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4/23/2015
ECMO Strategies for Refractory
Respiratory Failure:
The Who, How and Why
Christine Lasich RN, BSN, CCRN
Randall/Emanuel Severe Cardio-pulmonary Failure and ECMO (RESCUE) Center.
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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4/23/2015
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 team
Clinical
 Nursing – Bedside
 Nursing – ECMO Specialist
 Perfusionist
Administration
 ECMO Manager
 ECMO Director
 Respiratory Therapist
 ECMO Coordinator
 Physician
 Registrar
 Surgeon
 Critical Care
 PI Coordinator
 Interventional Radiology
 ECMO Bedside Educator
 Palliative Care/Social Worker
 ECMO Specialist Educator
 PT/OT/Speech Therapy
 Dietitian
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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4/23/2015
The Cannulas
The Pump
Centrifugal 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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4/23/2015
The Circuit
ECMO: How?
Physiology of Extracorporeal
Support
It comes full circle…
Flow and Sweep
 Flow = quantity of blood
Blood
returned to
patient via
“arterial”
cannula
Drainage via
venous
cannula
delivered (L/min)
 Sweep = Flow rate of oxygen
from blender to oxygenator
Flow
maintained by
centrifugal
pump
Blood
warmed to
normothermia
Oxygen and
ventilation via
membrane
oxygenator
ECMO
CIRCUITS
Flow
O2
Sweep
CO2
Rotoflow
Cardiohelp
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4/23/2015
Anatomy of an ECMO Circuit
 Essential Components:










Cannulas
Tubing
Pump
Oxygenator
Gas Blender
Heat exchanger
“Bridge”
O2 Sat measurement
Bubble detectors
Monitors and alarms
Display: SVO2, Hct
and Hgb from venous sensor
Venous drainage tubing: Deoxygenated blood draining from the patient.
Console
Arterial Blood Return Tubing: Oxygenated Blood returning to the patient.
Heat Exchanger
Oxygenator
Bridge
Centrifugal Pump
Venous Oxygen Sensor
The artificial endothelium
aka – the ECMO circuit
ECMO and Heparin
Anticoagulation
is essential to
prevent clotting
in the ECMO
circuit
Centrifugal
pump
Oxygenator
This makes
bleeding the
#1 risk factor
related to
ECMO
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4/23/2015
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.
Kaplan-Meier survival estimates, by allocat
63 %
 Eligible patients had potentially
reversible respiratory failure and
met strict entry criteria.
47%
 Findings: 6 month survival rate
63% versus 47% for control group.
50
100
Analysis time (days)
Conventional
150
ECMO
Noah et al.JAMA 2011. Peek Lancet. 2009
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4/23/2015
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 timedependent 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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4/23/2015
Who Needs ECMO?
• Refractory ARDS
•
Pneumonia • Sepsis •
Severe respiratory failure •
Shock • Near Drowning
• Bridge to transplant
• Trauma
ECMO Contraindications
** All Contraindications are relative **
 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 **
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VA vs VV ECMO
CARDIAC FAILURE
VenoArterial
PULMONARY FAILURE
VenoVenous
VenoArterialECMO
Cardiac
 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
Indications
 Patients who cannot
wean from cardiac
bypass
 Refractory cardiogenic
shock
o Bridge to VAD
o Bridge to transplant
o ECPR
Must have endpoint to care
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4/23/2015
VenoVenousECMO
Respiratory
 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
H
CT
A C HEST/A BDO
C TA
BDOMEN/PELV
MEN/P ELV
VenoVenousECMO
11/
Indications
 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.
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 Type II (Hypercapnic) Respiratory
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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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4/23/2015
Current definition of ARDS aka, the “Berlin
Definition”:
 Mild ARDS (PaO2 to FiO2 ratio 200 –
300)
mortality: 27%
20
 Moderate ARDS (PaO2 to FiO2 ratio 100
– 200)
mortality: 32%
 Severe ARDS (PaO2 to FiO2 ratio <
100)
mortality: 45%
28% of all ARDS is “severe”
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?
Hypoxia becomes refractory to conventional
management







