ecmo part 2 by dr.tinku joseph

Extracorporeal Membrane Oxygenation

Part - 2

Dr.Tinku JosephDM Resident

Department of Pulmonary medicineAIMS, Kochi

Email-: [email protected]

Contents in ECMO part 1

What is ECMO ? Evolution of ECMO Various Trials Types Indications Veno-venous V/S veno-Arterial

ECMO. Cannulation and Circuit

Contents in ECMO part 2

Monitoring ECMO patients Ventilatory strategies Sedation and pain control Weaning Complications Recent advances

Monitoring ECMO patients

Who comprises the ideal team?

Two intensivists (ECMO intensivist) and/or cardiothoracic surgeons: cannulation

One Medical Officer: monitor cannula position by ECHO

One Medical Officer: clinical management Perfusionist: ECMO priming and

maintenance Respiratory Therapist: lung protective

management, ventilator settings

• Nurses:– assists in the procedure.– supports clinical

management.– ONGOING CARE FOR

ECMO PATIENT• Radiologic Technician

Who comprises the ideal team?

Protocol for initiation and stabilization of ECMO

1) Check the cannula site2) Check all ports3) Connect the pressure tubing to the pressure line4) Connect the flow sensor to the flow meter5)Note patient vitals (prior to starting ECMO)6) Send pre –ECMO investigations: ABG, VBG, CBC


7) Confirm bolus dose of heparin is given8) Confirm the availability of blood and blood products9) Check for ACT machine10) Request Xray plate from radiology and place under

patient.11) Confirm circuit is primed properly


12) Connect Venous end of circuit to venous cannula13) Connect arterial end to artery (VA) or jugular vein

(VV)14) Recheck everything15) Open arterial clamp, clamp the bridge and then

open venous clamp for roller pump.16) Before starting ECMO start centrifugal pump to

provide forward flow


17) start the pump with flow of 20 ml/kg/min and gradually increase the flow after every 5-10 mins by 10ml/kg/min up to the desired flow.

18) Adjust gas flow to blood flow ratio 0-5:1 and start FiO2 of 21% and slowly increase to 100%.

19) Check for the color of venous and arterial blood.


20)Attach heater cooler unit to oxygenator and adjust temp to 37c

21) Check vitals again22) Check pre pump, pre and post oxygenator

pressures.23) Once desired flow is achieved come down on

ventilator settings to baseline.24) Monitor MAP-: 60-70mmhg25) Reduce inotropes26) If BP is high use NTG

27) Check ACT & ABG after one hour of starting ECMO28) If ACT is around 200 seconds then start with

heparin infusion @ 20 units/kg/hr29) <160 -: bolus dose of heparin30) >200 -: decrease heparin dose31) Monitor ABG -: Adjust ECMO settings


Nursing Considerations:

•

Nursing Actions Maintain strict infection control. Restrict access to essential personnel. Remove unnecessary invasive lines. Ensure that all required invasive access are

present, eg. NGT, core temp probe. Secure ET tube to maintain access during

procedure maintaining the sterile field.

Ensure crash trolley in close proximity Ensure fecal softeners as prescribed. Prepare and position patient. Place appropriate

mattress on bed. Clip hair on the proposed site with electric razor. Move the bed so the ECHO machine, ECMO trolley

and sterile field can be positioned

Nursing Actions

Nursing Assessments

• Routine Assessments:– HR, SaO2, SBP, MAP

• Hourly Assessments:– Neuro-vascular observation– Urine output– Core temperature– Ventilator observations

• Regular Assessments:– CVP– Neurological assessments– Sedation level

Dressing the cannula Only if there is significant exudates

or if not intact or secured. Required two nurses for dressing.

Dressing changes preferable in day shift.

Pull the dressing off towards the insertion site.

Blood Works and Diagnostics

Ensure current crossmatch PRBCs are available.

Daily electrolytes, Mg and LFT. CBC BD and as sos. PLATELET COUNT Daily blood cultures during spike of fever or

ideally beginning at 5th day of therapy. Pre and post oxygenator ABG c/o

perfusionist. ACT every 2 hours x 24 hours. APTT every 6 hours, target 55-75 s or as

specified by intensivist.

Ventilatory strategies

ELSO GUIDELINES FOR RESPIRATORY SUPPORT: Indication: “In hypoxic respiratory failure due to any cause ECLS

should be considered when the risk of mortality is 50% or greater and is indicated when the risk of 80% or greater.


A) 50% mortality risk can be identified by PaO2/FiO2 <150 on FiO2 >90% and/or Murray score 2 to 3. (Consider ECMO)

B) 80% mortality risk can be identified by a PaO2/FiO2 <80 on FiO2 >90% and Murray score 3 to 4. (ECMO Indicated)

2) Co2 retention due to asthma or permissive hypercapnia with a PaCo2 >80 or inability to achieve safe inflation pressure (Pplat <30cmH2O).

3) Severe air leak syndromes.


Goal -: to let the lung rest and yet not allow total lung collapse.

ECMO provides adequate gas exchange. Reduces chances of VILI. Patient may not require intubation at times. Low tidal volume required Less sedation Early rehabilitation.


