ECMO for Harborview · Limitations to care (code status) Related to treatment of current illness: Greater than 7 - 10 days on mechanical ventilator with peak airway pressure > 30
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4/23/2015
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Christine Lasich RN, BSN, CCRNRandall/Emanuel Severe Cardio-pulmonary Failure and ECMO (RESCUE) Center.
ECMO Strategies for Refractory Respiratory Failure:
The Who, How and Why
The Extracorporeal Life Support Organization
2013 Award for Excellence in Life Support
Demonstrates High quality standards
Specialized equipment and supplies
Defined patient protocols
Advanced education of all staff members
www.ELSO.org
NO DISCLOSURES
No financial relationships to disclose
Any reference to a specific brand or product is not intended as an endorsement, but rather a reflection of the device or product with which we are familiar.
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OBJECTIVES
Describe the clinical indications for ECMO support and discuss how ECMO supports oxygenation and ventilation
Describe nursing actions required to prepare a patient for initiation of ECMO
Identify the unique multisystem nursing considerations for adult patients on ECMO
The ECMO teamClinical
Nursing – Bedside
Nursing – ECMO Specialist
Perfusionist
Respiratory Therapist
Physician Surgeon Critical Care
Interventional Radiology
Palliative Care/Social Worker
PT/OT/Speech Therapy
Dietitian
Administration
ECMO Manager
ECMO Director
ECMO Coordinator
Registrar
PI Coordinator
ECMO Bedside Educator
ECMO Specialist Educator
Extracorporeal Membrane Oxygenation (ECMO): What?Mechanical
cardiopulmonary or pulmonary support
May be configured Venoarterial (VA) or Venovenous (VV)
Lungs no longer primary site of oxygenation and ventilation
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The Cannulas
The PumpCentrifugal pumps
Most prevalently used
Improved performance with less complications
Preload and afterload dependent
The Oxygenator
Hollow fibers (<0.5mm in diameter) coated with polymethylpentene
Allow diffusion of gas but not liquid.
As blood flows through the oxygenator, “sweep gas” (oxygen) is piped through the inside of the hollow fibers
Oxygen and CO2 diffuse across membrane
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The Circuit
ECMO: How?Physiology of Extracorporeal
SupportIt comes full circle…
Drainage via venous cannula
Flow maintained by
centrifugal pump
Oxygen and ventilation via
membrane oxygenator
Blood warmed to
normothermia
Blood returned to patient via “arterial” cannula
Flow and Sweep
Flow = quantity of blood delivered (L/min)
Sweep = Flow rate of oxygen from blender to oxygenator
Flow O2
Sweep CO2
ECMO CIRCUITS Rotoflow
Cardiohelp
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Essential Components: Cannulas Tubing Pump Oxygenator Gas Blender Heat exchanger “Bridge” O2 Sat measurement Bubble detectors Monitors and alarms
Anatomy of an ECMO Circuit
Console
Arterial Blood Return Tubing: Oxygenated Blood returning to the patient.
Venous drainage tubing: Deoxygenated blood draining from the patient.
Heat Exchanger
Oxygenator
Centrifugal Pump
Bridge
Venous Oxygen Sensor
Display: SVO2, Hctand Hgb from venous sensor
The artificial endotheliumaka – the ECMO circuit
ECMO and Heparin
Anticoagulation is essential to prevent clotting in the ECMO circuit
Oxygenator
Centrifugal pump
This makes bleeding the #1 risk factor related to ECMO
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Extracorporeal Membrane Oxygenation (ECMO)
Does not “cure” anything
It takes over the work of the heart or lungs while they heal
ECMO: Why?
Improving efficacy and outcomes with advent of new technology
Increasing patient volumes = more experience = more informed practice
Conventional Ventilation of ECMO for Severe Adult Respiratory Failure (CESAR)
180 patients randomized to either conventional management group or consideration for ECMO treatment.
Eligible patients had potentially reversible respiratory failure and met strict entry criteria.
Findings: 6 month survival rate 63% versus 47% for control group.
