Cardiotomy: Inability to wean from CPB after CT
Surgery
• Post Heart Transplant: Primary graft dysfunction
• Chronic Cardiomyopathy:
• Bridge to durable LVAD support
• Bridge to transplant
• Periprocedural support for high-risk PCI

14. VV-ECMO (Veno-Venous)
Goal is to rest the lung
1. Blood is drained from jugular or femoral vein
and returned to the venous circulation.
2. Mix with venous blood returning from
systemic organs and increases O2 and lower
Co2 in the right atrial blood
3. Does NOT provide cardiac support

15. Clinical Indications for VV-ECMO
• Acute respiratory distress syndrome:
• Severe bacterial or viral pneumonia
• Aspiration syndromes
• Extracorporeal assistance to provide lung rest
• Airway obstruction
• Pulmonary contusion • Smoke inhalation

16. Clinical Indications for VV-ECMO
• Lung transplant
• Primary graft failure s/p transplant
• Bridge to transplant
• Lung hyperinflation
• Status asthmaticus
• Pulmonary hemorrhage or hemoptysis
• Congenital diaphragmatic hernia

17. Single site cannulation
One double lumen catheter inserted
through the right I J into the right atrium
Blood is drained and returned through
separate lumens in the same cannula

18. Absolute Contraindications
for ECMO
• Unrecoverable heart and not a candidate for Tx
• Disseminated malignancy
• Known severe brain injury
• Unwitnessed cardiac arrest
• Prolonged CPR without adequate tissue perfusion
• Unrepaired aortic dissection

19. Absolute Contraindications
for ECMO
• Severe aortic regurgitation
• End-Stage organ dysfunction: COPD, Cirrhosis, ESRD
• Compliance: (Financial, cognitive, psychiatric, or social limitations
without social support)
• Peripheral vascular disease in VA ECMO
• Advanced age and Obesity

20. ECMO CIRCUIT

21. Ecmo circuit (pump)
• The pump speed is in revolutions per minute (RPM)
• Typical pump speeds are about 2000-6000 RPM
Flow through the pump depends on 3 things:
1. Pump speed
2. The blood volume available
3. Downstream resistance

22. Blender
• The blender is a device which
provides fresh gas to the
oxygenator. The gas is a mixture of
nitrogen and oxygen.

23. Oxygenator
• most complicated component
of the ECMO circuit
• It is essentially a large thin
membrane made of a polymer
which allows gas to diffuse
across it.
• oxygenate the patient's blood
and remove carbon dioxide.
• The rate that gas is delivered
is referred to as the sweep
and can be set anywhere
between 0-15 L/min.

24. Ecmo circuit (CONTROLLER)
• The controller allows
the operator of the
ECMO circuit to
adjust the settings
as needed.

27. Ecmo on patient with open
sternum

28. Preparation for Ecmo
• Multidisciplinary team approach
• Charge Nurse:
Call Ecmo coordinator who will activate the
team
Inform Surgeon/ Intensivist
Alert OR and perfussionist
Inform blood bank
Arrange Ecmo cart

29. Preparation for Ecmo
• Primary Nurse:
Should be present always at bedside
Co-ordinate with CN to arrange blood products
Ensure ABG and VBG available before insertion
Prepare: Inotropes/ Vasopressors'
IV heparin
Epinephrine/ Calcium, Soda bicarb
Albumin 5% and Normal saline
Sedation and paralytic agents

30. Preparation for Ecmo
• Primary Nurse:
Administer medications as needed
Give boluses of heparin
Run blood products
Titrates inotropes according to vitals
Blood gas and full set of laboratory investigations
ACT monitoring and anticoagulation Protocol

31. Anticoagulation:
• Prior to cannulation: Heparin 100units/kg( After introducing the
guide wire)
ACT range:
VA Ecmo: 180-220
VV Ecmo: 160-180
ACT should be measured hourly for first 12 hour and Q 4 hourly
unless clinically indicated
APTT every 4 hours then according to patient condition( Bleeding)
If low flow increase ACT
If Bleeding decrease ACT
Heparin protocol: 10-20 units/kg/hr

32. Titration:
Following cannulation
Blood flow increased until
respiratory and
hemodynamic parameters
are satisfactory
Target:
SaO2 in ABG > 90% in VA Ecmo
> 75% in VV Ecmo
SaO2 in VBG: 20- 25% lower than ABG
Adequate tissue perfusion evident
by:
Arterial blood pressure
Venous O2 saturation
Blood lactate level

33. Daily management
1. Monitor and record alarm limits
2. Ensure proper head to foot assessment
3. Check Ecmo circuit for clots, leak, connector and canula
position
4. Assess cannula site( Dressing and suture)
5. Ensure availability of 4 clamps at bedside
6. Ensure hand crank device available at bedside

