Policy & Guideline:
Adult Extra Corporeal Membrane Oxygenation (ECMO)
Campuses
Category
Responsibility for Review
Date Approved
Policy & Guideline
Royal Prince Alfred and
Liverpool Public Hospital
Intensive Care Units
Continuum of Care
ICU Clinical Nurse Educator
ICU Medical Consultant
Medical Perfusionist
June 2009
Review Date: June 2011
PURPOSE/EXPECTED OUTCOME:
This document describes the standardised management of adult patients receiving Extracorporeal
Membrane Oxygenation (ECMO) in ICU.
Author:
Author:
Author:
Author:
Author:
Author:
Author:
Fiona Daly <F.Daly@alfred.org.au>
Dr Vin Pelligrino <V.Pelligrino@alfred.org.au>
Arthur Preovolos <A.Preovolos@alfred.org.au>
Dr Paul Forrest pforrest@usyd.edu.au
Alice Coulson <alicecoulson@yahoo.co.uk
Melissa Donellan <ctsuphysiology@email.cs.gov.nsw.au
Belinda Parkins <Belinda.Parkins@swsahs.nsw.gov.au
Position:
Position:
Position:
Position:
Position:
Position:
Position:
ICU Clinical Nurse Educator, The Alfred Hospital
Intensivist, The Alfred Hospital
Perfusionist, The Alfred Hospital
Anaesthetist / Medical Perfusionist, RPAH
ICU Acting Clinical Nurse Educator, RPAH
Hospital Scientist, RPAH
Hospital Scientist, Liverpool Hospital
Extra Corporeal Membrane Oxygenation (ECMO)
Contents
1. Introduction __________________________________________ 3
2. General Indications for ECMO referral ____________________ 5
3. NSW ECMO referral guidelines __________________________ 7
4. Equipment____________________________________________ 8
4.1 Additional connections to the ECMO Circuit __________________ 9
4.2 Monitoring trans-membrane pressure ________________________10
5. ECMO Cannulation ___________________________________ 11
6. Maintenance of ECMO and Staffing _____________________ 13
7. Nursing Policy and Procedures __________________________ 17
8. Troubleshooting guide _________________________________ 20
8.1 Veno-venous ECMO _______________________________________21
8.1.1. Worsening hypoxia _________________________________21
8.1.2. Worsening hypercarbia ______________________________21
8.1.3. Increasing ECMO flow does not improve oxygenation ______21
8.2 Veno-arterial ECMO ______________________________________21
8.2.1. Worsening hypoxia _________________________________21
8.2.2. Worsening hypercarbia ______________________________21
8.3 Veno-arterial and veno-venous ECMO
8.3.1. ECMO pump flow not maintained ______________________22
8.3.2. "SIG" alarm on pump _______________________________23
9. ECMO Complications _________________________________ 25
9.1 Emergency ECMO Responses: Veno-Arterial ECMO ___________26
9.1.1. Pump failure_______________________________________26
9.1.2. Decannulation _____________________________________27
9.1.3. Circuit Rupture ____________________________________28
9.1.4. Circuit Air Embolism________________________________29
9.1.5. Cardiac Arrest _____________________________________31
9.1.6. Oxygenator failure __________________________________32
9.2. Emergency ECMO Responses: Veno-Venous ECMO ___________33
9.2.1. Pump failure_______________________________________34
9.2.2. Decannulation _____________________________________35
9.2.3. Circuit Rupture ____________________________________36
9.2.4. Circuit Air Embolism________________________________36
9.2.5. Cardiac Arrest _____________________________________37
9.2.6. Oxygenator failure __________________________________38
Page 2 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
1. Introduction
Patients who are hypoxaemic despite maximal conventional ventilatory support, who have significant ventilatorinduced lung injury or who are in cardiogenic shock may be considered for ECMO support. For respiratory failure, the
basic premise is that ECMO will allow the level of ventilatory support to be reduced, which may allow time for
recovery from the underlying pathology and recovery from ventilator-induced lung injury to occur.
The type of ECMO performed will depend on the patient’s underlying cardiac function. Veno-venous (V-V) ECMO is
usually performed for isolated respiratory failure, whereas veno-arterial (V-A) ECMO (full cardiopulmonary bypass) is
performed for combined cardiac and respiratory failure.
1a. Application of this Protocol

This protocol provides guidelines for the safe practice of ECMO at Royal Prince Alfred Hospital and
Liverpool Public Hospitals. It contains references to current equipment and staffing practices.
1b. Definitions
ECMO or Extra Corporeal Membrane Oxygenation is a form of extracorporeal life support where an external artificial
circulation carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched
with oxygen and has carbon dioxide removed. This blood then re-enters the patient circulation.
Circuit flow may be achieved using a pump (centrifugal or roller) or by the patients arterio-venous pressure gradient
(pumpless). At Royal Prince Alfred and Liverpool Hospitals, ECMO always involves a centrifugal pump to drive circuit
flow.
1c. Types
Forms of ECMO currently are:
 Veno-venous ECMO
 Veno-arterial ECMO
Veno-venous ECMO involves venous blood from the patient being accessed from the large central veins (via the
“access line”) and returned to the venous system near the right atrium (via the “return line”) after it has passed through
an oxygenator. It provides support for severe respiratory failure when no major cardiac dysfunction exists. When flow
through a single access cannula is insufficient to support the high ECMO flow rate that may be required in severe
respiratory failure, a second venous access cannula may be required.
Second access
cannula (SVC)
Fig. 1. An example of Veno – Venous ECMO
using two access cannulae
(SVC and IVC to right atrium)
Return
cannula
Access cannula
(IVC)
Page 3 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
V–V ECMO improves the patient’s oxygenation by reducing the amount of blood that passes through the lung without
being oxygenated and in addition, removes CO2 from the patient’s blood. This allows the level of ventilatory support to
be reduced- which reduces ventilator-induced lung injury.
The efficiency of oxygenation by the ECMO circuit depends on the pump flow relative to the patient’s cardiac output.
The patient’s oxygenation should increase with increasing ECMO flow rate, if this does not occur, recirculation of
blood between the inflow and outflow cannulae should be suspected (see section on instituting ECMO).
V-V ECMO is more efficient at removing CO2 from the blood than delivering oxygen. The amount of CO2 removal
depends on the ECMO flow rate relative to the patient’s cardiac output and also depends on the oxygen flow rate to the
oxygenator. Increasing oxygen flow rate decreases the CO 2 in the blood leaving the oxygenator (analogous to the effect
that increasing minute ventilation has on arterial PCO2). The oxygen flow rate to the oxygenator should be roughly
twice the ECMO flow rate. With an ECMO flow rate of approximately 2/3 the patient’s cardiac output, and an oxygen
flow rate of twice the pump flow, nearly all of the patient’s CO2 production can be removed by the oxygenator.
Veno-arterial ECMO involves venous blood from the patient being accessed from the large central veins and returned
to a major artery after it has passed through the oxygenator. It provides support for severe cardiac failure, (usually with
associated respiratory failure), most commonly after cardiac surgery
Low flow veno-arterial ECMO is a transitory form of ECMO support in which small cannulae (quicker to insert) are
inserted percutaneously. It is an emergent resuscitative intervention (also known as ECMO-CPR).
Figure A
Fig 2. Veno – Arterial ECMO
Return
cannula
Access
cannula
VENO-VENOUS OR VENO-ARTERIAL ECMO?
There are several advantages of V-V ECMO compared to V-A ECMO. V-V ECMO avoids the risks of potentially
serious arterial injury and also the consequences of air or clot embolisation from the circuit are less severe. V-V ECMO
is a low-pressure circuit compared to veno-arterial, resulting in less stress on the circuit tubing and the oxygenator and
may thereby improve their longevity. V-V ECMO produces less haemodynamic disturbance than veno-arterial as blood
is withdrawn from, and returned to the same side of the circulation. For example, increasing V-V ECMO flow will not
cause any change in the CVP, whereas increasing V-A ECMO flow will reduce the CVP (and pulmonary blood flow).
Finally, there is animal evidence that the preservation of pulmonary blood flow that occurs with V-V ECMO promotes
more rapid recovery from pulmonary sepsis than does V-A ECMO.
The major advantages of V-A over V-V ECMO is that it provides complete haemodynamic and respiratory support. It
may be indicated for severe cardiac failure following cardiac surgery either as a bridge to recovery or to another
destination therapy (heart transplant or to another implantable support device). Other indications for V-A ECMO in an
adult are cardiogenic shock associated with myocarditis, poisoning or hypothermia.
Page 4 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
1d. Cannulation
There are three ways of accessing the major vessels for ECMO:
 Surgical central cannulation
 Surgical peripheral cannulation
 Percutaneous cannulation
Surgical Central cannulation involves the surgeon connecting an arterial cannula or Dacron graft to the major vessels of
the thorax. If the arterial line is connected directly to the aorta, the chest is left open. However, the chest can be closed if
a major proximal branch of the aorta can be cannulated instead (such as a the right subclavian artery- via a reinforced
cannula or via a Dacron graft).
Surgical Peripheral cannulation involves the surgeon cannulating the femoral vessels via a cut-down of the femoral
vessels.
Percutaneous cannulation is performed using the Seldinger technique, which involves serial dilation of peripheral
vessels over a guide wire access. It does not involve any cutting of skin at insertion. The skin should form a tight seal
around the cannulae.
2. Indications for ECMO
ECMO is indicated for potentially reversible, life-threatening forms of respiratory and / or cardiac failure, which are
unresponsive to conventional therapy and it is always applied at the discretion of the managing intensivist or cardiac
surgeon. It is also occasionally used in patients with irreversible cardiac or respiratory disease in patients who are
candidates for a heart or lung transplant.
2a. Selecting the form of ECMO
1.
V-A ECMO: applied for the management of cardio-respiratory failure or cardiac failure where use of a
ventricular assist device (VAD) is deemed inappropriate.

