A day in the life……..

ECMO Course
Great Ormond Street Hospital
It is 03:00, the usual time for such events, and a 10
month old 8kg infant with Respiratory Syncytial
Virus Bronchiolitis has been referred and accepted
for ECMO. He is expected to arrive on the ECMO
unit in 45 minutes.

On what criteria will the infant have been accepted?

•OI > 40
•Diagnosis (potentially reversible)
•No prolonged cardiac arrest/Significant
neurological insult

Additional For Neonates?

•Cranial Ultrasound (< Grade 2 IVH)
•Weight > 2kg
•Gestation > 34 weeks
You have been allocated to prepare for
the infants arrival on the unit…
What do you need to consider when setting up a
bed-space for an ECMO admission?
•2 x Oxygen Points or Oxygen Splitter
•Enough Electrical Sockets/Extension leads
•Nitric/Oscillator
•Bed Position (+ pressure relieving mattress)
•Position of Ventilator (to patient’s left)
•Extension on rebreathe circuit
•Manometer
•Drugs (current, plus Heparin, Antibiotics, Fentanyl)
•Infection control precautions (FFP2/3 masks)
•Parents information booklets/Blood Tx pack
•Consent packs for any relevant trials
 What other departments will you
notify?
• Perfusion
• Surgeons
• Blood bank
• Cardiology
The transport team phones – they are about to leave
the referring hospital but the infant is very sick and
will need to be cannulated as soon as possible

What information do you need from the transport

team?
• Expected time of arrival
• Weight confirmation
• Latest status (drug/vent support, IV access)
• Parents accompanying?
• Parents marital status/parental responsibility
(consent)
• Consented for ECMO?
• Trials???
On arrival how do you position the infant?
• Head towards circuit
• Head left
• Neck extended
What type of support will this infant receive?
•Respiratory patient therefore aim for VV
•Assess cardiovascular stability on arrival
What type and size of cannula will you have
ready for the surgeon?
•VV Double Lumen: 15/18Fr
•VA Venous: 14/16/17Fr Arterial: 12/14/16Fr
(Requires familiarity with cannulas used at institution
– seek clarification if unsure)
04:00 The surgeons have made the
incision in the neck and are ready to
insert the cannula…

What do you do?

• Give Heparin Bolus 100units/kg
(Responsibility of surgeon to notify when
heparin required)
 The infant has been cannulated for VV
ECMO. The CentriMag circuit is blood
primed, attached and ready to go.

Where do you clamp and unclamp to

commence ECMO flow?
•Unclamp venous line, clamp bridge and unclamp
arterial line. (VBA)

What do you observe for?

• Forward flow
What flow, FiO2 and sweep gas rate should
you start at?
•Flow: 800ml/min
•FiO2: At least 0.6
•Sweep: 0.8L/min

