ECMO Patient Management

Self-Study Guide

Marcia Stahovich, RN, CCRN

Suzan Lerum, MSN, RN, CCRN

Becky Price BSN, RN, CCRN

Mechanical Circulatory Support Department

Sharp Memorial Hospital

05/2021

ECMO TEAM: ROLES

The Perfusionist & MCS (ECMO Team) team are responsible for technical management of the ECMO circuit.

The RN is responsible for monitoring & caring for the patient. The RN does not make any changes to the ECMO circuit but is responsible for reporting significant changes to the MD and/or MCS Team. Knowledge of circuit related emergencies is also necessary to safely care for the patient.

BEGINNING OF SHIFT CHECK

Connected to Red outlet power source

4 tubing clamps present

Spare console present in unit

Ultrasonic Paste for flow probe

Low flow alarm setting

High/low RPM alarms

Hand crank available

Absence of clots in oxygenator and circuit connections, clot tracker

Perfusionist pager on white board

MONITORING AND CARE OF THE PATIENT ON ECMO

ECMO CANNULA

Observe for “Chatter” (palpable kick or

visible shaking in drainage/venous

line).

Observe for Color differences between

access and return lines

Causes of chatter:

1. Hypovolemia is the most likely cause.

Assess preload & administer fluid as ordered.

2. Consider catheter malposition if volume ineffective (x-ray)

3. Consider clots affecting inflow line

Return cannula should be bright red and drainage cannula

should be dark red. Dark blood in return circuit indicates

problem with oxygen delivery system (disconnect from O2

Monitor for clots and fibrin in circuit.

Use flashlight to inspect lines,

oxygenator and pump.

Avoid tension or kinks in tubing

Monitor connections and insertion site

for bleeding

supply, clamp, empty tank etc.) or oxygenator failing. Bright

red blood in both drainage and return lines indicates both

cannula are in veins or both in arteries

Pay attention to connections and oxygenator as likely places for clots to form. Why? Stagnant or turbulent blood flow in these areas contributes to fibrin build up and clot formation. Small clots in oxygenator may form and not be detrimental to therapy. ECMO Team may simply monitor. A clot in the return line may be an emergency situation because it could potentially enter the patient’s arterial circulation and result in an embolic stroke or other embolic events. Call ECMO Team immediately if return line clot is seen. They may advise you to clamp the return line.

SECURING THE CANNULA & PATIENT POSITIONING

V-A ECMO: Patients remain on bedrest

V-V ECMO We actively mobilize these patients when they are stable.

Leg immobilizer may be used Always check with surgeon prior to first turn. Turns may be contraindicated in patients with an “open sternum” or unstable cannulae. Minimum of 3 staff at bedside for turns. One nurse should be assigned to stabilize cannulated leg. When turning, log roll with extremity straight Avoid elective linen and dressing changes between 1800 – 0800 hrs Elevate HOB by using reverse trendelenberg position

Headband secures V-V ECMO cannula

Patients are generally walked on the day shift, several times.

BLOOD GASES

Circuit gases: Blood gases will be drawn from the

circuit by ECMO RN. These gases are used to

monitor the ECMO circuit function. PaO2 from the

post oxygenator ECMO circuit should be 150 or

greater. Pre-oxygenator (SVO2) should be greater

than 70.

Sweep: ECMO is very effective at extracting CO2 independent of blood flow. The extraction depends on the surface area of the oxygenator membrane and the rate of gas flow. The gas flow or “sweep” contains CO2 so there is a concentration gradient between the blood and the gas. Increasing the speed of the gas flow (sweep) creates an ongoing high concentration gradient

Patient Gases: Blood gases should be drawn by the

RN from the patient at the same time as the circuit

gases are drawn, to assess and compare the status

of the circuit versus the patient.

Right radial blood gases should be drawn from the

VA patient (see explanation on next page).

These gases indicate the patient’s overall

adequacy of ventilation and oxygenation, acid-

base status, as well as how well blood flow is

reaching the upper body (VA ECMO).

Correction and optimization of the patient’s blood gases are done through the ECMO circuit, not the ventilator, unless there is a problem with the circuit.

Sweep is adjusted to increase or decrease CO2.