Central V-A ECMO: In cases where V-A ECMO is required for cardiac support and where lung
function is poor (large shunt) peripheral V-A ECMO should be avoided. This is because any native
cardiac output present will deliver hypoxic blood from the pulmonary veins preferentially to the
cerebral circulation (potentially causing severe cerebral hypoxia). Central V-A ECMO is most often
employed in patients undergoing cardiac surgery.

Peripheral V-A ECMO is appropriate when reasonable lung function exists and cardiac surgery is not
required
2.
Low-flow V-A ECMO (ECMO-CPR) is used only for initial support and stabilisation in emergent conditions
requiring V-A support
3.
V-V ECMO is used for isolated respiratory failure when adequate heart function for the duration of ECMO is
anticipated
4.
Hi-flow V-V ECMO is used when circuit flow via a single access cannula is inadequate to maintain safe
oxygenation. This may be required if smaller access cannulae have been placed percutaneously (although
25FR percuataneous cannulae have recently become available), in which case a second venous access cannula
may be required (eg. from an internal jugular vein).
2b. Pathological Processes Requiring V-A ECMO
Common
1. Graft failure: post heart / heart-lung transplant
2. Cardiogenic shock: AMI and complications (including: wall rupture, papillary muscle rupture, refractory VT /
VF)
3. Post cardiac surgery: unable to wean safely from cardiopulmonary bypass using conventional supports
Page 5 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
4.
5.
Other
1.
2.
3.
4.
5.
6.
7.
Sepsis with profound cardiac depression
Drug overdose with profound cardiac depression
Myocarditis
Chronic cardiomyopathy: as a “bridge” to longer term ventricular assist device
Pulmonary embolism
Cardiac or major vessel trauma
Massive haemoptysis / pulmonary haemorrhage
Pulmonary trauma
Acute anaphylaxis
2c. Pathological Processes Requiring V-V ECMO
Common
1. Severe pneumonia
2. ARDS
3. Acute lung (graft) failure following transplant
4. Pulmonary contusion
Other
1. Alveolar proteinosis
2. Smoke inhalation
3. Status asthmaticus
4. Airway obstruction
5. Aspiration syndromes
Page 6 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
3. NSW ECMO Referral Guidelines
The following flowchart provides the draft NSW referral indications and contraindications for referral for adult ECMO
support:
Page 7 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
4. Equipment
Perfusion Services are responsible for providing an ECMO pump and a primed circuit when ECMO is initiated in the
ICU. They should be contacted as early as possible after the decision to commence ECMO is made. In and out of
hours, the cardiothoracic team on call is brought in to establish ECMO (including the medical perfusionist), details of
the on-call staff kept are kept in CICU, with the hospital switchboard and on the RPAH Anaesthetic Department
website.


A spare ECMO circuit for exchange in the event of pump failure must be available in the theatre pump room.
Circuit priming and preparation are performed exclusively by Perfusion Services and equipment for this
function is stored in Theatre. Perfusion staff provide 24 hours emergency cover for this role.
ECMO Cannulae (stored in Theatre)
 Arterial Kits 50cm Medtronic Biomedicus cannulae: sizes:15 – 27F (19 and 21F at Liverpool Hospital)
 Venous Kits 150 cm Medtronic Biomedicus cannulae: sizes: 15 – 27F (19, 23 and 27 at Liverpool Hospital)
ECMO: initial set-up items:
•
•
•
•
•
•
•
Centrifugal pump module
Rota flow hand crank
Holder for ECMO
Holder for Rota-flow
ECMO pack
1x 1L crystalloid
2x tubing clamps
Further items that should remain with the patient:
•
•
•
•
•
•
•
•
•
•
•
•
Spare ECMO circuit
2x single transducer kits
ECMO operating notes, trouble-shooting guide and observation chart
Rota-flow manual
4 sterile tubing clamps
Sterile heavy scissors
Heparin-bonded 3/8 –3/8 connectors
Rota-flow paste
ACT machine and tubes
Heater-cooler
Cable ties and gun
30cm monitoring extension lines for use with CVVHD
Priming the ECMO circuit:
The circuit is primed from the pump head to the oxygenator, then to the sterile circuit
1.
2.
3.
4.
5.
Open the ECMO pack and hand the sterile pack off to the scrub nurse.
Remove the yellow auto air purge port cap on the oxygenator.
Clamp each prime line and put both spikes into 1L of crystalloid. Place a tubing clamp between the prime
lines.
Turn off all 3-way taps.
Connect pre- and post- membrane pressure transducers as well as the sampling manifold. The pressure
transducers should be flush-type (as diaphragm- type will clot after prolonged use).
a.
The pre-membrane manometer line (blue) connects to the luer port just proximal to the oxygenator
inflow.
Page 8 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
b.
6.
7.
8.
9.
10.
11.
The post-membrane (red) manometer line connects to the outlet side of the oxygenator via a luer port.
To gravity prime, hold the pump head at the same level as the prime bag. Open the clamp on the prime line
closest to it and then adjust the height of the pump head down slowly to prime, then prime through to the
oxygenator (a tubing clamp can be used to control the rate of flow of prime fluid through the circuit).
To prime the circuit distal to the oxygenator, clamp the line distal to the oxygenator, place the pump head in
the hand crank (or in the pump, if available) and open the clamp on the second prime line so that air can flow
up into the saline bag. Pump the prime around to de-air the rest of the circuit.
Once the circuit is primed, check if there are any bubbles and tap to remove. Remove any air in the tubing
clamp between the two prime lines by tapping it up to the saline bag. Once all the air is removed, remove the
tubing clamp between the prime lines.
Connect and turn on O2 gas line to oxygenator. Ensure that adequate tubing length is available.
Connect pre- and post- membrane pressure transducers to monitor cables.
Connect the heater-cooler.
4.1 Connections to the ECMO Circuit
Connections for Backflow cannula
To prevent ischaemia occurring distally to the arterial cannulation site in peripheral V-A ECMO, a backflow cannula is
inserted in the artery distal to the ECMO cannulation site. The backflow cannula is a wire wound 8FR catheter. It is
connected to the luer connector on the arterial cannula via a piece of extension tubing and a high flow three way tap.
These should be inserted and connected at the time of cannulation, or as soon as practical later.
Access Cannula
(Venous)
Return Cannula
(Arterial)
Tubing to backflow
cannula
Page 9 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
Connections for Continuous Renal Replacement Therapy (CRRT or CVVHD)
Ideally, the CVVHD circuit is connected to the ECMO circuit to prevent risk associated with dialysis catheter (e.g.
Vascath) insertion.
Connecting the CVVHD circuit to the ECMO circuit is usually performed by perfusion staff, although it may be
performed by an ICU nurse if they have been trained in this procedure. If the nurse is unsure how to make the
connections, they must contact perfusion staff for assistance (beware that this is a high-pressure circuit, opening the taps
to air will result in a spray of blood).
The commonest way to connect the CVVHD circuit to the ECMO circuit is to attach the access and return lines for
CVVHD to the two three-way taps between the outlet of the pump head and the oxygenator. The return line for the
CVVHD circuit is connected to the three –way tap closest to the oxygenator and the access line for CVVHD goes to the
three-way tap closest to the centrifugal pump. This part of the ECMO circuit (between the pump and the oxygenator)
has the highest positive pressure and may interfere with the functioning of the CVVHD (“PRISMA”) circuit:

High CRRT access pressure: If the pressure within the ECMO circuit causes the access pressure in the
CVVHD circuit to exceed the alarm limits for access pressure, the dialysis machine (“PRISMA”) alarm
sounds, and stops CVVHD. To prevent this from occurring, at least one 30cm monitoring extension line must
be attached to the access side of the PRISMA, this will lower the pressure and allow the PRISMA to function.
If the pressure on the access is still too high a second and even a third extension can be added. This may have
implications for anticoagulation targets. This is not a problem with newer “Prisma-flex” dialysis machines, as
positive access pressures can be selected from the set-up menu.

