ECMO

By, ANUPAMA.VARGHESE
Ist YEAR MSC NURSING
BBCON
 INTRODUCTION
• A form of extracorporeal life support where an external artificial
circuit carries venous blood from the patient to a gas exchange device
(oxygenator) where blood becomes enriched with oxygen and has
carbon dioxide removed.
• The blood is then returned to the patient via a central vein or an
artery.
 DEFINITION
ECMO is temporary support of heart and lung function by partial
cardiopulmonary bypass (up to 75% of cardiac output). It is used for
patients who have reversible cardiopulmonary failure from pulmonary,
cardiac or other disease.
 PHYSIOLOGY
Blood is drained from the patient to an external pump which pushes
the blood through a membrane gas exchanger (for oxygenation and
CO2 removal) and warmer and returns the blood to the patient’s
circulation.
The method requires heparin anticoagulation of the patient, that is
managed by frequent measurements of activated clotting time (ACT).
Various devices monitor pressures, flow, and temperature of the
ECMO blood and gas circuits, as well as physiological variables in the
patient.
 ECMO PRINCIPLE
• Desaturated blood is drained via a venous cannula
• CO2 is removed, O2 added through an “extracorporeal” device
• The blood is then returned to systemic circulation via another vein
(VV ECMO) or artery (VA ECMO).
 ECMO PRINCIPLE
• Desaturated blood is drained via a venous cannula
• CO2 is removed, O2 added through an “extracorporeal” device
• The blood is then returned to systemic circulation via another vein
(VV ECMO) or artery (VA ECMO).
 PRE-ECMO ASSESSMENT
chest x-ray and arterial pH and blood gas measurements
Physical examination with careful neurological examination
PT, PTT, fibrinogen, CBC with platelets, electrolytes, Ca, BUN,
Creatinine
Cranial ultrasound
Echocardiogram
 ECMO serves as a BRIDGING THERAPY and not a
curative therapy
Used as a:
bridge to recovery :– i.e., buying time for patient to recover
bridge to decision :- provide temporary support to patient and allow
clinicians to decide on the next step.
bridge to transplant :- provide support to patient while awaiting
suitable donor organ.
ECMO CIRCUIT & COMPONENTS
The basic components of ECMO circuit includes:
• a blood pump
• membrane oxygenator & heat exchanger
• controller
• cannulas
• tubing's
PUMPS
They are basically of 3 types:
• Roller pump
• Impellar pump
•centrifugal pump
Membrane Oxygenator :
• ECMO circuits have a gas exchange device called oxygenator, to add
Oxygen and remove CO2 from blood.
• Previously, silicon membrane oxygenators were used which are being
replaced by Hollow fibre PMP(polymethyl pentene) membrane
oxygenators.
• These are extremely efficient at gas exchange and demonstrate
minimal plasma leakage, low resistance to blood flow.
GAS EXCHANGE :
OXYGEN exchange depends on :
• Type of membrane & diffusion characteristics
• Thickness of the blood pathway
• Surface area of the membrane
• FiO2 in the gas phase
• Rate of blood flow
GAS EXCHANGE :
CO2 exchange depends on :
• Difference in CO2 conc. between blood and gas
• Size of membrane
• Fresh gas flow
• Blood pathway thickness
• Blood flow rate
HEAT EXCHANGER :
• In adults, it is usually built within the oxygenator.
• In pediatric cases, it is connected separately after the oxygenator in
the circuit.
• It is used for temperature regulation of the extracorporeal blood.
• Controller panel for pressure monitoring and blood gas monitoring
TUBINGS :
Depending on the heparin coating, they are of 2 types :
 regular
heparin coated
Different CONFIGURATIONS in ECMO
Most common configurations:
Veno-Venous ECMO (VV-ECMO):
• Used to support patients with severe respiratory failure refractory to
conventional therapies
• Blood is drawn from a central vein, pass through an ECMO machine
and then returned back via a central vein
Different CONFIGURATIONS in ECMO
Veno-Arterial ECMO (VA-ECMO):
• Used to support patients with severe cardiac failure (with or without
respiratory failure)
• Blood is drawn from a central vein, pass through an ECMO machine
and then returned back via a central artery ECMO
Arterio-Venous ECMO (AV ECMO) :
An arteriovenous (AV) extracorporeal circuit that uses the patient’s own
arterial pressure or incorporates a pump to drive blood across an
oxygenator can partially support the respiratory system by effectively
removing carbon dioxide (CO2) (extracorporeal CO2 removal [ECCO2R]
VENO-ARTERIAL ECMO (VA-ECMO)

Venous blood is accessed from the large central veins, pumped through
oxygenator and returned to the systemic arterial system in the aorta. It
provides support for severe cardiac failure with or without associated
respiratory failure.
 INDICATIONS OF ECMO
• Acute severe cardiac failure or respiratory failure with high mortality
risk and reversible and non-responsive to optimal conventional
therapy.
• In hypoxic resp failure due to any cause CO2 retention on Mechanical
Ventilation
• Need for intubation in a patient on lung transplant list
• Immediate cardiac or respiratory collapse (Pulmonary Embolism,
blocked airway) unresponsive to optimal care
Reversible Respiratory Failure :
• ARDS
• Severe Pneumonias
• Severe Acute Asthma
• Chemical and Inhalation hypersensitivity Pneumonitis
• Near Drowning
• Post traumatic Lung Contusion
• Autoimmune lung disease
Irreversible or Chronic Respiratory Failure :
It is indicated as a bridge, only when a patient is for lung assist device.
Eg : patient is waiting for lung transplant.
