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Christine Lasich RN, BSN, CCRNRandall/Emanuel Severe Cardio-pulmonary Failure and ECMO (RESCUE) Center.

ECMO Strategies for Refractory Respiratory Failure:

The Who, How and Why

The Extracorporeal Life Support Organization

2013 Award for Excellence in Life Support

Demonstrates High quality standards

Specialized equipment and supplies

Defined patient protocols

Advanced education of all staff members

www.ELSO.org

NO DISCLOSURES

No financial relationships to disclose

Any reference to a specific brand or product is not intended as an endorsement, but rather a reflection of the device or product with which we are familiar.

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OBJECTIVES

Describe the clinical indications for ECMO support and discuss how ECMO supports oxygenation and ventilation

Describe nursing actions required to prepare a patient for initiation of ECMO

Identify the unique multisystem nursing considerations for adult patients on ECMO

The ECMO teamClinical

Nursing – Bedside

Nursing – ECMO Specialist

Perfusionist

Respiratory Therapist

Physician Surgeon Critical Care

Interventional Radiology

Palliative Care/Social Worker

PT/OT/Speech Therapy

Dietitian

Administration

ECMO Manager

ECMO Director

ECMO Coordinator

Registrar

PI Coordinator

ECMO Bedside Educator

ECMO Specialist Educator

Extracorporeal Membrane Oxygenation (ECMO): What?Mechanical

cardiopulmonary or pulmonary support

May be configured Venoarterial (VA) or Venovenous (VV)

Lungs no longer primary site of oxygenation and ventilation

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The Cannulas

The PumpCentrifugal pumps

Most prevalently used

Improved performance with less complications

Preload and afterload dependent

The Oxygenator

Hollow fibers (<0.5mm in diameter) coated with polymethylpentene

Allow diffusion of gas but not liquid.

As blood flows through the oxygenator, “sweep gas” (oxygen) is piped through the inside of the hollow fibers

Oxygen and CO2 diffuse across membrane

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The Circuit

ECMO: How?Physiology of Extracorporeal

SupportIt comes full circle…

Drainage via venous cannula

Flow maintained by

centrifugal pump

Oxygen and ventilation via

membrane oxygenator

Blood warmed to

normothermia

Blood returned to patient via “arterial” cannula

Flow and Sweep

Flow = quantity of blood delivered (L/min)

Sweep = Flow rate of oxygen from blender to oxygenator

Flow O2

Sweep CO2

ECMO CIRCUITS Rotoflow

Cardiohelp

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Essential Components: Cannulas Tubing Pump Oxygenator Gas Blender Heat exchanger “Bridge” O2 Sat measurement Bubble detectors Monitors and alarms

Anatomy of an ECMO Circuit

Console

Arterial Blood Return Tubing: Oxygenated Blood returning to the patient.

Venous drainage tubing: Deoxygenated blood draining from the patient.

Heat Exchanger

Oxygenator

Centrifugal Pump

Bridge

Venous Oxygen Sensor

Display: SVO2, Hctand Hgb from venous sensor

The artificial endotheliumaka – the ECMO circuit

ECMO and Heparin

Anticoagulation is essential to prevent clotting in the ECMO circuit

Oxygenator

Centrifugal pump

This makes bleeding the #1 risk factor related to ECMO

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Extracorporeal Membrane Oxygenation (ECMO)

Does not “cure” anything

It takes over the work of the heart or lungs while they heal

ECMO: Why?

Improving efficacy and outcomes with advent of new technology

Increasing patient volumes = more experience = more informed practice

Conventional Ventilation of ECMO for Severe Adult Respiratory Failure (CESAR)

180 patients randomized to either conventional management group or consideration for ECMO treatment.

Eligible patients had potentially reversible respiratory failure and met strict entry criteria.

Findings: 6 month survival rate 63% versus 47% for control group.