High CVVHD return pressure: If the pressure within the ECMO circuit causes the return pressure in the
CVVHD circuit to exceed the alarm limits for return pressure, the dialysis machine (“PRISMA”) alarm
sounds, and stops CVVHD. No extension lines should be added to the return side or the CVVHD circuit (this
will only increase return pressures). Options to decrease pressure on the return side of the CVVHD circuit:
1. If the ECMO circuit has a backflow cannula: this can be accessed as a return site for the CVVHD circuit. See
diagram in section 4.1
2. The CVVHD circuit return blood can be connected to an alternative venous access (eg: peripheral IV)
In central ECMO (no backflow cannula) the return line could be attached to a peripheral line. If this is not possible, a
Perfusionist may be able to reduce the length of the return line by cutting it and interposing another connector.
If there is no alternative, separate dialysis catheter access may be required. This is rarely required.
4.2 Monitoring of trans-membrane pressures
The trans-membrane pressure is derived by subtracting the post- membrane pressure from the pre- membrane pressure
and this is routinely measured. The Pre- membrane pressure is measured at a connector near the venous inlet of the
oxygenator. The post membrane pressure is measured at a connector on the oxygenator’s arterial outlet. The pressures
are displayed on the ICU monitor. These connections will be made by a perfusionist.
The transmembrane pressure gradient should be less than about 50mmHg, an increase in the pressure drop across the
membrane oxygenator can indicate the formation of thrombus within the oxygenator. A steadily increasing
transmembrane pressure without a concomitant increase in the circuit flows is a sign that the oxygenator may need to be
replaced.
Page 10 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
5. ECMO Cannulation
This may be performed only by medical specialists who are trained in the insertion of these cannulae.
5a. Preparation of Patient








Consider Transoesophageal Echocardiography (TOE) guidance of cannula position.
Removal of hair from knees to umbilicus (femoral cannulation) and also from neck if jugular access required.
Lines inserted prior to ECMO cannulation:
o arterial line (preferably right radial for veno-arterial with femoral cannulation)
o long term CVC and / or pulmonary artery catheter. Note right femoral vein is preferable to left for
ECMO cannulae
Chest drains inserted prior to ECMO cannulation (if indicated)
Inotropes and vasopressor infusions made up and connected to patient
Order red blood cells to ensure a “post connection to circuit” Hb of 110 to 120g/L (minimum of 2 units
immediately available).
Adequate sedation and paralysis (if required)
Cannulae selection should be made with the assistance of the cannulae blood flow table
5b. Cannulae Blood Flow Table
Diameter
(Fr)
Arterial
cannula
Venous
cannula
15
2.3
1.5
17
3.05
2.0
19
3.9
2.7
21
5.0
3.5
23
6.5
4.5
Arterial Cannulae (Fr)
Percutaneous Cannulae Dimensions and flows I
15
3.8
4.55
5.4
6.5
8.0
17
4.3
5.05
5.9
7.0
8.5
19
5.0
5.75
6.3
7.7
9.2
21
5.8
6.55
7.4
8.5
10.0
23
6.8
7.55
8.4
9.5
11.0
15
17
19
21
23
Venous Cannulae (Fr)
Flow (l/min) thru Single
cannulae at pressure drop of
60 mm.Hg.
Flow (l/min) thru any two cannulae
connected in parallel at Combined
pressure drop of 60 mm.Hg.
5c. Cannulation
 Percutaneous cannulation is preferable to cut-down, to minimise bleeding from the cannulation sites.
 Decide on cannulation sites (femoral is preferable to jugular). Percutaneous subclavian arterial cannulation (for
ECMO) is not performed (but may be performed by surgical cut-down or with a Gore-Tex graft).
 Wash cannulation site with Chlorhex (specify solution: chlorhexidine in % alcohol) and wait until dry.
 Prepare heparin solution (for heparin locking cannulae): 10,000(u) in one litre of saline. Sterile 1 litre jug kept
on cannulation trolley
 Drapes (specify size) must be aseptically applied and extensive because of guide-wire length
 Medtronic cannulae kits and cannulation trolley contain all equipment required for insertion of cannulae
 If backflow cannulae are to be used, if possible they should be inserted percutaneously and heparin-locked
(prior to ECMO arterial cannula insertion).
 A Jostra 8F wire-wound cannula is to be used for backflow cannulation of the femoral artery. This is kept in
the pump room along with a 30cm connection line for attachment to the arterial cannula.
Page 11 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)







After successful guide-wire insertion for ECMO cannulae 5000-10000(U) bolus of heparin should be given to
maintain an ACT of >200
Large skin incisions are to be avoided with percutaneous dilation attempts as this weakens the tightness of the
fit around the cannulae once inserted
In V-A ECMO: the arterial (short) cannula should be fully inserted (to the length of the cannula)
In V-V and V-A ECMO: the return cannula should be positioned in the right atrium with TOE guidance.
In V-V ECMO: the access cannula should be at the level of the diaphragm (femoral insertion) or in the SVC
(internal jugular insertion). Final position will be determined by degree of recirculation and TOE guidance.
Heparin- lock cannulae immediately after insertion and clamp
In Hi-flow V-V ECMO: Y-connector should be heparin primed and connected
5d. Commencement of ECMO












Check ACT and ensure >200 seconds
Ensure oxygen line is connected to oxygenator. Gas flow should be commenced at a rate equal to or greater
than the anticipated circuit blood flow (usually 5-6L/min)
Clean loop is opened and handed to the cannulating physician
The circuit is cut between two clamps allowing sufficient length on the access line and return line to prevent
any tension on the circuit. Note the pump trolley is best kept at the “feet” end of the patient’s bed (picture)
Circuit is connected to cannulae ensuring no air is introduced
Clamps removed as circuit flows are gradually increased
Target flow rates are determined by the cannulating Physician
For V-V ECMO target flows must provide adequate arterial oxygenation
For V-A ECMO target flows must provide adequate oxygen delivery
Check patient and circuit arterial blood gases
Reduce ventilator settings as indicated
Establish baseline anticoagulation sampling times.
5e. Securing Access and Return lines


Once cannulae position have been confirmed femoral lines should be secured using Stomahesive to the
patient’s leg and covering with Elastoplast folded to create a channel for the circuit tubing. The elastoplast
folds are then sutured tightly around the tubing to create a firm hold (picture)
The internal jugular line is best stabilised by directing the tubing around the head before passage down the
body to the oxygenator. The loop around the head is immobilised by strapping around the patient’s forehead
5f. Positioning the Pump Head and Oxygenator