50 100 150Analysis time (days)
Conventional ECMO
Kaplan-Meier survival estimates, by allocat
63 %
47%
Noah et al.JAMA 2011. Peek Lancet. 2009
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EOLIA trial ECMO to rescue lung
injury in severe ARDS (EOLIA)
Ongoing international randomized controlled trial
Daniel Brodie
ECMO: Where?Regional Referral Program
ECMO care requires a trained, multidisciplinary team
ECMO patients have improved outcomes when cared for at experienced, high volume centers“..., advanced critical care for profound ARDS, including ECMO, represents the type of time-dependent and high-reliability practice that might best be provided in a focused setting in which the provider and systems aspects of performance would benefit from a high density of experience.”
Michaels et al. (2013)
Why Transfer?
CESAR TRIAL: “We recommend transferring of adult patients with severe but potentially reversible respiratory failure, …, to a center with an ECMO-based management protocol to significantly improve survival without severe disability.” - Peek et al. 2009
JAMA: “For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non–ECMO-referred patients.” – Noah et al. 2011
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Who Needs ECMO?
• Refractory ARDS• Pneumonia • Sepsis • Severe respiratory failure • Shock • Near Drowning• Bridge to transplant• Trauma
ECMO Contraindications
Related to patient’s premorbid condition: Age and size
Contraindication to anticoagulation
Chronic condition associated with poor outcome
Underlying terminal condition not related to ARDS
Limitations to care (code status)
Related to treatment of current illness: Greater than 7 - 10 days on mechanical ventilator with
peak airway pressure > 30 cmH2O and/or FiO2 > 0.8
** Must have an endpoint to care **
** All Contraindications are relative **
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VA vs VV ECMO
PULMONARY FAILURE VenoVenous
CARDIAC FAILUREVenoArterial
VenoArterialECMOCardiac
May be applied for management of cardiac and/or respiratory failure
Blood access via central vein and central artery, primarily femoral
Controls up to 80% of patient’s total cardiac output (CO)
VenoArterialECMO
Patients who cannot wean from cardiac bypass
Refractory cardiogenic shock
Indications
o Bridge to VADo Bridge to transplanto ECPR
Must have endpoint to care
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VenoVenousECMO
Provides pulmonary support only
Relies on the patient’s native heart function to circulate the newly oxygenated blood
“IV Oxygen”
Blood access via femoral and / or internal jugular vein
Respiratory
CTA CHEST/ABDOMEN/PELVCTA CHEST/ABDOMEN/PELV
11/
HH
6/1/19596/1/195953 YEAR53 YEARFF
Page: 69 of 121Page: 69 of 121
Acq no: 10Acq no: 10KVp: 140KVp: 140mA: 564mA: 564Tilt: 0Tilt: 0RD: 400RD: 400
CTA CHEST WWO + ABDOMEN/PELVIS W CONTRASTCTA CHEST WWO + ABDOMEN/PELVIS W CONTRASTCTA CHEST 125mL iso 370 dwsCTA CHEST 125mL iso 370 dws
2/2/2013 3:16:01 AM 2/2/2013 3:16:01 AM2093077920930779
APPLIEDAPPLIED LOC: -996.20 LOC: -996.20
THK: 2THK: 2HFSHFS
IM: 69 SE: 5IM: 69 SE: 5Compressed 7:1Compressed 7:1DFOV:40x40cmDFOV:40x40cm
W: 1800W: 1800C: -585C: -585
Z: 1Z: 1
RR LL
AA
PP cm cm
VenoVenousECMOIndications
Severe Refractory Respiratory Failure from potentially reversible cause.
Type I (Hypoxemic) Respiratory Failure (severe) with P:F <80 on FiO2 >90% with a Murray lung injury score of ≥ 3.0.
Type II (Hypercapnic) Respiratory Failure with a pH ≤ 7.2.
Acute Respiratory Distress Syndrome (ARDS)
No effective pharmacological treatment
Cornerstone to therapy remains supportive care with mechanical ventilation
ARDS Network recommendations for volume and pressure limited ventilation strategies associated with decreased mortality
Despite ARDSnet strategy, some patients continue to decline
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Mild ARDS (PaO2 to FiO2 ratio 200 –300)
mortality: 27%
Moderate ARDS (PaO2 to FiO2 ratio 100 – 200)
mortality: 32%
Severe ARDS (PaO2 to FiO2 ratio < 100)
mortality: 45%
20202020
28% of all ARDS is “severe”
Current definition of ARDS aka, the “Berlin Definition”:
ARDS Definition Task Force, Raneri VM, Reubenfeld GD, et al: Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33
ECMO: When?
