1. Adult ECMO Baylor University Medical Center at Dallas
2017
Adult ECMO
Presenter: Phillip Nguyen, CCP
ECMO Specialist

2. Disclaimer
This presentation is only a resource to assist ECMO staff with various adult ECMO modalities.
This guide is not meant to replace any educational protocols or physicians’ orders.
Material presented is from a combination of personal clinical experience and public data shared by others via the internet.

3. ECMO Intro

4. ECMO?? ECMO- ExtraCorporeal Membrane Oxygenation
A circuit outside the body ("extracorporeal") that oxygenates and removes carbon dioxide from the blood
ECMO functions as an artificial heart assisting the native heart with arterial blood flow and an artificial lung working in addition to the patient's own failing lungs.

5. ECMO Therapy Familiarity across various medical specialties
ECMO is basically a Ventricular Assist Device (VAD) with oxygenating and heating/cooling capabilities.
Without the oxygenator in the circuit, it would not be considered an ECMO, but simply a short term VAD.
ECMO applications:
Usage has significantly increased within the last 10 years with improved outcomes.
(2,200 cases in 2005 to 6,500 cases in 2014)
Improved technology
Longer lasting, more biocompatible oxygenators
Smaller pumps facillate transports to ECMO centers
Familiarity across various medical specialties
Communication among CV, Pulmonary, ER/Trauma, Intensivists
A viable life-extending option
Bridge to recovery or transplant

6. ECMO Transports: Ground & Air
Allow patients to be treated at a facility offering higher level of care and ECMO expertise.

7. Indications for ECMO
Acute respiratory failure despite maximum ventilatory support
Flash pulmonary edema
ARDS
Acute degenerative lung
Pneumonia
Bridge to lung transplant
Life threatening cardiac failure
Post-cardiogenic shock following cardiopulmonary bypass
Post myocardial infarction
Low EF and poor ventricular contractility
Bridge to permanent VAD or heart transplant

8. Contraindications Irreversible primary disease CNS injury
Lung injury for > 3 weeks
Risk of pulmonary fibrosis
COPD
Unwitnessed cardiac arrest
Active hemorrhage
Active infection
Multiple organ failure
Terminal cancer
Advanced age

9. ECMO Applications Criteria

10. Complications Infection- fatal sepsis Excessive bleeding Emboli Death
From anticoagulants given to prevent clotting
Brain, GI, Pulmonary bleed
Emboli
Air or clots from the ECMO circuit
Patients who undergo VA ECMO may have an increased risk of stroke since blood is returned to the arterial system
Death

11. ECMO Modalities

12. Modes of ECMO
The modes of ECMO refer to the blood vessels access and return site. Veno-Arterial (VA), Veno-Venous (VV), and Veno-Arterial & Venous (VAV ).
VA ECMO- blood circulated from the venous system and returned to arterial system after oxygenation
VV ECMO- blood circulated from venous system and returned to venous system after oxygenation
VAV ECMO- blood circulated from the venous system and returned to both the arterial and venous system after oxygenation.

13. Modes of ECMO
( V-V-A is same as VA-V)
ECMO

14. VA vs VV ECMO

15. VA vs VV ECMO
VA ECMO decreases preload of right heart and supplements left heart’s CO, thus assisting the heart as a whole.
VA increases overall body perfusion
VA decreases PA and increases MAP
Allows heart to rest
VV (Ex. Fem vein to IJ) is solely respiratory support, since oxygenated blood is returned to Venous side, before entering the lungs rather than systemic circulation.
VV ECMO is dependent on patient’s cardiac function to pump the oxygenated blood throughout the body.
VV ECMO blood flow is limited to the patient’s cardiac function
High VV ECMO blood flow may cause pulmonary hemorrhage

16. VAV ECMO (or VVA)
Oxygenated blood is “Y’ed” off into both Arterial and Venous circulation

17. ECMO Configuration Refers to: Cannula insertion sites and position:
Femoral vessels, aorta, right atrium, Internal jugular vein, Subclavian and Axillary vessels
Incision type:
Percutaneous, open cut-down, tunneling
Cannula type:
Single vs multi-stage, single vs dual lumen
Tip position:
Right atrium, tube graft sewn to artery, antegrade vs retrograde direction
Size:
Access Venous cannulas are generally larger lumen (22-28Fr) to allow better drainage and longer (50-55cm)
Return cannulas are smaller (16-20fr) and shorter (15-25cm)
Distal limb cannula (8-10fr)

