ECMO

The child I referred to in my last post who had been cannulated for severe ARDS is STILL on V-V ECMO, day 40 now. The amount of sedation this child needs to prevent flow problems is unbelievable. She's still needing flows of 80-90 mL per kg and she is still failing her O2 challenges. Her ventilator pressures on rest settings are still very high (PIP 28, PEEP 15) and her x-ray is looking cystic. The team has agreed to keep her on for a total run of 8 weeks, so 16 days to go; then there will have to be a decision made... The other day the circuit entrained some air and in the 30 seconds or so it took to de-air it, she dropped her sats to the 30's, her heart rate went to 40 and her BP bottomed out. The team has not been able to change the circuit (which is full of fibrin, clots and precipitated-out lipids), and no one is willing to even contemplate it! I expect that once they stop the pump, she'll go to Heaven very quickly.

Anybody out there have experience with a prolonged run like this? What were the outcomes?

Our little one who holds the record for the longest run of ECMO in our unit has finally gone to Heaven. She was on for 56 days, with no improvement whatsoever in her lungs, even with HFOV. She passed in her parents' arms very gently after the pump was stopped and she was extubated. Her dad, who had been very volatile throughout her stay with us, hugged the intensivist and thanked him for all our efforts in trying to make her better. It was all very bittersweet.

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!