4/6/2021

Ramanathan K R

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Focused Management

Patient Circuit
• Hemodynamic Monitoring • Anticoagulation
• Bleeding • ECMO Cannula anchoring
• Ventilator Management • “Look”
• Sedation • “Listen”
• Fluid/Renal Management • “Feel”
• Temperature
• Nutrition
• Skin Care
• Limbs Monitoring
• Infection
• Psychosocial

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Care of ECMO Cannula

• Check the cannulae:
– Dressing clean, intact and infection free
– ECMO catheter are well anchored and
cannulae have not migrated
• Intervention:
– Change dressing when soiled or
tampered
– Secure line to prevent tension & torsion
during movement
– Internal Jugular cannula exposed length
measured upon insertion and checked
during dressing change
– Skin marking of peripheral cannula is
made post insertion with indelible marker
– Line position checking done at least once
a shift

ECMO Handover: Dressing & Cannula

Stabilize lines with Adhesive

tape (Hypafix) & Crepe bandage
(Internal Jugular) Back up Handcrank
pump on
standby
Check site markings every shift

Dry and
Intact

Stitches at insertion sites & along the tubings, check during every dressing
change

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Document & Inform

Clots

• Formation of new clots

• Presence of Air bubble

ECMO Handover Checklist

Admission

Back from 
procedure

Shift to 
Shift

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ECMO Handover: Power Source

• ECMO machine connected

to UPS source
• Battery indicator is not
blinking
• Alarm setting set
appropriately

ECMO Handover: Gas supply

Air & oxygen hose connected

securely to appropriate wall outlet

Sweep gas turn on and

set as per prescribed

Green gas line connected securely

to Sechrist Blender

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ECMO handover: Heater Cooler

Set as
prescribed
temperature

Connected to oxygenator

ECMO Handover: Flow sensor

-clipped appropriately and

secured at cannulas

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ECMO Handover: Backup Equipment

Back up Handcrank
pump on
standby

Minimum 2
tubing
clamps

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Sedation

 Remains sedated for first 12-

24hrs
 Daily sedation vacation when
stable
 Neurological assessment
 Assess for intra-cerebral
changes
 Potential hemorrhagic
complication
 Potential embolic
complication

Anticoagulation in adult ECLS

Follow CTICU Guidelines: Anticoagulation in adult ECLS
 IV Heparin
 When initiating ECMO
• +/- loading of 70 unit/kg (max 4000 unit), as agreeable by surgeon & intensivist
 Start infusion at 10 units/kg/hour (VV ECMO)
15 units/kg/hour (VA ECMO/ VAV ECMO )
 Check APTT 6 hours later
Any decision to stop
45 – 60 sec VV heparin is only made at
 TARGET APTT: ICU consultant / senior
50 – 75 sec VA consultant level!!

Titrate as per institutional Heparin Calculator Guideline

APTT check:
 Q12 When at target
 Q6h When adjustments are made in the preceding 12 hours
 Q4h If APTT>100
CTICU Guidelines: Anticoagulation in Adult ECLS.Dr G Maclaren. Updated September 2018

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Bleeding
“Bleeding is the most common complication, 43% of ECMO”
Kulkarni, T. et. al., 2016. Extracorporeal membrane oxygenation in adults: A practical guide for internists .

Do…
Replace blood loss with appropriate blood products
Titrate Heparin as to target PTT
Maintain platelet count > 20-50 x10⁹/L (check min
q24h)

AVOID invasive access (e.g. venepuncture, change IV

cannula) or other non essential invasive procedures (e.g.
remove pacing wire or leg drain)

CTICU Guidelines: Anticoagulation in Adult ECLS.Dr G Maclaren. Updated September 2018

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Significant bleeding (>2-3ml/kg/hour)

– Keep INR < 1.3 (administering FFP + Vitamin K)

– Check fibrinogen levels & consider administering cryo if
<1.5-2.0 g/L
– Aim platelet count > 50 – 100 x10⁹/L (check q6h)

CTICU Guidelines: Anticoagulation in Adult ECLS.Dr G Maclaren. Updated September 2018

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Ventilation Management

i. Maintain resting ventilation

 FiO₂ < 0.4
 PEEP 5-15 cmH₂O
 PIP 20 cmH₂O
 VR <10 breath/min
(to prevent atelectasis)
 Vt 1-5 ml/kg

ii. Chest physiotherapy

(except open chest)
iii. VAP bundle

Annich, et.al. ECMO Extracorporeal Cardiopulmonary Support in Critical Care. 4thed. 2012. P. 151
ECMO: The Ultimate Support for the Cardiopulmonary System: AACN

Ventilation Management

 Titrate using ECMO gas blender

instead of the ventilator

 PaCO₂ controlled by the ECMO

gas blender sweep gas
- every 0.5 to 1L of sweep gas
affects the PaCO2 drastically

 PaO₂ controlled by the ECMO

circuit flow and FiO₂ from the
Gas Blender

 Check ABG after 15 mins with

each titration

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Hemodynamic Monitoring

In VV ECMO- dependent on patient’s own

hemodynamic

In VA ECMO- hemodynamic are controlled by

the blood flow (pump flow plus native cardiac
output), and vascular resistance

Target:
a. MAP > 65mmHg
b. Hourly ECMO flow
(CI >2.2L/min/m2 & tubing not tugging)