Sedation and Pain control

Goal: Keep the patient comfortable

with minimal sedation Daily interruption-give awake

cycle Avoid muscle relaxant as far as

possible.


Indications for sedation: To relieve pain and anxiety Decrease O2 consumption and CO2 production Prevent patient from removing lines Patient ventilator asynchrony To give normal sleep pattern at night Before any procedure


Indications for muscle relaxants: Patient ventilator asynchrony When patient movement interferes

with venous return To prevent accidental decannulation

– due to excessive patient movement

In awake patient:

Better lymphatic drainage from the lungs with the spontaneous breathing as compared to positive pressure ventilation.

Lesser haemodynamic effect, lesser ventilator requirements and peak pressures.

Better infection control

Weaning

After giving adequate rest to the organ.

When they show signs of improvement.

Criteria for weaning trial

RESPIRATORY: CXR is improving Lung compliance improve: compliance >0.5 mL/kg ABG- on rest ventilator setting with moderate ECMO

support PaO2 >60mmhg PaCo2 <50mmhg PH >7.35 Successful 100% oxygen challenge test.

CARDIAC: HR <120/min Systolic BP >90mmhg or pulse pressure >40mmhg,

mean arterial pressure >70mmhg CVP <12 mmhg Urine output > 0.5 cc/kg/hr (ARF case excluded) Good tissue perfusion as revealed by blood lactate <3

mol/L and SVO2 >65% CXR improving 2 D Echo-: EF >40%

Criteria for weaning trial

Method of weaning- VA

Slow gradual process Moderate ECMO & moderate ventilatory settings

(FIO2 <40%, PEEP 8-10)Method 1 Upgrade ventilatory settings and start inotropes if

required. Gradually reduce blood flow (10 ml/kg/hr). Continue

till minimum flow Heparin should be maintained to prevent circuit

clogging.

Method 2: Withdraw a total ECMO support for few minutes and

observe parameters If patient tolerates gradually period of off ECMO is

increased. Patient can tolerate >2 hours off ECMO, consider

decannulation

Method of weaning-VA

1) Decreasing pump flow (20 ml/kg/min) -: Not used now a days.

2)Oxygen supply is reduced. More simple way. FiO2 is reduced by 5% every 30 minutes. Ventilator

setting is upgraded. FiO2 is 21% then sweep gas flow is being reduced by

10% every 30 minutes Alternate method: Only sweep gas reduced. FiO2

unchanged.

Method of weaning-VV

Rush weaning

Forced to remove ECMO even when higher degree of support is required

Indications: Massive bleeding Severe haemolysis Worsening intracranial bleed Infection related to cannula

Risk of continuing ECMO is more than risk of discontinuing ECMO

Decannulation

Ensure two medical staff are involved in the removal of the cannulas, while a third medical staff clinically manage the patient.

Coordinate with perfusionist and respiratory technician about the plans.

Ensure that direct pressure is applied on the insertion site for at least 20 minutes and the ECMO intensivist will remain with the patient until hemostasis achieved.

Coordinate with intensivist about the need for sedation and pain medication before the procedure.

Carry out successive Doppler assessment of the decannulated limbs after catheter removal.

Complications

• PATIENT RELATED:• Bleeding• Hemolysis• Recirculation• Infection

• CIRCUIT RELATED:• Clot

formation• Plasma Leak• Oxygenator

Failure• Heat

Exchanger Failure

• Tubing, Connector Cracks and Blood Leakage

• EMERGENCIES:• Pump Failure• Decannulation• Air Embolism • Cardiac Arrest

Bleeding

Hourly cannula site assessment. Monitor clotting time, Hb, platelets. Ensure access sites are stabilized. Do

not dislodge clots directly from wounds or insertion sites.

Maintain enteral feeding if tolerated; ulcer prophylaxis.

Report blood loss. Ensure current crossmatched PRBC. Give blood products as ordered.

Hemolysis Monitor the lab results( CBC, U/E and urine) Hourly assessment for movement(kinking) of the access

cannula Hourly assessment of the temperature of the heat exchanger

Thromboembolism

Recirculation

Monitor the SPO2 and ABG values Colour of RETURNED BLOOD Ensure catheter security during patient

movement.

Infection

Prevent high risk of nosocomial infection. Closely watched for signs of infection

Circuit Related Complications

Clot formation Maintain anti-coagulation as prescribed Plasma Leak. Oxygenator Failure Heat Exchanged Failure Tubing Cracks or blood leakage

ECMO Emergencies

Pump failure- power check Decannulation- reinsertion Air embolism-

Cardiac Arrest- VA ECMO- - No Chest compression -VV ECMO-chest compression

ECMO Emergencies

Future of ECMO

Increased accessibility and use Reduction in costs Insurance / government support Smaller lines / volumes /

oxygenators Coated “stealth” tubings (nano

particles). Smaller or portable ECMO

machines

Newer ECMO machines

When God is going to do something wonderful he begins with a difficulty…….If he is going to do something very wonderful. He begins with a……..ECMO Machine(Quote by an ECMO survivor)

ecmo part 2 by dr.tinku joseph

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