 CONTRAINDICATIONS
• No absolute contraindications to ECLS in respiratory failure.
Relative contraindications due to poor outcome are :
Mechanical Ventilation at high settings ( FiO2 >90%) for 7 days or more.
Major pharmacological immunosuppression (absolute neutrophil count
< 400/mm3)
 CNS hemorrhage which is recent or expanding
 Non recoverable co-morbidity such as major CNS damage or terminal
Malignancy
Age : no specific age contraindication but increasing risk with age
 ECMO MECHANISM
It includes :
 INITIATION
 MAINTENANCE
 DISCONTINUATION
INITIATION
• Once it has been decided to initiate ECMO, the patient is
anticoagulated with i/v heparin and cannulae are inserted according to
the ECMO configuration ( VV or VA ECMO)
• Following cannulation, patient is connected to ECMO circuit, the
pump started with the flow of 20 ml/kg/min and gradually increased
every 5- 10 min by 10 ml/kg/min to reach the desired flow.
• Gas flow to blood flow ratio is adjusted to 0.5 : 1
• Once desired flow achieved, ventilator settings are brought down to
base line.
MAINTENANCE & MONITORING:
• Once the initial respiratory and hemodynamic goals have been
achieved, blood flow is maintained at that rate.
• Continuous venous oximetry, Pressure monitoring (MAP, pre-pump P,
pre and post oxygenator P), vital parameters (HR, RR, TEMP), Flow rates
(blood flow rate at 60-150 ml/kg/min), neurological status, vascular
status to be monitored.
• Anticoagulation is sustained during ECMO with a continuous infusion
of unfractionated heparin, titrated with activated clotting time(ACT) of
180- 210 sec.
WEANING & TRIAL OFF OF ECMO
INDICATIONS :
o For patients with Respiratory failure
o With cardiac failure.
o One or more trials of taking the patient off of ECMO should be
performed prior to discontinuing ECMO permanently
 COMPLICATIONS
• Bleeding: Occurs in 30-40% of patients on ECMO - Due to continuous
heparin infusion and platelet dysfunction.
• Thromboembolism: It is more common with VA ECMO than VV
ECMO as infusion is into systemic circulation. A sudden change in
pressure gradient indicates thrombus formation
• Cannulation related: Vessel perforation with haemorrhage , Arterial
dissection , Bleeding .
VA ECMO specific complications
• Cardiac thrombosis -retrograde blood flow in the ascending aorta in
VA ECMO. -stasis of blood can occur if left ventricular output is not
maintained leading to thrombosis.
• Coronary or cerebral hypoxia -coronary usually gets blood from native
circulation (from LV) -With compromised LV & LUNGS, relatively hypoxic
perfusion occurs.
Heparin induced thrombocytopenia
THE HARLEQUIN SYNDROME (north
south syndrome)
• Saturation of upper part of the body is lower than that of lower half. •
This is due to flow competition in the aorta – recovering heart vs ECMO
pump High cardiac output from native recovering heart prevents the
retrograde flow of ECMO to perfuse upper part.
• If pulmonary function is impaired : -”BLUE HEAD” : deoxygenated
blood to upper part -”RED LEGS” : hyper oxygenated blood to lower
part.
NURSING MANAGEMENT
1. Nursing implications for cannula site management
2. Skin integrity implications in ECMO patients
3. Early mobility in ECMO
4. Nursing implications for detection and prevention of systemic
complications related to ECMO
5. Nursing implications in ethics and ECMO withdrawal.
Nursing implications for cannula site
management
• Nursing care should include monitoring of the ECMO circuit as nurses
and associated staff, such as respiratory therapists and perfusionists,
are at the bedside with the patient continually.
• assessment for erythema, purulence, adequacy of securement, and
dressing integrity.
• It is significantly important to monitor for fixation of the ECMO
cannulae. Initial placement of ECMO cannulae is usually confirmed by
echocardiography and the position reaffirmed by radiographs
• Disruption of innate circulatory flow secondary to ECMO can result in
limb ischemia. Thus, it is important to monitor limbs, especially those
distal from cannulation sites.
• site assessment, as well as assessment of the abdomen, flanks, and
inguinal areas for ecchymosis, hypotension, and acutely worsening
anemia, is necessary
Skin integrity implications in ECMO patients
• Patients need to be turned and repositioned every 2 h as tolerated.
Turns should be scheduled and require a multidisciplinary team to
ensure patient safety.
• Silicone gel adhesive dressings should be utilized when possible and
can be applied on the sacrum, elbows, and heels.
Early mobility in ECMO
• Early physical rehabilitation and mobility implemented in patients
receiving ECMO support have been shown to significantly improve
patient outcomes
Nursing implications for detection and prevention
of systemic complications related to ECMO
• Renal and other intraabdominal complications: The bedside RN can
assist in early identification of AKI by monitoring urine output;
measuring strict fluid intake and output; assessing serial serum
chemistry values, particularly serum creatinine and trends of
electrolyte dyscrasias; and identifying physical exam findings
consistent with fluid overload.
Hematological complications
• With the significant risk for bleeding and the subsequent need for
anticoagulation, nursing can expect regular and repeated blood
draws, transfusions, and anticoagulant titration to be a part of their
daily practice in the care of the ECMO patient.
Nursing implications in ethics and ECMO
withdrawal
• Communication is the key in healthcare. An integral part of
communication is developing and maintaining a team not isolated to
healthcare workers but also including the patient and family. Early
involvement of the palliative care team and social work is crucial to
providing consistent support to the patient and family.
Interdisciplinary daily rounds including the bedside nurse, family
members, palliative care team, and social work are integral to find
commonalities for all regarding goals of care.