50 100 150Analysis time (days)

Conventional ECMO

Kaplan-Meier survival estimates, by allocat

63 %

47%

Noah et al.JAMA 2011. Peek Lancet. 2009

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EOLIA trial ECMO to rescue lung

injury in severe ARDS (EOLIA)

Ongoing international randomized controlled trial

Daniel Brodie

ECMO: Where?Regional Referral Program

ECMO care requires a trained, multidisciplinary team

ECMO patients have improved outcomes when cared for at experienced, high volume centers“..., advanced critical care for profound ARDS, including ECMO, represents the type of time-dependent and high-reliability practice that might best be provided in a focused setting in which the provider and systems aspects of performance would benefit from a high density of experience.”

Michaels et al. (2013)

Why Transfer?

CESAR TRIAL: “We recommend transferring of adult patients with severe but potentially reversible respiratory failure, …, to a center with an ECMO-based management protocol to significantly improve survival without severe disability.” - Peek et al. 2009

JAMA: “For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non–ECMO-referred patients.” – Noah et al. 2011

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Who Needs ECMO?

• Refractory ARDS• Pneumonia • Sepsis • Severe respiratory failure • Shock • Near Drowning• Bridge to transplant• Trauma

ECMO Contraindications

Related to patient’s premorbid condition: Age and size

Contraindication to anticoagulation

Chronic condition associated with poor outcome

Underlying terminal condition not related to ARDS

Limitations to care (code status)

Related to treatment of current illness: Greater than 7 - 10 days on mechanical ventilator with

peak airway pressure > 30 cmH2O and/or FiO2 > 0.8

** Must have an endpoint to care **

** All Contraindications are relative **

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VA vs VV ECMO

PULMONARY FAILURE VenoVenous

CARDIAC FAILUREVenoArterial

VenoArterialECMOCardiac

May be applied for management of cardiac and/or respiratory failure

Blood access via central vein and central artery, primarily femoral

Controls up to 80% of patient’s total cardiac output (CO)

VenoArterialECMO

Patients who cannot wean from cardiac bypass

Refractory cardiogenic shock

Indications

o Bridge to VADo Bridge to transplanto ECPR

Must have endpoint to care

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VenoVenousECMO

Provides pulmonary support only

Relies on the patient’s native heart function to circulate the newly oxygenated blood

“IV Oxygen”

Blood access via femoral and / or internal jugular vein

Respiratory

CTA CHEST/ABDOMEN/PELVCTA CHEST/ABDOMEN/PELV

11/

HH

6/1/19596/1/195953 YEAR53 YEARFF

Page: 69 of 121Page: 69 of 121

Acq no: 10Acq no: 10KVp: 140KVp: 140mA: 564mA: 564Tilt: 0Tilt: 0RD: 400RD: 400

CTA CHEST WWO + ABDOMEN/PELVIS W CONTRASTCTA CHEST WWO + ABDOMEN/PELVIS W CONTRASTCTA CHEST 125mL iso 370 dwsCTA CHEST 125mL iso 370 dws

2/2/2013 3:16:01 AM 2/2/2013 3:16:01 AM2093077920930779

APPLIEDAPPLIED LOC: -996.20 LOC: -996.20

THK: 2THK: 2HFSHFS

IM: 69 SE: 5IM: 69 SE: 5Compressed 7:1Compressed 7:1DFOV:40x40cmDFOV:40x40cm

W: 1800W: 1800C: -585C: -585

Z: 1Z: 1

RR LL

AA

PP cm cm

VenoVenousECMOIndications

Severe Refractory Respiratory Failure from potentially reversible cause.

Type I (Hypoxemic) Respiratory Failure (severe) with P:F <80 on FiO2 >90% with a Murray lung injury score of ≥ 3.0.

Type II (Hypercapnic) Respiratory Failure with a pH ≤ 7.2.

Acute Respiratory Distress Syndrome (ARDS)

No effective pharmacological treatment

Cornerstone to therapy remains supportive care with mechanical ventilation

ARDS Network recommendations for volume and pressure limited ventilation strategies associated with decreased mortality

Despite ARDSnet strategy, some patients continue to decline

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Mild ARDS (PaO2 to FiO2 ratio 200 –300)

mortality: 27%

Moderate ARDS (PaO2 to FiO2 ratio 100 – 200)

mortality: 32%

Severe ARDS (PaO2 to FiO2 ratio < 100)

mortality: 45%

20202020

28% of all ARDS is “severe”

Current definition of ARDS aka, the “Berlin Definition”:

ARDS Definition Task Force, Raneri VM, Reubenfeld GD, et al: Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33

ECMO: When?