18. Mode selection Therapy required Cardiac, pulmonary, or both
Long-term vs short-term
Central can. for short-term
Competitive flow and Mixing cloud
North/South syndrome VAV ECMO
Mobility
Avalon and tunneling
Type of incision
Percutaneous vs cut down
Vessel size
Some large patients have small vessels
Patient flow requirements (BSA x CI)
Dialysis integration in circuit
Cannula flow ratings
Recirculation concerns
Return Cannula size
Flows (L/min)

19. VA ECMO Therapy
VA ECMO is utilized in patients with cardiac failure. A catheter takes blood from a major vein, is pumped through the ECMO machine, and returned to the arterial circulation via a major artery.
The heart functions partially.
Ex. If patient required total CO=5L/min and pump flow=3L/min, then patient’s heart is ejecting about 2L/min.

20. VA ECMO Configurations
Central cannulation
Right atrium or Femoral Vein  ECMO  Ascending Aorta
Often following an open-heart procedure where heart is already cannulated and patient is not able to come off from CPB. (post-cardiogenic shock)
Peripheral cannulation
Either percutaneous or open cut-down
Percutaneous often done at bedside vs operating room for open cut-down
Femoral vein or Right IJ  ECMO  Femoral, Innominate, or Axillary Artery

21. “Mixing Cloud”
Ideally, the blood from the heart is adequately oxygenated from functional lungs.
The upper body receives the majority of the “mixed” blood.
If patient develops pulmonary issues, the “mixing cloud” becomes significantly desaturated.

22. “Mixing Cloud”
Fem Vein  ECMO  Fem Art  Mixing Cloud

23. VA ECMO Central Cannulation Peripheral Cannulation
Femoral Vein  ECMO Femoral Artery
Femoral Vein  ECMO Aorta

24. VA ECMO Central Cannulation
Chest partially closed
Often the same cannulas used for CPB are connected to the ECMO circuit via 3/8 connectors

25. VA Fem-Fem Peripheral Cannulation
Femoral Vein ECMO  Femoral Artery

26. VA Femoral Peripheral Cannulation
Limb cannula
*Most common method of VA cannulation is the femoral vein for blood access and femoral artery for blood return.

27. Distal Perfusion Cannula

28. Tube graft for VA ECMO return
Tube graft (8mm) are sometimes sewn to artery and then attached to return cannula.
This technique allows for perfusion in both directions versus with the cannula inside the vessel lumen often impeding flow to the opposite direction.
Arterial Cannula inside tube graft

29. VV ECMO Therapy
VV ECMO is typically used on patients with respiratory failure who needs mainly lung support. Blood is taken from a major vein and returned to another major vein after oxygenation, thus increasing the venous blood oxygen content before it enters the lung.
Pulmonary and systemic blood flows are equal and heart assumes total workload.
VV ECMO could be utilized as an RVAD if blood is returned to the PA, thus bypassing the right ventricle.

30. VV ECMO Configurations
Central cannulation
Right atrium, Femoral, IJ, or Subclavian vein  ECMO  Right atrium or Pulmonary artery
Can provide respiratory and RV support
Peripheral cannulation
Either percutaneous or open cut-down
Percutaneous often done at bedside vs operating room for open cut-down
Femoral, IJ, subclavian, or axillary vein ECMO  Femoral, IJ, Subclavian, or Axillary vein
With Fem Vein  ECMO  Fem Vein configuration, the return cannula should be placed closer to RA. The access cannula tip should be 10-15cm lower near the hepatic IVC.
IJ  ECMO  IJ (Same vessel with Avalon)

31. VV IJ-Fem Peripheral Cannulation
Femoral vein ECMO IJ

32. VV ECMO w/ Single IJ Cannula
Avalon dual-lumen cannula
From ECMO
To ECMO
Blood drain from SVC & IVC and returned to RA

33. Avalon Right IJ Cannulation

34. Mobility with Avalon cannulation

35. VAV ECMO Therapy
This method is utilized in patients requiring additional respiratory support, despite maximum ventilator settings and VA ECMO support.
Respiratory distress Upper body hypoxia and or acidosis from low arterial O2 sat or high CO2 from compromised lungs.
Ventilator is at 100% FiO2 or max rate
Pulse oximetry reading from toe can be 100% while from fingers is 70-80%. (North/south syndrome)

36. VAV ECMO Configuration
Femoral vein  ECMO  divided return line  Femoral artery AND Subclavian Vein (or IJ, Axillary Vein)
This configuration provides perfusion to the tissues and diverts oxygenated blood to the right atrium, boosting the pre-lung oxygen content.
Competitive flow is a concern due to lower resistance flowing to the veins (lower pressure system) compared to the flow to the artery.
Possibly clotting off of arterial line.