The pump head is kept with outlet at “6 o’clock”
The oxygenator is positioned in the oxygenator arm
Page 12 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
6. Maintenance of ECMO and Staffing
There is a medical perfusionist (a cardiac anaesthetist) and a pump technician available 24 hours for:
 Initiation of ECMO
 Priming of circuits
 ECMO circuit maintenance and nursing support
Out of hours (1800 to 0800 weekdays and weekends), the medical perfusionist may be contacted directly or via
switchboard. Their contact details should be left at the patient’s bedside. They should be contacted about all circuit and
patient issues related to ECMO.
The ICU consultant is responsible for all medical decisions involving ECMO while the patient is in ICU and must also
be notified of any changes. They can be contacted 24 hours.
6a. Circuit Management
In the “ECMO troubleshooting guide” there are algorithms for the management of line problems and the management
of unexpected hypoxia and hypercarbia.
The Jostra Quadrox D oxygenator is remarkably robust and is capable of several weeks of continuous function. The
performance of the oxygenator must be monitored by recording the trans-membrane pressure gradient (the difference in
pressure between the inflow and outflow side of the oxygenator) and blood gas analysis of the oxygenator outflow.
Trans-membrane pressure should be recorded hourly and blood gases from the oxygenator outflow (“post- membrane”)
should be performed every 12 hours. Circuit change-out is indicated if there is a trend towards increasing
transmembrane pressures and / or worsening oxygenator function (oxygenator outflow PaO 2 < 150mmHg). A normal
transmembrane pressure gradient is <50mmHg. There is no absolute transmembrane pressure value that indicates the
need for oxygenator replacement as this value will vary with the flow rate. The decision to change the oxygenator will
be based on the trend of transmembrane pressures and oxygenator performance and should also be considered if the
ECMO circuit is thought to be a source of sepsis.
With V-V ECMO, pre-membrane blood gases may be performed after the initiation of ECMO to rule out recirculation
of blood between the access and return cannulae. It is not necessary to perform pre-membrane blood gases in patients
on V-A ECMO.
The Jostra Rotaflow pump is also capable of several weeks of continuous operation. It is important to ensure that the
pump RPM rate is not too high for the maximum flow that can be delivered (“over-spinning” the pump). When the
maximum pump flow rate has been attained (which is determined by the rate of venous drainage in the access line),
increasing the RPM further will increase the negative pressure in the access line, producing ‘line-shake’ and increasing
the risk of haemolysis. “Over-spinning” of the pump is corrected by dropping the pump RPM until the flow rate starts
to drop. Because the rate of venous drainage in the access line is variable, if the pump RPM is constant and the venous
drainage falls (eg. due to decreased preload), the pump will over-spin and access flow limitation will start to occur.
Increased noise from the pump head may indicate that it is starting to fail. The other indications for changing the pump
head are the development of haemolysis (producing haematuria and an increased plasma free haemoglobin) and large
thrombus formation within the pump head.
6b. Respiratory management
Once adequate ECMO flows have been established and the patient’s oxygenation has improved, the level of ventilatory
support is reduced. Typical ventilatory goals would be FiO2 <0.7, PIP < 35cmH2O, PEEP < 15cmH2O and respiratory
rate < 10bpm. In patients on V-V ECMO, reverse diffusion of oxygen may occur if the oxygen tension in the
pulmonary artery (due to ECMO and native blood flow) exceeds alveolar pO2. As a rule of thumb, maintaining an FiO 2
of 0.6 while the patient is on V-V ECMO should avoid this problem.
The commonest respiratory management problem during V-V ECMO arises from the conflicting goals of maintaining
adequate oxygenation (which may require a high flow rate) and a low CVP (which is good for the lungs, but may cause
access limitation of ECMO flow). Hence the goal should be to maintain adequate patient oxygenation at the lowest CVP
possible. In practice, an arterial PaO2 of 55-60mmHg or an oxygenation saturation of 85-90% is acceptable. Pushing
fluids to maintain a high ECMO flow rate and an oxygen saturation of more than 90% may ultimately result in severe
fluid overload. If adequate oxygenation cannot be maintained at a low or normal CVP, a second access line should be
inserted.
Deep sedation sufficient to inhibit respiratory movement is required initially. Muscle relaxation may be necessary.
6c. Anticoagulation
Page 13 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
Although the ECMO circuit has an anticoagulant lining, low-dose heparin is usually administered to prevent clot
formation. The lowest effective level of anticoagulation is not known and heparin may be avoided altogether if the risks
of heparin therapy are considered excessive. Some patients with severe haemorrhage have safely undergone several
days of ECMO without any systemic anticoagulation at all, although in this situation it would be advisable to avoid
prolonged periods of low ECMO flow rates (less than 2 lpm).
For V-A ECMO following cardiopulmonary bypass, excessive bleeding due to coagulopathy is managed as usual. A
note of caution about the use of rFVIIa in patients on ECMO- it has been associated with acute generalised intravascular
thrombosis, producing acute circuit failure and death.
Following cardiac surgery, heparin is commenced when chest tube drainage is <100ml/h for 2-3hours, the patient is
normothermic and coagulation parameters are acceptable. Heparin should ideally be commenced within 24 hours
postoperatively and this is usually possible within 12 hours. The dose is titrated to maintain an ACT of 150-180, which
should be measured 2nd hourly until it reaches a stable level. Heparin resistance is usually due to ATIII deficiency – this
may be treated with fresh frozen plasma.
Once the ACT has stabilised after 12-24 hours, the APPT may become excessively prolonged in some patients. Hence
after 24 hours, the APPT is used to monitor anticoagulation (target range of 50-90seconds) as excessive anticoagulation
may occur otherwise. Bleeding from around ECMO cannulation sites can be a problem, pressure dressing may be
required, as may be blood or factor transfusion and on occasion, surgical exploration may be necessary. Any patient on
ECMO must have a current Group and X match and 2 units of blood must be immediately available.
The circuitry must be regularly checked for clot formation, which may develop within the pump head and on the inflow
side of the oxygenator. Flow below 2 lpm. for prolonged periods must be avoided. Small clots may be seen in the pump
head or on the inflow side of the oxygenator. This does not seem to adversely affect oxygenator function and therefore
may not necessarily warrant oxygenator change-out.
In the past, significant haemolysis occurred due to blood trauma from the centrifugal pump. This appears to occur much
less frequently with the Jostra impeller pump although the absolute incidence is not known. Rapidly fluctuating pump
flow due to inadequate venous drainage (“line shake” of the access line) may increase the risk of haemolysis, as may the
presence of a second access cannula (due to areas of low flow). Plasma-free haemoglobin should be measured when
clinically indicated. Acceptable values are 0.05-0.06g/l, Care must be taken when collecting the sample as forceful
aspiration of blood may produce significant haemolysis. If a valid plasma-free haemoglobin is >0.1g/l, the pump should
be changed.
6d. Temperature Management
As a heater-cooler is attached to the oxygenator, the patient’s temperature may be regulated. The aim is usually to
maintain normothermia but where clinically indicated, mild hypothermia (to 35Cº) may be performed. While the heater
cooler is running, the setting on its LED display should be set to about 37C.º The heater-cooler component of the
oxygenator may fail after a few days, however this is not usually an indication for changing out the oxygenator as
normothermia should be attainable with conventional techniques (Bair Hugger).
The heater-cooler settings should only be altered by the perfusion staff unless the nurse has been trained to do this.
Should the patient become unexpectedly hypo- or hyperthermic while on ECMO, the medical perfusionist on call must
be contacted immediately.
6e. Ward Rounds and Documentation
All ECMO patients should be reviewed on the morning ward round by an ICU consultant, a cardiac surgeon and a
medical perfusionist. Joint decisions about the management plan for that day will be made at this round and changes to
these plans should not be made without the agreement of these three consultants.

Daily objectives. A list of objectives MUST be filled in by the medical team each day of ECMO support at each
ward round. This specifies
o the times routine blood must be taken
o sets the daily objectives
o the management changes planned
o will form part of the medical record

