Foundations of ECLS: NursingPRESENTED BY: CHARLES ELLIOTT BSN, RN, CCRN-CSC

Warm Up #1

Patient arrives from cath lab s/p PCI x 2 to the LAD with acute cardiogenic shock resulting in ACLS initiation and subsequent ECMO cannulation. The patient has been in your room for about 45 minutes and as you’re drawing labs the O2 sat drops from 100 to 62 with a good pleth. The patient becomes bradycardic, has a MAP of 37 and is circling the drain fast. What do you do?

Entering The Room

Start at the patient Assess cannulation sites (bleeding, integrity, hematoma,

etc.) Assess cannulas (color, integrity, tie bands, sutures etc.) Assess oxygenator/pump if able Heater Emergency equipment on circuit Room air, Oxygen and power cables

Getting Report

Extensive discussion of head to toe assessment Cannula size and Location Any adverse or atypical events on the last shift Location of any fibrin/clots in the cannulas or in the

oxygenator. Pre and Post gas. Current RPM, Flow, Low Flow alarms and any other

applicable data.

Assessment

Detailed and precise assessments should occur on an hourly basis to ensure optimal intensive care and monitoring

Hourly Assessment: Vital signs q 15mins x 4, q 30mins x 2, and q1h while on

ECMO Temp, HR, cardiac rhythm, RR, SpO2, FiO2, O2 device,

CVP, PAP (if present), ABP, Adv. Hemodynamics (SVO2/CI/CO), Pump Speed, Pump Flow, Sweep, Drips

Head to Toe assessment

Neuro Patient at increased risk for embolic or hemorrhagic

event. Neuro status is necessary for goals of care and trending. Neurovascular assessment of all limbs especially limbs

with cannulas. Dopplers should be available to assess pulses

Head to Toe Assessment

Respiratory Daily CXR Regular auscultation of lung fields Elevate head of bed and continue q2h oral care Rescue ventilator settings

Head to Toe Assessment

GI/GU Increased risk for gut ischemia & GI bleeds. Be wary of NG tubes Increased risk for AKI. Trend labs and watch urine for

signs of hemolysis. Recommend Renal consult ASAP Strict hourly I&O’s

Head to Toe Assessment

Skin You name it, I’ve seen it. Increased risk for HAPI Frequent turning/offloading is a must and not

contraindicated. Bathe normally, use of CHG wipe or soap at least once a

shift. Eyes

Warm Up #2

You’re on night shift, you assess your patient, they’re a GCS of 15. Everything looks good, and you shut the lights off for the night. You begin to chart and just as you’re about to save…. The ECMO alarms, you enter the room, flip the lights on only to find an arterial cannula spraying the room with blood. What do you do?

Multidisciplinary Rounding

Daily objectives, possible procedures, and goals should be covered in detail

Previous 24 hour events and/or issues, lab results, and medications should be reviewed

All updates and concerns should be addressed by the rounding team in a timely manner - updates should be given by nursing, perfusion, RT, PT/OT, RD, etc.

- If ambulation is possible, timeframes should be scheduled to ensure availability of staff and resources at this time

Dressings Hourly monitoring of cannulation site(s) should be

performed by the primary nurse Any bleeding or saturation of dressings should be

immediately reported to the CT-Attending, CT Fellow, CT ARNP, and/or perfusion.

If dressings become saturated, the primary nurse should reinforce and/or change the dressing under sterile procedure (with sterile gloves, masks, gauze, sterile OR towels, Biopatch, and sterile tegaderm as needed with thorough caution)-All dressing changes should be performed by primary RN with perfusion at the bedside if there is any suspicion of cannula instability.

Troubleshoot oozing

LABSUsual orders include: ABG Q2 x3, Q4 x3, Q8 x3, Q24, if any changes needed,

restart sequence - q 8 hours & PRN: H&H, CBC, BMP, Mag, Phos, Lactate

Ica, K+ - q 24 hours &PRN: Free Hbg, aPTT, LDH, LFTs, pre and

post gases Maintain a type and cross of 4 units PRBC at all times Various other laboratory orders may be placed at the

discretion of the managing service.

