MURIEL, STEFFI SHANICE M.

SLMC INP GROUP 3- CCU

ECMO (EXTRACORPOREAL MEMBRANE OXYGENATION)

DEFINITION

ECMO is 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. This blood
then reenters the patient circulation. ECMO circuit blood flow is optimized to provide
adequate patient support in the absence of native lung or heart function.

Three modes of ECMO:

o VV-ECMO (Veno-Venous): for respiratory support

o VA-ECMO (Veno-Arterial): for respiratory and cardiac support
o V-PA ECMO (Veno-Pulmonary artery): support for right ventricular
function post left ventricular assist device (LVAD) insertion.

INDICATION

ECMO is indicated for life-threatening forms of respiratory and/or cardiac failure

where the risks of less invasive support are considered greater than the risks of
ECMO and there is a reasonable expectation of long-term survival without severe
disability.

CONTRAINDICATION

ECMO is contraindicated for patients with:

o Presence of additional severe chronic organ failures (e.g cirrhosis, COAD, end-
stage renal or hepatic failure
o Severe brain injury
o Malignancy
o Age> 75

PROCEDURE

1. Veno-Venous ECMO: Venous blood is accessed from the large central veins,
pumped through the oxygenator and returned to the venous system near the
right atrium. It provides support for the severe respiratory failure where the
circulation is powered entirely b y native cardiac function.
2. Veno-Arterial ECMO: Venous blood is accessed from the large central veins,
pumped through the oxygenator and returned to the systemic arterial system
in the aorta. Recirculation cannot occur in the V-A ECMO. It provides support
for severe cardiac failure (with or without associated respiratory failure).
MURIEL, STEFFI SHANICE M.
SLMC INP GROUP 3- CCU

3. Veno-Pulmonary Artery ECMO: Venous blood is accessed from the large

central veins, pumped through the oxygenator and returned to the pulmonary
arterial system. It provides short-term right ventricular and respiratory
support following LVAD insertion. The oxygenator does not necessarily need
to be included in the circuit when respiratory function is adequate, in these
circumstances the extracorporeal circuit is temporary RVAD.

ADVANTAGE AND DISADVANTAGES

VV-ECMO:

Advantages

normal lung blood flow

oxygenated lung blood

pulsatile blood pressure

oxygenated blood delivered to root of aorta

must be used when native cardiac output is high

Disadvantages

no cardiac support

local recirculation though oxygenator at high flows

reverse gas exchange in lung if FiO2 low

limited power to create high systemic arterial oxygen tension

VA-ECMO:

Advantages

can create high oxygen tensions

Disadvantages

relative lung ischaemia

non-pulsatile blood flow

possible poor perfusion of coronaries and cerebral vessels

MURIEL, STEFFI SHANICE M.
SLMC INP GROUP 3- CCU

distal limb ischaemia

risk of lung overventilation -> tissue alkalosis (monitor with ETCO2)

V-PA ECMO:

Advantages

no preferential perfusion to lower body

no possibility of hypoxic perfusion of cerebral vessels

can use very large cannulae (high flows)

Disadvantages

need sternotomy and tissue dissection

predisposes to severe bleeding

NURSING RESPONSIBILITIES

Assessment and Interventions:

NEUROLOGICAL
Neurological injury is COMMON in ECMO patients
Risk of cerebral vascular injury from stroke (ischemic or hemorrhagic)
Pupillary reaction
Painful stimuli and response !!
Sedation Assessment:
SAS: Sedation-Agitation Scale
Bis: Bispectral Index
TOF: Train of Four
GCS not helpful as these patients are all sedated and non-responsive
NIRS: Near infrared spectroscopy
Imaging: Daily ultrasound
Seizure Monitoring
Continuous EEG monitoring

RESPIRATORY
Impaired gas exchange
Oxygen
Carbon dioxide
Auscultation: Ventilator on low setting
Monitoring: ABGs; EtCO2
Lung recruitment, chest physio, suctioning
MURIEL, STEFFI SHANICE M.
SLMC INP GROUP 3- CCU

Imaging: Daily CXR

HEMODYNAMIC
VV ECMO = Does NOT affect hemodynamics
VA ECMO = Effect dependent on percentage of ECMO support
Tissue Perfusion
Cardiac Function: ECG, HR, ABP, MAP, CVP
Temperature: The lower the temperature, the higher SvO2, and the lower
the oxygen consumption
Observe for HYPOvolemia
CVP Monitoring: Low preload
Assess ECMO drainage line: Swinging or shaking

RENAL/URINARY
Decreased perfusion to the kidneys = Increased risk for acute renal failure
Assure and maintain patency of urinary catheter
Monitor HOURLY urine output and characteristics
Monitor HOURLY overall fluid balance
Diuretic(s) for any observable signs of edema or fluid retention/overload
Monitor labs and physical assessment for electrolytes imbalance
Peritoneal Dialysis or CRRT

GASTROINTESTINAL
If NPO with NGT, monitor NGT drainage color
Monitor bowel sounds and movement, assess stool color
Administer H2 blockers or PPI
Consult Dietician:
Monitor calorie count
Provide nutrition as soon as possible
NGT feeds
TPN
Monitor blood glucose: Insulin protocol
Weight daily if possible

DERMATOLOGICAL
Assess skin for redness, blisters, or breakdown
Keep skin clean and dry
Change body position AT LEAST every two hours
Use of pressure relief devices and/or mattress
Keep sheets dry and wrinkle-free
MURIEL, STEFFI SHANICE M.
SLMC INP GROUP 3- CCU

Float heels and elbows

Careful PRONE position = Stabilized line and cannula, check ECMO flow