Recruitment maneuvers
Neuromuscular blockade
Inhaled NO / EPO
Prone Positioning
APRV
HFOV / HFPV
ECMO
Hypoxia becomes refractory to conventional management
NEED FOR VENILATORY
SUPPORT
Conventional Ventilation with
ARDSnet Strategy
Continue HFOV/VDR
Continue APRV
Continue ARDSnet Strategy
ALI/ARDS Inclusion Criteria PaO2/FiO2 <300 (ALI)
PAO2/FiO2 <200 (ARDS) Bilateral Infiltrates No LA Hypertension Acute Onset No LA Hypertension
Consider CT scan: evaluate for reversible issues Consider for Recruitment Maneuvers
Optimize Cardiovascular Status/Swan-Ganz prn Address anatomical issues: PTX, effusions, etc Evaluate for Proning, Paralytics, Nitric Oxide
Assessment of Patient Improvement:
P:F ratio >200 On FiO2 < 70% and PEEP < 12
Meeting Ventilation Goals pH >7.25
Place on HFOV (or VDR) Consider Transfer
Recruitment Maneuver Must be approved by physician
CPAP 40 cmH2O for 40 sec -OR-
eSIGH with PEEP 10cm above LIP
set PEEP above Lower Inflection Point at end of
maneuver
Place on APRV Consider Consultation or Transfer
Assessment of Patient Improvement
Assessment of Patient Improvement See selection criteria – Table 1
Consider ECMO Transfer
Consider Initial use of VDR for: Pregnant or obese patient Inhalation injury Massive Secretions/Lobar
collapse Status Asthmaticus Massive Air leak
Yes
Yes
Yes
Yes
No
No
No
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KEY POINTS
Increased ventilator days and high ventilator settings are associated with higher mortality.
Preferred fewer than 7 intubated days
The longer the patient has been sick, the longer they will be on ECMO.
Early referral saves lives!
Baseline labs **Type and Crossmatch** Hct and coags
Anticipate fluid / blood volume resuscitation
Place all lines and tubes prior to initiation of anticoagulation Central Lines Peripheral IV Foley Catheter Feeding tube
Before going on ECMO
Transformation
Intensive Care to Operating Room
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COMMUNICATION
Blood bank
Respiratory Therapy
Pharmacist
Operating Room staff
X-Ray
Family
Supplies
Heparin Monitoring for effect:
ACT (goal ~1.5x normal, 180-220 seconds)
Heparin level (0.2-0.4)
Optimize AT III (>80)
Direct Thrombin Inhibitors
Argatroban
Bivalirudin
PTT (45-75)
Anticoagulation
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Cannulation: Going on ECMO May be performed in ICU or OR
Full sterile prep and OR team present
Deep sedation / paralysis essential
Heparin bolused (50-100 units / kg) prior to cannula placement
Coordination between surgeon, perfusion and bedside RNs
This is a critical time. The room needs to be quiet for clear communication
ECMO flow slowly increased to maximum tolerated, then decreased to lowest level required for adequate support.
Sit back and watch the red blood flow…
And we’re on….
What could go wrong?
Patient is bolused with approximately 1liter of saline from ECMO circuit
This essentially empties blood from the heart temporarily
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Code situations
Full ventilator support
Titrate vasoactive drugs
May need blood and products
Prepare code cart and ACLS drugs
May need to emergently switch to VA
Bedside Nurse Manages the Patient
ComplicationsVessel injury
Occurs less than 5%
Lung injury
Thrombus
Air emboli
Equipment Malfunction
Emergencies
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Bleeding Emergencies
• Time to call the blood bank
• Know your institution’s resources and policies
ECMO is initiated Oxygenation improves immediately
Perfusion improved
Myocardial function improved
Pulmonary pressures decrease
Wean inotropes and vasoactive drips
Rest settings on ventilator
Diagnostic Procedures
Labs ABG guides ECMO therapyPTT 45-75
Chest X-rayCannula placement
Occasional testsEchocardiogramEKGUltrasoundCT
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Multisystem care of the ECMO patient
Cardiovascular / Hemodynamic
Respiratory
Hematologic Considerations
Neurologic / Sedation
Renal
Metabolic / Gastrointestinal
Skin
Family
Recovery vs. Futility
Decannulation
VV: Pt. dependent on native hemodynamic physiology Support with inotropes, vasoactives, fluid, blood etc. as indicated MAP >65
VA: ECMO flow provides primary hemodynamic support May require fluid / blood / vasopressors to augment Maintain MAP 50-70
Cardiovascular and Hemodynamic Considerations
Trend markers of perfusion / native heart function Lactate
ABGs
SvO2
Continuous pulse contour analysis (PiCCOTM, FloTracTM) – VV only
Echocardiography
Urine output, skin color/temp, cap refill, etc.
