Extracorporeal Membrane Oxygenation

  Definition • Cardiopulmonary Bypass • Pulmonary support • Cardiac support Outcomes • International • CCHMC

Indications

      Meconium Aspiration Syndrome Persistent Pulmonary Hypertention of the Newborn Sepsis/pneumonia Respiratory Distress Syndrome Congenital Diaphragmatic Hernia Congenital Heart Disease

Criteria

      Weight greater than 1.8-2 kilograms At least 34 weeks gestation Less than 7 days mechanical ventilation IVH less than grade II Failure of maximal medical management Potentially reversible lung disease

Personnel

  ECMO Team • Attending • Fellows • Patient care provider • ECMO specialist • ECMO primer Hospital Services • Ultrasound • Cardiology • Nephrology • Neurology • Operating room staff

Circuit Layout

Process

    Cannula Placement • Veno-arterial • Veno-venous ECMO flows Heparinization • Activated Clotting Time • Blood Products Respiratory Support

ECMO Cart

Bladder Box

Cobe Pump

Membrane Oxygenator

Heat Exchanger

CDI

Roles

   Patient Care Provider • RN who cares for the patient ECMO Specialist • RN or RRT who has received special education • Responsible for the ECMO machine and management ECMO Primer • ECMO specialist who has received further training and is able to prepare the ECMO circuit

Before going on ECMO

      Draw labs - includes type and cross Order blood products Obtain consent from family Prepare ECMO circuit (ECMO Primer) Draw up code drugs IV Access

During Cannulation

    Administer meds as ordered for pain/sedation/paralysis Monitor the patient as you would for any bedside surgical procedure • Frequent vital signs - especially blood pressure (may need to give volume) Have access to a stable IV site. You will be asked to give the loading dose of Heparin at some point during the surgery. Obtain CXR once cannulas are placed

During Run

       Switch all IV drips to ECMO circuit CVC Care Medication/blood product administration Double check everything with the ECMO specialist.

Cannula site care. Done Q4hrs. • Wash site with 1/2 strength H 2 O 2 , • Apply betadine ointment • Cover with sterile 4x3.

Physical care of the patient Lab draws

Decannulation

      Obtain IV access if needed. Move all drips to the patient before clamping.

Draw up code drugs Will continue the Heparin drip until the final decision has been made to decannulate.

Obtain consent for decannulation.

Give meds for pain/sedation/paralysis Usually continue Cannula site care for 24 hours after coming off ECMO

Emergency Care

    If the patient needs to be removed emergently from ECMO due to mechanical failure, there are several things you can do. You should have been shown how to take the patient off ECMO using V B-A. Clamp the Venous cannula, open the Bridge, clamp the Arterial cannula.

Call for assistance.

Manage the patient, You will need to ventilate (increase vent support or handbag). Administer meds/fluids as needed.

Have someone available to get needed supplies.

Complications

         Bleeding/Hemorrhage Reperfusion injuries Inability to wean Mechanical failure Electrolyte Imbalance Edema Renal Failure Hypovolemia Hypertension