ECMO

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...)

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.

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...

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.