37. Fem Vein  ECMO  Fem Artery & Jugular Vein

38. ECMO Cannulas & Equipment

39. Single lumen Cannulas VENOUS CANNULA (19-28 Fr, 50-55 cm)
ARTERIAL CANNULA (16-20 Fr, cm )
**Cannula selection is patient specific. Larger patients requiring higher flows warrant cannulas with larger lumen or French size (Fr) **1 mm=3 Fr**

40. Dual Lumen Cannula Avalon Catheter
Drains blood from SVC & IVC and returns oxygenated blood to right atrium directed at tricuspid valve
13fr to 31fr (4.3mm to 10.3mm)
Allows for single cannulation site
Less incision sites reduces the chances of bleeding and infection
Ease of mobility
Mal position or SVC occlusion may lead to poor drainage of the head vessels and cause head swelling

41. Limb Cannula Provides perfusion to the distal part of the leg.
Often utilized when femoral return cannula is placed in femoral artery, impeding flow to distal limb.
Prevents leg ischemia, compartment syndrome, and mottling of legs
Pulses are routinely checked in ICU for flow verification via doppler

42. Cannula Insertion Kits & Dialators

43. Cardiohelp Transport Circuit (Veno-Arterial ECMO)
Oxygenated Blood to Femoral Artery
mmHg
Line pressure monitor
Blood from Femoral Vein
Pump Console
Gas/ FiO2 Regulator
Centrifugal Pump
Oxygenator/Heat Exchanger

44. Cardiohelp In-house Cart

45. ECMO EQUIPMENT CDI 500 Blood gas, Hct, Saturation monitor Pump console
Gas blender
Maquet Rotaflow centrifugal pump console with adjustable arm
Maquet Rotaflow centrifugal pump with sterile tubing pack
Maquet Quadrox oxygenator/heat exchanger
Edwards Lifesciences or Maquet Avalon arterial and venous cannulas
Medtronic Biomedicus Biocal heater/cooler
Terumo/Sarns CDI 500 blood gas monitor
Sechrist oxygen/air blender
Medtronic DLP Pressure Display
Heater/cooler

46. ECMO Initiation
Notify physician and ECMO Specialist (ES) immediately if ECMO therapy is warranted.
low sustained MAP from hypokinetic heart; Max inotropic/vasoactive support
low arterial saturations from unresponsive lungs; Max vent settings
Equipment and Surgical field supplies for OR, cath lab, or bedside initiation
ECMO circuit w/ attached heater/cooler setup by the ES
Cut-down vascular tray, 4 Sterile tubing clamps, cannulas, insertion kits w/ guide wires, cannula stitches, ultrasound machine for locating vessel, heparin, 1L NS with turkey bulb syringe,
Physician chooses ECMO mode and begins to locate blood vessels for cannulation.
Patient must be heparinized prior to insertion of cannulas
Due to the continuous circulation of blood through a foreign surface (ECMO), anticoagulation therapy is warranted. The oxygenator is the primary component of circuit that is prone to clots.
Heparin bolus of units/kg and maintenance drip started at 500 units/hr
Target anticoagulation levels:
Partial Thromboplastin Times (PTT) Activated Clotting Time (ACT) secs
Dosing protocol is also dependent on patient’s current hemostasis (bleeding, coagulation, TEG)
Alternative Anticoagulants: Angiomax, Argatroban
The ES assist physician with cannula selection and flow requirements
Physician inserts cannulas and connects it to ECMO circuit tubing
ECMO Specialist performs pre-bypass checklist and confirms with physician before initiating ECMO therapy.
Therapeutic flow and gases are confirmed with physician.
Physician secures the cannulas & tubing to the patient with stitches while the ES tie-bands all tubing connections.

47. ECMO Management

48. ECMO MANAGEMENT: FIRST AND FOREMOST
Trace the circulation of blood
Mode of ECMO?
What is the circuit supporting? Lungs , heart, or both?
If cardiac support, is it right heart, left heart, or both?
Confirm the type of ECMO (VA,VV, VAV)
Determine where the venous blood is coming from and where the oxygenated blood is returning to.
Ex of VA: Fem vein to fem artery
Ex of VV: Fem vein to Right IJ to or Fem vein to PA
Always trace the blood flow starting at the origin (cannulation site), through the ECMO circuit, and all the way back to the patient.

