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Baylor University Medical Center at Dallas 2017 Presenter: Phillip Nguyen, CCP ECMO Specialist 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 Allow patients to be treated at a facility offering higher level of care and ECMO expertise. Acute respiratory failure despite maximum ventilatory support Flash pulmonary edema ARDS Acute degenerative lung Pneumonia Bridge to lung transplant Life threatening cardiac failure 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 • Infection- fatal sepsis Excessive bleeding From anticoagulants given to prevent clotting Brain, GI, Pulmonary bleed 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 Death 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 Oxygenated blood is “Y’ed” off into both Arterial and Venous circulation 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) 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) 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. 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) 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. 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. 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. Central cannulation Right atrium, Femoral, IJ, or Subclavian vein ECMO Right atrium or Pulmonary artery ▪ Can provide respiratory and RV support 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 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 Pulse oximetry reading from toe can be 100% while from fingers is 70-80%. (North/south syndrome) 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. 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** • • • • • 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 1. 2. 3. 4. 5. 6. 7. 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. 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 flowexposes 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. Four tubing clamps Flow probe ultrasonic gel: Repasting when “sig” light alarms (Rotaflow pumps only) Flash light: Checking for clots in oxygenator every 4hrs Backup pump: Leave plugged in so battery charges Manual hand crank: For prolonged power failure 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 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 Do not exceed line pressure > 300 mmHg Sheer stress may cause hemolysis and platelet activation Disconnection of tubing Yellow gas line Green gas line Sweep = Gas Rate (L/min) Increase sweep to lower pCO2 Decrease to raise pCO2 FiO2 (oxygen flow index) Settings Range: 21-100% (0.21-1.0) O2 Increase to raise pO2 Start sweep gas at a ratio of 1:1 of Gas/Blood Flow with FiO2 at 100% oxygen Run a patient ABG and ECMO arterial outlet sample after 30mins following initiation and make proper adjustments 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 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 To maximize oxygenation Increase ECMO blood flow Increase Hct levels Increase patient’s sedation 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. 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) 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) 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. Edematous patients is problematic Pulmonary edema would further compromise patient’s lungs gas exchange capabilities 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 Since most ECMO patients are fluid overloaded and edematous, aggressive diuresis is sometimes warranted. CVVHD can be added to the existing ports on the ECMO circuit. Ideal for patients with renal failure and fluid overloaded 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 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 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 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: _____ / / / / / / / / / / / / / / / / / / / / / / / / Pump Console SN: ECLS Specialist Name CHART COPY Patient Heart Temp Rate sPO2 (%) / Lab Type pH pCO2 pO2 Anticoagulation Blood Gas BE / HCO3 Hb / Hct / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / Pt / / / / / / / / / / / / / / / / / / / / / / / / 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 Minimum sustained blood flows: >2L/min Prevents potential clot formation in circuit and/or patient 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. 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