ECMO - page 6

I have been an ECMO R.N. for three years working side by side with another R.N.( one runs the pump the other doing pt. care) Now the PICU is training Respiratory Therapists to manage the pump. Does... Read More

  1. by   Polednice
    Thank you for confirming we're doing the right thing, Janfrn!!
  2. by   NotReady4PrimeTime
    Our patients are most often cannulated in the neck vessels, with a left atrial vent in a femoral if needed. We also have kids who come from the OR with their CPB cannulae still in situ... transthoracic cannulae. Our last case was one such, and she bled like nobody's business the first night. The surgeons ended up coming in at midnight to find the source; they did the surgery in the unit and oh look, there's an arterial tear. She was MUCH better after that!

    We only rarely take kids to the OR for decannulation. Those would be the kids we aren't certain will do well, and they have everything ready to recannulate. Mostly we decannulate in the patient's room or out in the main unit if we haven't been able to put them in a room due to our isolation needs. The surgeons reconstruct the vessel walls when the cannulae are removed and the bleeding is minimal. We put a pressure dressing on and leave it for 48-72 hours. Can't use FemoStop on kids for obvious reasons.
  3. by   Polednice
    It seems that making the surgeons to stop bleeding troubles more nurses than I've imagined...

    By the way, docs from the dept of children's surgery came to learn about our ECMO exploits, because they plan to start with ECLS for their patients, too. I'm not sure we're the best example...
  4. by   elizabells
    Quote from janfrn

    We only rarely take kids to the OR for decannulation. Those would be the kids we aren't certain will do well, and they have everything ready to recannulate.
    Jan, just out of curiosity, how long do you wean/clamp before decannulating? Admittedly I've only been at this 18mo, but I haven't seen a re-cannulation yet. We wean slooooooow and clamp for a long time before decannulating.

    Hmm, also maybe your kids have more available vessels than our babies. We can only use the carotid and jugular, obviously, so recannulating is not a good option.
  5. by   NotReady4PrimeTime
    We usually start weaning and take a couple of days to take them from full flows to the minimum to keep the circuit from clotting. Then we clamp the bridge for anywhere from 12 hours to a day. The number of kids who haven't made it off pump are very small. The vessels available are dependent on the size of the child. Around the holidays we had a baby (11months) arrest out on the ward for a prolonged period. The surgeons decided to go ahead and cannulate, even though she had been down for more than an hour; she had already had several surgeries and had been on ECMO once. They draped and cut the right side of her neck (the preferred site) but couldn't find a vessel that was big enough to use. So they had to quickly repair that and turn her head and open the other side of her neck, while compressions were ongoing (11 doses of epi, too). She needed an LA vent and they cannulated BOTH her fems... so now she has NOTHING that can be used again. She was successfully weaned after about 8 days of ECMO, but has suffered a catastrophic brain injury and likely a spinal cord clot. Very sad.

    Our bigger kids are treated much like adults. We've cannulated them in whatever vessels are the easiest approach. The cardiovascular team does the kids who need V-A support, and the general surgeons do the kids who are treated for respiratory reasons. (We've done ECMO for severe adenovirus, severe and unresponsive asthma, diaphragmatic hernia, hepatopulmonary syndrome post-transplant and a couple of other non-cardiac reasons. This time last year we had a toddler on for ALL complicated by RSV... she didn't survive.) It's a toss-up as to which site is the easiest to care for from a nursing standpoint. There are more positioning options for the femoral cannulation, but VAP prevention is more difficult unless the kid is really small, because reverse Trendelenberg turns the bed into a slide. Wheee!

    I'm going to be submitting an abstract to AACN to present at NTI 2009 on the nursing care of the pediatric ECMO patient. I'm gathering data as we speak...
  6. by   elizabells
    In re the left-side cannulation... I've wondered before how that would work, if she'd already been on ECMO once. Maybe I'm not understanding the definition of "ligated" properly, but if you were on ECMO twice, wouldn't they *have* to use the same side? I'd think that using both sides of the neck would result in not having a functional carotid on either side when you were done. I guess unless they reconstructed the vessels, which we don't do at my hospital.

    Our general surgeons do all cannulations, both VA and VV, unless of course it happens in the course of CT surgery in the OR.

    I'd love to read that paper when you're done with it!
  7. by   NotReady4PrimeTime
    We try to reconstruct all the vessels, because some of our kids are going to be back many times before they either grow out of their cardiac issues or die. Decannulation often takes a couple of hours while they do the reconstruction. With our little ECMO frequent flyer, she had a clot in her internal jubgular and the external jugular wasn't big enough. She ahs also had femorla clots with multiple collaterals. Her family knows that ECMO and CPB are both out of the question for her now but aren't willing to believe that she's going to die. They've agreed to a modified DNR (no intubation, no compressions, no push drugs) but insist that we do everything up to that point. So we'll keep her in an ICU bed for however long it takes. Sad.

    My AACN presentation will be an oral one. I think I'll do a Power Point to go with it. Maybe I'll run my abstract by you before I submit it.
  8. by   elizabells
    I'll be happy to read it!