Nutrition Nutrition should be addressed as soon as possible to

supplement loss of PO intake. RD should be present at AM rounds for daily updates Post-pyloric DHT should be placed as soon as possible

- tube feeds should be initiated whenever possible- if vasopressors infusing, trophic feeds should be

initiated Gastric OG/NG tube should be placed as soon as

possible if patient is intubated for decompression, content removal, and to prevent aspiration

Positioning Each case is unique and specific based on type and

location of cannula Positioning and turning should only occur when the

patient is hemodynamically stable and can tolerate movement

Patients with central cannulation with an open sternum should not be turned and alternative pressure point diversions should be used at all times (i.e. Z-flo/sheep skin)

complete (>45 degrees) turning should be timed with resources present whenever possible

nocturnal turning (1800-0700) should be performed with caution at all times

PositioningOrganization to turn alleviating pressure points: extra personnel should be present at all times primary RN should be responsible for cleaning and

assessing the posterior aspect of the patient secondary RNs and/or NCTs should be designated to

turn, monitor vital signs and monitor ECMO access site and lines/tubes

Perfusion staff should be designated to manage and monitor the circuit for any kinking, tension, labile flows and/or oxygenation status-must always be at bedside to turn

Transportation Intra-hospital transportation (Radiology, OR, Cath Lab) should only

occur based on the essential and critical needs of the patient Coordination /organization between radiology, RT, perfusion, CT

service, CCM, and nursing staff should be performed to guarantee available resources and timing

primary RN should be responsible for monitoring the patient during movement and throughout the procedure

secondary RNs and/or NCTs should accompany the movement of the patient to destination

perfusion should be responsible for monitoring the circuit, pump, and cannulae during movement and throughout the procedure

CCM/CT service member should accompany any movement of the patient if at all possible to assist at any point an emergency occurs

Weaning Should be done with the approval of the Attending MD in

communication with the perfusionist and primary nurse.VA weaning: Initiation of Inotropes (Dobutamine, Milrinone) and

Epinephrine drips usually occurs for vasoactive support Occurs by decreasing RPM’s (flows), increase vent settings as

indicated, ABGs as orderedVV weaning: Occurs by decreasing FiO2 % and sweep via blender and

flow meter. Flows will be decreased as well. Increase vent settings as indicated, remove O2 from circuit,

ABGs as ordered

Warm Up #3

Patient is on VA ECMO. ABG comes back with a PaO2 of 45 and an O2 saturation of 80. Circuit is intact with perfect oxygenator function. Vent settings are PRVC, 40% FiO2, rate of 15, peep of 8 and volume of 450. What’s happening and what do you do?

Pre-Cannulation

Assign Roles Remove all excess furniture and equipment from room. Pull patient bed away from wall, patient nude in neutral

alignment. Bilateral neck and groin shaved and prepped. Place defib pads on patient Ensure meds at bedside: vasoactive, anticoagulation,

sedation.

Pre-Cannulation

Drips primed and ready to go IVF: LR, NS, Albumin Blood products if needed. Ensure Type and Cross for 4

units is sent immediately. Assist MD with insertion of new lines or switching lines. Have all supplies brought to the room and available. Baseline labs should be sent at this time.

Final Notes

Bedside ECMO Cannulation is becoming common practice

Requires multidisciplinary teamwork Nursing judgment is crucial and critical in all ECMO

patients It is the nurse’s responsibility to provide meticulous

assessments, thorough analysis of laboratory results, and comprehensive communication with the multidisciplinary staff

Final Notes

Most importantly, the primary RN is responsible for optimal intensive care and monitoring, as well as monitoring the ECMO circuit

At all times, presence at the bedside while any other personnel and/or family members are in the room is imperative

Family members should remain in a predetermined area on the side of the bed opposite of the circuit, pump, and cables to avoid unnecessary contact