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Trends in Extracorporeal membrane oxygenation(ECMO) nursing
Presentation · October 2015
DOI: 10.13140/RG.2.2.28102.06728
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Sonia Cherian
Dubai Hospital, Dubai Health Authority, UAE
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Trends in Extracorporeal
membrane oxygenation
(ECMO) nursing
Sonia Cherian
DH
Objectives:
At the end of the lecture the staffs will be able to :
• Understand the meaning of ECMO & how it works
• Explain the types of ECMO & how it works
• Verbalise the difference between ECMO and CPB
• List down the various indications & contraindications for
ECMO
• Explain the complications of ECMO
• Ennumerate the various nursing implications for a patient
on ECMO
• Verbalise the ECMO emergencies
• Understand the use of ECMO in neonates & pediatrics
Outline:
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Brief history & meaning
Difference between ECMO and CPB
How does ECMO work
Types of ECMO & their differences
Indications
Contraindications
Complications
Special considerations
Nursing implications
ECMO Emergencies
Documentation
ECMO in Neonates & Pediatrics
Outcomes & Future
History of ECMO
• In May 1953, Gibbon used artificial oxygenation and perfusion support
for the first successful open heart operation.
• In 1954, Lillehei developed the cross-circulation technique by using
slightly anesthetized adult volunteers as live cardiopulmonary bypass
apparatuses during the repair of certain congenital cardiac disorders.
• In 1965, Rashkind and coworkers were the first to use a bubble
oxygenator as support in a neonate dying of respiratory failure.
• In 1969, Dorson and colleagues reported the use of a membrane
oxygenator for cardiopulmonary bypass in infants.
• In 1970, Baffes et al reported the successful use of extracorporeal
membrane oxygenation as support in infants with congenital heart
defects who were undergoing cardiac surgery.
• In 1975, Bartlett et al were the first to successfully use ECMO in
neonates with severe respiratory distress.
What is ECMO?
• ECMO (Extra-Corporeal Membrane
Oxygenation) is an extracorporeal
technique of providing both cardiac and/or
respiratory support oxygen to patients
whose heart and/or lungs are severely
diseased or damaged and can no longer
serve their function.
ECLS
• The term extracorporeal life support (ECLS) denotes the
use of prolonged extracorporeal cardiopulmonary
bypass, usually via extrathoracic cannulation, in
patients with acute, reversible cardiac or respiratory
failure who are unresponsive to conventional medical
or pharmacologic management.
• ECMO is the traditional term associated with this
technique, ECLS is the current, preferred mnemonic
since the term "life support" encompasses functions
other than "oxygenation", including cardiac and
hemodynamic support as well as carbon dioxide
elimination.
Is it a therapeutic intervention?
• It is important to recognize that ECLS is not a
therapeutic intervention.
• Instead, ECLS simply provides cardiopulmonary
support so that the patient is spared the deleterious
effects of high airway pressure, high FiO2, and
perfusion impairment
• During ECLS, "reversible" pathophysiologic
processes are allowed to resolve either by
spontaneous means or by medical or surgical
therapeutic intervention.
How is it different from Cardiopulmonary bypass
ECMO
1. frequently instituted
using only cervical
cannulation, which can
be performed under
local anesthesia
2. used for longer-term
support ranging from 310 days
3. Purpose - to allow time
for intrinsic recovery of
the lungs and heart
Cardiopulmonary Bypass
1. usually instituted by
transthoracic cannulation
under general anesthesia
2. used for short-term
support measured in
hours
3. Purpose – Temporary
support during various
types of cardiac surgical
procedures.
• The roller pump causes less hemolysis,
• The venous reservoir is used with the roller pump
for neonatal ECMO.
• The oxygenator is responsible for exchanging both
oxygen and carbon dioxide
• The heat exchanger warms the blood using a
countercurrent mechanism.
Safety Devices/Monitors:
• Air bubble detectors can identify microscopic air
bubbles in the arterialized blood and automatically
turn off the blood pump.
• Arterial line filters between the heat exchanger and
the arterial cannula are used to trap air, thrombi,
and other emboli.
• Pressure monitors, which are placed before and
after the oxygenator, measure the pressure of the
circulating blood and are used to monitor for a
dangerous rise in circuit pressure- critical in
preventing circuit disruption in the face of distal
occlusion.
• A continuous venous oxygen saturation monitor
and temperature monitor are other important
safety features.
