I was just wondering how many of you utilize adult ECMO at your facility? We've had quite a few of them recently... two major successes, and two, which I can only describe as likely to end up as "epic fails." We recently started doing a lot more heart transplants, and thus, our ECMO usage has increased.
I am also wondering about staffing ratios and if you have specific policy/procedures and/or order sets you utilize when someone is on ECMO. I really like taking care of these patients, and I'm interested in possibly getting some ideas to help set up some order sets for my unit. Our NICU does a lot of ECMO, but obviously a preemie on ECMO is a whole different ball game, and typically our adults need arterio-venous instead of just veno-venous assistance.
As it is now, we currently begin with a 2 nurse to 1 patient ratio when a patient is first put on ECMO. Once the patient has stabilized somewhat, we go to 1:1. A perfusionist is also present 24 hours. There are at least 4 doctors who currently do ECMO setups, and each one of them has a different idea of what the Hgb/Hct should be, as well as lab frequencies, so it's a huge pain when one is initially set up, since they typically don't think to write these types of orders until we call 5 times to ask.
For example, one doc wants Q2 hr ABGs and lactic acids, but didn't want to check the H+H/plt any more than Q8 hrs, until my patient's platelets kept coming back critically low, and I got him to change the frequency on those tests. I think it would be a good idea to have a set list of orders from which the surgeon can choose from after he sets up the ECMO. For example, where he wants the ACT to be (usually 180-200), the parameters for H+H/plt, CVP parameters, standing orders for blood, platelets, albumin, etc, and boxes to check with lab frequencies.
I'd like to get some ideas so I can approach our UBC and my manager about this, so that we can make it a little more streamlined in the future. Any input would be greatly appreciated (heck, if you have an order set, feel free to message me for my e-mail address, if you wouldn't mind sharing it).
Apr 24, '09
I was just at a conference this past Saturday discussing the use of vv-ECMO in ARDS. They're having some success with it-- especially long-term morbidity-- at St. Lukes in Houston by initiating ECMO at the onset of ARDS versus its prior use as a last-ditch effort. I'm not all that familiar with va-ECMO, though-- we're just a community hospital just about never keep anything more complicated than IABP.
Apr 24, '09
Actually one of our vv ECMOs right now is an ARDS patient.
Apr 24, '09
Do you have an "ECMO team"? Or are your patients managed by your CV team? I come from the Pediatric world but we do alot of AV and VV ECMO in the PICU.... RDS and CV population. We have an ECMO service with it's own docs(which are Peds intensivists and neonatologists) that have come up with standing orders for VV and VA patients. Its nice because no one changes your lab times or goes to far off the "norm"- sometimes depending on the pt the will tolerate lower plateletts and such but for the most part its pretty standard.
Maybe you could form some kind of committe and work on a more standardized order set? I doubt my order set would help you ----- hopefully someone in the adult world has one for you! Good luck!
Apr 25, '09
Quote from PICNICRN
Do you have an "ECMO team"? Or are your patients managed by your CV team?
Unfortunately, there is no ECMO "team" at this time. The patients are managed by the CV surgeons, which is why it makes it a bit more difficult to streamline. I did e-mail my manager and ask if we can get a few people together to start discussing this... hopefully we can put something together!
Apr 27, '09
Honestly, I think it only takes one Doc with a special interest! Maybe you could "encourage" one of your docs to be the "director" of the ECMO team. Come up with a standing order set- frequency of labs, standing orders for blood products, ect.... they all think their way is the best! You should have them jumping at the opportunity to "make the rules" !
BTW... it is really nice that you have a perfusionist! jealous!
Apr 27, '09
We do tons of ECMO, both AV and VV. We use both for respiratory support and/or circulatory support as a "bridge to decision" regarding more permanent mechanical circulatory support. We also sometimes in people with both poor LVs and poor resp function transition from ECMO (using biomedicus or jostra pump) to longer term support by removing the oxygenator and adding a centrimag pump.
We have a perfusionist at the bedside 24/7 while there's an oxygenator inline. Once oxygenator is removed, artificial heart engineers run the centrifugal pumps for circulatory support. They are 1:1 initially in CTICU, then 1:2 once stable (next shift after implantation generally).
At my old hospital, we did come up with a protocol and course to train ICU nurses on taking care of ECMO. We were able to assist with perc insertion in the unit, and got great results. One of the intensivist docs was the champion and the ECMO program was his baby. We would call perfusion for oxygenator changes, but apart from that, nurses did the gases, altered sweep gas rate according to a nomogram, etc.
Nov 5, '09
Is your center registered with ELSO? IF so, query the ECLS.net regarding order sets, staffing, etc. All of those topics have been visited recently. It sure makes life easier to have everyone on the same page!
As far as staffing goes, I'll tell you about my center. We do about 70 patients/year, neonates-18yrs in the NICU, CICU, and PICU. We have a team of 9 full-time primers and 40+ ECMO Specialists (mix of nurses and RCP's who work in their own unit 2 shifts and for ECMO 1 shift if there are ECMO patients on. If no ECMO, the third shift goes back to their unit). All 3 units have attendings and fellows trained on ECMO, and each unit has their own 'ECMO director' MD. We follow order sets specific to 3 populations: neonates, peds/adults, and cardiac patients (any age). Thoses sets were developed by the units' Ecmo Director MD with LOTS of assistance from the ECMO primer/admin staff. The sets include standardized lab frequency/times, ACT ranges, parameters to maintain CO2/pH and/or BP, standing orders for blood/plt/ffp transfusions, CVVH when needed, etc.
The patients are usually staffed at a ratio of 1:1, plus an ECMO specialist for the pump. Occasionaly, the neo in the NICU will be stable enough that he's staffed 1:2, but the 2 pt's are next to eachother (seperated only by a curtain) and there's still a specialist sitting the pump.
Hope this helps!
Oct 10, '11
We run our ECMO patients as a 1:1 assignment. Occasionally we will take an ECMO patient and another light assignment but we try to not let this happen. We drawn labs frequently initially and then go to q4 or q6 hours. It really depends on the patient. Giving blood is based on the patients stability and appearance the H&H is not the only concern. We have perfusion in the hospital during the day and on call at night they are not in the unit 24/7.
So I have a question about pressure ulcers and what others do to prevent them in this population. We can't always turn these patients due to cannula position. Does anyone have advice?
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