1. Jason Lippy, RN Paula Minor, RN University of Maryland Medical Center March 2012

2. What is ECMO?  Extra Corporeal Membrane Oxygenation  Blood is drained from the venous system  Oxygenated through an artificial lung, removing carbon dioxide  Returned to the patient

3. Goal of ECMO  Ensure oxygen supply meets/exceeds the patient’s demands  Prevent end organ dysfunction and tissue death.  Rest heart and/or lungs  Allow time for healing

4. ECMO FLOW Blood Flow 1. Deoxygenated Blood Drained from Venous Circulation 2. Blood Pump Centrimag Rotaflow 3. Membrane Oxygenator/ Heat Exchanger (Quadrox) Hollow fiber polymethylpentene 4. Oxygenated Blood Returned to the Patient 5. Pressure monitor 1 2 3 4 5

6. Venovenous (VV) ECMO  Blood is drained FROM and returned TO the venous circulation  Does NOT provide hemodynamic support  Goal is to rest the lungs  Allow time for healing

7. Venoarterial (VA) ECMO  Provides pulmonary and hemodynamic support  Heart and lungs are bypassed  Venous/drainage and arterial/return  Nonpulsatile

8. Multidisciplinary Team  Critical Care Physician and/or Surgeon  Attending Physician / Nurse Practitioner  Bedside RN / Resource RN  ECMO Specialist (RN, RT or Perfusionist)  Respiratory Therapist Communication is the Key!!!

9. Pre-ECMO Management  Documentation Consent, Orders, Current Type X  Bedside ECMO,open chest & code cart, back-up ECMO (on unit), central line cart PRBC, heparin, NS, sedation, narcotics  Pre-Procedure Are New Lines Needed? Wound Care Consult (Specialty Bed) Gastric Tube /Small Bowel Tube Placement Baseline Neuro, pulse, ECG, labs

10. VV ECMO: Two Site Cannulation 1 Drainage, 1 Return Internal Jugular Vein Femoral Vein or Saphenous Vein

11. Cannulation Dressings

12. Cannula Positions

13. Single Site Cannulation One double lumen catheter is inserted through the right IJ into the right atrium Blood is drained and returned through separate lumens in the same cannula www.avalonlabs.com

15. ECMO Considerations Based on Systems

16. Neurologic Management / Goals  Brain Injury  Sedation Vacation  RASS 0 to -2 by Day 3  Pain  Cluster Care ECMO Considerations  CNS insult prior to ECMO  Watch for signs of Intraventricular Hemorrhage/Infarct  First 72 hours difficult sedation titration  Propofol (watch Triglycerides)  Precedex (brady)  Narcotics

17. Cardiovascular Management / Goals  Sinus rhythm  MAP appropriate for age and condition  Pulses (VV ECMO)  Extremities ECMO Considerations  Chattering  Volume Deficit  ECMO Flow  Pulmonary HTN  Right sided heart failure  Vasoactive use

18. Respiratory Management / Goals  Minimal Vent Settings  Pulmonary Toilet  Frequent Repositioning ECMO Considerations  Daily Chest X-ray  CO2 control  ETCo2 monitor gradient  “Red Rubber” suction  Specialty mattress  Prone

19. Respiratory ABG Patient & Arterial side of oxygenator VBG Venous side of oxygenator RECIRCULATION!!!

20. Heme Issues  Appropriate HGb for the appropriate situation Remember blood can be bad  Heparin bonded cannula  Centrifugal pumps less damage  Anticoagulation ACT (Hourly initially the your call) ○ Target 160-180 Anti Xa (q 6 hours when stable q 12) ○ Target 0.3-0.7 Platelet >50,000 Daily TEG Analysis, Plasma Free Hgb, LDH

22. 22 Hemoscope TEG-Based Guidelines TEG® Value Clinical Cause Suggested Treatment R between 7 - 10 min  clotting factorsx 1 FFP or 4 ml/kg R between 11-14 min  clotting factorsx 2 FFP or 8 ml/kg R greater than 14 min  clotting factors x 4 FFP or 16 ml/kg MA between 49 -54 mm  platelet function 0.3mcg/kg DDAVP MA between 41 -48 mm  platelet functionx5 platelet units MA at 40 mm or less  platelet functionx10 platelet units Angle less than 45°  fibrinogen level.06 u/kg cryo LY30 at 7.5% or greater, C.I. less than 3.0 Primary fibrinolysis antifibrinolytic of choice LY30 at 7.5% or greater, C.I. greater than 3.0 Secondary fibrinolysis anticoagulant of choice LY30 less than 7.5%, C.I. greater than 3.0 Prothrombotic state anticoagulant of choice

23. Gastrointestinal Management / Goals  Small bowel feeding  Daily Stool  Gastritis Prophylaxis ECMO Considerations  Bleeding  Ischemia  Hyper-bilirubinemia not always hemolysis

24. Renal Management / Goals  Even Fluid Balance  Renal protection therapy Good CI Good MBP ECMO Considerations  SCUF -Hemo concentrator  CRRT (prisma flex)  Hyperosmomolar / hyperoncotic  pH control

25. Skin  Frequent Repositioning  Specialty Mattress  Aseptic Technique  No New Sticks  Wound Care Consult  Edema

26. Patient and family support  Must define prognosis  Help MD understand family expectations  Should define end-points  Team communication

27. Intra Hospital Transport …Don’t Do It !!  Group Effort  Trial Run – scout the path  Transport Team

28. The Future of ECMO

29. References Allen, S., Holena, D., McCunn, M., Kohl, B., & Sarani, B. (2011). A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ecmo) in critically ill adult patients. Journal of Intensive Care Medicine (Sage Publications Inc.), 26(1), 13-26. Retrieved from EBSCOhost. Bojar, R.M. (2011). Manual of Perioperative Care in Adult Cardiac Surgery Fifth Edition. Hoboken, NJ: Wiley-Blackwell. Gay, S., Ankney, N., Cochran, J., & Highland, K. (2005). Critical care challenges in the adult ECMO patient. Dimensions of Critical Care Nursing, 24(4), 157-164. Retrieved from EBSCOhost. Peterson, K., & Brown, M. (1990). Extracorporeal membrane oxygenation in adults: a nursing challenge. Focus on Critical Care, 17(1), 40-49. Retrieved from EBSCOhost. Santiago, M., Sanchez, A., Lopez-Herce, J., Perez, R., Del Castillo, J., Urbano, J., & Carrillo, A. (2009). The use of continuous renal replacement therapy in series with extracorporeal membrane oxygenation. Kidney International, 76(12), 1289-1292. Retrieved from EBSCOhost. Scott, L., Boudreaux, K., Thaljeh, F., Grier, L., & Conrad, S. (2004). Early enteral feedings in adults receiving venovenous extracorporeal membrane oxygenation. JPEN Journal of Parenteral & Enteral Nutrition, 28(5), 295-300. Retrieved from EBSCOhost. Short B.L., Williams, L (2010) ECMO Specialist Training Manual, Third Edition. Michigan: Extracorporeal Life Support Organization

30. References Sievert, A., Uber, W., Laws, S., & Cochran, J. (2011). Improvement in long-term ecmo by detailed monitoring of anticoagulation: a case report. Perfusion, 26(1), 59-64. doi:10.1177/0267659110385513 Van Meurs K, Lally KP, Peek G, Zwischenberger JB (2005) ECMO: Extracorporeal Cardiopulmonary Support in Critical Care, Third Edition. Michigan: Extracorporeal Life Support Organization