Types:
There are several forms of
ECMO, the two most
common of which being
1.Veno-arterial (VA)
2.Veno-venous (VV).
3.Double lumen Veno-venous
(DLVV)
In both modalities, blood
drained from the venous
system is oxygenated
outside of the body.
In VV ECMO, no cardiac
support is provided.
Veno-Arterial ECMO:
• A venous cannula - placed in
the right common femoral
vein for extraction .
• An arterial cannula - placed
into the right femoral artery
for infusion.
• The tip of the femoral venous
cannula should be maintained
near the junction of the
inferior vena cava and right
atrium, while the tip of the
femoral arterial cannula is
maintained in the iliac artery.
Central VA ECMO:
Central VA ECMO - with cannulae
in the right atrium and
ascending aorta
• This method may be used if
cardiopulmonary bypass has
already been established.
• Transthoracic cannulation
allows left heart decompression
by cannulation of the left
atrium. This is useful in patients
with primary left heart failure.
Veno-Venous (VV):
• In Veno-venous ECMO – the blood
is returned to the venous system.
• Venous cannulae are usually placed
in the right common femoral vein
for drainage and right internal
jugular vein for infusion.
• Alternatively, a dual lumen
catheter is inserted into the right
internal jugular vein, draining
blood from the superior and
inferior vena cavae and returning it
to the right atrium
Differences Between Venoarterial and Venovenous
Extracorporeal Membrane Oxygenation
Venovenous ECMO
Venoarterial ECMO
Indications:
Criteria for the initiation of ECMO include acute severe cardiac or
pulmonary failure that is potentially reversible and unresponsive to
conventional management
Hypoxemic respiratory failure with a ratio of arterial oxygen
tension to Fraction of Inspired Oxygen (PaO2/FiO2) of <100 mmHg
despite optimization of the ventilator settings, including the FiO2,
PEEP, and I:E ratio.
Hypercapnic respiratory failure with an arterial pH <7.20
Refractory cardiogenic shock
Cardiac arrest
Failure to wean from cardiopulmonary bypass after cardiac
surgery
As a bridge to either cardiac transplantation or placement of a
ventricular assist device
Contraindications:
The relative contraindications are:
1.Conditions incompatible with normal life if the patient recovers
2.Preexisting conditions that affect the quality of life (CNS status,
end stage malignancy, risk of systemic bleeding with
anticoagulation)
3.Age and size of patient
4.Futility: patients that are too sick, have been on conventional
therapy too long, or have a fatal diagnosis.
Initiation, Titration & Maintenance
Initiation
Performed only by expert
The patient is anticoagulated with
intravenous heparin. The cannulae are
inserted, connected to the appropriate limbs
of the ECMO circuit. ECMO support is
initiated.
Titration
The blood flow is increased until respiratory
and hemodynamic status is stable, then the
blood flow is maintained at that rate.
Maintenance
Frequent assessment and adjustments are
facilitated by continuous venous oximetry,
which directly measures the oxyhemoglobin
saturation of the blood in the venous limb of the
ECMO circuit.
Complications
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Fatal Sepsis
Massive hemorrhage (Approximately 50% of reported deaths)
Thromboembolism (devastating with VA ECMO than VV ECMO)
Pericardial tamponade (from blood or air)
Tension pneumothorax or hemothorax
Drug effects (alteration in serum concentration of drugs due to increased
volume of distribution)
Cannula related Cx (vessel perforation with hemorrhage, arterial dissection,
distal ischemia, and incorrect location).
HIT (If suspected, the heparin infusion is usually replaced by a non-heparin
anticoagulant)
Veno-Arterial specific complications (LL Ischemia, compartmentsyndrome)
Pulmonary hemorrhage
Cardiac thrombosis (due to stasis when LV output is not maintained)
Metabolic Cx (imbalances in ph, sodium, potassum, Ca & sugar)
Critical care challenges in ECMO patient , CACCN, Sep 2008
Special considerations:
Blood flow
• Near-maximum flow rates - during VV ECMO to optimize oxygen delivery. In
contrast, the flow rate used during VA ECMO must be high enough to provide
adequate perfusion pressure and venous oxyhemoglobin saturation but low
enough to provide sufficient preload to maintain left ventricular output.
• pO2 persist low at high FiO2, and Hct is > 35%, flow is increased in increments of
20 cc/min.
