Ecmo on bleeding adult

[Jessica1982]

Hi y'all,

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 :)

-Jess

[EricJRN, MSN, RN]

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.

[Jessica1982]

Hmm. No amicar. I will ask about that tomorrow when I work tho, see if the perfusionists have seen it work for adults. I have a feeling the perfusionists would freak out about giving it tho...with their greatest concern being the risks associated with changing out the oxygenator d/t clotting. I totally understand their reasoning... But also she's a transplant patient, right? So they're thinking "she's going to bleed, just replace it" and we're thinking, "all these products create more antibodies, possibly creating a difficult lung transplant match."

It's really frustrating. I am wondering if part of the problem is she's on flolan, which tends to drop her platelets. Her TEG yesterday way off..showing over anticoagulation. Sorry these are a lot if details that don't male sense unless you see the pt I guess.

I will ask about amicar. Thank you so much for the suggestion!

[Biffbradford]

Aren't you asking for medical advice?

[Jessica1982]

As I said, I'm asking for books, references, or experiences. Was just trying to paint the clinical picture.

[ghillbert, MSN, NP]

What pump are they using, some seem to be more tolerant of reduced anticoagulation than others before they thrombose. We like the centrimag pump. It's a lot more expensive than the maquet, biomedicus, jostra etc though. There are heparin-coated circuits.

You can switch to bivalirudin or other antiXa drug instead of heparin if HIT is suspected. Close anticoagulation monitoring with thromboelastography may be useful to optimize the "sweet spot" for anticoagulation.

There are various ventilatory options to optimize lung preservation but if she is awaiting lung transplant these may be irrelevant. Continual bronchs may be causing mechanical trauma that is better avoided or minimized since you can control her oxygenation through the ecmo circuit.

The bottom line may be that you need to stop anticoagulation all together. If it is necessary to prevent the hemorrhaging, you just have to do it and deal with swapping out the oxygenator or pump head as necessary. If you do this, they need to ensure low flow states are avoided to reduce the risk of thrombosis. As with all of these decisions, it's a risk/benefit assessment by the medical team.

There are lots and lots of ecmo protocols online if you google or search pubmed eg:

http://www.icuadelaide.com.au/files/manual_ecmo.pdf

http://www.perfusion.com/cgi-bin/absolutenm/templates/articledisplay.asp?articleid=1807

http://www.rch.org.au/cardiac_surg/perfusion.cfm?doc_id=7509

http://www.gosh.nhs.uk/clinical_information/clinical_guidelines/cmg_guideline_00062

http://www.med.umich.edu/AnesCriticalCare/Documents/Protocol%20Manual/Critical%20Care%20Protocol%207%20ECMO%20Section%20legal.pdf

[NotReady4PrimeTime, RN]

Aren't you asking for medical advice?

The prohibition regarding asking for medical advice is directed to those posts that read something like this: "My mother has end-stage liver failure and her doctor wants her to.... Should we agree?" It's not aimed at the sort of questions the OP has asked.

[Biffbradford]

I'm not trying to stir the pot, but it's up to the MDs to call the shots. They know how to research difficult patients as well as anyone.

[EricJRN, MSN, RN]

I'm not sure what came over me. If we just listen to what we're told and keep independent thought to a minimum, the good doctor will make everything okay.

I'm off to starch my cap now. If I behave, the doc may let me hold his stethoscope this week.

[felineRN]

I'm not sure what came over me. If we just listen to what we're told and keep independent thought to a minimum, the good doctor will make everything okay.

I'm off to starch my cap now. If I behave, the doc may let me hold his stethoscope this week.

Ha! I know this thread is quite old. However, hilarious!