I am a former traveler, now a permanent staff nurse in an icu in Texas, where we do bedside ecmo. This week I took care of my first ecmo pt: 35 year old, 45 kg korean woman, mother of three, with severe idiopathic pphtn, complicated by chf and congestive hepatopathy, who deteriorated on me over 2 days to the point of a pulmonary hemorrhage and the need for emergent intubation and canulation for ecmo as a bridge to lung transplant (which for money reasons is not an option til sept 1st...this is a whole other issue I could rant about, but will suppress). Sweetest people in the world, her husband and her. Her PA pressures had been running 90's-100's/40's-50's for the days I had her, despite medical management. She is still hemorrhaging to the point of needing bronchs 2-3 xs a day bc it's so bad she ceases to ventilate. Of course thank goodness for ecmo...but we need to keep her anticoagulated for the machine. The surgeons and intensivists are going back and forth with our heparin orders, trying to balance bleeding while preventing the oxygenator from clotting off. She tested HIT + buy we're waiting on a seratonin release assay to confirm...
Does anyone have any advice in dealing with this sort of patient? I welcome any ideas. I believe this hospital has only been doing ecmo at bedside for a year. Any books, references, experience stories would be so helpful. I'm mentally, emotionally, physically exhausted from the last 3 days, but I keep wanting to work extra to learn as much as I can, and I know her and her family so well now...
ANY advice would be great. I'm praying we make it until September first...then there's the transport we'll worry about. Ay ay ay.
Thanks in advance for taking the time to read all this
Is she on Amicar (aminocaproic acid)? Keep in mind that I am still measuring my ECMO specialist career with a wristwatch
and that I only do neonates, but we use Amicar for ECMO patients with bleeding or a risk of bleeding. It works by inhibiting the breakdown of fibrin plugs.
In newborns, it's fairly common that we use ECMO for things like congenital diaphragmatic hernia which may require on-pump repair. They'll add a continuous Amicar infusion (actually a bolus followed by continuous infusion) to the circuit prior to surgery in order to minimize bleeding. We recently used it to prevent worsening of a mild intraventricular hemorrhage in one of our babies.
Amicar can complicate your heparin management. Sometimes within a few hours you'll start to see quite a bit of clotting in the circuit. I'm not sure exactly how the HIT would affect the feasibility of using Amicar though.
Last edit by EricJRN on Aug 26, '11