Left ventricular monitoring
• Left ventricular output is rigorously monitored during VA ECMO because left
ventricular output can become worse.
Diuresis
• Since most patients are fluid-overloaded when ECMO is initiated, aggressive
diuresis is warranted once the patient is stable on ECMO.
• Ultrafiltration can be easily added to the ECMO circuit if patients are unable to
produce sufficient urine for diuresis.
Fluid management
Excluding blood products, 80 – 100 ml/kg/day of volume is generally given
Special considerations contd…
ACT
• Hourly ACT monitoring is mandatory as patient is on heparin infusion &
Heparin is titrated according to the ACT levels. The desired ACT levels for a
patient on ECMO support is 180-200 sec
Hemoglobin & hematocrit levels
• The hemoglobin levels should be maintained at least above 10 gm/dl, so as to
ensure adequate oxygen carriers. Hct >35
ABG, lactate, glucose or VBG
When metabolic acidosis persist the flow is reduced
Venous Oximetry
• The venous saturation levels displayed on the monitor reflects the
oxyhemoglobin saturation at the venous end of the ECMO circuit.
Platelets - monitored very closely; their levels must not be too high nor too low.
Platelet levels above 100,000/ mm3 is acceptable.
PT , Fibrinogen level >150
Electrolytes and ionized calcium
Albumin -20% Albumin considered when serum albumin < 2.5.
Nursing Implications:
Infection Control
• All pre-existing invasive lines should be changed prior to starting
therapy. Maintain asepsis while handling lines.
Anti-coagulation
• Despite the utilisation of heparin coated circuits anti-coagulation
remains an essential aspect of the therapy.
Immobility
• Due to the patient’s acuity and the risk of catheter dislodgement,
the patient on ECMO will have significantly restricted mobility.
Pressure Gradient
• The gradient between the pre and post oxygenator pressures
indicates the amount of pressure required for blood to pass
through the oxygenator. An increasing gradient indicates that
higher pressures are needed for the blood to pass.
Hourly Assessment
• HR, SBP, MAP
• Neuro-Vascular Observations to cannulated
limbs
• Urine Output
• Core Temperature
• ET CO2
• Routine Ventilation Observations
Regular Assessment
• 3/24 CVP
• 3/24 neurological assessment
• Nursing assessment of sedation
requirements to prioritize the protection of
cannula & circuit integrity.
Pre & Post Oxygenator Blood gases
ACT 2 hourly
General Nursing Care
1. Pressure Area Care and Patient Positioning
Log rolling with a designated staff member will be allocated
to ensure circuit and cannula safety during the turn. This
person should direct the turn.
ECMO therapy is associated with fluid shifts and the patient
will develop edema, positioning should be aimed to
minimize its effect.
2. Gentle care with regard to anticoagulant therapy
3. Dressing changes when there is a significant amount of
exudate or if the dressing is no longer secure. Prevent
accidental dislodgement
Always pull the dressing off towards the insertion site. This
will minimize the risk of dislodging the cannula.
Nursing Implications
4. Drug levels
ECMO will effect drug functioning. Drugs known to be effected by
sequestration include Fentanyl, Propofol and Midazolam. There is a
drop in serum concentration. This can increase the amount of
medication required to effectively sedate the patient. However the
effect can reverse over time.
5. Circuit management
Ensure the circuit is safely positioned and unlikely to be kinked or
trapped in surrounding equipment. Assess the flow by auscultation.
