Awake, alert, oriented & non ventilated...on ECMO?? - page 2

by umcRN 19,922 Views | 28 Comments

Just a random question. I was doing some research on my own and stumbled across this youtube video: I don't know who the child is or why she is on ECMO but what caught me off guard was that she was sitting up, not... Read More


  1. 0
    Many of the component parts are small - for example the Levitronix Centrimag is about the size of a cantaloupe, and the Jostra Quadrox is about the size of a 5-high stack of CDs - but there are so many components and pieces-parts that the whole system needs a large cart. If there are DLPs in use (pressure pods that measure the mean pressure in any of the cannulae), well those boxes are about the size of a 72-pack of Lipton tea bags. If you're using a CDI monitor for those pressures, it's the same size as a laptop computer. The flow sensor boxes are the size of an old VCR, there are cylinders of oxygen and Carbogen on the cart and an assortment of other bits. When we take our ECMO kids on road trips (to CT/cath lab/OR) we have to use the trauma elevator (aka the Megavator) so that all the equipment and staff to run it can fit. Fun times!
  2. 0
    janfrn thank you very much for your input and guidance. I really appreciate it. I have found ECMO very interesting - and even more interesting the different protocols for it between the two large hospitals I have seen it used at.

    Thanks again!
  3. 0
    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.
  4. 0
    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.
  5. 0
    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.
  6. 0
    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.
  7. 1
    DeLanaHarvickWannabe likes this.
  8. 0
    Wow!! Thanks!
  9. 0
    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
  10. 0
    Quote from IDoNotGiveOut
    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!


Top