Sweep % O2 is adjusted to address high or low

PaO2

“Sweep” “%O2”

through the entire membrane, thus increasing CO2 extraction and removal. V-V ECMO: We attempt to wean and extubate if gases are acceptable and patient can maintain airway/clear secretions. The circuit should adequately manage gas exchange. The preference is to place patients on higher ECMO support and eliminate the ventilator, if possible. Optimization of ABG and acid-base is accomplished by circuit adjustments as long as the patient can clear/protect their airway and manage secretions adequately. airway clearance strategies of pep valve, ICS, etc are essential to maintain extubation

Mixed Venous Oxygen Saturation (SvO2)

Measured in the venous line (preoxygenator) reflecting the oxygen delivery/consumption of the patient

and allows for early interventions such as pump flow adjustments, increased sedation, red cell

transfusions etc

BLOOD PRESSURE MONITORING

Blood pressure monitoring must be by arterial line

in patients with VA ECMO.

Use the MAP to monitor and guide drug titration.

Return of a pulsatile arterial waveform is used as a

measure of ventricular recovery in V-A ECMO

Patients on V-V should have a normal arterial waveform. Swan ganz is important for VA ECMO.

If the patient’s heart contributes significantly to cardiac output, the arterial waveform may have a normal appearing wave. However, if the patient’s heart is completely dependent on the circuit, they may have a very dampened looking arterial waveform. Why? V-A ECMO provides non-pulsatile blood flow via a centrifugal pump.

ANTICOAGULATION

Low dose Heparin is initiated as soon as possible

after the patient is placed on ECMO.

PTT is used to titrate the Heparin drip.

Circulatory Support will draw the PTT from the

circuit or patient.

RN communicates the result MD and titrates Heparin as ordered.

We see more clots in V-A circuits with low PTT's. ELSO recommends ACT 180-200 seconds, PTT 45-55 but lower PTT/ACT goals may be ordered depending on the patient’s condition. For example, a lower PTT may be justified for patients who are bleeding or have a history of cerebral aneurysm. It is acceptable, but not desirable, to stop Heparin for significant bleeding. Only the Intensivist can make this call.

TEMPERATURE

The patient’s temperature can be optimized with

use of a heating/cooling device connected to the

circuit. ECMO Team will make all temperature

adjustments to the ECMO circuit

If the patient becomes hyper or hypothermic

during ECMO, contact the ECMO Team. An

adjustment to the circuit is possible.

Therapeutic hypothermia may be initiated via the circuit if indicated post cardiac arrest for 24hours.

Monitor core (patient) temperatures whenever

possible. The most reliable core temperature

sources are PA catheter, esophageal, bladder, &

rectal temperature (in that order). For longer

term, awake, extubated patients, an oral

temperature is acceptable. Axillary temperatures

are not acceptable.

Patients have a tendency toward hypothermia due

to large blood volume in tubing exposed to room

air. This means that a low-grade fever may be a

BIG deal and indicate a need for cultures.

DRESSINGS

Dressings over the cannulation site should be changed if there is significant accumulation of blood beneath the dressing or if the dressing is loose. Reinforce at night.

Dressings should be removed toward the insertion site to minimize the chance of catheter dislodgement. Jugular cannulation-remove in head to toe direction; Groin cannulation-remove in toe to head direction. If bleeding, avoid removing any clot that has

formed.

Surgicel should be applied to site for antimicrobial

properties. Dressing change weekly & prn soiling.

COMPLICATIONS

BLEEDING

Bleeding is the most common complication of ECMO. The RN should assess patient hourly for bleeding, minimize trauma to tissues to prevent bleeding, closely monitor labs, report evidence of blood loss and administer blood products as ordered.

Ensure a current clot is available in blood bank and stay ahead on blood products if necessary. Activate orders for Massive Blood Transfusion, if appropriate, for patients with significant ongoing bleeding after arrival to SICU – notify blood bank additionally by phone call, if activated.

PULMONARY HYPERTENSION

Increased PA pressures and pink frothy secretions from ETT are signs to look for in VA ECMO.

HEMOLYSIS

Monitor for signs of hemolysis (pink-

tinged urine), increasing LDH.

Send LDH or plasma-free hemoglobin

if ordered.

