PowerPoint presentation on ECMO (Extracorporeal Membrane Oxygenation). Part 2 focuses on Monitoring ECMO patients Ventilatory strategies, Sedation and pain control, Weaning, Complications and recent advances in ECMO. For better understanding please have a look at ECMO part 1 before going through part 2.

1. Extracorporeal Membrane Oxygenation
Part - 2
Dr.Tinku Joseph
DM Resident
Department of Pulmonary medicine
AIMS, Kochi
Email-: tinkujoseph2010@gmail.com

2. Contents in ECMO part 1
 What is ECMO ?
 Evolution of ECMO
 Various Trials
 Types
 Indications
 Veno-venous V/S veno-Arterial
ECMO.
 Cannulation and Circuit

3. Contents in ECMO part 2
 Monitoring ECMO patients
 Ventilatory strategies
 Sedation and pain control
 Weaning
 Complications
 Recent advances

4. Monitoring ECMO patients

5. 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

6. • Nurses:
– assists in the procedure.
– supports clinical
management.
– ONGOING CARE FOR
ECMO PATIENT
• Radiologic Technician
Who comprises the ideal team?

7. Protocol for initiation and stabilization
of ECMO
1) Check the cannula site
2) Check all ports
3) Connect the pressure tubing to the pressure line
4) Connect the flow sensor to the flow meter
5)Note patient vitals (prior to starting ECMO)
6) Send pre –ECMO investigations: ABG, VBG, CBC

8. Protocol for initiation and stabilization
of ECMO
7) Confirm bolus dose of heparin is given
8) Confirm the availability of blood and blood products
9) Check for ACT machine
10) Request Xray plate from radiology and place under
patient.
11) Confirm circuit is primed properly

9. Protocol for initiation and stabilization
of ECMO
12) Connect Venous end of circuit to venous cannula
13) Connect arterial end to artery (VA) or jugular vein
(VV)
14) Recheck everything
15) Open arterial clamp, clamp the bridge and then
open venous clamp for roller pump.
16) Before starting ECMO start centrifugal pump to
provide forward flow

10. Protocol for initiation and stabilization
of ECMO
17) start the pump with flow of 20 ml/kg/min and
gradually increase the flow after every 5-10 mins by
10ml/kg/min up to the desired flow.
18) Adjust gas flow to blood flow ratio 0-5:1 and start
FiO2 of 21% and slowly increase to 100%.
19) Check for the color of venous and arterial blood.

11. Protocol for initiation and stabilization
of ECMO
20)Attach heater cooler unit to oxygenator and adjust
temp to 37c
21) Check vitals again
22) Check pre pump, pre and post oxygenator
pressures.
23) Once desired flow is achieved come down on
ventilator settings to baseline.
24) Monitor MAP-: 60-70mmhg
25) Reduce inotropes
26) If BP is high use NTG

12. 27) Check ACT & ABG after one hour of starting ECMO
28) If ACT is around 200 seconds then start with
heparin infusion @ 20 units/kg/hr
29) <160 -: bolus dose of heparin
30) >200 -: decrease heparin dose
31) Monitor ABG -: Adjust ECMO settings
Protocol for initiation and stabilization
of ECMO

13. Nursing Considerations:
•

14. Nursing Actions
 Maintain strict infection control.
 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.

15.  Ensure crash trolley in close proximity
 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

16. Nursing Assessments
• Routine Assessments:
– HR, SaO2, SBP, MAP
• Hourly Assessments:
– Neuro-vascular observation
– Urine output
– Core temperature
– Ventilator observations
• Regular Assessments:
– CVP
– Neurological assessments
– Sedation level

17. Dressing the cannula
 Only if there is significant exudates
or if not intact or secured.
 Required two nurses for dressing.
Dressing changes preferable in day
shift.
 Pull the dressing off towards the
insertion site.

18. Blood Works and Diagnostics
 Ensure current crossmatch PRBCs are
available.
 Daily electrolytes, Mg and LFT.
 CBC BD and as sos. 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.

19. Ventilatory strategies
 ELSO GUIDELINES FOR RESPIRATORY SUPPORT:
 Indication:
 “In hypoxic respiratory failure due to any cause ECLS
should be considered when the risk of mortality is
50% or greater and is indicated when the risk of 80%
or greater.

