Ecmo

Extracorporeal membrane oxygen nursing care and management

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

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

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

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

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

6. HISTORY

7. 1972 Long-term  ECMO  :-  first  successfully  used  in 1972 in an adult patient with post-traumatic respiratory failure

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

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

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

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

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

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

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

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

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

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

18. ECMO CIRCUIT

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

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

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

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

23. Ecmo on patient with open sternum

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

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

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

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

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

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

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

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

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

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

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

35. NURSING

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

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

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

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

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

41. Heparin Induced T hrombocytopenia HIT can occur in patients with ECMO When HIT is proven, Heparin infusion should be replaced by non- heparin anticoagulant.

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

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

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

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

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

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

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

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

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

51. DOCUMENTATION