Recruitment maneuvers

Neuromuscular blockade

Inhaled NO / EPO

Prone Positioning

APRV

HFOV / HFPV

ECMO

Hypoxia becomes refractory to conventional management

NEED FOR VENILATORY

SUPPORT

Conventional Ventilation with

ARDSnet Strategy

Continue HFOV/VDR

Continue APRV

Continue ARDSnet Strategy

ALI/ARDS Inclusion Criteria PaO2/FiO2 <300 (ALI)

PAO2/FiO2 <200 (ARDS) Bilateral Infiltrates No LA Hypertension Acute Onset No LA Hypertension

Consider CT scan: evaluate for reversible issues Consider for Recruitment Maneuvers

Optimize Cardiovascular Status/Swan-Ganz prn Address anatomical issues: PTX, effusions, etc Evaluate for Proning, Paralytics, Nitric Oxide

Assessment of Patient Improvement:

P:F ratio >200 On FiO2 < 70% and PEEP < 12

Meeting Ventilation Goals pH >7.25

Place on HFOV (or VDR) Consider Transfer

Recruitment Maneuver Must be approved by physician

CPAP 40 cmH2O for 40 sec -OR-

eSIGH with PEEP 10cm above LIP

set PEEP above Lower Inflection Point at end of

maneuver

Place on APRV Consider Consultation or Transfer

Assessment of Patient Improvement

Assessment of Patient Improvement See selection criteria – Table 1

Consider ECMO Transfer

Consider Initial use of VDR for: Pregnant or obese patient Inhalation injury Massive Secretions/Lobar

collapse Status Asthmaticus Massive Air leak

Yes

Yes

Yes

Yes

No

No

No

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KEY POINTS

Increased ventilator days and high ventilator settings are associated with higher mortality.

Preferred fewer than 7 intubated days

The longer the patient has been sick, the longer they will be on ECMO.

Early referral saves lives!

Baseline labs **Type and Crossmatch** Hct and coags

Anticipate fluid / blood volume resuscitation

Place all lines and tubes prior to initiation of anticoagulation Central Lines Peripheral IV Foley Catheter Feeding tube

Before going on ECMO

Transformation

Intensive Care to Operating Room

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COMMUNICATION

Blood bank

Respiratory Therapy

Pharmacist

Operating Room staff

X-Ray

Family

Supplies

Heparin Monitoring for effect:

ACT (goal ~1.5x normal, 180-220 seconds)

Heparin level (0.2-0.4)

Optimize AT III (>80)

Direct Thrombin Inhibitors

Argatroban

Bivalirudin

PTT (45-75)

Anticoagulation

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Cannulation: Going on ECMO May be performed in ICU or OR

Full sterile prep and OR team present

Deep sedation / paralysis essential

Heparin bolused (50-100 units / kg) prior to cannula placement

Coordination between surgeon, perfusion and bedside RNs

This is a critical time. The room needs to be quiet for clear communication

ECMO flow slowly increased to maximum tolerated, then decreased to lowest level required for adequate support.

Sit back and watch the red blood flow…

And we’re on….

What could go wrong?

Patient is bolused with approximately 1liter of saline from ECMO circuit

This essentially empties blood from the heart temporarily

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Code situations

Full ventilator support

Titrate vasoactive drugs

May need blood and products

Prepare code cart and ACLS drugs

May need to emergently switch to VA

Bedside Nurse Manages the Patient

ComplicationsVessel injury

Occurs less than 5%

Lung injury

Thrombus

Air emboli

Equipment Malfunction

Emergencies

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Bleeding Emergencies

• Time to call the blood bank

• Know your institution’s resources and policies

ECMO is initiated Oxygenation improves immediately

Perfusion improved

Myocardial function improved

Pulmonary pressures decrease

Wean inotropes and vasoactive drips

Rest settings on ventilator

Diagnostic Procedures

Labs ABG guides ECMO therapyPTT 45-75

Chest X-rayCannula placement

Occasional testsEchocardiogramEKGUltrasoundCT

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Multisystem care of the ECMO patient

