Transcript Slide 1

Jason Lippy, RN
Paula Minor, RN
University of Maryland Medical Center
March 2012
What is ECMO?
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Extra Corporeal Membrane Oxygenation
Blood is drained from the venous system
 Oxygenated through an artificial lung,
removing carbon dioxide
 Returned to the patient
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Goal of ECMO
Ensure oxygen supply meets/exceeds the
patient’s demands
 Prevent end organ dysfunction and tissue
death.
 Rest heart and/or lungs
 Allow time for healing
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ECMO FLOW
Blood Flow
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1. Deoxygenated Blood Drained
from Venous Circulation
2. Blood Pump
Centrimag
Rotaflow
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2
4
1
3. Membrane Oxygenator/
Heat Exchanger (Quadrox)
Hollow fiber
polymethylpentene
4. Oxygenated Blood Returned
to the Patient
5. Pressure monitor
Venovenous (VV) ECMO
Blood is drained FROM and returned TO the
venous circulation
 Does NOT provide hemodynamic support
 Goal is to rest the lungs
 Allow time for healing
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Venoarterial (VA) ECMO
Provides pulmonary and hemodynamic
support
 Heart and lungs are bypassed
 Venous/drainage and arterial/return
 Nonpulsatile
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Multidisciplinary Team
Critical Care Physician and/or Surgeon
 Attending Physician / Nurse Practitioner
 Bedside RN / Resource RN
 ECMO Specialist (RN, RT or Perfusionist)
 Respiratory Therapist
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Communication is the Key!!!
Pre-ECMO Management
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Documentation
 Consent, Orders, Current Type X
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Bedside
 ECMO,open chest & code cart, back-up ECMO (on unit),
central line cart
 PRBC, heparin, NS, sedation, narcotics
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Pre-Procedure
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Are New Lines Needed?
Wound Care Consult (Specialty Bed)
Gastric Tube /Small Bowel Tube Placement
Baseline Neuro, pulse, ECG, labs
VV ECMO:
Two Site Cannulation
 1 Drainage, 1 Return
 Internal Jugular Vein
 Femoral Vein or Saphenous
Vein
Cannulation Dressings
Cannula Positions
Single Site Cannulation
 One double lumen
catheter is inserted
through the right IJ
into the right atrium
 Blood is drained
and returned
through separate
lumens in the same
cannula
www.avalonlabs.com
ECMO Considerations Based
on Systems
Neurologic
Management / Goals
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Brain Injury
Sedation Vacation
RASS 0 to -2 by Day 3
Pain
Cluster Care
ECMO Considerations
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CNS insult prior to ECMO
Watch for signs of Intraventricular
Hemorrhage/Infarct
First 72 hours difficult sedation
titration
Propofol (watch Triglycerides)
Precedex (brady)
Narcotics
Cardiovascular
Management / Goals
ECMO Considerations
Sinus rhythm
 MAP appropriate for
age and condition
 Pulses (VV ECMO)
 Extremities
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Chattering
 Volume Deficit
 ECMO Flow
 Pulmonary HTN
 Right sided heart
failure
 Vasoactive use
Respiratory
Management / Goals
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Minimal Vent Settings
Pulmonary Toilet
Frequent
Repositioning
ECMO Considerations
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Daily Chest X-ray
CO2 control
ETCo2 monitor gradient
“Red Rubber” suction
Specialty mattress
Prone
Respiratory
ABG
Patient &
Arterial side of oxygenator
VBG
Venous side of oxygenator
RECIRCULATION!!!