    I think the hardest part of our jobs (as we've discussed in other threads) are the kids who we KNOW aren't getting better, but we can't seem to communicate that to the families. Up in our PICU we had a toddler on ECMO for 38 days, which is unHEARD of in our hospital. She had adenovirus, and ended up with 8 chest tubes, was on the oscillator the entire time she was on ECMO (again, unheard of for us, don't know about anyone else) and saddest of all, in a way, no ears. They just couldn't stop the skin breakdown. At one point her entire skull was covered in Duoderm. Even after she came off ECMO she took a really long time to pass. We had runs going in the NICU the whole time she was on, and the perfusionists started showing up earlier and earlier so they could come to us instead of the PICU, because it was just too sad.
  9. by   Ventjock
    Quote from elizabells
    I'll be happy to read it!

    I think the hardest part of our jobs (as we've discussed in other threads) are the kids who we KNOW aren't getting better, but we can't seem to communicate that to the families. Up in our PICU we had a toddler on ECMO for 38 days, which is unHEARD of in our hospital. She had adenovirus, and ended up with 8 chest tubes, was on the oscillator the entire time she was on ECMO (again, unheard of for us, don't know about anyone else) and saddest of all, in a way, no ears. They just couldn't stop the skin breakdown. At one point her entire skull was covered in Duoderm. Even after she came off ECMO she took a really long time to pass. We had runs going in the NICU the whole time she was on, and the perfusionists started showing up earlier and earlier so they could come to us instead of the PICU, because it was just too sad.
    thats horrible
  10. by   NotReady4PrimeTime
    Our longest run to date was 56 days, same kind of patient... a toddler with adeno. She didn't survive, and we knew pretty much from the start that she wouldn't. The family situation was very sad; her sister had been murdered the month before and the parents were still reeling from that when she got sick. Our infectious diseases doc told the family that recovery from adeno would take six to eight weeks, and they took that to mean that we'd keep her on ECMO for that long. Because of the family's psychological needs we did just that. Every day she'd fail her oxygen challenge and we'd just keep going. Then on the 56th day it was agreed that she'd come off. She was moved off the bed and onto her mother's lap and the bridge was clamped; she died in minutes. She too had many areas of skin breakdown, no matter what we did. It was terrible.
  11. by   Polednice
    That's really very sad, about the kids in your ICUs!! ...I really admire what you do for your little patients!!

    ...and I am also interested in that abstract of your lecture, Janfrn!
  12. by   califalcon
    Hi to all: I am new to the forum but with a very extensive service as an RN both in military and civilian sections.

    ECMO started catching my interest when in 1995 I arranged for an ECMO transport from Kapiolani to Orange County California and had to deal with rearranging flights with the US Coast Guard because the ECMO unit would not fit in the Gulfstream we were using.

    The modality has grown considerably...the Air force at Wilford Hall, UM and Arkansas are the only known centers to do Mobile ECMO in the US. However, they self limit their transports to patients who are referred to their facilities or in the case of WHMC, to military and their dependents. I only know of two or three transports that were done externally.

    I have been in the aeromedical world since the beginning of the aeromedical development flying the injured under fire in a Huey and went on to develop my own aeromedical service and international development company.

    Now, after getting calls to transport ECMO patients and being basically refused by the current Mobile providers, I have contacted the Pentagon and received the assurance of support to develop and promote Mobile ECMO services that will also be used by the USAF .....without any hospital affiliation that will eliminate the need to search for the means to get a patient from one center to the other or deal with hospital politics.

    I will be very happy to hear what needs exist and what it is we need to do to plug the holes.

    We will be placing a LearJet in service for this....which will eliminate the need for large military cargo aircraft and imagine....minimize the costs to the taxpayers.

    thanks for the opportunity to participate in this forum

    Manny
    Last edit by sirI on Mar 1, '09
  13. by   NotReady4PrimeTime
    Our transport team has successfully provided mobile ECMO for four children now. The first transport was a logistical nightmare; it was Canada Day and the military transport planes were all tied up with fly-pasts and other events that had been prearranged to which they'd deployed earlier in the week. The air ambulance was too small, so we chartered a Lear to go pick up the child, an 11 year old post arrest. The referring hospital had the expertise to cannulate but not the resources or manpower to follow through. Another hospital closer to the referring center had been approached but they refused. Our team flew out with our pump and equipment; getting the kid switched over went well, but the only elevator accessible to the PICU there was too small to contain all the equipment so the pump and oxygenator had to be taken off the cart and put on the bed between the kid's legs for the elevator ride. The city had no ambulance that could accommodate the equipment and crew, so the fire department dispatched a flat-bed and a dozen strapping firefighters to dead lift the stretcher, circuit and pump onto the truck. We have video tape of the whole process, entertaining to watch, but I can only imagine the anxiety the crew was feeling!

    Many lessons were learned from that experience. The next mobile ECMO came from the same hospital and went much more smoothly. The other two came from a small hospital about 600 miles from here; both were neonates and both survived the transport only to die later of severe neurological complications.

    I'm considering sharing your web-site address with our ECLS coordinator and our transport coordinator. I'm sure there are great things to be exchanged!

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