Transcript ExtraCorporeal Membrane Oxygenation-ECMO

Baylor University Medical Center at Dallas
2017
Presenter:
Phillip Nguyen, CCP
ECMO Specialist
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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.
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.
 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
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Allow patients to be
treated at a facility
offering higher level of
care and ECMO expertise.
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Acute respiratory failure despite maximum ventilatory
support
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Flash pulmonary edema
ARDS
Acute degenerative lung
Pneumonia
Bridge to lung transplant
Life threatening cardiac failure
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Post-cardiogenic shock following cardiopulmonary bypass
Post myocardial infarction
Low EF and poor ventricular contractility
Bridge to permanent VAD or heart transplant
•
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
•
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Infection- fatal sepsis
Excessive bleeding
 From anticoagulants given to prevent clotting
 Brain, GI, Pulmonary bleed
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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
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Death
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The modes of ECMO refer to the blood vessels
access and return site. Veno-Arterial (VA), VenoVenous (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.
( V-V-A is same as VA-V)
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
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Oxygenated blood is “Y’ed” off into both
Arterial and Venous circulation
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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)
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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)
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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.
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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. (postcardiogenic shock)
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Peripheral cannulation
 Either percutaneous or open cut-down
▪ Percutaneous often done at bedside vs operating room for open cutdown
 Femoral vein or Right IJ  ECMO  Femoral, Innominate,
or Axillary Artery
• 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.
Fem Vein  ECMO  Fem Art  Mixing Cloud
Peripheral Cannulation
Femoral Vein  ECMO Femoral Artery
Central Cannulation
Femoral Vein  ECMO Aorta
Chest
partially
closed
Often the same cannulas used for CPB are connected to the ECMO circuit via 3/8 connectors
Femoral Vein ECMO  Femoral Artery
Limb cannula
*Most common method of
VA cannulation is the femoral vein
for blood access and femoral artery for blood return.
Arterial Cannula
inside tube graft
• 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.
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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.
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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.
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Central cannulation
 Right atrium, Femoral, IJ, or Subclavian vein  ECMO 
Right atrium or Pulmonary artery
▪ Can provide respiratory and RV support
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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)
Femoral vein ECMO IJ
Avalon dual-lumen cannula
From ECMO
To ECMO
Blood drain from SVC & IVC and returned to RA
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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
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Pulse oximetry reading from toe can be 100%
while from fingers is 70-80%. (North/south
syndrome)
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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.
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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.
Fem Vein  ECMO  Fem Artery & Jugular Vein
Jugular vein
VENOUS CANNULA (19-28 Fr, 50-55 cm)
ARTERIAL CANNULA (16-20 Fr, 15-25 cm )
**Cannula selection is patient specific. Larger patients requiring higher flows
warrant cannulas with larger lumen or French size (Fr)
**1 mm=3 Fr**
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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
• 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
Oxygenated Blood to Femoral Artery
mmHg
Line pressure monitor
Blood from Femoral Vein
Gas/ FiO2 Regulator
Centrifugal Pump
Oxygenator/Heat Exchanger
Pump Console
CDI 500 Blood gas, Hct,
Saturation monitor
Pump console
Gas blender
Heater/cooler
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8.
Notify physician and ECMO Specialist (ES) immediately if ECMO therapy is warranted.
1. low sustained MAP from hypokinetic heart; Max inotropic/vasoactive support
2. low arterial saturations from unresponsive lungs; Max vent settings
Equipment and Surgical field supplies for OR, cath lab, or bedside initiation
1. ECMO circuit w/ attached heater/cooler setup by the ES
2. 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.
1. Patient must be heparinized prior to insertion of cannulas
2. 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.
3. Heparin bolus of 75-100 units/kg and maintenance drip started at 500 units/hr
4. Target anticoagulation levels:
1. Partial Thromboplastin Times (PTT) 40-50 Activated Clotting Time (ACT) 200-250 secs
2. Dosing protocol is also dependent on patient’s current hemostasis (bleeding, coagulation, TEG)
3. 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.
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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.
VA ECMO
VV ECMO
2.5 CI x BSA (Until ven line chatters, ven line pressure < -150mmHg, Art
line press > 300mmHg, 4500 RPM)
2.5 CI x BSA (Until ven line chatters, ven line pressure < 150mmHg, Art line press > 300mmHg, 4500 RPM)
The calculated high flows with the existing cannula sizes,
placement, volume status
BSA = Sq rt [(height cm x weight kg)/3600]
BSA = Sq rt [(height cm x weight kg)/3600]
Min Pump flow
2.0 L/min to prevent circuit clot
2.0 L/min to prevent circuit clot
Pump flow required to achieve Patient’s Ven O2 Sat > 55-60% & MAP>6065mmHg
Pump flow required to maintain Patient’s Art O2 sat (or
continuous pulse oximetry) > 88-90%
(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 optimized settings.
Max Pump flow
The lowest flow maintained (> 5 mins) during weaning.
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)
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 PostOxy results.
FiO2
Set FiO2 to 100% at initiation of ECMO.
Adjust accordingly after obtaining Patient’s ABG and PostOxy results.
Weaning
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 95-100%, but the Ven O2 Sat could be in the 40-50’s.
Adjust gas flow to maintain Patient’s pCO2 at physiologic levels: 35-45
mmHg **With VA ECMO, maintain Post-Oxygenator’s pCO2 35-45 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 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.
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)
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 FiO2: Should NOT be changed from Pre-weaning settings.
Reassess patient’s hemodynamics/ Ven Sat/ ABG with each incremental
foreign surfaces (oxygenator, tubings), consumption of
change.
clotting factors, increased hemolysis kidney injury
hematuria, chlolemic nephrosis
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.