Cardiovascular / Hemodynamic

Respiratory

Hematologic Considerations

Neurologic / Sedation

Renal

Metabolic / Gastrointestinal

Skin

Family

Recovery vs. Futility

Decannulation

VV: Pt. dependent on native hemodynamic physiology Support with inotropes, vasoactives, fluid, blood etc. as indicated MAP >65

VA: ECMO flow provides primary hemodynamic support May require fluid / blood / vasopressors to augment Maintain MAP 50-70

Cardiovascular and Hemodynamic Considerations

Trend markers of perfusion / native heart function Lactate

ABGs

SvO2

Continuous pulse contour analysis (PiCCOTM, FloTracTM) – VV only

Echocardiography

Urine output, skin color/temp, cap refill, etc.

Pulmonary artery catheters?

Pt. temp controlled by heat exchanger

Additional Hemodynamic Considerations

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Infection Abx

Antiviral therapy (H1N1)

Inflammation Plasmapharesis

IVIG

Trauma Surgical repair

*Infectious Disease and Pharmacy input is crucial*

Treating the Underlying Problem

The lungs are no longer the primary site of oxygenation and ventilation!!!

3 R’s

Rest

Recover

Recruit

Respiratory Considerations

Reducing pressure and FiO2

ELSO Recs: Mode: pressure controlFiO2: 0.3PEEP: 10-15 cmH2OPIP: ~20 (PEEP + 10)F: 4-5

LEH: Mode: Volume Diffusive Respirator (VDR)FiO2: 0.4PEEP: 12*PIP: 24*F: 15Percussive Rate = 500

Other: CPAP, MMV, Extubation?

Rest

* VDR settings: PEEP = Oscillatory PEEP; PIP = Pulsatile Flow

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What is the VDR?A pneumatically powered, pressure limited, time-cycled, high frequency flow interrupter.

Delivers smaller, percussive tidal volumes at rates that range between 300-700 oscillations per minute at lower pressures.

Enhances oxygenation, promotes CO2 clearance and facilitates mobilization of secretions while minimizing barotrauma

Increased secretion clearance necessitates vigilant oral care and secretion maintenance by RN staff

* Kunugiyama SK, Schulman CS. High-Frequency percussive ventilation using VDR-4 ventilator: an effective strategy for patients with refractory hypoxemia. AACN Advanced Crit Care. 2012;23(4):370-389

Recruit Recruitment maneuvers

Positional Therapy

Bronchoscopy

Aggressive diuresis

Ventilator recruitment maneuvers

Initiated once lungs begin to show recovery

Pulmonary Hypertension Management

IV agents: Epoprostenol (Flolan), Nitroglycerin

Inhaled agents: Nitric Oxide, Epoprostenol

Tracheostomy

Pneumothorax (To drain or not to drain?)

Additional Respiratory Considerations

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Systemic anticoagulation essential

Bleeding is a major complication of ECMO Visible versus occult Common bleeding sites:

**ICH on ECMO usually extensive and fatal**

Minimize Hemolysis Monitor Plasma Free Hgb

Hematologic Considerations

Intracranial Mucous membranes

Cannulation Sites Central lines and PIVs

Surgical sites GI Tract

Vigilant monitoring Coagulation studies Plts, PT/INR, Fibrinogen, Viscoelastography (TEG™ / Rotem™)

Cannula sites, IVs, mucous membranes, neuro exam

Maintain Coagulation factors at acceptable levels Platelets ≥ 50,000* INR ≤ 2.2 Fibrinogen ≥ 100,000

Minimize venipuncture, fingersticks, insertion of tubes/drains, etc.

Bleeding Management(Focus on prevention)

Return coagulation status to normal

D/C anticoagulant infusion (if necessary)

Thrombostatic dressings

OR as last resort

When Intervention is Required: (Bleeding Management

continued)

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Maintain sedation and analgesia with least amount required to provide effective support & maintain safety

Daily awakening trials as soon as tolerated

Neuromuscular blockade?