Monitor circuit for chattering hourly

Monitor temperature of heat

exchanger hourly

Normal plasma-free hemoglobin is < 50 mg/dl. If elevated, Perfusion Team/MDs will investigate causes. May be able to reduce hemolysis by reducing RPM’s in circuit, if tolerated. Chatter is a sign that significant negative pressure is required to maintain blood flow; the greater the pressure, the more likely hemolysis can occur. Excessive heat may precipitate hemolysis

FLOW

Monitor circuit parameters and report

any significant increases/decreases in

circuit flow.

Administer vasoactive medications as

ordered to maintain desired flows.

A significant drop in blood flow may be related to a patient condition or a circuit problem. Therefore, make sure to notify the team immediately. Look for any other patient or circuit-related changes observed at the time of flow drop, i.e. positional, medication changes, volume loss, etc. RPMs may be adjusted by the ECMO Team. The goal is to optimize flow with the lowest possible RPMs. While the circuit is providing some degree of CO (potentially 100% in cardiogenic shock) adjustments in preload and afterload can have a profound effect on BP and perfusion. While inotropic requirements should be reduced or eliminated once the circuit is in place, vasodilators may be needed to lower the SVR versus vasopressors to raise the SVR, as appropriate.

INFECTION

The patient on ECMO is at high risk for infection.

Oral care, elevating HOB to 30 degrees, central line care, foley care & mobilization of patient (when possible) all are infection prevention measures.

The RN caring for the patient should be meticulous regarding prevention of infection. Closely monitor patient for signs of infection.

Extracorporeal blood flow may mask a fever. Other signs of infection should be investigated. Consider white count, bands, new hemodynamic instability, elevated lactate or other signs of organ failure. There should be a low threshold for obtaining blood cultures.

ARRHYTHMIAS

Tolerance of arrhythmias will vary by patient and circuit

The V-A ECMO circuit provides perfusion via the centrifugal pump, regardless of native CO, so even life-threatening arrhythmias will likely be tolerated. Notify the MD/NP for guidance. The V-V ECMO patient does NOT have support of cardiac function and will need standard treatment of arrhythmias. If defibrillation is indicated for any ECMO patient, proceed in standard fashion while ensuring that pad placement is not directly touching components of the circuit.

CANNULATED EXTREMITY (V-A ECMO)

Monitor leg for signs of

thrombosis/ischemia/compartment

syndrome.

Check pulses, color, temperature,

sensation & capillary refill.

Consider measuring leg diameter.

Alert MD if changes occur

Compartment Syndrome

Leg ischemia may occur in V-A ECMO if a side arm flow catheter is not in place on the arterially cannulated lower extremity (see below).

Side arm flow or back-flow cannula

Signs & Symptoms of Compartment syndrome:

Pain is often reported early and almost universally.

Paresthesia (altered sensation e.g., "pins & needles") in the cutaneous nerves of the affected compartment is another typical sign.

The compartment may also feel very tense and firm (pressure).

Tense and swollen shiny skin, sometimes with obvious bruising of the skin.

Congestion of the digits with prolonged capillary refill time.

A lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often well below arterial pressures and pulse is only affected if the relevant artery is contained within the affected compartment.

Paralysis of the limb is usually a late finding.

Fasciotomy may be required

CLOTTING IN CIRCUIT

Clots generally form slowly & are not an emergency situation. The ECMO Team monitors and identifies when changes to the circuit are appropriate. Document clots in the Clot tracker and notify of ECMO Team of clots >5mm However, if the circuit is completely clotted and stops, or you see a clot in the return line, call ECMO Team STAT. They may ask you to clamp the line. If circuit is stopped, RN will implement orders for rescue ventilator settings, inotropes, pacemaker rate etc. Anticipate heparin bolus, volume infusion, and immediate return to OR.

