Polednice

Well, transporting ECMO... sounds more like a sci-fi to me! For our ECMO team it was a great deal to transport it across the tiny park we have between our dept and radiology! Not to imagine transporting it across the ocean! As far as Czech health care system doesn't have position of RT, there are just the RNs (RNs, who are not afraid of the machine, rather than being specially trained! - The situation I am trying to change!), perfusionists and doctors to care about ECMO. And our outcomes depend on the state of the patient before the cannulation... our last two cases were really a "cowboy" things, because even before the cannulation they were literally dead, having only the brain stem at work... MODS and SIRS included. I wish I understood our criteria for ECMO!

Hello!! What an interesting topic with ECMO!! I'm sorry I can't contribute, just wonder... well, except a tiny bit. We had a 64 years old ECMO patient about two months ago. He was acutely admitted for massive ischemia of myocardium, with the major part of his heart out of work, and with 1 sqcm large hole in his ventricular septum. Those were just "our" diagnoses, cardiosurgical, further he suffered from severe renal failure and severe form of diabetes. They planned to operate on him, but first they wanted to find out what's in his head, so he had to be transported to CT within the area of our hospital. Our perfusionists managed to disconnect the pump and the oxygenator from the rest of the machine... and with only a source of oxygen...they fixed them to the pole of the patient's bed. Although they went just a few meters away, it cost the whole team nerves. Anyway, the patient had the brain's death diagnosed and soon afterwards his ECMO session was terminated. I'm not sure this procedure is possible with all types of the machine and definitely not sure for how long can the patient cope without the ECLS heat exchanger / warming unit (Sorry, I don't know the exact term for this in English!)... but this one "survived" this transportation.

That's really very sad, about the kids in your ICUs!! ...I really admire what you do for your little patients!! ...and I am also interested in that abstract of your lecture, Janfrn!

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...

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

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!!)

..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?

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.

Hurray!!!...having another ECMO under my care!!!!!..another opportunity to learn...having our perfusionist present I can discuss the matter with him!!..this time the patient is sedated, forunately!!

By the way, this is my department, the whole building it is... so sorry I have no pictures from inside our ward!...it belongs to the General Teaching Hospital in Prague.http://kardiochirurgie.lf1.cuni.cz/

Oh, that would be wondeful of you!!... I am speechless...or I would be repeating myself... but still: Thank you!! I did some serious search and found ECLS Guidelines of Great Ormond Street Hospital in the UK..and quantities of ECMO articles on Medscape and PubMed... well, as I wrote before, plenty to learn!!!

Woooooow!!! I can't even express, how excited I feel about it all!!.. and thankful!!... I'm already going through some guidelines for ECMO I've found on the net, nursing care standards included!! And it all has just intensified the feeling our team has a lot ..a lot..a lot to learn!!

Good news for my little "project"!! My colleagues and the head doctor of our ward got interested, too!!!...spending Friday and the whole weekend at work with them (We've got 12 hrs shifts, days and nights.), I've had enough time to survey, what do they all think about such an enterprise.. and.. what I've got was a very positive response, even from the doc!! He, too, admitted we've got plenty to learn about ECMO and that we do need a system for its management!! I know he will be very willing to contribute... so, they all are prepared to support our future guidelines for using it!! ..so, I just have to go on with searching the web for any piece of information available to expand the stock of targets we already have for the nursing care. And with a contribution other members of our team, nurses, docs and perfusionists... and your "guidance"... it might work. PS:Thanks for your support, too!!

Oh, what you have written is so full of HOPE!! ... I can't be thankful enough for it and for the effort you put into scanning those standards of your ward!! Today I discussed the matter with my dpt manager, her reaction was more than encouraging and she promissed to help me. What I actually hope for is to put together a team of my colleague nurses with some experience with ECMO, perfusionists and doctors... and use your standards as a guidance... to make our own. To make all members of the team as knowledgeable as they need to be, and what more, to set clear goals in every aspect of care and how to achieve them according to the needs of our patients. Taking into consideration the enviroment of our department and all the resourses we have, of course. Well, I must confess I'm feeling a little bit foolish... I'm feeling like a kid who's been given an expensive musical instrument...and who learns to play it in a symphony orchestra. Thank you once more..!!

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!

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...

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?

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??