Extracorporeal Membrane Oxygenation Definition Definition Cardiopulmonary BypassCardiopulmonary...

Extracorporeal Membrane Extracorporeal Membrane OxygenationOxygenation

DefinitionDefinition• Cardiopulmonary BypassCardiopulmonary Bypass• Pulmonary supportPulmonary support• Cardiac supportCardiac support

OutcomesOutcomes• InternationalInternational• CCHMCCCHMC

IndicationsIndications

Meconium Aspiration SyndromeMeconium Aspiration Syndrome Persistent Pulmonary Hypertention of Persistent Pulmonary Hypertention of

the Newbornthe Newborn Sepsis/pneumoniaSepsis/pneumonia Respiratory Distress SyndromeRespiratory Distress Syndrome Congenital Diaphragmatic HerniaCongenital Diaphragmatic Hernia Congenital Heart DiseaseCongenital Heart Disease

CriteriaCriteria

Weight greater than 1.8-2 kilogramsWeight greater than 1.8-2 kilograms At least 34 weeks gestationAt least 34 weeks gestation Less than 7 days mechanical Less than 7 days mechanical

ventilationventilation IVH less than grade IIIVH less than grade II Failure of maximal medical Failure of maximal medical

managementmanagement Potentially reversible lung diseasePotentially reversible lung disease

PersonnelPersonnel ECMO TeamECMO Team

• AttendingAttending• FellowsFellows• Patient care providerPatient care provider• ECMO specialistECMO specialist• ECMO primerECMO primer

Hospital ServicesHospital Services• UltrasoundUltrasound• CardiologyCardiology• NephrologyNephrology• NeurologyNeurology• Operating room staffOperating room staff

Circuit LayoutCircuit Layout

ProcessProcess

Cannula PlacementCannula Placement• Veno-arterialVeno-arterial• Veno-venousVeno-venous

ECMO flows ECMO flows Heparinization Heparinization

• Activated Clotting TimeActivated Clotting Time• Blood ProductsBlood Products

Respiratory SupportRespiratory Support

ECMO CartECMO Cart

Bladder BoxBladder Box

Cobe PumpCobe Pump

Membrane OxygenatorMembrane Oxygenator

Heat ExchangerHeat Exchanger

CDICDI

RolesRoles

Patient Care ProviderPatient Care Provider• RN who cares for the patientRN who cares for the patient

ECMO SpecialistECMO Specialist• RN or RRT who has received special educationRN or RRT who has received special education• Responsible for the ECMO machine and Responsible for the ECMO machine and

managementmanagement ECMO PrimerECMO Primer

• ECMO specialist who has received further ECMO specialist who has received further training and is able to prepare the ECMO circuittraining and is able to prepare the ECMO circuit

Before going on ECMOBefore going on ECMO

Draw labs - includes type and crossDraw labs - includes type and cross Order blood productsOrder blood products Obtain consent from familyObtain consent from family Prepare ECMO circuit (ECMO Primer)Prepare ECMO circuit (ECMO Primer) Draw up code drugsDraw up code drugs IV AccessIV Access

During CannulationDuring Cannulation

Administer meds as ordered for Administer meds as ordered for pain/sedation/paralysispain/sedation/paralysis

Monitor the patient as you would for Monitor the patient as you would for any bedside surgical procedureany bedside surgical procedure• Frequent vital signs - especially blood Frequent vital signs - especially blood

pressure (may need to give volume)pressure (may need to give volume) Have access to a stable IV site. You Have access to a stable IV site. You

will be asked to give the loading dose will be asked to give the loading dose of Heparin at some point during the of Heparin at some point during the surgery. surgery.

Obtain CXR once cannulas are placedObtain CXR once cannulas are placed

During RunDuring Run

Switch all IV drips to ECMO circuit Switch all IV drips to ECMO circuit CVC CareCVC Care Medication/blood product administrationMedication/blood product administration Double check everything with the ECMO Double check everything with the ECMO

specialist.specialist. Cannula site care. Done Q4hrs. Cannula site care. Done Q4hrs.

• Wash site with 1/2 strength HWash site with 1/2 strength H22OO22, , • Apply betadine ointmentApply betadine ointment• Cover with sterile 4x3.Cover with sterile 4x3.

Physical care of the patientPhysical care of the patient Lab drawsLab draws

DecannulationDecannulation

Obtain IV access if needed. Move all drips Obtain IV access if needed. Move all drips to the patient before clamping.to the patient before clamping.

Draw up code drugsDraw up code drugs Will continue the Heparin drip until the Will continue the Heparin drip until the

final decision has been made to final decision has been made to decannulate.decannulate.

Obtain consent for decannulation.Obtain consent for decannulation. Give meds for pain/sedation/paralysisGive meds for pain/sedation/paralysis Usually continue Cannula site care for 24 Usually continue Cannula site care for 24

hours after coming off ECMOhours after coming off ECMO

Emergency CareEmergency Care If the patient needs to be removed emergently If the patient needs to be removed emergently

from ECMO due to mechanical failure, there are from ECMO due to mechanical failure, there are several things you can do. You should have been several things you can do. You should have been shown how to take the patient off ECMO using V-shown how to take the patient off ECMO using V-B-A. Clamp the Venous cannula, open the Bridge, B-A. Clamp the Venous cannula, open the Bridge, clamp the Arterial cannula.clamp the Arterial cannula.

Call for assistance.Call for assistance. Manage the patient, You will need to ventilate Manage the patient, You will need to ventilate

(increase vent support or handbag). Administer (increase vent support or handbag). Administer meds/fluids as needed.meds/fluids as needed.

Have someone available to get needed supplies.Have someone available to get needed supplies.

ComplicationsComplications Bleeding/HemorrhageBleeding/Hemorrhage Reperfusion injuriesReperfusion injuries Inability to weanInability to wean Mechanical failureMechanical failure Electrolyte ImbalanceElectrolyte Imbalance EdemaEdema Renal FailureRenal Failure HypovolemiaHypovolemia HypertensionHypertension