ECMO

Pediatric Critical Care Columnist · Jun 5, 2007

I'm not on the ECMO team, but I am one of the primary RNs who provide nursing care to the patient on ECMO. We have an average of 12-15 runs a year, ranging from a few days to 8 weeks. Our ECLS specialists typically work only 6 hour shifts on the pump; they're very busy for much of the time. The entire circuit is inspected hourly looking for air, fibrin and clots. The activated clotting time of the blood in the circuit is tested hourly as well. All bloodwork is interpreted by the ECLS specialist and any blood products required by the patient are ordered by them. Only albumin and packed cells are given via the circuit; everything else (platelets, cryoprecipitate, fresh frozen plasma, anti-thrombin III, and often packed cells too) are given on the patient side by the nurse. The ECLS specialist has his/her own documentation. A stable run can be "boring" because everything is routine. But there are a variety of complications that can occur. The circuit can clot off, or entrain a bunch of air, the pump can fail, the circuit can spring a leak, the cannulae can become dislodged... and the patients usually bleed A LOT, even when everything goes well. I've been the bedside nurse for all of these except the pump failure. Sometimes the patient needs surgical intervention, such as a mediastinal wash-out for tamponade, or to be recannulated. And sometimes they have to go for CT scan or to the cath lab... that's a waking nightmare. It can be very stressful at times. But it never gets old. I spent two days with a toddler a couple of weeks ago who was being bridged to transplant. We had to open his chest on the first day; the second day was quieter but it gave me a chance to educate the family about heart transplants and to provide emotional support. I was off for nine days to attend a conference, and when I came back he'd had his transplant and was doing well. Love it!

bbluvnursing, RN · Jun 6, 2007

Our RT's do not run the ECMO pump on my unit... just one RN running the pump and the other doing pt. care

Polednice · Feb 1, 2008

Hello!

I am so sorry for having found this forum this late!! I would like to share my experience with ECMO and read your comments just to learn how to manage better! Well, ECMO occurs in my ward (Cardiosurgery Post-op Intensive Care) two or three times a year. Our nurse to patient ratio is 1:1 and we have also at least one OR perfusionist on call. Now I have my second ecmo patient under the care. The first one survived it successfully, being weaned in two weeks...but with this one...well...we have a hard time with his anticoagulation management. We take patient's ACT and APTT every 3 hours, with all the other coagulation factors every 24 hours and consult the results with a doctor and some perfusionist, and according to them we change the speed of heparin infusion (usually 15,000IU/50ml). But despite the care we give the matter, blood started to coagulate in the oxygenator. First on the arterial pole of the membrane and when this started to disappear another clotting on the venous pole occured. Even if there was DIC diagnosed in my patient, the clotting appeared 5 days earlier. Has it ever happened to you as well?? How did you manage then??

Pediatric Critical Care Columnist · Feb 1, 2008

Our ECMO patients are monitored much more closely for DIC and other clotting abnormalities. ACTs are done hourly; PT, INR, fibrinogen and platelets are run q8h, and antithrombin III levels are run at least once a day. It's not uncommon for us to be giving platelets q8h, giving AT III daily and tweaking coags with FFP and cryoprecipitate as needed. Packed red cells are given as needed to maintain hemoglobin within our target range. Our ECLS orders give very detailed instructions about where our targets are and what to do if they're not met; the ECMO specialist has a good deal of autonomy in decision-making in those situations. We rarely have problems with the circuit clotting off although we may have fibrin deposits or stable clots in the venous limb. We ran a patient on V-V ECMO for eight weeks on a single circuit a couple of years ago.

We do a lot more ECMO than you do in your unit, Polednice. We might do 30 runs in a year, and a while back we had three kids on at the same time. We have one right now, an infant with a complex defect who came from the OR yesterday on ECMO. She had surgical bleeding that required the CV surgical staff to come in at 11 pm to re-explore her chest, which was done right in the unit. By morning she was much more stable. Our ECMO patients survive about 90% of the time, and the majority of those do so without major neurological insult.

Polednice · Feb 2, 2008

Janfrn, I have to admit I envy you all the experience you have with ECMO!! We deal with adult patients only and ECMO is the last possible therapy we can offer as a heart support when other means fail to help. And we mostly privide A-V extracorporeal oxygenation. But as you can see, there are not many opportunities for the whole team to gain more experience, with just two or three cases per year occuring. But still, our OR perfusionists with a help from haematology specialist are now trying to work out some standards, too. I wish we'd had them before the first problems appeared!!

Is there any possibility I could have a look at your dept. standarts?? I would really appreciate it!

And one more question: Do you avoid using acetylsalycylate with ECMO patinents?

elizabells, BSN, RN · Feb 2, 2008

Not sure which "New York hospitals" the poster upthread was referring to that use RRTs on pump, but I'm at the major peds hospital in NYC and we have an all-perfusionist staff. Our director of neonatology is interested in having RNs move into those positions a bit, so I'm working on a proposal to go to U of Mich's training program.

Pediatric Critical Care Columnist · Feb 2, 2008

Oops, messed that one up. Let's try again.

I'll see what I can do about getting you a copy of our ECLS order sheets, polednice. They're pretty self-explanatory. I'm off for the weekend and work nights Monday. I should be able to grab some then.