ECMO observation chart The electronic or paper nursing ECMO observation chart must be maintained and
reviewed by the rostered medical perfusionist. Nursing staff can communicate any difficulties with
observations with the rostered perfusionist. This data will form part of the medical record.
6f. Medical management
Page 14 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
Investigations required for patients on ECMO include:
 Daily CXR
 Daily bloods: FBE; Ur, Cr, Elect; Mg; PO4; LFT
 Clotting: APTT, INR, Fibrinogen are performed daily (morning bloods)
 APTT is performed 6 hourly as determined by the ICU consultant while the patient is on ECMO.
 The ACT is usually used to titrate heparin in the first 24 hours and is measured 6 hourly over the first day. It is
performed by the attending nurse, using 2 mls of arterial or venous blood. A usual target for ACT in the nonbleeding patient with platelet count > 80,000 is 140–180.
 Beyond 24 hours, the APTT performed in the Haematology lab is primarily used to guide heparin therapy. It is
performed 4 times per day and is routinely labelled as urgent to ensure safe response times. A usual target for
APTT in the non -bleeding patient with platelet count > 80,000 is 60-90..
 Plasma free Hb is performed when clinically indicated. The safe range for this is < 0.1g/L. Levels above this
MUST be discussed with ICU Consultant and medical perfusionist.
 Blood cultures 3 times per week or as indicated. Unlike other patients, these samples should be taken from the
circuit or through existing lines. Do NOT perform venipuncture for the collection of blood cultures. (Samples
from circuit are obtained by a perfusionist)
 Other cultures as indicated
Doppler examination of the blood flow in the back-flow cannula is indicated if deteriorating leg perfusion is observed
in the cannulated leg.
Antibiotics (vancomycin) to prevent line sepsis is commenced at the start of ECMO. Other antibiotics are prescribed as
indicated.
Stress ulcer prophylaxis is standard.
No procedure can be performed on a patient on ECMO without the consent of the ICU consultant.
Protamine is contraindicated for patients on ECMO as it can cause serious circuit related thrombosis
All changes to circuit flows, gas and blood, should be relayed to the medical perfusionist via ICU Senior Registrar
All changes to circuit anticoagulation should be relayed to the medical perfusionist via ICU Senior Registrar
6g. Nursing care
Nursing education available to further knowledge of ECMO care includes
 ECMO Education Program
 Bedside consultation with a medical perfusionist
Nursing responsibilities are to patient care. Responsibility for technical maintenance of the ECMO circuit lies with the
medical and technical perfusionists at Royal Prince Alfred and Liverpool Hospitals.
Patient positioning and the safe performance of pressure area care are affected by ECMO support.
 Patients with ECMO support with an “open sternum” may not be rolled and require alternate means of
preventing pressure area care eg: KCI mattress. Daily chest x-rays and other patient moves require a Jordan
Frame and the presence of medical staff and/or perfusionist to ensure no change in circuit flows result as a
consequence of movement.
 Other patients on ECMO support can be log-rolled and moved for chest x-rays. These moves can be safely
performed but require a designated staff member to ensure no tension is transmitted to the cannulae and the
circuit tubing is not kinked. This includes patients with surgical grafts for femoral artery access but extra care
is required to prevent obstruction to ECMO flow at this site. Moves are scheduled between the hours of 0800
and 2000 and not during the night (unless there is an urgent patient need).
 All moves are to be performed with medical staff knowledgeable in ECMO, immediately available to assess
any circuit changes that may occur.
CVVHD connection to the ECMO circuit should be performed by perfusion staff or by a nurse who is trained in this
procedure.
CVVHD disconnection can be performed by nursing staff. The three- way tap is turned off to the CVVHD circuit and
the CVVHD circuit can then be disconnected and a sterile bung applied. The three way tap is NOT to be flushed with
Page 15 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
any solution including normal saline. Betadine solutions must be used to wipe the connection points when
disconnecting the ECMO circuit.
No component of the circuit can be cleaned with alcohol containing solutions, as alcohol may damage the circuit
tubing. If alcohol containing solutions do contact the circuit, the perfusionist on call must be immediately notified.
6h. Perfusionists
Medical perfusionists are responsible for the technical support required for all phases of ECMO support. They are in
attendance for all cases of ECMO initiation and in the event of patient instability and their contact details should be
available at the patient’s bedside. A medical perfusionist should attend the morning ward round and review the patient
prior to leaving the hospital Monday-Friday. The medical perfusionist on –call should also attend the Saturday and
Sunday morning ward round.
Circuit blood gases from the post-membrane pressure line should be taken twice a day and additionally as determined
by the perfusionist.
Transports out of ICU are supervised by a perfusionist. All non-emergent transports are performed “in hours”
Nursing education at scheduled daily visits, to review observations and address nursing concerns related to ECMO
6i Weaning ECMO
The decision to wean ECMO is made by the ICU consultant, and in cardiac patients, it is made in conjunction with
cardiac surgeons.
The principals of V-A ECMO weaning:
 A period of prolonged low flow (~1 lpm.) is advisable while native heart function is carefully assessed (TOE).
As this increases the risk of stasis and clotting within the circuit, additional heparin is required to increase the
ACT of about 400s.
 If respiratory function is a concern, it is possible to turn off gas flow to the oxygenator (only at circuit flows
≤1.5L/min) and assess oxygenation achieved using the ventilator exclusively. Note: in this situation the circuit
flow acts as a right-to-left shunt. If adequate oxygenation and CO2 removal can be maintained in the presence
of this shunt it is likely that respiratory failure can be managed without ECMO.
Principals of V-V ECMO weaning:
 Circuit flow need not be reduced at any stage. No additional heparin is required. Full ventilation is reestablished, then the oxygen flow to the oxygenator is turned off and clamped. TOE is not required.
Removal of cannulae: Removal of arterial ECMO cannulae should always be removed as an “open” surgical procedure
and be accompanied with the vessel wall repair. Venous cannula can be removed and pressure applied to the site for 20
minutes.
Post-decannulation Doppler: Lower limb venous Doppler studies should be performed following decannulation- as
prolonged femoral venous cannulation promotes distal DVT formation.
Page 16 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
INTENSIVE CARE SERVICE
Nursing Policy & Procedures
THE NURSING CARE OF PATIENTS RECEIVING ECMO THERAPY
GOAL: The safe and effective nursing care of patients receiving ECMO therapy
Introduction
The aim of this policy is to outline and detail the nursing care of patients on ECMO. This guideline does not
replace the Area ECMO policy, but merely highlights the nurses’ responsibilities as detailed throughout the policy,
and therefore full reading of the trust policy is mandatory in order to become familiar with the holistic management of
patients receiving ECMO therapy.
Care of the patient undergoing ECMO support follows the principles common to the care of all critically ill,
ventilated patients in that there are a wide range of complex care needs to be met, and a level of skill and experience is
required in order to maintain safety whilst meeting those needs. Nursing responsibilities are to maintaining a safe
environment and to patient care; the technical maintenance of the ECMO circuit lies with the medical and technical
perfusionists at RPAH and therefore any issues are to be reported to them as per area policy (eg circuit issues or heatercooler issues).
Nursing Care
The nursing requirements specific to the patient on ECMO are primarily related to the nursing responsibilities
of maintaining a safe environment, continuous monitoring and pressure area care. All other nursing care is as per care of
critically ill, ventilated patients or as directed by the multi-disciplinary team.
Author:
Author:
Author:
Author:
Author:
Author:
Author:
Fiona Daly <F.Daly@alfred.org.au>
Dr Vin Pelligrino <V.Pelligrino@alfred.org.au>
Arthur Preovolos <A.Preovolos@alfred.org.au>
Dr Paul Forrest pforrest@usyd.edu.au
Alice Coulson <alicecoulson@yahoo.co.uk
Melissa Donellan <ctsuphysiology@email.cs.gov.nsw.au
Belinda Parkins <Belinda.Parkins@swsahs.nsw.gov.au
Position:
Position:
Position:
Position:
Position:
Position:
Position:
ICU Clinical Nurse Educator, The Alfred Hospital
Intensivist, The Alfred Hospital
Perfusionist, The Alfred Hospital
Anaesthetist / Medical Perfusionist, RPAH
ICU Acting Clinical Nurse Educator, RPAH
Hospital Scientist, RPAH
Hospital Scientist, Liverpool Hospital
Extra Corporeal Membrane Oxygenation (ECMO)
Maintaining a Safe Environment
NURSING INTERVENTION
RATIONALE

Significant instability is often experienced
during the first 24 hrs following
commencement of ECMO.

Frequency of obs and monitoring denotes
the need for two nurses in order to
maintain safety
Safety checks performed on commencement of shift
to include:
 ECMO plugged into BLUE back up plug
 Hand crank available
 Secure and labelled oxygen flow
connections to oxygenator
 Correct flow setting on oxygen flow meter
 Pump auscultation
 Pump access line movement (shaking,
swinging or still)

Emergency equipment specific to ECMO
is required in the event of any circuit
malfunction or issues in order to maintain
the perfusion and oxygenation of patients
Pump auscultation gives an indication of
the effectiveness of blood flow through the
pump.
An audible continuous hum should be
heard, any additional sounds should be
reported to perfusionist as abnormal
Check blood fridge daily, ensuring 2 units of blood
available, checking expiry date of cross match.

Report need for a new up date cross match and reordering of blood to medical team ASAP

The ECMO patient must NOT be left unattended at
any time
- relief for breaks should be arranged so that a
suitably experienced member of staff is monitoring
the patient and ECMO circuit at all times

On commencement of ECMO, patients must be care
for at a 2:1 ratio for first 24hrs
- reviewed by NUM, In-charge and
intensivist after 24hrs
- subsequent nurse: patient ratio decided
according to patient acuity and care needs
Observations are to be performed ½ hourly for the
first 24hrs




Page 18 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Two units of blood must be available at all
times in case of emergency requiring
immediate transfusion i.e failure of circuit,
exsanguination
Due to changing patient conditions, cross
matches become invalid after three days
(72hrs) and therefore the blood available
from that cross match will not longer be
suitable for transfusion
The ECMO patient is dependent on the
circuit for maintenance of oxygenation +/cardiac output
Any disruption to ECMO flow will result
in rapid deterioration, which if not rapidly
rectified will result in death
The ECMO patient is also a ventilated
patient and therefore should not be left
unattended as per care of ventilated
patients
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
Monitoring the Patient on ECMO
NURSING INTERVENTION
RATIONALE
ECMO pump flow rate
- to be monitored continuously
- alongside continuous monitoring of circuit
lines for any movement eg shaking or
swinging
- documented hourly with rpm setting for
trend monitoring.
Any drop in blood flow to be reported immediately
and managed promptly as per Area ECMO policy
guideline section ‘ECMO trouble shooting guide’.
Pre and post membrane pressures
- to be monitored continuously
documented hourly throughout ECMO
therapy for trend monitoring





Blood flow through the ECMO circuit is
essential for maintenance of gaseous
exchange and haemodynamic stability
Any disruption to pump flow rate and
blood flow will have significant effects on
pt’s stability and should therefore be
identified and managed immediately
Pre and post membrane pressures are a
guideline to the viability of the oxygenator
Ideally the difference to be <50mmHg
Any increasing trend in pressure difference
may indicate the oxygenator is clotting
Inspection of oxygenator
- Performed 8 hourly
- and set for clot formation

Visible clots on the inflow side of the
oxygenator may give an indication that the
set is clotting
Patient temperature
- to be initiated and continuously monitored
throughout ECMO therapy via either:
- blood thermister in the presence of a
PiCCO/ PA catheter
- nasopharyngeal or rectal probe, or via
catheter temperature probe in the absence
of blood temp monitoring
- to be documented hourly for trend
monitoring

To promote homeostasis, normal body
temperature must be maintained, unless
mild hyperthermia is clinically desired
Continuous monitoring allows for early
detection and therefore management of
temperature changes
In the absence of blood temperature
monitoring, the rectal, catheter &
nasopharyngeal routes have been proven in
the literature as both reliable and practical
Haemodynamic status
- continuously monitor pt and ECMO set for
changes namely:
- drop in BP/ CVP
- evidence of hypovolaemia in the form of
fluctuating flow rates and ‘shaking’ of
ECMO tubes





