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

[umcRN, BSN, RN]

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 sedated, not intubated and interacting with her family around her. It astounded me! I work in a nicu so most of our ecmo babies are PPHN or CDH (causing pphn) so by physiology of the disease are usually intubated and somewhat or very sedated. I also know in our PICU/CICU ecmo kids are typically very well sedated. I was wondering if there were units (well obviously there are per the video) that do not sedate children on ECMO and how well that works? Also what would cause a child to be so sick to need ECMO but not need to be intubated and ventilated as well??

I am very curious about this and love to learn so am interested to hear your thoughts. If you make it to the end you will get to the part I almost jumped out of my seat at...grandma getting ready to wash her hair and helping to reposition her with no one apparently watching the cannula in her neck!

[NotReady4PrimeTime, RN]

It's hard to know why she's on ECMO from the video. It's not due to post cardiotomy failure as there's no sternotomy scar, but it could quite conceivably be cardiomyopathy. She has an arterial cannula in her neck and bilateral venous drainage cannulae in her fems. I couldn't tell if there was an oxgenator on the circuit, but she has moderate work of breathing and her sats were in the high 60's on the monitor. She could have a primary respiratory cause for ECMO or she could be post-cardiac arrest from any number of causes. (Think about your H's and T's.) If she's on ECMO as a bridge to cardiac transplant, then it would be possible to allow her to be awake and to extubate her. We do that here for some of our older kids, but they're generally VAD patients. If her circuit is more of a VAD than an ECMO circuit, then it's entirely possible. As for Grandma washing her hair, well I did have some qualms about that too, but there was someone else at the bedside off-camera, and that cannula extends about 6 inches into her chest under her clavicle and probably has a honkin' huge pursestring suture around it at the skin. Last time I worked a weekend I levitated a child on ECMO off the bed at least a half dozen times for dressing and linen changes while someone else did the cleaning up and laying down. It's the transthoracic cannulae that freak me out.

[umcRN, BSN, RN]

Hmm, I guess I never thought of ecmo like a VAD. I've never dealt with a pediatric VAD but did use to work as an aid on an adult cardiac unit in a hospital with a huge VAD program so I guess it is kind of similar. I think it's just something about the cannulas so obviously filled with blood flowing in and out of her and watching her be awake and interactive through it that freaked me out a little bit! Also only ever dealing with infants on ecmo I guess the cannulas would be quite a bit longer in a child and less likely to kink/move our of place.

Thanks for the input! It's just so interesting to me...although I guess if she is waiting some kind of transplant it's nice that she doesn't have to spend all that time heavily sedated & paralyzed.

[NotReady4PrimeTime, RN]

They recover so much quicker and better post-transplant if they've been awake, active and able to participate in their own care while they were waiting. Our program tries to switch them from ECMO to a Berlin heart as soon as possible, but for kids who need an oxygenator (we use Jostra Quadrox) for whatever reason, the Levitronix Centrimag VAD is what we use. The circuit is much shorter and since it's a centrifugal pump driven by a magnet, if there's any kinking of the cannulae, the pump just stops. In the photo below, the console on the left is the control unit. The oxygenator is the blood-filled cylinder on the lower right and the pump itself is the angled steel cylinder just below.

Once we get them stable and not requiring the oxygenator, the Levitronix comes off and the Berlin goes on. Older kids are able to shower, go to school and even go home.

[Penelope_Pitstop, BSN, RN]

I snooped around the mother's (I assume it to be the mother's) YouTube channel and discovered that she had NSIP. I wish I knew more about her history, and I'm curious regarding her outcome. If you look at the other uploaded videos, you can find ones of her robust and healthy. She's truly a beautiful girl. I hope she and her family are doing well.

[littleneoRN]

I've seen a picture of someone ambulating on ECMO. Our center isn't that brave. Yet. :)

[NotReady4PrimeTime, RN]

So I was on the right track, sort of. Bridge to transplant, but lungs and not heart. I'm not sure why her sats would be so low though. With an oxygenator in the circuit her sats should be higher.

[imaginations]

Here in Australia most hospitals have ECMO protocols that involve the patient being sedated & paralysed. Only some of the major heart/lung transplant centres have gotten as far as patients being awake and extubated on ECMO so far!

janfrn I'm only a student nurse and a lot of the brand names for the different pumps you're using are totally foreign to me. Is there somewhere you could point me to learn more about the things you're referring to?

[NotReady4PrimeTime, RN]

Sure thing... But first look at the pictures again. That first image is of a Levitronix Centrimag centrifugal pump with the actual pump in the lower right corner. The oxygenator just above it is a hollow-fibre one, probably made by Permselect. Here's some info on the Centrimag: http://www.texasheartinstitute.org/Research/Devices/levitronix.cfm

This photo shows a Jostra QuadroxD oxygenator on the left, the diamond-shaped box in the upper left. The centrifugal pump here is a Jostra Rotaflow (lower centre), and this is very similar to the way we configure our circuits.

http://www.ncbi.nlm.nih.gov/pubmed/15072251

This cylindrical silicone membrane oxygenator is the type we used to use. It's a Medtronic version and is used with a roller pump rather than a centrifugal one..

We find we're having to change the circuits much less often since we began using the Jostra... smaller priming volumes, less hemolysis, less coagulopathy, better titration of oxygenation and CO2 clearance. Our very first run with the Jostra system lasted 56 days with no need to change the circuit.

[umcRN, BSN, RN]

Thanks for all the input! I love seeing the different technologies that are able to be used successfully. I don't know what kind of ECMO pump my hospital has, we did just start using a new one and have a few runs recently in the NICU, it is still a very large machine.

[NotReady4PrimeTime, RN]

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!

[imaginations]

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!