Pulmonary artery catheters?
Pt. temp controlled by heat exchanger
Additional Hemodynamic Considerations
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Infection Abx
Antiviral therapy (H1N1)
Inflammation Plasmapharesis
IVIG
Trauma Surgical repair
*Infectious Disease and Pharmacy input is crucial*
Treating the Underlying Problem
The lungs are no longer the primary site of oxygenation and ventilation!!!
3 R’s
Rest
Recover
Recruit
Respiratory Considerations
Reducing pressure and FiO2
ELSO Recs: Mode: pressure controlFiO2: 0.3PEEP: 10-15 cmH2OPIP: ~20 (PEEP + 10)F: 4-5
LEH: Mode: Volume Diffusive Respirator (VDR)FiO2: 0.4PEEP: 12*PIP: 24*F: 15Percussive Rate = 500
Other: CPAP, MMV, Extubation?
Rest
* VDR settings: PEEP = Oscillatory PEEP; PIP = Pulsatile Flow
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What is the VDR?A pneumatically powered, pressure limited, time-cycled, high frequency flow interrupter.
Delivers smaller, percussive tidal volumes at rates that range between 300-700 oscillations per minute at lower pressures.
Enhances oxygenation, promotes CO2 clearance and facilitates mobilization of secretions while minimizing barotrauma
Increased secretion clearance necessitates vigilant oral care and secretion maintenance by RN staff
* Kunugiyama SK, Schulman CS. High-Frequency percussive ventilation using VDR-4 ventilator: an effective strategy for patients with refractory hypoxemia. AACN Advanced Crit Care. 2012;23(4):370-389
Recruit Recruitment maneuvers
Positional Therapy
Bronchoscopy
Aggressive diuresis
Ventilator recruitment maneuvers
Initiated once lungs begin to show recovery
Pulmonary Hypertension Management
IV agents: Epoprostenol (Flolan), Nitroglycerin
Inhaled agents: Nitric Oxide, Epoprostenol
Tracheostomy
Pneumothorax (To drain or not to drain?)
Additional Respiratory Considerations
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Systemic anticoagulation essential
Bleeding is a major complication of ECMO Visible versus occult Common bleeding sites:
**ICH on ECMO usually extensive and fatal**
Minimize Hemolysis Monitor Plasma Free Hgb
Hematologic Considerations
Intracranial Mucous membranes
Cannulation Sites Central lines and PIVs
Surgical sites GI Tract
Vigilant monitoring Coagulation studies Plts, PT/INR, Fibrinogen, Viscoelastography (TEG™ / Rotem™)
Cannula sites, IVs, mucous membranes, neuro exam
Maintain Coagulation factors at acceptable levels Platelets ≥ 50,000* INR ≤ 2.2 Fibrinogen ≥ 100,000
Minimize venipuncture, fingersticks, insertion of tubes/drains, etc.
Bleeding Management(Focus on prevention)
Return coagulation status to normal
D/C anticoagulant infusion (if necessary)
Thrombostatic dressings
OR as last resort
When Intervention is Required: (Bleeding Management
continued)
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Maintain sedation and analgesia with least amount required to provide effective support & maintain safety
Daily awakening trials as soon as tolerated
Neuromuscular blockade?