20. Ventilatory strategies
 A) 50% mortality risk can be identified by PaO2/FiO2
<150 on FiO2 >90% and/or Murray score 2 to 3.
(Consider ECMO)
 B) 80% mortality risk can be identified by a PaO2/FiO2
<80 on FiO2 >90% and Murray score 3 to 4. (ECMO
Indicated)

22. 2) Co2 retention due to asthma or permissive
hypercapnia with a PaCo2 >80 or inability to achieve
safe inflation pressure (Pplat <30cmH2O).
3) Severe air leak syndromes.
Ventilatory strategies

23.  Goal -: to let the lung rest and yet not allow total
lung collapse.
 ECMO provides adequate gas exchange.
 Reduces chances of VILI.
 Patient may not require intubation at times.
 Low tidal volume required
 Less sedation
 Early rehabilitation.
Ventilatory strategies

26. Sedation and Pain control
Goal:
 Keep the patient comfortable
with minimal sedation
 Daily interruption-give awake
cycle
 Avoid muscle relaxant as far as
possible.

27. Sedation and Pain control
Indications for sedation:
 To relieve pain and anxiety
 Decrease O2 consumption and CO2 production
 Prevent patient from removing lines
 Patient ventilator asynchrony
 To give normal sleep pattern at night
 Before any procedure

28. Sedation and Pain control
Indications for muscle relaxants:
 Patient ventilator asynchrony
 When patient movement interferes
with venous return
 To prevent accidental decannulation
– due to excessive patient
movement

30. In awake patient:
 Better lymphatic drainage from the lungs with the
spontaneous breathing as compared to positive
pressure ventilation.
 Lesser haemodynamic effect, lesser ventilator
requirements and peak pressures.
 Better infection control

32. Sedation and Pain control

33. Weaning
 After giving adequate rest to the
organ.
 When they show signs of
improvement.

34. Criteria for weaning trial
RESPIRATORY:
 CXR is improving
 Lung compliance improve: compliance >0.5 mL/kg
 ABG- on rest ventilator setting with moderate ECMO
support
PaO2 >60mmhg
PaCo2 <50mmhg
PH >7.35
 Successful 100% oxygen challenge test.

35. CARDIAC:
 HR <120/min
 Systolic BP >90mmhg or pulse pressure >40mmhg,
mean arterial pressure >70mmhg
 CVP <12 mmhg
 Urine output > 0.5 cc/kg/hr (ARF case excluded)
 Good tissue perfusion as revealed by blood lactate
<3 mol/L and SVO2 >65%
 CXR improving
 2 D Echo-: EF >40%
Criteria for weaning trial

36. Method of weaning- VA
 Slow gradual process
 Moderate ECMO & moderate ventilatory settings
(FIO2 <40%, PEEP 8-10)
Method 1
 Upgrade ventilatory settings and start inotropes if
required.
 Gradually reduce blood flow (10 ml/kg/hr). Continue
till minimum flow
 Heparin should be maintained to prevent circuit
clogging.

37. Method 2:
 Withdraw a total ECMO support for few minutes and
observe parameters
 If patient tolerates gradually period of off ECMO is
increased.
 Patient can tolerate >2 hours off ECMO, consider
decannulation
Method of weaning-VA

38. 1) Decreasing pump flow (20 ml/kg/min) -: Not used
now a days.
2)Oxygen supply is reduced. More simple way.
 FiO2 is reduced by 5% every 30 minutes. Ventilator
setting is upgraded.
 FiO2 is 21% then sweep gas flow is being reduced by
10% every 30 minutes
 Alternate method: Only sweep gas reduced. FiO2
unchanged.
Method of weaning-VV

39. Rush weaning
 Forced to remove ECMO even when higher degree of
support is required
 Indications:
 Massive bleeding
 Severe haemolysis
 Worsening intracranial bleed
 Infection related to cannula
Risk of continuing ECMO is more than risk of discontinuing ECMO

40. 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.

41. 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

42. 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.

43. 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

44. Thromboembolism

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

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

47. Circuit Related
Complications
 Clot formation
Maintain anti-coagulation as prescribed
 Plasma Leak.
 Oxygenator Failure
 Heat Exchanged Failure
 Tubing Cracks or blood leakage

58. ECMO Emergencies
 Pump failure- power check
 Decannulation- reinsertion
 Air embolism-

59.  Cardiac Arrest- VA ECMO-
- No Chest compression
-VV ECMO-chest
compression
ECMO Emergencies

60. Future of ECMO
 Increased accessibility and use
 Reduction in costs
 Insurance / government support
 Smaller lines / volumes /
oxygenators
 Coated “stealth” tubings (nano
particles).
 Smaller or portable ECMO
machines

61. Newer ECMO machines

62. When God is going to do
something wonderful he
begins with a difficulty…….
If he is going to do something
very wonderful.
He begins with a……..
ECMO Machine
(Quote by an ECMO survivor)