What should happen to the infant’s

ventilation and inotropic support?
• Ventilation – rest settings (Pressures 20/10, rate 10,
FiO2 0.21)
or CPAP if air leaks
• Inotropes – Monitor. Should be able to reduce
slowly as on VV support.
04:30am. Your first arterial blood gas result:
PH 7.1
PCO2 6.4
PO2 5.8 What should you do?
SaO2 78% •Increase sweep
Hct 0.32 •Assess perfusion/treat accordingly
HCO3 18 •Red cell transfusion
BE -6
Lac 6.0
What would you expect your
ACT 999
post membrane blood gas to
read?
pO2 25-35KPa
 Ok, you have done that, what about the
heparin?
•Check Activated clotting time (ACT) q15mins
What systemic checks should you do
now and where do you record them?
•Cannula Secure – •Back up console present
sutures/headband •Position of backup motor ok
•Tubing secured to bed •Self test ok/record date
•Calibrate transducers •Mains power to both consoles
•Set alarm limits •Clamps
•Revolution step increase •Emergency connectors
(50/100) •2 Oxygen cylinders
•Sensitivity Normal •Check circuit (cable
•Battery charged ties/components/clots/air)
What test/investigations would you
order at this time and why?
Verification of cannula position:
• Chest x-ray
• ECHO
Optimise haematology following dilution:
• Full blood count
• Clotting screen
05:00 – You now recheck the arterial
blood gas and get the following result:
PH 7.39
CO2 5.2 What do you do?
PO2 7.9 Commence Heparin Infusion
SaO2 88%
Hct 39
HCO3 27
BE +1 What is the strength of the
Lac 5.0
ACT 323 infusion, where will you connect it,
and what rate should it commence
at?
20units/Kg/ml infusion, connected post
pump. Commence at 1ml/hr
05:30 Well done. You have started the Heparin, your
arterial gas is good and everything is stable.
Suddenly your alarm sounds. The pre-membrane
pressure has increased by 100mmHg to 200 mmHg.
What is an acceptable pre-membrane pressure and
what is the probable cause of the rise?
What should you do?
•Know safe pressure limits for oxygenators used
Pre-Membrane <300mmHg, Trans membrane <150mmHg )
•Establish Cause of rise: Oxygenator or Distal to oxygenator?
•Check post-membrane pressure:
- Post membrane unchanged - check Oxygenator, ?clots
- Post membrane increased - increased flow?, pt awake?,
hypertension?, obstruction?
•Evaluate whether intervention required?
06:30 – The flow is now 1.2L/min with a
sweep of 0.8L/min. What percentage flow is
this? 150%
The next arterial blood gas gives you the
following results:
PH 7.4
Co2 5.9 Why might the PO2 be so low
PO2 4.6 and what action could you take?
SaO2 68
Hct 0.32 Low Hct:
BE -1 •Haemodilution?
Lac 4.9 •Bleeding?
ACT 193 Establish cause, transfuse, correct
clotting screen if required
If PO2 remained low post transfusion,
what action might you take?

• Check post membrane SaO2 / PO2

• ?Recirculation
– Increase / decrease flows and assess effect
– Change patient position
– Echo - cannula position optimal?
07:00 The full blood count and clotting
screens arrive:
Hb 8.0 What are the normal
WCC 1.6 values for platelets,
Platelets 56
Fibrinogen 0.8 fibrinogen and clotting?
PT 40 Platelets > 100,000, then
APTT 110 80,000
TT 30 Fibrinogen >1.0
PT 9-12
APTT 26-38
What are you going toTT
do?9-15
Transfuse platelets 10ml/Kg + Cryoprecipitate 5ml/Kg
Where do you infuse platelets and why?

• Patient IV access if possible

• Post membrane if transfused into circuit
(if using an open bridge, fully clamp) GOSH.

That completes day 1

Day 2 07:45
Handover: you are in the process of giving platelets.
The ACT is 126 what do you do?
• Stop platelet infusion •Increase Heparin infusion
• Heparin bolus •Re-check in 15 mins

08:15 You are doing your circuit checks and you

notice a clot in one of the connectors, what do you
do about it?
Assess risk to patient of leaving v’s removal
(?obstruction to flow, ?venous/arterial side, ease of
removal)
Where are the clots most likely to form?
Low flow and turbulent areas.
The bedside nurse notices that the infants
central temperature is 32 degrees.
What might be the problem?
• Positioning of Temperature probe
• Water heater (off, underfilled, malfunctioning,
incorrectly connected).