49. Max Pump flow Min Pump flow Therapeutic Pump flow Sweep FiO2 Weaning
VA ECMO
VV ECMO
VAV ECMO
Max Pump flow
The calculated high flows with the existing cannula sizes, placement, volume status
2.5 CI x BSA (Until ven line chatters, ven line pressure < -150mmHg, Art line press > 300mmHg, 4500 RPM)
BSA = Sq rt [(height cm x weight kg)/3600]
2.5 CI x BSA (Until ven line chatters, ven line pressure < -150mmHg, Art line press > 300mmHg, 4500 RPM)
3.5 CI x BSA (Until ven line chatters, ven line pressure < -150mmHg, Art line press > 300mmHg)
 **Flow is divided between 2 cannulas**
Min Pump flow 
The lowest flow maintained (> 5 mins) during weaning.
2.0 L/min to prevent circuit clot
4.0 L/min (2.0 L/min each cannula) to prevent circuit clot
Therapeutic Pump flow
The prescriptive pump flow to achieve physician’s prescribed parameters (Ven sat, MAP, O2 Sat, pH, pCO2)
 Ex. 3L/min of flow may be therapeutic to a patient with < 1.6 BSA but may be insufficient for > 2.5 BSA
 **When reestablishing flows after a no-flow state (oxy changeout, repaste, etc), correlate previous RPM’s with blood flow (on ECMO flow sheets). An increase in RPMs to achieve same previous flow requires evaluation. (May need volume, cannula obstruction, etc)
Pump flow required to achieve Patient’s Ven O2 Sat > 55-60% & MAP>60-65mmHg
(Ven sample could be drawn from ECMO circuit on the pre-Rotaflow inlet side if Swan or central line not available)
Assuming Sweep gas and FiO2 are at optimized settings. (post-oxygenator O2 sat >95%)
 Be aware that a patient’s ABG could look perfect and the continuous pulse oximetry could read %, but the Ven O2 Sat could be in the 40-50’s.  
Pump flow required to maintain Patient’s Art O2 sat (or continuous pulse oximetry) > 88-90%
Assuming Sweep gas and FiO2 are optimized settings.
For VV, decrease pump flow to 3L/min before decreasing sweep or FiO2. This reduces hemolysis and consumption of platelets and clotting factors by decreasing circuit exposure.
 AND
  Art O2 sat or continuous pulse oximetry > 90-95% 
Flow probe from Cardiohelp can be installed to measure the individual blood flows through the divided return blood tubing.
Sweep
Set sweep gas to 1:1 ratio at initiation of ECMO. Ex: 4L/min sweep to 4L/min of pump flow
Adjust accordingly after obtaining Patient’s ABG and Post-Oxy results.
Adjust gas flow to maintain Patient’s pCO2 at physiologic levels: mmHg  **With VA ECMO, maintain Post-Oxygenator’s pCO mmHg (regardless of required gas flow, since failing oxygenator will require higher flows)  **If we neglect the Post-oxy CO2, we are negating the effects of North/South syndrome. A radial art line sample correlates to upper body blood oxygenated by the patient’s lungs and perfused by the patient’s native heart whereas a femoral return cannula may be perfusing non-physiologic pCO2 or pH blood to the lower body. The higher the blood flow, the more this would have a negative effect on the “overall” perfusion of the patient. As the heart recovers, this effect is more noticeable.
Adjust gas flow to maintain Patient’s pCO2 at physiologic levels: mmHg
 ** Physicians may have a target pH rather than a CO2 level. (permissive hypercapnia)
 Lowest: 0 L/min (O2 line disconnected)
Highest: 10L/min
 With VV ECMO, the Post-oxygenator pCO2 level is irrelevant in our management of sweep.  However, it is still necessary to draw a Post-Oxy gas to determine the effectiveness of the hollow fiber membrane in CO2 removal.
Adjust gas flow to maintain Patient’s pCO2 at physiologic levels: mmHg
AND
Post-Oxygenator’s pCO mmHg.
FiO2
Set FiO2 to 100% at initiation of ECMO.
Adjust FiO2 to maintain Patient’s Art O2 sat > 95%
 With VA ECMO, we should also maintain Post-Oxygenator’s O2 Sat > 95%, (regardless of required FiO2, since failing oxygenator will require higher FiO2) ** If we neglect the Post-oxy O2 Sat, we are negating the effects of North/South syndrome. A radial art line sample correlates to upper body blood oxygenated by the patient’s lungs and perfused by the patient’s native heart whereas a femoral return cannula may be perfusing non-physiologic pO2, O2 Sat, or pH blood to the lower body. As the heart recovers, this effect is more noticeable.
Adjust FiO2 to maintain Patient’s Art O2 sat > 88-90%
Lowest: 21% room air (yellow line)
Highest: 100% Oxygen (green line)
With VV ECMO, the Post-oxygenator pO2 level and O2 Sat is irrelevant in our management of FiO2
 Set FiO2>60% and sweep > 1L/m before drawing a Post-Oxy gas to determine the oxygenator’s performance.
Post-Oxygenator’s O2 Sat > 95%
Weaning
Begin to wean if patient’s hemodynamics, Ven Sat, ABG is greater than the minimum parameter set by the physician.
 **Note that high Pump flow is more traumatic to the blood than high Sweep or FiO2 . ** Higher Pump flowexposes blood cells to sheer stress, higher frequency of exposure to foreign surfaces (oxygenator, tubings), consumption of clotting factors, increased hemolysis kidney injury hematuria, chlolemic nephrosis
Pump Flow: Begin by decreasing Pump flow to Min flow of 2L/min at increments of 0.5 L/min each time.
 Sweep: Maintain same ratio. Ex If Pre-wean settings are 2L/min Sweep gas to 4L /min Pump flow, then weaning settings should be approximately 1L/min Sweep to 2L/min Pump flow. (1:2 ratio)
FiO2: Should NOT be changed from Pre-weaning settings.
 Reassess patient’s hemodynamics/ Ven Sat/ ABG with each incremental change. 
Decrease Sweep and/or FiO2 as tolerated by patient’s ABG
 Sweep: Decrease to Min Sweep of 0L/min at increments of L/min each time.
 FiO2: Decrease to 21% at increments of 5-10% each time. **Note that if Sweep is at 0L/min, FiO2 is N/A. The gas rate is zero and essentially no gas exchange is taking place in the oxygenator.  Pump Flow: Once sweep AND FiO2 is at lowest settings, decrease Pump flow from 3L/min to 2L/min and disconnect gas line. Allow 12hrs of recirculation and reassess patient’s ABG before terminating VV ECMO
Depends on whether the physician is weaning VA or VV or both.
 If weaning off to decannulate or convert to only either VA or VV only, begin by decreasing blood flows to
4.0 L/min (2.0 L/min each cannula) to prevent circuit clot.  **Do not wean Sweep or FiO2 if still on VAV, only pump flows, since ECMO is perfusing the tissues and bypassing the lungs.