Neurologic Considerations

**Note: Some medications shown to have increased adsorption to circuit and oxygenator**

Neuro Assessment Sedated and paralyzed? Hourly pupil response

assessment

Train of four

Low threshold for Head CT with neuro change

Pupilometry

Near Infrared Spectroscopy (NIRS)

Bispectral index monitor (BIS)

Renal Considerations

Euvolemia is the goal

Diurese aggressively

Hemofiltration

CRRT if necessary Directly into circuit

HD Catheter

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Place post-pyloric feeding tube pre-ECMO if possible

Early consult from dietician

Enteral nutrition as soon as tolerated

TPN until tube feed tolerated at goal rate

Probiotic supplements

GI continuity

Stress ulcer prevention

Blood glucose management per hospital critical care insulin management protocol

Gastrointestinal / Metabolic Considerations

Skin Care Considerations

Eyes

Mucous membranes

Blisters

Pressure points

Q 2 hour turning and ROM essential

Continence management

Include family as much as possible

Allow family presence in rounds

Include in plan of care

Honest and direct communication

Early palliative care consult

Family Care Considerations

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Possibility of stopping for futility should be discussed with family at outset of therapy

Promptly discontinue ECLS when there is irreversible organ damage and no option for transplant

Definition of irreversible damage depends on the institution and available resources

Arbitrary timeframes for recovery are discouraged

Futility

Hemodynamic stability

Patient tolerates decreasing ECMO Flow and Sweep

Evidence of clearing on CXR and bronchoscopy

Pulmonary “step-up”

Signs of Recovery

VV: Wean flow and sweep to minimal settings

Set ventilator to acceptable settings

“cap off” oxygenator

Maintain ECMO blood flow while monitoring SaO2, PO2 and CO2.

VA: Reduce flow.

Clamp access and return lines

Monitor SaO2, PO2 and CO2.

If VA for cardiac support, ECHO very helpful

Trial off

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May be performed at bedside if vascular repair not required

Anticoagulant off for 30-60 minutes

Get “comfortable”

Decannulation

Education and team maintenance

Intra-hospital Transport

Inter-hospital Transport

Program Considerations

Formal ECMO education process ECMO handbook for bedside nurses

Skills, drills, simulation, lecture, online SLMs

Collaborate with Pt. care champions

Additional mandatory CEUs

Roles Bedside RNs

Transport RNs

ECMO Specialists

ECMO Education and Team Maintenance

Simulation Lab

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Intra-hospital Transport• Have a plan

• Bedside RN is the team leader

• Clear hallways• Coordinate with receiving department

Inter-hospital Transport

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For additional information:

www.elso.org

ReferencesAnnich,., G.M., Lynch., W.R., MacLaren, G., Wilson, J.M., Bartlett, R.H. (2012). ECMO Extracorporeal Cardiopulmonary Support in Critical Care (4th ed.). Ann Arbor, MI: Extracorporeal Life Support Organization.

ARDS Definition Task Force, Ranieri V.M., Rubenfeld, G.D., et al. (2012). Acute respiratory distress syndrome: the Berlin definition. JAMA 307 2526-2533

Bibro C, Lasich C, Rickman R, et al. Critically ill patients with H1N1 influenza A undergoing extracorporeal membrane oxygenation. Crit Care Nurse. 2011;31:e8-e24

ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support Extracorporeal Life Support Organization, Version 1.3 November 2013 Ann Arbor, MI, USAwww.elsonet.org

ELSO Adult Respiratory Failure Supplement to the ELSO General GuidelinesVersion 1.3 December 2013 Ann Arbor, MI, USA www.wlsonet.org

Holleran, R. (2010). ASTNA: Patient Transport, principles and practice (4th ed). Mosby, INC.

Michaels, A.J., Hill, J.G., & Long,., W.B., Young, B.P. Sperley, B.P., Shanks, T.R., Morgan, L.J. (2013). Adult refractory hypoxemic acute respiratory distress syndrome treated with extracorporeal membrane oxygenation: the role of a regional referral center. The American Journal of Surgery,205(), 492-499

Noah MA, Peek GJ, Finney SJ, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A (H1N1). JAMA 2011;306:1659-1668

Peek GJ, Mugford M, Tiruviopati R, et al. Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet. 2009;374(9698):1351-1363

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Christine Lasich, RN, BSN, CCRNLegacy Emanuel Hospital

CLasich@lhs.org

Thank you!