Neurologic Considerations
**Note: Some medications shown to have increased adsorption to circuit and oxygenator**
Neuro Assessment Sedated and paralyzed? Hourly pupil response
assessment
Train of four
Low threshold for Head CT with neuro change
Pupilometry
Near Infrared Spectroscopy (NIRS)
Bispectral index monitor (BIS)
Renal Considerations
Euvolemia is the goal
Diurese aggressively
Hemofiltration
CRRT if necessary Directly into circuit
HD Catheter
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Place post-pyloric feeding tube pre-ECMO if possible
Early consult from dietician
Enteral nutrition as soon as tolerated
TPN until tube feed tolerated at goal rate
Probiotic supplements
GI continuity
Stress ulcer prevention
Blood glucose management per hospital critical care insulin management protocol
Gastrointestinal / Metabolic Considerations
Skin Care Considerations
Eyes
Mucous membranes
Blisters
Pressure points
Q 2 hour turning and ROM essential
Continence management
Include family as much as possible
Allow family presence in rounds
Include in plan of care
Honest and direct communication
Early palliative care consult
Family Care Considerations
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Possibility of stopping for futility should be discussed with family at outset of therapy
Promptly discontinue ECLS when there is irreversible organ damage and no option for transplant
Definition of irreversible damage depends on the institution and available resources
Arbitrary timeframes for recovery are discouraged
Futility
Hemodynamic stability
Patient tolerates decreasing ECMO Flow and Sweep
Evidence of clearing on CXR and bronchoscopy
Pulmonary “step-up”
Signs of Recovery
VV: Wean flow and sweep to minimal settings
Set ventilator to acceptable settings
“cap off” oxygenator
Maintain ECMO blood flow while monitoring SaO2, PO2 and CO2.
VA: Reduce flow.
Clamp access and return lines
Monitor SaO2, PO2 and CO2.
If VA for cardiac support, ECHO very helpful
Trial off
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May be performed at bedside if vascular repair not required
Anticoagulant off for 30-60 minutes
Get “comfortable”
Decannulation
Education and team maintenance
Intra-hospital Transport
Inter-hospital Transport
Program Considerations
Formal ECMO education process ECMO handbook for bedside nurses
Skills, drills, simulation, lecture, online SLMs
Collaborate with Pt. care champions
Additional mandatory CEUs
Roles Bedside RNs
Transport RNs
ECMO Specialists
ECMO Education and Team Maintenance
Simulation Lab
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Intra-hospital Transport• Have a plan
• Bedside RN is the team leader
• Clear hallways• Coordinate with receiving department
Inter-hospital Transport
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For additional information:
www.elso.org
ReferencesAnnich,., G.M., Lynch., W.R., MacLaren, G., Wilson, J.M., Bartlett, R.H. (2012). ECMO Extracorporeal Cardiopulmonary Support in Critical Care (4th ed.). Ann Arbor, MI: Extracorporeal Life Support Organization.
ARDS Definition Task Force, Ranieri V.M., Rubenfeld, G.D., et al. (2012). Acute respiratory distress syndrome: the Berlin definition. JAMA 307 2526-2533
Bibro C, Lasich C, Rickman R, et al. Critically ill patients with H1N1 influenza A undergoing extracorporeal membrane oxygenation. Crit Care Nurse. 2011;31:e8-e24
ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support Extracorporeal Life Support Organization, Version 1.3 November 2013 Ann Arbor, MI, USAwww.elsonet.org
ELSO Adult Respiratory Failure Supplement to the ELSO General GuidelinesVersion 1.3 December 2013 Ann Arbor, MI, USA www.wlsonet.org
Holleran, R. (2010). ASTNA: Patient Transport, principles and practice (4th ed). Mosby, INC.
Michaels, A.J., Hill, J.G., & Long,., W.B., Young, B.P. Sperley, B.P., Shanks, T.R., Morgan, L.J. (2013). Adult refractory hypoxemic acute respiratory distress syndrome treated with extracorporeal membrane oxygenation: the role of a regional referral center. The American Journal of Surgery,205(), 492-499
Noah MA, Peek GJ, Finney SJ, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A (H1N1). JAMA 2011;306:1659-1668
Peek GJ, Mugford M, Tiruviopati R, et al. Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet. 2009;374(9698):1351-1363
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Christine Lasich, RN, BSN, CCRNLegacy Emanuel Hospital
CLasich@lhs.org
Thank you!
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