The document discusses pressure ulcers in patients undergoing extracorporeal membrane oxygenation (ECMO). It outlines the challenges in preventing pressure ulcers in these critically ill patients, whose skin is fragile and blood flow is compromised. It describes a quality improvement program at Texas Children's Hospital to reduce pressure ulcer rates through increased awareness, a skin care bundle including frequent repositioning and moisturizing, and specialized mattresses. The program achieved a reduction in pressure ulcer rates after implementation.

1. Timothy Lee MD, FAAP, FACS
Surgical Director of ECMO
Associate Professor of Surgery and Pediatrics
PRESSURE ULCERS IN THE
ECMO PATIENT
WUWHS - Florence, Italy 2016
Texas Children’s Hospital
Baylor College of Medicine

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PRESENTATION OUTLINE
• Overview of ECMO
• Pressure ulcers in the neonatal / pediatric ICU
• Pressure ulcers in the ECMO patient
• Conclusion

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Extracorporeal Membrane
Oxygenation (ECMO)
• “Life support”
• Support
 Central cannulation - heart
Peripheral cannulation – carotid artery and
internal jugular vein
• Big Concern – Cannulas falling out

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INDICATIONS FOR ECMO
Neonatal ECMO
1. Congenital diaphragm
hernia
2. Meconium aspiration
3. Sepsis
4. Persistent pulmonary
hypertension of the
newborn

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PATIENT ON ECMO

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ECMO CIRCUIT

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ECMO OUTCOMES (REGISTRY
REPORT)

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PRESENTATION OUTLINE
• Overview of ECMO
• Pressure ulcers in the neonatal / pediatric
ICU
• Pressure ulcers in the ECMO patient
• Conclusion

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PRESSURE ULCERS IN PEDIATRIC
POPULATION
• High risk population
18 to 27% of patients in the ICU develop
pressure ulcers
• Risk Factors
– Inotropic support
– Cardiac surgery
– ECMO
– Prolonged intubation

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PRESSURE ULCERS IN THE ICU
Schindler CA et al. Am J Crit Care 2011; 20: 26

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WHY FOCUS ON PRESSURE
ULCERS??
1. Hospital length of stay
2. Increased patient morbidity
3. Decreased patient and family satisfaction
4. Increased economic burden

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FINANCIAL COSTS OF PRESSURE
ULCERS
Cost of pressure ulcers - 11 billion dollars per
year
Additional 2.2 million days in the hospital
Up to $40,000 dollars per pressure ulcer
Bergstrom N, et al AHCPR Publication No. 95-0642;US Department of Health and Human
Services;2010.

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PRESENTATION OUTLINE
• Overview of ECMO
• Pressure ulcers in the neonatal / pediatric ICU
• Pressure ulcers in the ECMO patient
• Conclusion

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CHALLENGES OF SKIN CARE IN
ECMO PATIENTS
Neonatal Skin
- Fragile and thin
- Weak epidermal and dermal bond
Critically ill patients
- Poor tissue perfusion
- Suboptimal nutritional status

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PATIENT SKIN INTEGRITY ON ECMO
Higher concentrations of pericapillary
bleeding
Increased incidence of capillary
microthrombi
Reduced capillary mean blood flow
Wester T et al. Clin Hemorrheol Microcirc 2013 Jan 28

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CHALLENGES OF SKIN CARE IN
ECMO PATIENTS
• Head carries a greater proportion of body
weight
• Cannulas within the neck
• Occiput is the most common area of ulcers
• Patient’s are unstable and difficult to turn
and reposition

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NUTRITIONAL SUPPORT
• Protracted catabolic stress
• Lose up to 15% of lean body mass over a 7
day ECMO course
• Minimal nutritional goals
1. 100 – 120 kcal/kg/day
2. 3 g/kg/day
Jacksic et al. ASPEN guideline; JPEN 2010; 34:247

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CINCINNATI CHILDREN’S
EXPERIENCE
• Study 2010 to 2013
• Instituted a new skin
ulcer prevention
protocol
• Used a 500 ultra high
performance foam
mattress
T Haines, S Kraus, C O’Brien, et al.