How quickly should you try to re-warm the

infant? 0.5°C per hour

What should you look out for while you are

doing so?
Evidence of cerebral irritation, MABP, CVP, ECG.
Good, the infants temperature is climbing.
The infant passes urine, which is slightly
pink. What could be the reason?
• Haemolysis
• Localised bleeding (infection/trauma)
What could you do?
Check Plasma Free Hb:
•Normal (???) send urine for microbiology,
?abdominal ultrasound.
•High (???) assess circuit, check pressures
within circuit.
If all pressures in the circuit are within normal
range, how would you check that the readings
are correct?
• Venous pressure – calibrate transducer, check for
visible clots/air in pigtail/pressure isolator (pressure
isolator may often be blood filled, to check patency
reduce/increase flow by 10%, venous pressure
should change accordingly)
• Pre / Post membrane pressures – calibrate
transducers, check patency of pressure monitoring
line (flush if in doubt), aspirate appropriate pigtails.
09:00 Arterial blood gas results
pH 7.21
PCO2 9.2 You put up the sweep gas to 1L,
PO2 11.2 but the Co2 continues to rise?
SaO2 95% What problem may be occurring?
HCO3 25
Hct 0.4 Wet membrane
BE -1.2
Lac 2.9 How would you remedy this?
ACT 189
Sigh membrane or increase sweep gas

Well done you find the source of the problem

and the CO2 normalises.
11:00 The pump keeps alarming to alert you
to low flows even though your revolutions are
unchanged.
What is the cause?
• Insufficient Pre-load
• Alarm limits have been changed

What action would you take?

•Reduce Revs
•Re-assess desired ECMO flows and alarm limits
•Consider volume
11:30 Problem resolved. You turn your back to the
circuit to record events when the pump alarms. As
you move towards the console to investigate, you
notice that the pumphead impeller is stationary. The
message “MOTOR DRIVE FAIL” is displayed on the
console. What do you do?
• Clamp infant off ECMO support
• Shout for help
• Switch on backup console
• Switch off primary console
• Move pump head to backup motor
• Increase revolutions of backup motor to >1500
• Unclamp to re-establish ECMO support
• Increase revolutions to re-establish full flows
• Transfer pressure monitoring lines and flow probe
• Set alarm limits/safety checks
• Complete Incident form and document in patient notes
• Contact Perfusionists or ECMO Co-ordinators for a
replacement back-up console.
Well done the infant is re-established on full
ECMO support and all is well with the world.

Just as you decide you are due a well earned rest and some
lunch, the Doctors ward round finally arrives at your bedspace.
You sigh, but hand over your patient, proud of the stability you
have now achieved.

Just at that moment however, you notice that your venous

pressure is now reading -55mmHg.

What is an acceptable venous pressure?

Up to -30mmHg
 What are the possible causes of high
negative venous pressure?
What action would you take and why?
• Intravascular fluid status - volume required?
(what?)
• Cannula/tubing obstruction/restriction
– Increased intrathoracic pressure (Assess and treat
underlying problem CXR/Echo)
– Physical kink/obstruction (Check CXR/Echo,
check tubing, tubing clamps, circuit layout, and
correct if possible)
– Desired flow greater than cannula estimated rated
flow (Assess requirement for additional venous
cannula/reduction in ECMO flows)
If large negative venous pressures are left
untreated what effects would you expect to
observe?
• Haemolysis (→ Renal Failure)
• Thrombocytopenia (platelet destruction)
You check through your circuit but can see no
obvious reason for this change, and your fluid
balance is positive by 200ml. An urgent chest
x-ray is ordered.
Your venous pressures are now reading -65.
What do you do?
Reduce flows whilst waiting for CXR
The Chest X Ray is taken, and illustrates a
large pneumothorax.
What do you do and why?
• Not compromising patient/flows – conservative
management (CPAP)
• Tension Pneumothorax/affecting flows – Chest
drain insertion.
Decision is made to insert a chest drain. What
are the risks of this procedure for a child on
ECMO?
Bleeding +++
What preparation is required?
• Optimise clotting
• Reduce Heparin (aim for ACTs 160-180)
• Most experienced surgeon available
• Talk to family about risks of procedure
• Prepare child if awake
• Analgesia (Fentanyl 10mcg/kg)
• Positioning
• Equipment

The procedure goes uneventfully, and you are able to

resume full ECMO flows with satisfactory venous
pressures. At this point YOU collapse with hunger
What should we do????