Over the last couple of years we've started using ECMO for many more purposes than just bridge to transplant. Our long runs are usually for pulmonary reasons. And we've seen a real increase in the number of kids we are doing E-CPR for. They've had a prolonged cardiac arrest in the PICU, or the cath lab or out on the cardiology inpatient unit and are emergently cannulated in PICU while we see if the heart is salvageable. Sometimes it is and sometimes it isn't. Of those cases about half of them return to their baseline function within a few weeks after they're decannulated. The other half have a range of issues, from mild neurological deficits to death. One boy was resuscitated with E-CPR last month, transplanted last week and is showing signs of being just as he was before he got sick. Gotta love those ones.

This is a photo of our unit when we had three simultaneous runs. (That really eats up the resources, especially the human ones.)

Polednice · Feb 4, 2008

Wow, that looks great, Janfrn!!! Really, I can only admire your skills and experience you achieve with working in such a place!!...but still I can't tell the difference between pediatric and our adult ECMO patients, because I'm new to ECMO in general. Now, the whole team is learning.

Our present patient is 41 years old male. He was admitted to our ward due to PAH, which couldn't be managed with both, conservative (Ventavis, Flolan) or operative (PEA) therapy. Curious thing is, that the PAH occured instantly (As the patient says, he just stopped to breathe, because it was far too exhausting.), from the complete health. (Well, there was just a minor flu he swears he cured according to his GP!) In fact, this man used to run at least 4 miles a day, did triathlon and many other sports, and passed medical tests for pilots half a year ago!!...anyway, his present PAP is 90 mmHg, and is high as his systolic arterial blood pressure by now. His right heart chambers are dilated and even less able to cope with almost completely obliterated pulmonary circulation. He was cannulated in an hour after his arrival to our ward, and ECMO was set on 3 liters/minute flow. The flow now had to be increased to 4.5 liters/minute, and still he could do with even higher flow. So, his only chance is the lung transplant...(Even if placed on the head position on the waiting list, still it lasts about 120 days to make it!)

Except the blood-clotting problem I've mentioned already, we have to deal with the patient himself. Being conscious, he is completely aware of everything happening to him, talking to us, watching TV as well as the tubing with blood and so on.

Well, there are certainly more problems to manage... not just with the oxygenator as it seems...

Pediatric Critical Care Columnist · Feb 4, 2008

The basic principles of ECMO are the same no matter the size of the body. We've had neonates on and we've had older teenagers with grown-up bodies on and what we do is exactly the same. The differences will be in the reasons for going on ECMO. With kids it could be for cardiac reasons, obviously, or for things like severe asthma, respiratory failure from adenovirus, diaphragmatic hernia and other severe respiratory failures. Another difference is that we don't let the kids be too awake. It's enought aht we can assess neurological status every few hours then back to sleep. Because the circuits are sized to the patient, even a little agitation can affect their flows and all the rest of the "dominoes": oxygenation, cardiac output, tissue perfusion... And our flows are ordered in mls/kg/min. Full support would be considered 100 mls/kg/min for most patients. The need for deep sedation causes skin integrity problems, of course; the limited range we have for moving the kids only makes it harder. We usually put several layers of high-density foam under them so that they're protected from pressure somewhat and reposition what we can when we can.

Your patient is in a pretty precarious position isn't he? Lung transplants aren't done all that often here at all, so I can understand your difficulties. Keep up the good work!

CHBRRT · Feb 7, 2008

Only RRT's run ECMO at Children's Hosp. Boston. There is an RN taking care of that aspect and 1 RRT that is the ECMO specialist who runs the circuit as well as the vents (Vent, Hi-Fi, and Nitric).

Polednice · Feb 7, 2008

So, my patient was weaned from ECMO on Monday morning and I am really happy for him! It seems that his heart and lungs got enough rest and started to work satisfactorily. Yet it doesn't diminish his need for the "new" lungs. Being put in the international program Eurotransplant, the waiting period for him could last up to 120 days or longer, because he is the rare B negative type!

Now I am trying to put together all the new things I have learned during the time spent with the patient and ECMO... and put together all the problems that had to dealt with, to make sort of troubleshooting manual. I hope our pefusionists will help.

Thank you for help, Janfrn!!...I shall discuss taking ACT every hour and other coagulation factors as you do, with our team to make a standart out of it! We really do need some for the future patients!

Pediatric Critical Care Columnist · Feb 8, 2008

You're most welcome. I wasn't able to access any order sheets when I worked Monday night but I'll have another chance on Saturday. Might take me a few days to get them scanned and ready for sending, but since your guy is decannulated, that's probably okay...

The waiting list for organs here is not short either. I was at the liver transplant clinic today with my son and one of the coordinators was saying that we're currently doing about 80 livers a year, but have over 300 on the list. The rare blood type thing is an "oh-that's-good-oh-that's-bad" scenario. It can mean a VERY long wait, or it can mean receiving a transplant before the really bad times arrive. The winter that my son had his transplant, there was a little girl with glycogen storage disease type IV who had AB negative blood on the list even though she was still at home, on no meds and thriving. She had been listed because they knew she'd eventually reach end-stage but because of her blood type she'd probably wait a long time. Well, she was transplanted in early April and went home May 8th. Amazing.