52. Patient Safety Checklist
Four tubing clamps
Flow probe ultrasonic gel: Repasting when “sig” light alarms (Rotaflow pumps only)
Flash light: Checking for clots in oxygenator every 4hrs
Backup pump: Leave plugged in so battery charges
Manual hand crank: For prolonged power failure
CV surgeons’ and Perfusionists’ contact numbers
Complete checklist each time you take on an ECMO shift.
*Don’t assume everything is there from previous shift.*

53. Pump Blood Flows Patient specific
Pump blood flow is increased until respiratory and hemodynamic status is stable
Estimated flow (L/min)= 2.5 (cardiac index) x BSA
Near maximum flow rates are usually desired during VV ECMO to optimize oxygen delivery.
In contrast, the flow rate used during VA ECMO must be high enough to provide adequate perfusion pressure and O2 sat, but low enough to provide sufficient preload to maintain left ventricular output.
Max blood flow is limited by venous drainage cannula
Do not exceed line pressure > 300 mmHg
Sheer stress may cause hemolysis and platelet activation
Disconnection of tubing

54. ECMO GAS EXCHANGE
Yellow gas line
Green gas line

55. Sweep Gas and FiO2 Adjustments
Sweep = Gas Rate (L/min)
Increase sweep to lower pCO2
Decrease to raise pCO2
FiO2 (oxygen flow index)
Settings Range: % ( ) O2
Increase to raise pO2
Start sweep gas at a ratio of 1:1 of Gas/Blood Flow with FiO2 at 100% oxygen
Run a patient ABG and ECMO arterial outlet sample after 30mins following initiation and make proper adjustments
Blow off condensation in oxygenator every 4-6hrs by turning up sweep gas to L/min for few seconds (sneezing)
O2 & Air Blender