Assess the circuit for blood leakage
Kicking’ is a sign of inadequate access. Look for any kinks or compression
of the cannula or circuit. OR inadequate blood flow should be
suspected and the ECMO
‘Kicking’ is indicative of turbulent blood flow which will accelerate the
development of clot formation and hemolysis. A reduction in the pump
speed or vascular filling may be required
ECMO Emergencies - Rare but potentially
catastrophic
1. Pump Failure – Call for help, Clamp line and stop pump,
Re-engage pump head, Establish the cause and correct if
possible
2. Air Embolism in circuit – Call for help, clamp, head down
3. Decannulation •
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Call for help, Clamp circuit, Apply pressure to the
cannulation site)
Assign someone to manage the clinical status of the
patient,
Apply rescue ventilation settings Initiate resuscitation as
required),
4. Cardiac Arrest – ACLS
Nursing Documentation
ECMO in Neonates:
Indications:
• Associated with primary pulmonary hypertension (idiopathic
PPHN, meconium aspiration syndrome, respiratory distress
syndrome, group B streptococcal sepsis, and asphyxia)
• Congenital diaphragmatic hernia (CDH)
Selection criteria
• Gestational age of 34 wks or more
• Birth weight of 2000 g or higher
• No significant coagulopathy, intracranial hemorrhage (grade 1
intracranial hemorrhage)
• Mechanical ventilation for 10-14 days or less
• Reversible lung injury
• No major untreatable cardiac malformation
• Failure of maximal medical therapy
ECMO in Pediatrics
• Low cardiac output
• Pulmonary vaso-reactive crisis following repair of congenital heart
defect leading to severe hypoxemia, low cardiac output, or both
• Rarely, as a bridge to cardiac surgery in patients with serious endorgan damage OR as a bridge to cardiac transplant
• Possibly, as a bridge to recovery in temporary cardiomyopathy
secondary to renal failure, myocarditis, and burns
OutcomesAccording to the indication for the ECMO:
Acute respiratory failure - With acute respiratory
failure use of ECMO has been shown to improve
survival rates. The reported survival rates range
from 50-70 percent. (in observational and
uncontrolled clinical trials).
Cardiac failure – Veno-arterial (VA) ECMO is a
bridge to further therapy, either a ventricular
assist device, transplant or recovery.
Survival rates in adults, ECMO survival rates are
increased from 35% to 66%.
ECMO has yet to have proven survival benefit in
adults with ARDS.
Rodriguez-Cruz E. ‘Extracorporeal membranous oxygenation’
Medscape MedPulse. Aug 27,2013.
SICU – MICU, DH
Project:
• A teaching for the ICU nurses at DH (in May 2014) during the unit
meeting, which ensured maximum attendance.
• All about ECMO, its care and followed by a discussion with the
perfusionists post lecture.
• This was repeated in April 2015 at ECCC, Dubai 2015
• This not increased the nurses’ knowledge and confidence at
bedside and but also their cooperation with the perfusionists.
• They became more competent in caring for these patients.
Discharge outcome in Adults treated with ECMO
Single-center, retrospective review of all 212 adult patients treated with
ECMO from 2005 through 2009. cardiac (n=126) or respiratory (n = 86)
failure.
Mean age was 51 (SD, 14.5)years; support duration was 135 (SD, 149)
hours. Survival to discharge was 33% overall; 50% for respiratory indication
and 21% for cardiac indication patients.
Patients with poor outcomes were older (53 vs 47 years, P = .007),
For respiratory patients, poor outcome was associated with more
ventilator days before ECMO (poor, 6 vs good, 3; P = .01)
Conclusions Patients with respiratory indications for ECMO experienced
better survival than did cardiac patients. Increasing age was associated
with poor outcome. Complications, regardless of indication, were common
and associated with poor outcome.
(American Journal of Critical Care. 2014; 23:365-377)
Future:
• Applications for ECMO may expand in the future to include
percutaneous temporary left ventricular assistance and low flow
ECMO for CO2 removal (ECOOR). In addition, new technologies
will improve the simplicity and safety of ECMO, including new
oxygenators, pumps, and surface coatings.
• A recent study showed that a factor XIIa inhibitory antibody
provides thromboprotection in extracorporeal circulation
without increasing bleeding risk.
• ECMO use on cadavers can increase the viability rate of
transplanted organs.
REFERENCES:
• American Journal of Critical Care. “Discharge outcome in Adults treated
with ECMO” 2014; 23:365-377
• ECMO Program website, University of Michigan, Pediatric Surgery
retrieved from
http://surgery.med.umich.edu/pediatric/research/interests/ecmo.shtml
• http://emedicine.medscape.com/article/1818617-overview
• E. Joubert – Huebner ‘ECMO Management Clinical Guide’ Chief
Perfusionist^Heart Center Eppendorf, Hamburg retrieved from
http://www.cardiac-ecc.com/ECMO_Management_Lecture_5.pdf
• Extracorporeal Life Support Organization (ELSO) - www.elso.org
• Royal Adelaide Hospital ‘ECMO-Nursing care & Responsibilities’ 1st edition
July 2010 retrieved from
file:///C:/Users/Thomas/Downloads/ECMO%20Nursing%20care%20%20r
esponsibilities%255b1%255d.pdf
• Canadian Association of critical care nurses “Critical Care
Challenges in ECMO patient” 2008, 19;2.
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