ALI/ARDS Inclusion Criteria
PaO2/FiO2 <300 (ALI)
PAO2/FiO2 <200 (ARDS)
Bilateral Infiltrates
No LA Hypertension
Acute Onset
No LA Hypertension
Recruitment maneuvers
Neuromuscular blockade
Inhaled NO / EPO
Prone Positioning
APRV
HFOV / HFPV
ECMO
NEED FOR
VENILATORY
SUPPORT
Yes
Conventional
Ventilation with
ARDSnet Strategy
Recruitment Maneuver
Must be approved by physician
CPAP 40 cmH2O for 40 sec
-OReSIGH with PEEP 10cm above
LIP
set PEEP above Lower
Inflection Point at end of
maneuver
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:
Continue
ARDSnet
Strategy
Yes
P:F ratio >200
On FiO2 < 70% and PEEP < 12
Meeting Ventilation Goals pH >7.25
No
Place on APRV
Consider Consultation or Transfer
Continue
APRV
Consider Initial use of VDR for:
 Pregnant or obese patient
 Inhalation injury
 Massive Secretions/Lobar
collapse
 Status Asthmaticus
 Massive Air leak
Yes
Assessment of Patient Improvement
No
Place on HFOV (or VDR)
Consider Transfer
Continue
HFOV/VDR
Yes
Assessment of Patient Improvement
See selection criteria – Table 1
No
Consider ECMO
Transfer
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4/23/2015
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!
Before going on ECMO
 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
Transformation
Intensive Care
to
Operating Room
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4/23/2015
COMMUNICATION
 Blood bank
 Respiratory Therapy
 Pharmacist
 Operating Room staff
 X-Ray
 Family
Supplies
Anticoagulation
 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)
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4/23/2015
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
And we’re on….
 ECMO flow slowly increased to maximum tolerated, then
decreased to lowest level required for adequate support.
 Sit back and watch the red blood flow…
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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4/23/2015
Code situations
Bedside Nurse Manages the Patient
Full ventilator support
Titrate vasoactive drugs
May need blood and products
Prepare code cart and ACLS
drugs
May need to emergently switch
to VA
Complications
Vessel injury
Thrombus
Lung
injury
Equipment
Malfunction
Occurs less
than 5%
Air emboli
Emergencies
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4/23/2015
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 therapy
PTT 45-75
Chest X-ray
Cannula placement
Occasional tests
Echocardiogram
EKG
Ultrasound
CT
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4/23/2015
Multisystem care of the
ECMO patient
 Cardiovascular / Hemodynamic
 Respiratory
 Hematologic Considerations
 Neurologic / Sedation
 Renal
 Metabolic / Gastrointestinal
 Skin
 Family
 Recovery vs. Futility
 Decannulation
Cardiovascular and
Hemodynamic Considerations
 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
Additional 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
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4/23/2015
Treating the Underlying
Problem
 Infection
 Abx
 Antiviral therapy (H1N1)
 Inflammation
 Plasmapharesis
 IVIG
 Trauma
 Surgical repair
*Infectious Disease and Pharmacy input is crucial*
Respiratory Considerations
 The lungs are no longer the primary site
of oxygenation and ventilation!!!
 3 R’s
 Rest
 Recover
 Recruit
Rest
 Reducing pressure and FiO2
 ELSO Recs:
Mode: pressure control
FiO2:
PEEP:
PIP:
F:
0.3
10-15 cmH2O
~20 (PEEP + 10)
4-5
 LEH:
Mode: Volume Diffusive Respirator (VDR)
 Other:
CPAP, MMV, Extubation?
FiO2: 0.4
PEEP: 12*
PIP:
24*
F:
15
Percussive Rate = 500
* VDR settings: PEEP = Oscillatory PEEP; PIP = Pulsatile Flow
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4/23/2015
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
Additional Respiratory
Considerations
 Pulmonary Hypertension Management
 IV agents: Epoprostenol (Flolan), Nitroglycerin
 Inhaled agents: Nitric Oxide, Epoprostenol
 Tracheostomy
 Pneumothorax (To drain or not to drain?)
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4/23/2015
Hematologic Considerations
 Systemic anticoagulation essential
 Bleeding is a major complication of ECMO
 Visible versus occult
 Common bleeding sites:
Intracranial
Mucous membranes
Cannulation Sites
Central lines and PIVs
Surgical sites
GI Tract
 **ICH on ECMO usually extensive and fatal**
 Minimize Hemolysis
 Monitor Plasma Free Hgb
Bleeding Management
(Focus on prevention)
 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.
When Intervention is Required:
(Bleeding Management
continued)
 Return coagulation status to normal
 D/C anticoagulant infusion (if necessary)
 Thrombostatic dressings
 OR as last resort
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4/23/2015
Neurologic Considerations
 Maintain sedation and analgesia with least amount
required to provide effective support & maintain safety
 Daily awakening trials as soon as tolerated
 Neuromuscular blockade?
**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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4/23/2015
Gastrointestinal / Metabolic
Considerations
 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
Skin Care Considerations
 Eyes
 Mucous membranes
 Blisters
 Pressure points
 Q 2 hour turning and ROM essential
 Continence management
Family Care Considerations
 Include family as much as
possible
 Allow family presence in
rounds
 Include in plan of care
 Honest and direct
communication
 Early palliative care consult
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4/23/2015
Futility
 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
Signs of Recovery
 Hemodynamic stability
 Patient tolerates decreasing
ECMO Flow and Sweep
 Evidence of clearing on CXR
and bronchoscopy
 Pulmonary “step-up”
Trial off
 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
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4/23/2015
Decannulation
 May be performed at bedside if vascular repair not
required
 Anticoagulant off for 30-60 minutes
 Get “comfortable”
Program Considerations
 Education and team maintenance
 Intra-hospital Transport
 Inter-hospital Transport
ECMO Education and Team
Maintenance
 Formal ECMO education process




ECMO handbook for bedside nurses
Skills, drills, simulation, lecture, online SLMs
Collaborate with Pt. care champions
Additional mandatory CEUs
 Roles
Simulation Lab
 Bedside RNs
 Transport RNs
 ECMO Specialists
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4/23/2015
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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4/23/2015
For additional information:
www.elso.org
References
Annich,., 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, USA
www.elsonet.org
ELSO Adult Respiratory Failure Supplement to the ELSO General Guidelines
Version 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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4/23/2015
Christine Lasich, RN, BSN, CCRN
Legacy Emanuel Hospital
CLasich@lhs.org
Thank
you!
27