56. Other Considerations Supplemental ventilator settings
ECMO decreases the work load of lungs
Goal is to decrease barotrauma caused by high Peak Inspiratory Pressures
Lower FiO2 to decrease oxygen toxicity
To maximize oxygenation
Increase ECMO blood flow
Increase Hct levels
Increase patient’s sedation

57. ECMO: ABG Management
The oxygenator’s outlet pO2, pCO2, and O2 saturation will only tell you the efficiency of the oxygenator, NOT the patient’s respiratory status.
Adjustments made to sweep or FiO2 will only change the oxygenator’s parameters, NOT the patient’s.
The patient’s ABG will mainly be affected by ECMO’s pump blood flow and/or ventilator settings and NOT the sweep or FiO2 settings (assuming oxygenator’s pO2, CO2 are within target parameters)

58. ECMO: ABG Management
If ECMO gases are within target parameters and the patient’s ABG’s are not optimal
Increase blood flow if venous drainage allows it
Volume may have to be administered
Increase the Hb/Hct levels with RBC’s
Adjust ventilator settings to improve patient’s gas exchange
Patient may require re-intubation (if not already intubated)

59. Fluid management
Third spacing is common with ECMO patients. Fluid shifts could directly affect pump flows.
The pump is dependent on the intravascular volume. If volume shifts into the interstitial space, the circulating volume decreases, thus pump flow.
Edematous patients is problematic
Pulmonary edema would further compromise patient’s lungs gas exchange capabilities

60. Fluid management
Maintaining a colloid osmotic pressure >25mmHg will reduce interstitial edema, thus stabilizes the intravascular volume to allow desired pump blood flow.
Albumin-natural colloid osmotic
(Normal serum albumin range gm/100mL)
Mannitol- acts both a colloid osmotic & loop diuretic
Lasix-diuretic
FFP-colloid osmotic

61. Fluid management
Since most ECMO patients are fluid overloaded and edematous, aggressive diuresis is sometimes warranted.
CVVHD can be added to the existing ports on the ECMO circuit.
Ideal for patients with renal failure and fluid overloaded

62. Acidosis and Alkalosis
Acidosis- decreased in pH
Respiratory- insufficient CO2 removal by lungs or ECMO
Increase sweep gas on ECMO or ventilator settings
Metabolic- normal CO2, but low pH due to inadequate oxygenation of tissues
Increase pump blood flow to boost tissue perfusion
Alkalosis-increased in pH
Respiratory- excessive CO2 removal
Decrease sweep gas on ECMO or ventilator settings
Metabolic- normal CO2, but high pH
Excessive urine output may cause this
Lactated ringers may correct this

63. CDI 500 Monitor Continuous in-line blood gas monitoring device
Instantaneous display of results with changes in gas and blood flow settings
Reduces frequency of blood sampling
Less risk of contamination and less lab cost
Measures post-oxygenator’s pH, pCO2,pO2, HCO3, Base excess, O2 Sat, K+, temp
Measures patient’s Ven Sat and Hct

64. Charting
Frequency: Per physician’s order. Typically flows/RPMs hourly and ABG’s every4-6hrs
Chart entry:
Vitals: Time, MAP, PA & CVP (if avail), heart rate, pulse oximetry, temp
Circuit: blood flow, pump RPM, gas flow, FiO2
Labs: ACT, PTT, pH, pCO2, pO2, Art O2 sat, Ven O2 sat, HCO3, base excess, Hb/Hct
RPM’s relative to blood flow is important
High RPM’s with same flow may be indicator of high resistance due to line obstruction, clots, etc

66. Critical Parameters Minimum sustained blood flows: >2L/min
Prevents potential clot formation in circuit and/or patient
Maximum heater settings: <37 degrees Celcius
Turn off heater after patient’s desired temperature is reached. Patient’s temp often > set temperarture

67. Venous line (inlet to pump) is “chattering/shaking” or if blood flow is constantly fluctuating
Solution: Decrease pump flows by 0.5 L/min increments until chatter goes away and then start troubleshooting
Patient may have low volume and need replacement due to:
Blood loss
Excessive urine output
Third-spacing (edema)
Obstruction of inlet or outlet lines due to:
Kinking of lines
Migration or physical obstruction at cannula tips

