Awake, alert, oriented & non ventilated...on ECMO??

Pediatric Critical Care Columnist · May 31, 2011

You're most welcome. It's true that protocols are very much determined by the facility running the program. Our program is about the largest in Canada, with an average of 40 runs a year for the last few years. Our protocols have evolved over that time as well, with the addition of a thrombosis team to help us manage our anticoagulation, the change in systems and as a result of some incidents that revealed some weaknesses in our education. It's important to make it as safe and effective as possible and that's what we're trying to do.

imaginations · May 31, 2011

I'm yet to experience paediatric ECMO, though paediatric intensive care is what I'm really interested in! I'm currently a third (and final!) year BN student and I've just completed my second last semester with two clinicals in adult intensive care, including one cardiothoracic specific placement. I am looking forward to my paediatric dedicated semester beginning in August and potentially getting some exposure to paediatric cardiothoracics and ECMO and discovered the differences in policy and procedure between the two patient populations.

One of the kids hospitals here (one of the very few!) recently set a record with one of their patients for spending the longest amount of time on ECMO.

Pediatric Critical Care Columnist · Jun 1, 2011

Peds CVT is very different from adults, as I'm sure you'll find. It's not so much a learning curve as it is a ladder!

Our longest run to date was 75 days. Sadly the outcome was not what we were hoping for.

imaginations · Jun 1, 2011

I believe this child ran over 76-77 days pre and post lung transplant (she wasn't even listed when she went on the pump) and is now successfully off the pump, out of ICU and on the ward! She was also transfered between the paediatric facility she was originally at to the transplant centre (adult facility but also currently the only heart/lung transplant centre in the state) on the pump.

porterwoman · Jun 2, 2011

http://abclocal.go.com/wtvd/video?id=8162701

umcRN, BSN, RN · Jun 2, 2011

http://abclocal.go.com/wtvd/video?id=8162701

Wow!! Thanks! :yeah:

IDoNotGiveOut · Aug 13, 2011

Where I work we have had a many adult patients on ECMO awake, ambulating, talking, eating. I admit it is a bit disconcerting at first to see a VV ECMO patient with central cyanosis and giant blood filled tubes sticking out of her neck sitting in a chair, eating a popsicle and texting her friends. But it's also kind of awesome to think that X days ago, this patient was paralyzed on 28 PEEP FiO2 1.0 and had a predicted mortality of >50%. These H1N1/pneumonia/TRALI/ARDS VV adults are ideal for this and getting them awake and even ambulating on ECMO are almost always the goals of care. I've never seen it in peds but I don't see why an older child couldn't do the same. Same with VA if the cannulas are in the neck.

If there are femoral cannulas the activity part is not possible but they can still do upper body exercises. There is no reason they can't be awake provided they are directable and cooperative. As far as extubation it depends on the reasons they are on ECMO (cardiac, respiratory, or cardiac and respiratory failure?). Say it is a primarily cardiac case with decent lungs that we can easily support on the vent and even anticipate extubation within a few days based on respiratory status however cardiac function is poor. That patient should probably stay vented, go on a VAD and get off ECMO, and extubate as soon as is appropriate. If respiratory failure is involved then they will probably be on ECMO for a bit longer. IF they are calm, comfortable and cooperative enough to be awake, then wake them up and extubate! It seems counter-intuitive to extubate with severe respiratory failure, but in a patient on ECMO whose lungs aren't doing anything, the oxygenator is their lungs, and the vent's pretty useless anyway. They can interact with their family, participate in care decisions, eat and drink, do coughing, deep breathing and incentive spirometry, and hopefully get out of bed. Obviously allowing a patient to do all these things is advantageous over snowing them for a number of reasons, including decreasing VAP. Also it allows for better patient assessments since they can report subjective symptoms and a neuro change can be detected very quickly.

