ECMO

[3230]

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 anyone else work in a hospital where this is common practice? Is nursing responsible for the actions (Comission or omission) of the therapist?wj

[NotReady4PrimeTime, RN]

Okay. That's a little bit of an interesting reaction! Good for you, bad for the patient...

[Polednice]

Well, I really didn't mean it like being glad... not for the patient, for sure!!...anyway, there's an improvement seen by this one, his antikoagulation is looked at much closely. Perfusionists alone have felt the need of better management and came up with a regular check of ATC, and aPTT.

[Polednice]

..as another ECMO appeared in our ward, more colleagues of mine see the necessity of some standards. So, we decided to join our efforts, already putting together material related. And since yesterday, perfusionists are supporting us, too, coming up with their comments.

However, as the greatest problem now we see the care of the cannules. As with the previous patient, also with this one, bleeding along the cannules is troubling us. The blood loss can be considerable in a few days, and the frequent change of the bandages is no good for the patient, too, even if performed as aseptic as possible. We've tried many types of the bandaging material, Kaltostat included, but all are consumed in four or five hours...even the stitches added do not help.

I'm feeling very stupid to ask a piece of advice in such an obvious matter, but still, you are far more experienced... How can we keep the cannules "clean" with the patient being so heavily heparinised?

[NotReady4PrimeTime, RN]

We run into the same problem at times. When the patient is really bleeding from the cannulation sites, we usually try to disturb the site as little as possible, meaning that we reinforce the dressing as needed rather than changing it. If you have any kind of clot forming at the site, pulling the dressing off is only going to cause the bleeding to continue. So even though it's really ugly to look at and the risk of infection is higher, we choose to leave it. We put absorbant pads with waterproof backing under the head and neck or whichever site we have that's bleeding and change it frequently. Sometimes we have the surgeon come back and put a couple of stitches in to tighten up the exit site. Oh, and once I had a patient on ECMO who had two art lines, and the surgeon decided that we really needed to discontinue the femoral one... couldn't wait. I told him that he would have to come and remove the line, then apply the necessary pressure to the site because I simply didn't have the time. I got the whole group of fellows who took turns. Wow!! (The patient ended up dying that night, but not due to bleeding...)

[elizabells, BSN, RN]

We once had an ATTENDING who wanted to pull an ECMO baby's umbilical arterial line (because we really don't like to leave them in more than a week) and start a peripheral art line. Thank GOODNESS the ECMO fellow talked him out of it. I don't know WHAT he was thinking.

[Polednice]

So as I see it, generally we do the same thing, like adding more layers of absorbent dressing (mostly SurgiPads) and not removing the blood clots sticking to the stitches, just sending some tiny samples to microbiology lab.

Actually, yesterday they managed to stop the bleeding by administering adrenalin and trimecain into the tissue surrounding the cannules... no blood appeared in more than 10 hours after this procedure. Do you use this technique with your patients, too??

And for the compress after decannulation (All of our ECMO cannules were inserted into femoral vessels, A and V.)... with the previous patient, the one with PAH, we used FemoStop system and it worked pretty well. But otherwise, our surgeons are taking turns in compressing the site, as well... with us moving the patient's bed up and down according to the docs' statures. But it depends on the severity of the bleeding... we might transport our patients to the theatre if necessary or they perform the operation right in our ward. (This being a perfect occasion, when you become three nurses in one: ICU, theatre and anestesiology!!...after one such a shift my shoes fell apart from all the running!!)

[Polednice]

Thank you for confirming we're doing the right thing, Janfrn!!

[NotReady4PrimeTime, RN]

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.

[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...

[elizabells, BSN, RN]

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.

[NotReady4PrimeTime, RN]

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...

[elizabells, BSN, RN]

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!