Any suspicion of changing haemodynamic status to
be reported and discussed with medical team, and if
necessary managed as per ‘ECMO troubleshooting
guide’ in the main Area policy
Inspect access and return cannulae
- hourly, observing for oozing of blood, and
maintenance of secure dressings


Page 19 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Hypovolaemia (relative or absolute) may
result in disrupted blood flow through the
circuit
Sucking down of the access cannula
against the vessel wall may occur in
hypovolaemia potentially causing trauma
to vessel endothelium and haemolysis
Blood flow through the ECMO circuit is
essential for maintenance of gaseous
exchange, and also to maintaining
haemodynamic stability
Significant blood ooze from the cannulae
site may contribute to further
haemodynamic instability
Secure dressings are required to maintain
cleanliness of cannulae sites, and also to
help stabilise the cannulae
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
Monitoring the Patient on ECMO cont…
Vascular observations of lower limbs
- to be performed hourly and to include:
 Limb temperature
 Limb colour
 Pedal pulses
 Capillary refill

Due to the large bore cannulae distal
arterial perfusion may be compromised in
A-V ECMO, while the venous cannulae
may lead to DVT formation.
Urine output
- Observe for evidence of haematuria
Inform MO if present

Haematuria is often present when there is
haemolysis, and therefore should be
reported and investigated appropriately
Coagulation monitoring
- to be guided by medical team
- as per Area policy

A combination of monitoring of ACT and
APPT is used in the first 24hrs, from which
point it may only be necessary to monitor
APPT
Patient Positioning, Patient Care and Pressure Area Care
NURSING INTERVENTION
Patient to remain nursed on their back
Head may be elevated to 30 degrees as per best
practice
RATIONALE
 To maintain continuous monitoring of
circuit and cannula
 Elevation to more than 30degress may
result in disruption of flow to cannula and/
or damage to vessel
Patient to be nursed on pressure relieving mattress
at earliest practicable opportunity

Inability to turn patient and adopt normal
pressure relieving measures places patient
at increased risk of pressure ulcer
formation
All activities of nursing care involving the
movement of the patient must be done with a
designated person to watch ECMO cannulae,
tubing and flow rates
All moves are to be performed with medical staff
knowledgeable in ECMO available in the unit

Any disruption to ECMO circuit or flow
will result in significant patient instability
and compromise

Any disruptions, or changes to the circuit
and flows need to be rapidly assessed and
managed in order to maintain patient
stability
If not contra-indicated the patient may be rolled
using a log roll technique up to an angle of 30
degrees
- therefore minimum of 5 staff required

Extended or lengthy periods of movement should
be performed using a Jordan Frame to elevate
patient (e.g in order to give hygiene care or attend to
posterior wounds)

Neutral alignment of lower thorax,
abdomen and lower limbs can be
maintained during log rolling, therefore
minimising any disruption to cannula
position and blood flow
Prolonged movement increases the risk of
disruption of blood flow to cannulae
Supine position can be maintained whilst
patient in Jordan frame therefore
minimising any disruption in blood flow
Page 20 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest

Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
8. ECMO trouble-shooting guide
VENO-VENOUS ECMO
8.1.1 Worsening hypoxia
Ensure:
Pump flow is adequate (> 2/3 cardiac output)
100% oxygen is being supplied to the oxygenator
Oxygenator is functioning correctly (outflow pO 2 > 150mmHg)
Consider:
Increasing pump flow / increasing ventilation / cooling patient to 35ºC
8.1.2 Worsening hypercarbia
Ensure:
Pump flow is adequate (>2/3 cardiac output)
Oxygen flow to oxygenator is at least twice the pump flow rate
Consider:
Increasing ECMO flow rate / increasing ventilation /cooling patient to 35ºC
8.1.3 Increasing flow rate does not improve oxygenation
Ensure recirculation is not occurring:
If the access and return cannulae are too close together, recirculation of blood may occur between them (oxygenated
blood is drawn down the access cannula). Hence increasing ECMO flow may not improve the patient’s oxygenation. To
diagnose recirculation, take a blood gas from the venous side of the oxygenator. This should have a venous pO2. If the
pO2 is higher than the patient’s venous pO2, reposition (withdraw) the access line. Consider adding a second venous
access line via a Y-connector.
VENO-ARTERIAL ECMO
8.2.1 Worsening hypoxia
Differential hypoxaemia (lower pO2 in the upper body compared to the lower body) can occur during peripheral
veno-arterial ECMO when there is severe respiratory failure combined with a high cardiac output. In this situation,
the heart is supplying the upper body with de-oxygenated blood, while the ECMO circuit supplies the lower body
with oxygenated blood. To detect this problem, patient blood gases should be sampled as close to the heart as
possible (hence a right radial arterial line is preferable to a left radial line). Similarly, monitoring of the oxygen
saturation of the upper body should be performed with a pulse oximeter on the right hand or with a transcutaneous
oximeter attached to the patient’s forehead.
To treat differential hypoxaemia, the following steps may be necessary:




Ensure the oxygenator is functioning correctly (return line pO 2 > 150mmHg)
Ensure the ECMO flow is as high as possible (within constraints of return line pressure)
Increasing the patient’s ventilation/ PEEP / FiO2
Consider re-siting the return line from the femoral to the right subclavian artery (via a Goretex graft rather than
a cannula- to maintain distal perfusion to the arm).
8.2.2 Worsening hypercarbia
Ensure:
Pump flow is adequate (>2/3 cardiac output)
Oxygen flow to oxygenator is at least twice the pump flow rate
Consider:
Increasing ECMO flow rate / increasing ventilation /cooling patient to 35ºC
Page 21 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
VENO-VENOUS AND VENO-ARTERIAL ECMO
8.3.1
Page 22 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
8.3.2 “SIG” alarm on pump console
This alarm may occur on the Jostra pump console (but not on the Biomedicus pump). The flow rate indicator on the
pump says “SIG” while the pump is still functioning normally. (RPM rate unchanged). The pump continues to function
normally, although flow rate is not displayed. This occurs when the cream that is applied to the flow sensor (under the
black clip at the outlet of the centrifugal Jostra pump) has dried out and needs to be replaced. This may be prevented by
wrapping the flow sensor in cling-wrap whenever the Rotafow pump is used.
Response: Contact perfusion services in or out of hours.
If perfusion services are not immediately available, they may ask you to perform the following steps:
 Re-establish full ventilation.
 Stop pump slowly and clamp inflow and outflow lines to the centrifugal pump.
 Unclip the black clip on the flow sensor and remove the pump head.
 Re-apply silicone cream to flow sensor.
 Unclamp lines and slowly increase flow back to normal level.
Page 23 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9. ECMO Complications
Haemolysis
If haemolysis is suspected while on ECMO, the following steps should be taken:
Plasma free-haemoglobin testing: Samples are taken carefully and very slowly through the shortest and widest
available sampling port (preferably venous). Samples are labelled as urgent (using labels provided by perfusion
services) and must be hand delivered to the lab to avoid shaking that will falsely raise the plasma free-haemoglobin.
Normal operating plasma free-haemoglobin level is <0.1 g/L. A confirmed plasma free-haemoglobin at or above 0.1 or
any high reading associated with clinical evidence of intravascular haemolysis (see below) or circuit malfunction (such
as “access insufficiency”) demands a rapid response and must be communicated to perfusion services and the ICU
Consultant urgently.
Elevated plasma free-haemoglobin readings: Any elevated readings should be re-checked immediately with a repeat
sample from a venous port (NOT a stab) and handled meticulously. Repeatedly high readings are confirmation of
intravascular haemolysis. Causes are:
 Clot within the circuit or near the cannulae orifices;
 Inadequate venous return (poor circulation)
 Inappropriate pump speed settings
Signs of haemolysis: Red (or dark brown in extreme cases) urine; high potassium; renal failure; jaundice (late sign).
Signs of access insufficiency: Access insufficiency occurs when flow into the circuit from the patient is inadequate for
the pump speed settings. This may occur if the venous return is insufficient or there is obstruction near the inlet of the
cannulae. Blood flow into the circuit becomes episodic and pressure swings can be very large resulting in damage to red
blood cells. The access line tubing may visibly shake or have a palpable “kick”. Continuous, hourly observation of the
access line is part of routine nursing care of a patient on ECMO.
Management of haemolysis:
 Increase volume state and review pump settings (if signs of access insufficiency present)
 TOE to ensure cannula not obstructed
 Consider changing the circuit
 Reset anticoagulation targets
Emergency Complications with ECMO care
Emergency complications are dramatic, life threatening changes involving the ECMO circuit that demand immediate
responses. They are largely preventable: see accompanying section:
The responses required for a range of possible (but extremely rare) emergency complications in patient requiring venoarterial and veno-venous ECMO are given in the accompanying section:
 Emergency ECMO Responses: Veno-arterial ECMO
 Emergency ECMO Responses: Veno-venous ECMO
Page 24 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.1 Emergency ECMO Responses: Veno-Arterial ECMO
Emergency ECMO responses are fortunately rare. In general these complications are almost
entirely preventable.
Possible complications are:
9.1.1
Pump Failure
9.1.2
Decannulation
9.1.3
Circuit Rupture
9.1.4
Air Embolism
9.1.5
Cardiac Arrest
9.1.6
Oxygenator Failure
9.1.7
Changing the circuit
Page 25 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.1.1. Pump failure
(Veno – Arterial Response)
Definition:

This is a no flow state due to failure of the electrical pump to drive pump head.
Effects:

If the circulation is mainly mechanically driven: this is associated with haemodynamic collapse

If a significant non-mechanical (native) circulation is present: The ECMO circuit becomes a passive conduit
as it contains no valves or occlusive rollers. Hence reversal of blood flow (from the aorta to the central veins along its pressure gradient) will occur, which will reduce the cardiac output and increase the preload to the
right heart. The extent of hypotension and hypoxia that may result will depend on the underlying cardiac
function.
Causes:

Pump head disengagement: eg. accidental contact with pump-head or incorrect initial placement of pump head
or pump head adaptor

Electrical motor failure

Battery failure (no AC power connected)
Prevention:

Always maintain the pump head in a position to minimise the risk of contact especially with devices such as
portable x-ray, haemofilter and TOE

Minimise time on battery

Ensure AC “Power Off” alarm is turned on when using wall power

Console not in use, needs to be plugged into AC power and “on Switch” turned on in order to recharge battery
Response:

Clamp lines

Re-establish full ventilation

Examine circuit: identify pump head disengagement; exclude torsion, kinking or compression of tubing




Call for help. Contact perfusion services
Pump head disengagement
1.
Clamp line (anywhere on ECMO circuit) and turn off pump
2.
Re-engage pump head
3.
Turn pump on to 1000 rpm and remove clamp
4.
Gradually increase rpm to previous setting
Electrical motor failure
1.
Clamp line (anywhere on ECMO circuit) and turn off pump
2.
Consider manual cranking whilst obtaining spare blood pump (console)
3.
Re-engage pump head in new blood pump
4.
Turn on blood pump to 1000 rpm and remove clamp
5.
Gradually increase revs to previous settings
Battery failure: Re-establish AC power or commence manual cranking
Page 26 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
NOTE : If ECMO is off for any period of time, clotting in the circuit is a possibility
9.1.2. Decannulation
(Veno – Arterial Response)
Definition:

This is the removal of either the access or return cannula
Effect:
1.
Haemodynamic collapse and hypoxia of varying severity (depending on underlying cardiac and respiratory
reserve)
2.
In centrally cannulated, immediate loss of ECMO support and:
a.
if arterial, cannula would be pulled out of or torn off Aorta resulting in catastrophic blood loss
b.
if venous, cannula would be pulled out of Right Atrium.
3.
In peripherally cannulated, massive blood loss from cannulation site (may be controllable)
4.
Possible introduction of air into ECMO circuit and patient
Causes:

Extreme tension being placed on tubing and hence cannulae and cannulation sites
Prevention:

Anchoring the cannulae to the patient

Use of a spotter to ensure that lines remain free during patient manoeuvres
Response:

Clamp the circuit proximal to the disconnected cannula and turn pump off

Call for help

Contact ICU Consultant, Perfusionist & Surgeon

If peripheral cannulation apply pressure to the cannula site

Position patient head down

Give volume to replace blood loss

Increase the ventilator settings and inotropes to compensate for loss of support.

If central cannulation, prepare for chest opening
Page 27 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.1.3. Circuit Rupture
(Veno – Arterial Response)
Definition:

This is the disruption of any part of the circuit
Effects:


Massive blood loss
Haemodynamic collapse and hypoxaemia of varying severity (depending on underlying cardiac and respiratory
reserve)

Possible introduction of air into ECMO circuit
Causes:

Fracture and breakdown of polycarbonate components after being cleaned with alcohol

Broken three way tap

Accidental cutting or puncturing of circuit tubing
Prevention:

Do not allow any part of the circuit to come into contact with alcohol or other organic solvent such as volatile
anaesthetic

Allocated person to act as “spotter” to ensure that three way taps are not snagged on anything during patient
manoeuvres

Care with needles and instruments near tubing
Response:

Clamp the circuit on either side of the circuit disruption

Call for help. Contact perfusion services and ICU consultant

Assign roles for concurrent patient and circuit management
Patient Management:

Increase the ventilator settings and inotropes to compensate for loss of support.

Give volume to replace blood loss
Circuit Management:

If fractured three way tap: if possible place sterile gloved finger over leak
-
Page 28 of 40
Connection change
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.1.4. Circuit Air Embolism
(Veno – Arterial Response)
Definition:

This is the introduction of air into the ECMO circuit.
Effects:
1.
Massive air embolus into the pump head will deprime the pump and stop it pumping leading to haemodynamic
collapse and hypoxaemia of varying severity (depending on underlying cardiac and respiratory reserve)
2.
Possible introduction of air embolus into the patient
Causes:

Introduction of air into the circuit via a peripheral cannulation site

Fracture of connector on the inlet side of the pump

Accidental introduction through he pump inlet pressure monitoring site
Prevention:

Only ECMO trained consultants to perform CVC insertion

Only perfusionist to manipulate the inlet side of the pump

Do not allow connectors to come into contact with alcohol or organic solvent
Response:

Clamp the circuit (anywhere on circuit) and switch off pump to prevent further introduction of air into the
patient

Call for help. Contact perfusion services and ICU Consultant

Assign roles for concurrent patient and circuit management

Patient Management
-
Position patient head down
-
Inotropic support to maintain MAP
-
Ventilation support (increase minute ventilation as tolerated with
FiO2 100 %)

-
Volume load
-
Consider hypothermia to 34, barbiturates, steroids, mannitol, lignocaine
Circuit Management (removal of air)










Page 29 of 40
Clamp arterial return line
Turn pump off
Position patient head down
Increase the ventilator settings and inotropes
Give volume
Consider: hypothermia to 34°, barbiturates, steroids, mannitol, lignocaine
Consider aspiration of the right heart using existing lines
Examine circuit for site of air introduction; seal if possible or replace
If no air on the outlet side of oxygenator:
Rotate pump head outlet to 12 o’clock.
Ensure air vent on oxygenator is open. If pump head is not deprimed, slowly turn on pump, using
partial clamp release to help control flow; the air will be vented from the oxygenator provided the
flow is low. Alternatively, attach a 60 ml luer lock syringe to circuit venting port distal to oxygenator
and aspirate air and blood.
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)





Page 30 of 40
Return pump head to 6 o’clock position.
If air on the outlet side of oxygenator:
Clamp the arterial return cannula on the patient side of the luer lock port; remove first clamp.
Attach a 60 ml luer lock syringe to the luer lock port and aspirate air and blood.
Once all air is removed from circuit, remove clamps and resume ECMO
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
-
9.1.5. Cardiac Arrest
Veno – Arterial Response
Definition:

This is the cessation of native cardiac function. Pulseless circulation
Effects:

Little haemodynamic effect if circuit flow is above 4 L/min
Causes:

Cardiac stunning

Hyperkalaemia

Arrhythmia ie: VF
Prevention:

Need to exclude reversible factors

Consider inotropic support
Response:

Establish adequate circuit flow

Notify ICU consultant and Perfusionists

Address reversible factors
Page 31 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.1.6. Oxygenator failure
Veno – Arterial Response
Definition:

Gas transfer failure is a gradual process that is identified by worsening pO 2 values in the postmembrane blood gases or by an increasing trans-membrane pressure gradient. It requires an elective
response by perfusion services. More emphasis

Other causes of oxygenator failure are:
1.
Water leak external (heat exchanger rupture)
2.
Water to blood leak
Effects:

Heat Exchanger Rupture: Water spraying everywhere, loss of ability to control blood temperature through
oxygenator

Water to Blood Leak: Massive haemolysis and sepsis

Heat Exchanger Rupture: Excessive water pressure in heat exchanger

Manufacturing defect
Causes:
Prevention:

Ensure that no equipment is rolled over or obstructs the heater cooler hoses attached to the oxygentaor
Response:

Turn off Heater Cooler

Contact Perfusionist and ICU Consultant

Use warming blanket to control patient temperature
Page 32 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.2. Emergency ECMO Responses: Veno-Venous ECMO
Emergency ECMO responses are fortunately rare. In general these complications are almost
entirely preventable.
Possible complications are :
9.2.1
9.2.2
9.2.3
9.2.4
9.2.5
9.2.6
Page 33 of 40
Pump Failure
Decannulation
Circuit Rupture
Air Embolism
Cardiac Arrest
Oxygenator Failure
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.2.1. Pump failure
Veno – Venous Response
Definition:

This is a no flow state due to failure of the electrical pump to drive pump head.
Effects:


Hypoxia / hypercarbia
Haemodynamic collapse may occur as a result of severe hypoxia.
Causes:

Pump head disengagement: eg. accidental contact with pump-head or incorrect initial placement of pump head
or pump head adaptor