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500 ULTRA-HIGH PERFORMANCE
FOAM

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CINCINNATI CHILDREN’S
EXPERIENCE
• 69 patients within their study
• 31 patient used the new ultra-high performance
(UHP) foam
• ECMO hours
233 hours for memory foam
220 hours for ultra-high performance foam
• The skin ulcer rate dropped from 13.5% to 5%
using the UHP foam (p=0.001)
T Haines, S Kraus, C O’Brien, et al.

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TEXAS CHILDREN’S HOSPITAL
• “You don’t know, what you don’t know”
– ISPEW 2013 - Miami
• Roughly 35 ECMO patients per year at TCH
• “Deep dive into ECMO pressure ulcers”
• Initiated a quality improvement program in 2014

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What are we trying
to accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act Plan
Study Do
Model for Improvement
Model
for
Improvement

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QUALITY REVIEW - TCH
“Estimated” ECMO pressure ulcer rate was
extremely high
90 percent were within the occiput region
Strategies to implement
1. Increase awareness of risk factors
2. Skin care bundle
3. Daily skin care rounds
– Mechanism for reporting
– Educational

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SKIN CARE WORKFLOW FOR ECMO
PATIENTS
ECMO ACTIVATION
PATIENT PLACED ON
APPROPRIATE MATTRESS
CANNULAS ARE PLACED
PLACE GEL PILLOWS
MAPs > 45
Mixed venous Sat > 65
Ph > 7.2
Cessation of any bleeding
TURN Q 2 HOURS IF
PATIENT TOLERATES
DAILY SKIN ASSESSMENT
OPTIMIZE NUTRITION
ADDRESS SKIN CONCERNS

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ULCER RISK SCORING SYSTEM
Neonatal Skin Risk Assessment
Scale
1. Mental Status
2. Mobility
3. Activity
4. Nutrition
5. Moisture
Scoring System
Each category has 4 points
Greater than 13 points indicates
at risk patient

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SKIN CARE BUNDLE
Bedside Signs For Skin
Care
1. Skin Assessment
2. Turning patients
3. Control Moisture
4. Nutrition

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SPECIFICS OF BUNDLE ELEMENT
• Complete skin assessment
every 6 hours
• Assessment beneath
medical equipment (i.e.
cannulas)
• Pressure redistribution
every 2 hours
• Pressure diffusing
mattresses
• Moisture wicking pads
Lateral ECMO patient

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PREVENTING PRESSURE ULCERS
IN THE NICU
GEL PILLOWS DELTA FOAM MATTRESS

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IMPLEMENTATION STRATEGIES – 4 “E”
1. Educate
– Bedside providers
2. Engage
– “Why is this important
– Ongoing continued medical education
3. Ensure
– Availability of resources (equipment, personnel,
etc.)
4. Equalize
– Team approach, shared leadership

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CLINICAL OUTCOMES - 2014
• Sixteen NICU ECMO patients
• Diagnosis
– CDH
– Meconium aspiration
– Persistent pulmonary hypertension newborn
• Total ECMO days was 126
• Pressure ulcers in 2 patients –stage 1
• No accidental decannulations

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CLINICAL OUTCOMES- 2015
• Ten NICU ECMO patients
• Diagnosis
– CDH
– Meconium aspiration
– Persistent pulmonary hypertension newborn
– Birth asphyxia
• Total ECMO days was 101
• Pressure ulcers in 1 patients – ECMO cannula
• No accidental decannulations

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SKIN CARE PROGRAM OVERVIEW
• Recognize the problem
• Formal process to review
• Formal protocol for skin care
• Increased vigilance by
caregivers

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CONCLUSIONS
• ECMO patient’s are at significant risk for skin
breakdown
• Multi-disciplinary approach is needed to
address this problem
• Care team vigilance is critical for preventing
skin breakdown
• Area is fruitful for future research

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ACKNOWLDEGEMENT
Program Coordinator
Alexandra Luton MN, APRN, CCNS, NNP-BC
Skin Care Team
Allison Watson BSN, RN
Mary Samuelson BSN, RN

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QUESTIONS
Texas Children’s Pavilion
for Women
Texas Children’s
Hospital