68. Sudden tubing disconnection
Solution: Stop further blood loss
Quickly grab 2 tubing clamps and clamp BOTH the inlet and outlet tubing coming out of patient (close to cannula sites)
Goals is to prevent patient exsanguination
Call ECMO Specialist/perfusionist ASAP
Call surgeon and request for heparin bolus due to no-flow state
Possibly clotting inflow/outflow cannulas

69. Patient’s venous saturation decreases < 60% on VA ECMO
Solution: Maximize pump flows (2.5 CI).
Increase patient’s sedation and pain meds. Increase Hct with pRBC’s.
Venous saturation is the primary indicator of patient’s O2 consumption
Often occurs when patient is waking up or agitated
Venous saturation will NOT be improved by adjusting settings on oxygenator (Sweep/FiO2)

70. Visible clot in oxygenator causing drop in pump flows
Solution: Change out oxygenator
Alert surgeon and request for heparin bolus to allow for low/no flow state during oxygenator change-out
Adjust ventilator settings to accommodate for the decrease in oxygenator’s efficiency
Call perfusionist ASAP
Perfusionist will change out circuit if necessary

71. Other Considerations Low pulse oximetry reading may be due to:
Pulse oximetry placement (ear vs fingers vs toes)
Inadequate perfusion (Low CO for VV, low pump flow for VA)
Inadequate oxygenation from pulmonary edema
Possibly place pt on diuretics or dialysis to remove fluid
Recirculation of ECMO blood flow (VV only)
Proximity of cannulas placement.
Pump blood flows too high.
North-South Syndrome (VA only)
Patient’s upper body is hypo-perfused/hypoxic due to poor cardiac or respiratory failure compared to the lower body that is adequately perfused/oxygenated by the ECMO circuit.

72. BUMC ECMO Transport Coordination
Physician or surgeon at OSH contacts our on-call ECMO surgeon (on-call schedule in resource binder at charge nurse’s station)
Our on-call ECMO surgeon contacts ECMO Specialist on shift via ES phone Things to consider when surgeon calls:
VA or VV ECMO support required? (VA usually more urgent and critical)
If VA, does patient have IABP or Impella?
If VA, is the patient in OR or ICU?
Is our surgeon traveling with perfusionist to cannulate or is the perfusionist going alone and relying on surgeon at referring hospital to cannulate?
Does our surgeon prefer ground or air transport (also depending on weather)
Ask our ECMO surgeon to call our Transfer Center to begin transfer
ES then calls Transfer Center ( ) to confirm that BUMC accepted OSH patient and request for patient’s:
Name, DOB, Weight (for air transport maximum capacity calculations), Height
OSH location (room number and their nurse’s contact if possible)
Insurance coverage
If patient has Swan, RN medic has to travel with patient
If the patient is local or within a chopper radius <150 miles, call Careflite to arrange for perfusionist and equipment pickup at BUMC (Roberts Tower off Junius St in front of fountain for ground pickup). **Remind Careflite staff to bring correct mounting bracket for the Cardiohelp.
If the patient is from any Ft. Worth hospital and requiring ground transport back to BUMC, we have to instruct the OSH nurse taking of the patient to contact Medstar to arrange for pick up at the OSH.
Ellis County contracts with American Medical Response (AMR) for EMS , therefore Careflite must call AMR for clearance before transferring patient from Baylor Waxahachie ground.
The ground ambulance has to be equipped for transporting ECMO patients
Larger truck, Cardiohelp yellow bracket, O2 source, electrical plugs
Call our on-call perfusionist
relay patient info to CCP and inform CCP ETA of Careflite to BUMC
request perfusionist weight if air transport. Need surgeon’s weight also if traveling by air.
If an insured patient is located outside Careflite’s chopper radius, call Innovative Ecmo Concepts to arrange for fixed-wing plane pickup. They have their own perfusionists. If they are not available, then we arrange Careflite to pick up the BUMC perfusionist and/or surgeon, Cardiohelp console, ECMO packs, cannulas, via ground to airport where Careflite’s fixed-wing is located (Lovefield, or Grand Prairie Airport)
ES will coordinate with Charge Nurse and prepare our ICU room for the OSH ECMO patient:
Cardiohelp cart, Heater/cooler, and gas lines setup

73. BUMC Transport Team

74. Questions/Comments VA

75. Thank You !!