Heme Issues
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Appropriate HGb for the appropriate situation
 Remember blood can be bad
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Heparin bonded cannula
Centrifugal pumps less damage
Anticoagulation
 ACT (Hourly initially the your call)
○ Target 160-180
 Anti Xa (q 6 hours when stable q 12)
○ Target 0.3-0.7
 Platelet >50,000
 Daily TEG Analysis, Plasma Free Hgb, LDH
Hemoscope TEG-Based Guidelines
TEG® Value
Clinical Cause
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Suggested
Treatment
x 1 FFP or 4 ml/kg
R between 7 - 10 min
 clotting factors
R between 11-14 min
 clotting factors
R greater than 14 min
 clotting factors
MA between 49 -54 mm
 platelet function
MA between 41 -48 mm
 platelet function
x 2 FFP or 8 ml/kg
x 4 FFP or 16
ml/kg
0.3mcg/kg
DDAVP
x5 platelet units
MA at 40 mm or less
 platelet function
x10 platelet units
Angle less than 45°
LY30 at 7.5% or greater,
C.I. less than 3.0
LY30 at 7.5% or greater,
C.I. greater than 3.0
LY30 less than 7.5%, C.I.
greater than 3.0
 fibrinogen level
.06 u/kg cryo
antifibrinolytic of
choice
anticoagulant of
choice
anticoagulant of
choice
Primary fibrinolysis
Secondary fibrinolysis
Prothrombotic state
Gastrointestinal
Management / Goals
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Small bowel feeding
Daily Stool
Gastritis Prophylaxis
ECMO Considerations
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Bleeding
Ischemia
Hyper-bilirubinemia
 not always hemolysis
Renal
Management / Goals
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ECMO Considerations
Even Fluid Balance
Renal protection therapy
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 Good CI
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 Good MBP
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SCUF -Hemo concentrator
CRRT (prisma flex)
Hyperosmomolar /
hyperoncotic
pH control
Skin
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Frequent Repositioning
Specialty Mattress
Aseptic Technique
No New Sticks
Wound Care Consult
Edema
Patient and family support
Must define prognosis
 Help MD understand family expectations
 Should define end-points
 Team communication
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Intra Hospital Transport
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Group Effort
 Trial Run – scout the path
 Transport Team
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…Don’t Do It !!
The Future of ECMO
References
Allen, S., Holena, D., McCunn, M., Kohl, B., & Sarani, B. (2011). A review of the fundamental principles and evidence base
in the use of extracorporeal membrane oxygenation (ecmo) in critically ill adult patients. Journal of Intensive Care Medicine
(Sage Publications Inc.), 26(1), 13-26. Retrieved from EBSCOhost.
Bojar, R.M. (2011). Manual of Perioperative Care in Adult Cardiac Surgery Fifth Edition. Hoboken, NJ: Wiley-Blackwell.
Gay, S., Ankney, N., Cochran, J., & Highland, K. (2005). Critical care challenges in the adult ECMO patient. Dimensions of
Critical Care Nursing, 24(4), 157-164. Retrieved from EBSCOhost.
Peterson, K., & Brown, M. (1990). Extracorporeal membrane oxygenation in adults: a nursing challenge. Focus on Critical
Care, 17(1), 40-49. Retrieved from EBSCOhost.
Santiago, M., Sanchez, A., Lopez-Herce, J., Perez, R., Del Castillo, J., Urbano, J., & Carrillo, A. (2009). The use of
continuous renal replacement therapy in series with extracorporeal membrane oxygenation. Kidney International, 76(12),
1289-1292. Retrieved from EBSCOhost.
Scott, L., Boudreaux, K., Thaljeh, F., Grier, L., & Conrad, S. (2004). Early enteral feedings in adults receiving venovenous
extracorporeal membrane oxygenation. JPEN Journal of Parenteral & Enteral Nutrition, 28(5), 295-300. Retrieved from
EBSCOhost.
Short B.L., Williams, L (2010) ECMO Specialist Training Manual, Third Edition. Michigan: Extracorporeal Life Support
Organization
References
Sievert, A., Uber, W., Laws, S., & Cochran, J. (2011). Improvement in long-term ecmo by detailed monitoring of
anticoagulation: a case report. Perfusion, 26(1), 59-64. doi:10.1177/0267659110385513
Van Meurs K, Lally KP, Peek G, Zwischenberger JB (2005) ECMO: Extracorporeal Cardiopulmonary Support in
Critical Care, Third Edition. Michigan: Extracorporeal Life Support Organization