1. ECLS Updates GTCAC-AACN FALL SYMPOSIUM November 10, 2016
Sharon Wahl, RN, MSN, CCRN, CCNS

4. ECMO/ECLS ExtraCorporeal Membrane Oxygenation
ExtraCorporeal Life Support

5. Types of ECLS VA – VenoArterial VV – VenoVenous
Provides cardiac and respiratory support
VV – VenoVenous
Provides respiratory support only

6. ELSO (ExtraCorporeal Life Support Organization)

7. Survival Rates

9. 2009 CESAR trial published H1N1 pandemic Advances in technology
UK trial, showed improved survival in patients with severe respiratory disease when transferred to ECLS center vs. standard treatment
H1N1 pandemic
Advances in technology

10. Candidates for ECLS Indications Contraindications
Severe heart or lung failure – consider at 50% mortality risk, indicated at 80% mortality risk
Majority of contraindications are relative – evaluate on individual basis
Preexisting conditions affecting quality of life – CNS status, inability to anti-coagulate, end stage malignancy
Futility
Age and ? Size of patient

11. Patient + Cannula + Pump + Oxygenator + Cannula = ECLS

12. CIRCUIT

13. ECLS CANNULATION

14. VA CENTRAL CANNULATION
Drain from the right atrium
Return to the ascending aorta
Usually cardiac surgery cases with postoperative failure, open chests

16. Comparison VA ECLS VV ECLS De-oxygenated blood to lungs Nonpulsatile
Removes preload
Increases afterload
Risk of arterial inflow emboli
Only way to provide cardiac support
Average run 5-7 days
In and out right side – oxygenated blood to lungs
Normal LV pulsation
No effect preload or afterload
Microemboli/air to lungs
Respiratory support
No hemodynamic support
Average run days

17. Nursing Considerations

18. General Nursing Goals Stabilization Comfort and organ rest
Prevent and/or manage complications related to ECLS and ICU
Understand how ECLS is affecting your patient and provide comprehensive care of patient

19. Bleeding most common complication
All ECLS patients are anticoagulated to maintain patency of circuit
Careful transfusion
GI prophylaxis
Observe cannulation sites
Fix coagulopathy
Lower PTT goals– observe circuit closely for clots
Surgery may be indicated to control bleeding
CNS bleed is significant complication

20. Cerebral hypoxia
Oxygenated blood from ECLS circuit mixes with blood ejected from ventricle – blood from ECLS retrograde
Location of mixing dependent on ejection fraction of LV and ECMO flow or support
Usually mixes in proximal ascending aorta or aortic root
As ejection fraction improves the mixing point changes
May result in hypoxic blood perfusing proximal aortic branches
Degree of lung function is a variable

21. Mercy Hospital - Coon Rapids, MN
April 2013
VA ECMO Admixture

22. Cerebral hypoxia
Use right radial arterial line for ABGs or measure O2 saturations on right hand
ABGs drawn from femoral site may appear fully saturated
Blood supply to the right hand is most distal from ECLS cannula
Increase vent settings if lungs are working
Pulmonary recruitment
Increase ECLS support, pump flow
Add an additional cannula – VAV ECLS
Oxygenated blood to the lungs

23. Monitoring Regional O2 Saturation
Gives site specific data on tissue perfusion – regional not global
Venous-weighted measure of O2 saturation – Reflects venous oxygen reserve
Non-invasive, early warning of ischemia and compromised tissue perfusion

24. Monitoring Regional O2 saturation
General Guidelines
Typical values 58-82%
Regional O2 saturation (rSO2) of 50 or a 20% decline from baseline are cause for concern and intervention
rSO2 of 40 or 25% decline from baseline are associated with ischemic brain injury, neurologic dysfunction and adverse outcomes
Monitor trends – wide variance in baseline

25. LIMB ISCHEMIA Use smaller catheters to cannulate - 15-17 Fr arterial
Retrograde perfusion catheter
Cannulate posterior tibial artery or SFA and “Y” off arterial cannula
6-8 Fr catheter
Reperfusion injury, monitor for compartment syndrome
Rooke boots