REPORTABLE CONDITIONS

1. Excessive bleeding 2. Changes in appearance of cannulated leg (V-A ECMO) 3. Chatter in return line 4. Abnormal labs or blood gases 5. ACT results outside goal range 6. Significant drop in flow or increase in RPMs 7. Hypotension 8. Arrhythmias 9. Cardiac arrest or emergency situation 10. Any fever > 38.0o 11. Air or clot in circuit 12. Signs of pulmonary hypertension

DOCUMENTATION

ECMO Nursing documentation is in Adult Cardiac Specialty Section ECMO Team will Document hourly:

RPM

Flow

Gas Flow or “Sweep” & O2

PTT & Heparin dose

SVO2

ECMO machine temperature

Document every 2 hours:

Pulses

Extremity appearance V-A ECMO

Insertion site

Circuit Inspection for Clots

EMERGENCIES

CANNULA DISLODGEMENT

Call ECMO Team & physician for help

Clamp both lines

Stop pump

Hold pressure on bleeding site

Change ventilator settings to increase support (V-V likely to only require rescue ventilator support)

Increase inotropes/administer volume in V-A ECMO

Send someone to blood bank to obtain blood

Call surgeon, interventional cardiologist, pulmonary intensivist ASAP

Why do we clamp lines? If lines are not clamped and catheter is displaced air embolus ( line dislodged)

or significant hemorrhage (return line dislodged) are likely.

LOSS OF POWER AND BATTERY

Call ECMO Team for help

If power failure, battery should take

over. You will hear an alarm when the

circuit switches to battery. Battery

time is 30 – 60 minutes.

If batteries fail, hand pumping initiated

Circuit should always be plugged into

emergency outlet with power lines

secured to floor

CARDIAC ARREST

Call ECMO Team and Intensivist STAT Surgeon should be called ASAP Patient may be defibrillated or paced

VA ECMO provides full cardiac support & CPR should not be required. Just treat the arrhythmia or hypotension. V-V ECMO is different and CPR may be required.

CPR is ok unless open chest

AIR EMBOLISM

If air is observed in circuit, clamp circuit & call ECMO Team STAT ECMO Team will address air removal from circuit. Nurse will position patient head down, maintain blood pressure & place patient on 100% FiO2 on ventilator. Call RT to reset ventilator for rescue support

Causes: Air entrained from an inadequately positioned catheter; Breakage or crack in a connector on the pre pump access cannula; accidental introduction of air to the circuit. Take caution in preventing catheter disruption/cracks when moving patient, bed, or when equipment (x-ray, CVVH, TEE, etc) is brought into room From a nursing standpoint, it is extremely importrant to keep all central line ports closed and avoid any introduction of air into the patient. Why? The negative pressure in the venous access line can pull air from an open port in a central line. Be careful with your lines! If gravity flowing albumin, blood products or fluid, watch carefully and clamp before air can enter blood stream. No vented bottles, they may introduce air.

References:

• ELSO Guidelines: https://www.elso.org/Resources/Guidelines.aspx • ECMO Specialist Training Manual 4th Edition – ELSO

https://www.elso.org/Publications/ECMOSpecialistTrainingManual4thEdition.aspx • ELSO Recommendations for training:

https://www.elso.org/Portals/0/IGD/Archive/FileManager/97000963d6cusersshyerdocumentselsoguidelinesfortrainingandcontinuingeducationofecmospecialists.pdf

• ELSO Registry of Extracorporeal Life Support Organization. Michigan: Ann Arbor, 2015 • https://www.elso.org/Registry/Statistics/InternationalSummary.asps. • https://www.elso.org/Education/ECMO101IntroductoryModules.aspx • Adelaide ECMO Manual: http://www.icuadelaide.com.au/manual.html • ECMO Nursing care responsibilities.pdf - Central Adelaide

...centraladelaidelol.com/.../ECMO%20Nursing%20care%20%20responsibi • Monitoring & Nursing ECMO: slide show with key points for nursing care of ECMO patient:

http://www.slideshare.net/velianton/ecmo-nursing-monitoring • ELSO Recommendations for training:

https://www.elso.org/Portals/0/IGD/Archive/FileManager/97000963d6cusersshyerdocumentselsoguidelinesfortrainingandcontinuingeducationofecmospecialists.pdf

• ECMO Nursing care responsibilities.pdf - Central Adelaide ...centraladelaidelol.com/.../ECMO%20Nursing%20care%20%20responsibi...

DAMAGE TO LINE

If the line is damaged and leaking you can do the following and call ECMO Team

Take caution in preventing catheter disruption/cracks when moving patient, bed, or when equipment (x-ray, CVVH, TEE, etc) is brought into room. Do not use alcohol on circuit.