Adjust gas flow to maintain Patient’s pCO2 at physiologic levels:
35-45mmHg
** 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 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.
Decrease Sweep and/or FiO2 as tolerated by patient’s ABG
Sweep: Decrease to Min Sweep of 0L/min at increments of 0.5-1
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
VAV ECMO
3.5 CI x BSA (Until ven line chatters,
ven line pressure < -150mmHg, Art line
press > 300mmHg)
**Flow is divided between 2
cannulas**
4.0 L/min (2.0 L/min each cannula) to
prevent circuit clot
Pump flow required to achieve
Patient’s Ven O2 Sat > 55-60% &
MAP>60-65mmHg
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.
Adjust gas flow to maintain Patient’s
pCO2 at physiologic levels: 35-45
mmHg
AND
Post-Oxygenator’s pCO2 35-45 mmHg.
Adjust FiO2 to maintain Patient’s Art
O2 sat > 95%
AND
Post-Oxygenator’s O2 Sat > 95%
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.
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Four tubing clamps
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Flow probe ultrasonic gel: Repasting when “sig” light alarms
(Rotaflow pumps only)
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Flash light: Checking for clots in oxygenator every 4hrs
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Backup pump: Leave plugged in so battery charges
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Manual hand crank: For prolonged power failure
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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.*
Patient specific
Pump blood flow is increased until respiratory and
hemodynamic status is stable
 Estimated flow (L/min)= 2.5 (cardiac index) x BSA
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 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
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Do not exceed line pressure > 300 mmHg
 Sheer stress may cause hemolysis and platelet activation
 Disconnection of tubing
Yellow gas line
Green gas line
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Sweep = Gas Rate (L/min)
 Increase sweep to lower pCO2
 Decrease to raise pCO2
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FiO2 (oxygen flow index)
 Settings Range: 21-100% (0.21-1.0) O2
 Increase to raise pO2
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Start sweep gas at a ratio of 1:1 of Gas/Blood Flow
with FiO2 at 100% oxygen
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Run a patient ABG and ECMO arterial outlet sample
after 30mins following initiation and make proper
adjustments
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Blow off condensation in oxygenator every 4-6hrs
by turning up sweep gas to 10-15 L/min for few
seconds (sneezing)
O2 & Air Blender
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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
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To maximize oxygenation
 Increase ECMO blood flow
 Increase Hct levels
 Increase patient’s sedation
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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.
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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)
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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)
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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.
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Edematous patients is problematic
 Pulmonary edema would further compromise
patient’s lungs gas exchange capabilities
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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 3.5-5.0 gm/100mL)
 Mannitol- acts both a colloid osmotic & loop diuretic
 Lasix-diuretic
 FFP-colloid osmotic
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Since most ECMO patients are fluid
overloaded and edematous, aggressive
diuresis is sometimes warranted.
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CVVHD can be added to the existing ports on
the ECMO circuit.
 Ideal for patients with renal failure and fluid
overloaded
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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
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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
• 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
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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
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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
EXTRACORPOREAL LIFE SUPPORT (ECLS) Specialist Flow Sheet- Part 1
Support Type:
VA-ECMO VV-ECMO VA-VV-ECMO Other ___________
Circuit settings
Time
Flow
(L/m)
RPM
Sweep FiO2
(L/m) (%)
Vitals
MAP
Sys / Dia
Physician’s
Parameters
PA
Sys / Dia
/
[ECMO Circuit Serial/Lot Numbers]
Shift
Initial
Ht: _____ Wt:_____ BSA: _____
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Pump Console SN:
ECLS Specialist Name
CHART COPY
Patient Heart
Temp
Rate
sPO2
(%)
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Lab
Type
pH
pCO2
pO2
Anticoagulation
Blood Gas
BE / HCO3
Hb / Hct
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Heater SN:
) on ECLS
Supervising Physician: ________________________
Lab Type: Patient (Pt) Post-oxy (Ox)
CVP
Day (
Oxygenator Lot:
Art
O2 Sat
Ven
O2 Sat
PTT
(secs)
Heparin
(units/hr)
Tubing Pack Lot:
Date: From _____-_____-_____ to _____-_____-_____
Patient Sticker
Baylor University Medical Center
Dallas, TX
ECLS Flow Sheet- Part 1
Rev 8.18.15
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Minimum sustained blood flows: >2L/min
 Prevents potential clot formation in circuit and/or
patient
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Maximum heater settings: <37 degrees Celcius
 Turn off heater after patient’s desired temperature
is reached. Patient’s temp often > set temperarture
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:
1. Blood loss
2. Excessive urine output
3. Third-spacing (edema)
 Obstruction of inlet or outlet lines due to:
1. Kinking of lines
2. Migration or physical obstruction at cannula tips
Solution: Stop further blood loss
1. 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
2. Call ECMO Specialist/perfusionist ASAP
3. Call surgeon and request for heparin
bolus due to no-flow state
 Possibly clotting inflow/outflow cannulas
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)
Solution: Change out oxygenator
1. Alert surgeon and request for heparin bolus
to allow for low/no flow state during
oxygenator change-out
2. Adjust ventilator settings to accommodate
for the decrease in oxygenator’s efficiency
3. Call perfusionist ASAP
 Perfusionist will change out circuit if necessary

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.
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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 214.818.5951. 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 214.820.6444 to begin transfer
ES then calls Transfer Center (214.820.6444) 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 800.442.6260 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 817.927.9620 to arrange for pick up at the OSH.
 Ellis County contracts with American Medical Response (AMR) 469.383.3766 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 800.874.3266 to arrange for fixedwing 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
VA