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Lethal Cardiac Arrhythmias

VA ECMO
• Avoid CPR
• Treat cause
• Cardioversion
Danger of 
catheter 
dislodgement

VV ECMO
• Perform CPR
• Circulation not adequately
supported by ECMO flow

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Fluids / Renal Management

• Goal- to achieve normal dry weight

• Evaluate for signs of fluids overload
• Aim urine output 0.5 to 1 ml/kg/hour
• Hematuria
 heparin infusion & cells damage
 Urine dipstick PRN
 Plasma free Hemoglobin

Continuous Renal Replacement Therapy (CRRT)

• Initiate dialysis early if

excessively +ve balance with
poor urine output
• Carried out by trained nurse via
ECMO circuit

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Temperature

i. Maintain between 36 to 36.5oC

by using heat exchanger in
ECMO system

ii. Use rectal probe for continuous

monitoring
• Check rectal area to ensure no
ulceration from prolonged rectal
probe

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Infection

* The Infection may go unrecognized as temperature

is modulated by the machine
i. Monitor infection markers (FBC daily & WBC trend)
ii. Strictly hand hygiene

iii. Aseptic when handling wounds and lines

iv. Limit visitors and staff flow

v. Whenever open procedures:

Restrict all traffic flow to bed area
Stop all visitors if possible
Strict cap, mask and apron for all personnel within the sterile field

Skin Care / Dressing

• Prevent skin breakdown especially at pressure

areas
• Assess skin around IV and cannula sites for
bleeding and hematoma

Intervention
Regular careful turning as tolerated
Use transparent dressing for better visualization of cannula site (if
no bleeding)
Careful change of dressing if soaked (except central cannulation)
Pressure relieving mattress and foam

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Limbs Monitoring
i. Check distal perfusion hourly:
 Edema or congestion
 Pulses
 Mottling / impending ischemia (especially peripheral ECMO, may
need distal perfusion cannula)

Occluded

Distal Perfusion
Cannula

Pitsis, A.A., & Visouli, A. N. (2008)

Family & Psychosocial

Evaluate family  Re-orientate

coping mechanism, regularly
strengths, needs  Maintain
Frequent consistent day/night
updates orientation
Family involvement  Explain
in care intervention
Refer medical  Promote sleep
social worker with no
(MSW) early pharmacological
• financially intervention
• psychosocial

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Focused Management

Goals:
1. Monitor progress towards established goals
 Oxygenation
 Anticoagulation
 Hemodynamic stability
 Recovery of lung function

ECMO: The Ultimate Support for the Cardiopulmonary System: AACN

Focused Management

Goals:
2. Monitor for potential complication
 Cannula dislodgement
 Infection / sepsis
 Air emboli
 Hemorrhage / Disseminated Intravascular Coagulopathy
(DIC)
 Metabolic changes
 Renal failure
 Pressure ulcers
 Neurologic complication
 Vascular complication

ECMO: The Ultimate Support for the Cardiopulmonary System: AACN

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References:
• ECMO: The Ultimate Support for the Cardiopulmonary System. AACN. Available
at https://www.aacn.org/docs/EventPlanning/WB0009/ECMO-Presentation-
12zbj5yt.pdf. Accessed 12 April 2019
• Kulkarni, T., Sharma, N.S., & Diaz-Guzman, E. (2016). Extracorporeal membrane
oxygenation in adults: A practical guide for internists. Cleveland Clinic Journal Of
Medicine, 83 (5), 373-384.
• Pediatric Extracorporeal Membrane Oxygenation. Available at
http://emedicine.medscape.com/article/1818617-overview. Accessed on 12 April
2019
• ELSO Guidelines for Adult Respiratory Failure. Available at
https://www.elso.org/Portals/0/ELSO%20Guidelines%20For%20Adult%20Respir
atory%20Failure%201_4.pdf . Accessed on 12 April 2019
• ELSO Guidelines for Adult Cardiac Failure. Available at
https://www.elso.org/Portals/0/IGD/Archive/FileManager/e76ef78eabcusersshyer
documentselsoguidelinesforadultcardiacfailure1.3.pdf .Accessed on 12 April
2019

References:
• CTICU Guidelines: Anticoagulation in Adult ECLS. Author: Dr G Maclaren.
Updated September 2018
• CTICU ECMO Activation & Decannulation Flow Chart. Updated August 2014
• Annich, G.M., Lynch, W.R., MacLaren, G., Wilson, J.M., & Bartlett, R.H. (2012).
ECMO Extracorporeal Cardiopulmonary Support in Critical Care. 4th. ed. USA.
• Graves, N, Birrell, F., & Whitby, M. (2005). Effect of pressure ulcers on length of
hospital stay. Infect Control Hosp Epidemiology. 26, 293-297
• Pitsis, A.A., & Visouli, A. N. (2008). Update on ventricular assist device
management in the ICU. Current Opinion in Critical Care, 14(5), 569-578

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