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Jason Lippy, RN Paula Minor, RN University of Maryland Medical Center March 2012. ECMO and the Adult Patient: Nursing considerations. What is ECMO?. Extra Corporeal Membrane Oxygenation Blood is drained from the venous system Oxygenated through an artificial lung, removing carbon dioxide - PowerPoint PPT Presentation
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ECMO AND THE ADULT PATIENT:NURSING CONSIDERATIONS
Jason Lippy, RNPaula Minor, RNUniversity of Maryland Medical CenterMarch 2012
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
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
ECMO FLOWBlood Flow
1. Deoxygenated Blood Drained from Venous Circulation
2. Blood PumpCentrimagRotaflow
3. Membrane Oxygenator/ Heat Exchanger (Quadrox)
Hollow fiberpolymethylpentene
4. Oxygenated Blood Returned to the Patient
5. Pressure monitor
1
23
4
5
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
Venoarterial (VA) ECMO Provides pulmonary and hemodynamic
support Heart and lungs are bypassed Venous/drainage and arterial/return Nonpulsatile
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!!!
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
VV ECMO: Two Site Cannulation
1 Drainage, 1 Return Internal Jugular Vein Femoral Vein or Saphenous
Vein
Cannulation Dressings
Cannula Positions
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
ECMO Considerations Based on Systems
NeurologicManagement / 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
CardiovascularManagement / 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
RespiratoryManagement / 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
Respiratory
ABG
Patient &Arterial side of oxygenator
VBG Venous side of oxygenator
RECIRCULATION!!!
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 >50,000Daily TEG Analysis, Plasma Free Hgb, LDH
22Hemoscope TEG-Based GuidelinesTEG® Value Clinical Cause Suggested
TreatmentR between 7 - 10 min clotting factors x 1 FFP or 4 ml/kg
R between 11-14 min clotting factors x 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 function x5 platelet units
MA at 40 mm or less platelet function x10 platelet units
Angle less than 45° fibrinogen level .06 u/kg cryoLY30 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
choiceLY30 less than 7.5%, C.I.
greater than 3.0 Prothrombotic state anticoagulant of choice
GastrointestinalManagement / Goals Small bowel feeding Daily Stool Gastritis Prophylaxis
ECMO Considerations Bleeding Ischemia Hyper-bilirubinemia
not always hemolysis
RenalManagement / Goals Even Fluid Balance Renal protection therapy
Good CI Good MBP
ECMO Considerations SCUF -Hemo concentrator CRRT (prisma flex) Hyperosmomolar /
hyperoncotic pH control
Skin Frequent Repositioning Specialty Mattress Aseptic Technique No New Sticks Wound Care Consult Edema
Patient and family support Must define prognosis Help MD understand family expectations Should define end-points Team communication
Intra Hospital Transport …Don’t Do It !!
Group Effort Trial Run – scout the path Transport Team
The Future of ECMO
ReferencesAllen, 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
ReferencesSievert, 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