26. Pulsatility – VA ECLS Pump-flow is non-pulsatile
Arterial line increasingly dampened as pump flow increased
Some pulsatility is desirable – recommended 10 mm minimum
Stagnation at aortic root
LV dilation – leading to pulmonary edema and hemorrhage
Difficult to attain with very low EFs

27. Offload the left ventricle
IABP – decrease afterload allow LV to eject
Atrial septostomy
Percutaneous transeptal atrial puncture
Blood flows from left to right and drains into ECLS cannula
Vent left ventricle
Cannula from LV to venous drainage cannula

28. Impella Gaining favor as method to decompress LV when used with ECLS
Crosses aortic valve, motor pulls blood through to aorta

29. VV ECLS

30. VV ECLS Rate of infusion blood to deoxygenated blood is typically 3:1
Results in lower O2 sat – 80-85% typical for VV ECLS, 85-92% with double lumen cannula
Adequate O2 sat if cardiac output and hemoglobin/hematocrit can maintain oxygen delivery
Any native lung function will increase O2 sat

31. Recirculation
Oxygenated blood in circuit is taken up by venous drainage catheter
Less recirculation with dual lumen cannulas
Falling arterial O2 sat with increasing circuit SVO2
Affected by:
ECLS pump flow – linear relationship
Venous catheter position – positioned high in SVC or low in IVC increases recirculation
Native cardiac output – improved output decreases recirculation
Right atrial blood volume – increasing intravascular volume can decrease recirculation

32. Ventilator Management
Oxygen delivery is supplied or augmented by ECLS
Rest settings on ventilator
Low tidal volumes (4-6 ml/kg)
Plateau pressures < 35 cm H2O
PEEP 5
FiO

33. SWEEP
Increasing sweep flow increases CO2 clearance, does not affect oxygenation

34. Hemodynamics of Resp Failure on V-V ECLS
PVR and SVR decrease – higher mixed venous oxygen saturation in pulmonary arteries
Cardiac return increases – improved oxygen delivery to coronary arteries
Perfusion improves
Decreased vent pressures
Patient may initially require inotropes/vasopressors but are usually able to wean off

35. Sedation
In initial stages sedation and paralysis utilized to facilitate ventilator management, decrease O2 demand
ELSO recommendations – minimal sedation after 48 hours
Trend toward managing patients with less sedation, preferable to not keep paralyzed but as awake and alert as possible
May not know neuro status prior to initiation of ECLS – neuro checks frequently, may need CT, EEG – high risk for intracranial hemorrhage, may have hypoxic injury pre-ECLS
EEG monitoring for hours

36. MOBILITY

37. Nutrition Early initiation of feeding associated with improved healing
Place feeding tube early – avoid complications associated with anticoagulation

38. Pressure ulcers Patients are at high risk for pressure ulcers
Suspected deep tissue injury (SDTI) have been identified as category of pressure injury
May be caused by hypoxic reperfusion vs. pressure
Research needed to determine effective prevention and management strategies

39. KEYS to success
Communication
Teamwork

40. Psych/Social
Update the family, be responsive to their needs, educate the family
Realistic expectations while preserving hope
Define goals in terms of a few days at a time
Palliative Care and Ethics

41. Futility Have discussion with family prior to starting ECLS
Continue to have some form of this conversation daily
Define futility
3 days of no cardiac function in patient who is not candidate for advanced therapies
2 weeks of no lung function in patient who is not transplant candidate
Irreversible lung or brain injury
Resources available
Prolonged support with little chance of success
Care giver fatigue

42. What’s next for ecls?

43. SEPSIS Historically sepsis has been contraindication for ECLS
Treat underlying cause while providing organ blood flow and tissue oxygenation
Require high flows on ECLS circuit
Wean inotropes once optimal flow achieved
Coagulopathy – DIC
ROTEM to identifying underlying cause

44. ECPR Initiation of ECLS during CPR
Cannulate for ECLS at bedside – more common in ED
Evaluate use of resources vs outcomes

45. ECPR criteria Criteria
Age 18-75
Arrest of cardiac origin – V tach or V fib
ETCO2 > 20
ECLS candidacy to be determined by AHF & Intensivist physicians
Decision made by 10 minutes into code
Goal target time from arrest to initiation of ECMO < 60 minutes