34. Daily management
7. Make sure Ecmo plug is connected to red electrical circuit
8. Check function of heat exchanger, water level and color
9. CXR as ordered
10. ACT and coagulation profile
11. Maintain temperature 37c and avoid hypothermia

35. Ventilator management
• Low setting to allow lungs to rest
low respiratory rate with long inspiratory time
PIP under 25cmH2O
FiO2 (30-40%)
PEEP between 5-15cm H2O
Initial Deep sedation to inhibit respiratory efforts

36. Volume fluid balance
• Keep CVP 5-10 mmHg (rationale: Adequate volume for venous
drainage)
• Consider diuretics until dry weight
• If ARF – consider hemodialysis

37. Blood transfusion guidelines
• Hb <10 1-2 PRBC
• INR >2 4 FFP
• Platelet < 100 6 platelets
• Fibrinogen < 1.0 8 cryoprecipitate

38. • VV Ecmo: if patient became unstable use ACLS immediately
• VA Ecmo: If patient became Unstable try to trouble shoot as we have
cardiac support with Ecmo
• If there is no flow: decrease the speed and give volume

39. NURSING

40. NURSING
• Maintain strict infection control
• Restrict accesses to essential personnel
• Remove unnecessary invasive lines
• Ensure crash cart trolley in close proximity
• Restriction in Mobility: Ensure appropriate mattress. Once a
day pressure care,
Preferably in day shift
• Log rolled
• Ecmo patient must not be left unattended at any time.

41. NURSING
• Mouth, Eye and catheter Care
• Use swabs, no tooth brushes
• No Shaving with razor
• Do not dislodge clots covering wound and insertion site
• Don’t do routine tracheal and mouth suction.

42. Preventing & managing
complications
PATIENT RELATED
• bleeding
• Hemolysis
• recirculation
• infection
CIRCUIT RELATED
• clot formation
• oxygenator failure
• heat exchanger Failure
• Blood leakage
EMERGENCIES
• Pump failure
• Decannulation
• Air embolism
• Cardiac arrest

43. Bleeding
• occurs in 30- 40% of patients in ECMO
• Due to continuous heparin infusion and platelet dysfunction
TREATMENT
• Maintaining platelet count
• Decrease heparin infusion & maintain ACT at 160 Sec
• Surgical Exploration if major bleeding occurs

44. CRITICAL LIMB ISCHEMIA-
PREVENTON
Inserting distal perfusion
cannula in femoral artery
distal to ECMO cannula.

45. Heparin Induced
Thrombocytopenia
• HIT can occur in patients with ECMO
• When HIT is proven, Heparin infusion should be replaced by non-
heparin anticoagulant.

46. Recirculation
• Reinfused blood is withdrawn
through the drainage cannula
without passing through the
systemic circulation
INTERVENTION
• Increase the distance between
cannula
• Use the single site double lumen
cannula
• Addition of another drainage
cannula

47. CARDIAC ARREST
• VV ECMO
.call for help
.CPR
.Reversible causes
• VA ECMO
.Establish adequate flow
.Call for help
.Reversible Causes
.CPR may not be needed
unless pump compromised

48. ACCIDENTAL
DECANNULATION
• Call for Help
• Clamp Circuit
• Turn of pump
• CPR
• Establish ventilation & ionotropic support
• Volume ( Note: Total circuit volume 500cc)
• Peripheral : Apply pressure
• Central: Prepare chest opening

49. CIRCUIT RUPTURE
• Clamp the circuit
• Call for help
• Contact medical team
• Increase the ventilator support and inotropes
to compensate for loss of support
• Give volume to replace blood loss
• In the event of cardiopulmonary arrest , CPR
should be commenced

50. Circuit air embolism
• Clamp the circuit and switch off pump to
[prevent potential introduction of air into
the patient
• Call for help
• Provide ventilation and hemodynamic
support(including CPR as indicated)

51. Heat exchanger failure
• Turn off heater
• Contact team
• Use warming blanket to control patient temperature

52. Pump failure
• Call for help
• Contact team
• Provide ventilation and hemodynamic support
• ECMO specialist or perfusionist should be available to troubleshoot
ECMO console

53. Weaning
Be knowledgeable of the signs of weaning
• Improving oxygenation
• Reduced Co2 Retention
• Improving Chest X ray
• Blood flow unchanged in Ecmo
• Stable ABG > 6 hours without Oxygenator support

54. DECANNULATION
• Clotting and Platelet level before decanulation
• Discontinue heparin infusion 2-4 hours or as ordered
prior to decanulation
• Ensure that direct pressure is applied on the insertion
site for at least 20 min
• Lower limb Doppler.

55. DOCUMENTATION