Care of a patient on ECMO is a whole different way of thinking. We often joke about the imaginary line in the doorway that residents won't cross. The cardiopulmonary anatomy and physiology is completely different, and all the normal indicators like labs and vitals that we work so hard to learn in our critical care environments have completely different meanings and interventions. The giant blood pumping machine of death in the room shifts focus away from the patient and onto the technology. It is intimidating and confusing at first. But it can be an incredibly useful tool to liberate patients from pharmacologic paralysis, the ventilator and VAP :yeah:

umcRN, BSN, RN · Aug 13, 2011

Where I work we have had a many adult patients on ECMO awake, ambulating, talking, eating. I admit it is a bit disconcerting at first to see a VV ECMO patient with central cyanosis and giant blood filled tubes sticking out of her neck sitting in a chair, eating a popsicle and texting her friends. But it's also kind of awesome to think that X days ago, this patient was paralyzed on 28 PEEP FiO2 1.0 and had a predicted mortality of >50%. These H1N1/pneumonia/TRALI/ARDS VV adults are ideal for this and getting them awake and even ambulating on ECMO are almost always the goals of care. I've never seen it in peds but I don't see why an older child couldn't do the same. Same with VA if the cannulas are in the neck.
If there are femoral cannulas the activity part is not possible but they can still do upper body exercises. There is no reason they can't be awake provided they are directable and cooperative. As far as extubation it depends on the reasons they are on ECMO (cardiac, respiratory, or cardiac and respiratory failure?). Say it is a primarily cardiac case with decent lungs that we can easily support on the vent and even anticipate extubation within a few days based on respiratory status however cardiac function is poor. That patient should probably stay vented, go on a VAD and get off ECMO, and extubate as soon as is appropriate. If respiratory failure is involved then they will probably be on ECMO for a bit longer. IF they are calm, comfortable and cooperative enough to be awake, then wake them up and extubate! It seems counter-intuitive to extubate with severe respiratory failure, but in a patient on ECMO whose lungs aren't doing anything, the oxygenator is their lungs, and the vent's pretty useless anyway. They can interact with their family, participate in care decisions, eat and drink, do coughing, deep breathing and incentive spirometry, and hopefully get out of bed. Obviously allowing a patient to do all these things is advantageous over snowing them for a number of reasons, including decreasing VAP. Also it allows for better patient assessments since they can report subjective symptoms and a neuro change can be detected very quickly.
Care of a patient on ECMO is a whole different way of thinking. We often joke about the imaginary line in the doorway that residents won't cross. The cardiopulmonary anatomy and physiology is completely different, and all the normal indicators like labs and vitals that we work so hard to learn in our critical care environments have completely different meanings and interventions. The giant blood pumping machine of death in the room shifts focus away from the patient and onto the technology. It is intimidating and confusing at first. But it can be an incredibly useful tool to liberate patients from pharmacologic paralysis, the ventilator and VAP

It's amazing what technology can do these days. Thanks for sharing!

dhippensteel · Oct 11, 2011

I do ECMO in the adult world and if the patient is cannulated through the neck with a cannula that can both take blood out and push blood back in (like a giant dialysis catheter). We have them out of bed and when we can they are extubated and can eat. This is not often as it can only be used for respiratory failure. Our AV ECMO is almost always cannulated in the groin and this patients can't sit up so are usually kept intubated and sedated

Pediatric Critical Care Columnist · Oct 11, 2011

Lately we've had a couple of patients facing long-term V-A ECMO and had Berlin heart cannulae placed instead of conventional ECMO cannulae. These cannulae allow the patient to be up and walking around because of where they're placed. They tunnel through the upper abdominal wall and have Dacron velour covers that create a very secure bond with the skin and tunnels. Of course, going for walks is a huge undertaking!

Thoratec2

Penelope_Pitstop, BSN, RN · Oct 11, 2011

Lately we've had a couple of patients facing long-term V-A ECMO and had Berlin heart cannulae placed instead of conventional ECMO cannulae. These cannulae allow the patient to be up and walking around because of where they're placed. They tunnel through the upper abdominal wall and have Dacron velour covers that create a very secure bond with the skin and tunnels. Of course, going for walks is a huge undertaking!

How long term are we talking, Jan?

Thanks in advance for the info. This stuff fascinates me!

Pediatric Critical Care Columnist · Oct 11, 2011

Indefinitely... months or more!