46. TARGETED TEMperature management
Can regulate temperature to be whatever you want
May warm patient if indicated – exposure
Cooling patient:
Cerebral protection
ECPR patients “Coolit” – intravascular cooling catheter or external gel pads are preferred to cool
May have modified goal due to bleeding concerns
Circuit cannot rewarm precisely
Lower metabolism, sepsis
Coagulopathy
May consider for circuit changes

47. Circuit management
ECLS circuit is traditionally managed by ECLS specialist – perfusion, RT, or RN
Increasing volume of patients - more programs are transitioning to RN managed circuits with backup

48. RVAD – Biventricular impella
PROTEK Duo
ABIOMED Impella RP®
Double lumen catheter from Tandem Life
Right ventricular assist device
Inserted percutaneously, pulls blood from right atrium to pulmonary artery
mpella-rp/

49. ECLS specialty centers Will certification be required?
Current topics
ECLS specialty centers
Will certification be required?
Smaller, smarter, portable systems
Standard of care?
Algorithms to guide providers when to initiate ECLS

50. CASE STUDY
39 year old male with no significant medical history presented to outside ED with cough, body aches, headache, chills and congestion x 5 days
T-103.6, O2 sat 91% - pain with deep breaths, BP 79/41
Lactate – 4.9, Crt 2.32, EF 40-45%
Presented at 0530, intubated at 1000, Vent settings: CMV-18, FiO2 100%, PEEP-12
– 7.18/51/126/18 O2 sat 90%
12 mcg/min, 90 mcg/min, .04 units/min – maintaining MAP at 65, systolic 80-90

51. Case study VA ECMO initiated @ 1752 day of admit
Cannulated RFV 25 Fr, RFA 21 Fr
Flows 6 – 6.5 liters/min

52. CASE STUDY Regional O2 saturations
To OR with Vascular surgery for fasciotomy, acute ischemia related to spasms
Time
L) Leg
R) Leg
2000 65 60
2100 59 43
2200 30

53. CASE STUDY – DAY #2 Troponin 28.17
To cath lab – no significant disease, repeat cardiac echo EF < 10% - stress cardiomyopathy
Neo off, Levo 0-3 mcg/min, Vaso .04 Units/min – sedation
PCV – 8, PEEP – 8, FiO2 – 50%, PIP-25
Blood and sputum cultures from admit positive for Beta Streptococcus group A
CRRT started previous evening on return from OR, creatinine peak 2.64, trending down

54. CASE STUDY – day #6

55. CASE Study – Day #6 ABGs 7.42/40/252/25 EF 30-35%
On/off small dose Nipride, 2.5 – weaned off
PCV-10, PEEP -10, FiO2 80%, PIP – 31
ECMO flow 6-6.5, sweep – 6.5, FiO2 90%
Transitioned to VV ECMO with 31 Fr Avalon in RIJ – dual lumen catheter

56. CASE study – day #10
Off all vasoactive drips – sedation, paralytics on
ECMO flow 4.75, FiO2 100%, Sweep – 9
PCV – 10, PEEP – 5, FiO2 – 100%, PIP – 28
To OR for R) BKA
Oxygenator changed – brief asystole arrest requiring atropine, epi, CPR

57. Case study Decannulated at bedside on Day #23
Transitioned off vent 10 days later and discharged to LTAC

58. REFERENCES
Annich, G.; Lynch, W.; MacLaren, G.; Wilson, J.; Bartlett, R. (Ed.) ECMO Extracorporeal Cardiopulmonary Support in Critical Care, 4th Edition, Extracorporeal Life Support Organization.
Extracorporeal Life Support Organization General Guidelines for all ECLS Cases (2013). Retrieved October 28, 2016 from
Peek, G., Mugford, M., Tiruvoipati, R., Wilson, A., Allen, E., Thalanany, M., ….. Elbourne, D. (2009). Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygentation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet, 374,
Rao, A., Preston, A., Strauss, R., Stamm, R., & Zalman, D. (2016), Risk factors associated with pressure ulcer formation in critically ill cardiac surgery patients. Journal of Wound Ostomy Continence Nursing, 43(3), 1-6.