Electrical motor failure

Battery failure (no AC power connected)
Prevention:

Always maintain the pump head in a position to minimise the risk of contact especially with devices such as
portable x-ray, haemofilter and TOE

Minimise time on battery

Ensure AC “Power Off” alarm is turned on when using wall power

Console not in use, needs to be plugged into AC power and “on Switch” turned on in order to recharge battery
Response:

Re-establish full ventilation with 100% oxygen

Examine circuit: identify pump head disengagement; exclude torsion, kinking or compression of tubing

Call for help. Contact perfusion services

Pump head disengagement


1.
Clamp line (anywhere on ECMO circuit) and turn off pump
2.
Re-engage pump head
3.
Turn pump on to 1000 rpm and remove clamp
4.
Gradually increase rpm to previous setting
Electrical motor failure
1.
Clamp line (anywhere on ECMO circuit) and turn off pump
2.
Consider manual cranking whilst obtaining spare blood pump (console)
3.
Re-engage pump head in new blood pump
4.
Turn on blood pump to 1000 rpm and remove clamp
5.
Gradually increase revs to previous settings
Battery failure: Re-establish AC power or commence manual cranking
NOTE : If ECMO is off for any period of time, clotting in the circuit is a possibility
Page 34 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.2.2. Decannulation
Veno – Venous Response
Definition:

This is the removal of either the access or return cannula
Effect:


Hypoxaemia
Haemodynamic collapse and hypoxaemia of varying severity (depending on underlying cardiac and respiratory
reserve)

In central cannulation, right atrial and vena caval damage resulting in catastrophic blood loss

In peripheral cannulation, massive blood loss from cannulation site
Causes:

Extreme tension being placed on tubing and hence cannulae and cannulation sites
Prevention:

Anchoring the cannulae to the patient

Use of a spotter to ensure that lines remain free during patient manoeuvres
Response:

Call for help

Increase the ventilator settings to compensate for loss of support.

Contact ICU Consultant, Perfusionist & Surgeon

Clamp the circuit proximal to the disconnected cannula and turn pump off

If peripheral cannulation apply pressure to the cannula site

Give volume to replace blood loss
Page 35 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.2.3. Circuit Rupture
Veno – Venous Response
Definition:

This is the disruption of any part of the circuit
Effects:

Massive blood loss

Haemodynamic collapse and hypoxia of varying severity (depending on underlying cardiac and respiratory
reserve)

Possible air embolus
Causes:

Fracture and breakdown of polycarbonate components after being cleaned with alcohol

Broken three way tap

Accidental cutting or puncturing of circuit tubing
Prevention:

Do not allow any part of the circuit to come into contact with alcohol or other organic solvent such as volatile
anaesthetic

Allocated person to act as “spotter” to ensure that three way taps are not snagged on anything during patient
manoeuvres

Care with needles and instruments near tubing
Response:

Clamp the circuit on either side of the circuit disruption

Call for help. Contact perfusion services and ICU consultant

Assign roles for concurrent patient and circuit management

Patient Management
-
Increase the ventilator settings and inotropes to compensate for loss of support.
-
Give volume to replace blood loss

Page 36 of 40
Circuit Management
-
If fractured three way tap: if possible place sterile gloved finger over leak
-
Connection change
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.2.4. Circuit Air Embolism
Veno – Venous Response
Definition:

This is the introduction of air into the ECMO circuit.
Effects:

Massive air embolus into the pump head will de-prime the pump and stop it pumping

In Veno – Venous ECMO, this will lead to severe hypoxaemia

Haemodynamic collapse and hypoxaemia of varying severity (depending on underlying cardiac and respiratory
reserve)

Introduction of air embolus into the patient
Causes:

Introduction of air into the circuit via a peripheral cannulation site

Fracture of connector on the inlet side of the pump

Accidental introduction through he pump inlet pressure monitoring site
Prevention:

Only ECMO trained consultants or cardiac surgeons to perform ECMO cannulation

Only perfusionist to manipulate the inlet side of the pump

Do not allow connectors to come into contact with alcohol or organic solvents
Response:

Clamp the circuit (anywhere on circuit) and switch off pump to prevent further introduction of air into the
patient

Call for help. Contact perfusion services and ICU Consultant

Assign roles for concurrent patient and circuit management

Patient Management

-
Position patient head down
-
Inotropic support to maintain MAP
-
Ventilation support (increase minute ventilation as tolerated with100 % oxygen)
-
Volume load
-
Consider hypothermia to 34, barbiturates, steroids, mannitol, lignocaine
-
Consider aspiration of the right heart using existing lines
Circuit Management (removal of air)








Clamp arterial return line
Turn pump off
Position patient head down
Increase the ventilator settings and inotropes
Give volume
Consider: hypothermia to 34°, barbiturates, steroids, mannitol, lignocaine
Consider aspiration of the right heart using existing lines
Examine circuit for site of air introduction; seal if possible or replace

If no air on the outlet side of oxygenator:
Rotate pump head outlet to 12 o’clock.
Page 37 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)






Ensure air vent on oxygenator is open. If pump head is not deprimed, slowly turn on pump, using partial
clamp release to help control flow; the air will be vented from the oxygenator provided the flow is low.
Alternatively, attach a 60 ml luer lock syringe to circuit venting port distal to oxygenator and aspirate air
and blood.
Return pump head to 6 o’clock position.
If air on the outlet side of oxygenator:
Clamp the arterial return cannula on the patient side of the luer lock port; remove first clamp.
Attach a 60 ml luer lock syringe to the luer lock port and aspirate air and blood.
Once all air is removed from circuit, remove clamps and resume ECMO
9.2.5. Cardiac Arrest
Veno – Venous Response
Definition:

This is the cessation of patient’s circulation. ECMO flow will diminish accordingly
Effects:

Patient will be in cardiac arrest.
Causes:

Usual causes of cardiac arrest
Prevention:

Identify risk factors and treat
Response:

Call for help

Notify ICU consultant and perfusionist

CPR

Reduce ECMO flows if signs of circuit access insufficiency
Page 38 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
8.2.6. Oxygenator failure
Veno – Venous Response
Definition:

Gas transfer failure is a gradual process that is identified through routine blood gas analysis and
requires elective responses by perfusion services. More emphasis


Other forms of oxygenator failure considered are :
i. Water leak external (heat exchanger rupture)
ii. Water to blood leak
Effects:

Heat Exchanger Rupture : Water spraying everywhere, loss of ability to control blood temperature through
oxygenator

Water to Blood Leak : Massive haemolysis and sepsis
Causes:

Heat Exchanger Rupture : Excessive water pressure in heat exchanger

Manufacturing defect
Prevention:

Ensure that no equipment is rolled over or obstructs the heater cooler hoses attached to the oxygentaor
Response:

Turn off Heater Cooler

Contact Perfusionist and ICU Consultant

Use warming blanket to control patient temperature
Page 39 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline
Extra Corporeal Membrane Oxygenation (ECMO)
9.1.7. Changing the circuit
Change the whole circuit in the event of either an oxygenator or pump failure.
It should take less than 60 seconds to to cut and change the tubing.
Indications
 Increasing transmembrane pressure gradient; it should be <50 mmHg
 Oxygenator outflow PaO2 <150 mmHg
 Heat exchanger rupture
 Increased noise from pump head
 Large thrombus formation within pump head
 Development of haemolysis
Method
 Re-establish full ventilation.
 Apply defib pads - (as some patients will arrest due to hypoxia - especially respiratory cases).
 Prime the new ECMO circuit, as per the document ECMO SETUP.
 Double-clamp the new patient loop, divide it between the clamps, insert a straight ⅜” connector into each end
and prime the connectors with a syringe of saline.




If the new circuit has been primed in the hand crank, remove the pump head from the hand crank.
Disconnect the heater-cooler tubing from the old oxygenator.
Disconnect the fresh gas line from the old oxygenator.
Position one person on each side to cut and change the tubing.
 Stop the old pump slowly and clamp the arterial return and venous access lines close to the patient.
 Divide the lines close to the clamps on the side of the clamps away from the patient and prime their ends using a
syringe of saline.
 Connect the new lines to the ends of the old lines.
 If the new circuit was primed in the hand crank, remove the old pump head from the pump and insert the new
pump head.
 Unclamp the lines and slowly increase flow back to normal level.
 Connect the fresh gas line to the new oxygenator.
 Connect the heater-cooler tubing to the new oxygenator.
 Apply gun-ties to the new connections in the lines.
The blood remaining in the old circuit may be drained into citrate bags for re-infusion, unless there is thrombus in
the circuit.
Page 40 of 40
Target: ICU Nursing, Medical & RPAH Perfusionist Staff
Maintained by: Dr. Paul Forrest / Melissa Donnellan
Contact: Dr. Paul Forrest
Developed: Jan 07
Last Review: May 07
Review Due: Jan 08
Approved by: Dr Paul Forrest
Title: ECMO Policy & Guideline