I think we’ve all received shift report at some point in time and thought, “what support is my patient on exactly?” ECLS terminology shifts from specialist to specialist, physician to physician, and institution to institution. Thanks to The ELSO Maastricht Treaty for ECLS Nomenclature: abbreviations for cannulation configuration in extracorporeal life support, we can all ‘get on the same page’. The consensus was reached by an international consortium of ELSO representatives from North America, Latin America, Europe, South and West Asia, and Asian-Pacific chapters. Nomenclature is structured in four levels; configuration, cannulation site, tip position, and cannula dimension. The position paper then goes on to clarify nomenclature for peripheral cannulation, central cannulation, combined central and peripheral cannulation, and parallel independent devices. Through standardization of nomenclature, I should be able to jump on a flight in Boston, land in Melbourne, Australia, and find that my patient is on Vfl-Afrdt/Vja-Asg and immediately know exactly what support the patient is on. As ECMO configurations and complexity continue to evolve, this standardization of nomenclature only stands to benefit the extracorporeal community by improving communication worldwide.
Submitted by Jeliene LaRocque RRT-NPS, RRT-ACCS
As extracorporeal modalities expand into nontraditional support of critically ill patients, the question of “Will Extracorporeal Modalities Replace Conventional Ventilators?” becomes a valid and interesting thought.
A recent article discussed ECCO2R as an Adjunct to Ventilation in ARDS. Extracorporeal CO2 removal, also referred to as respiratory dialysis, has demonstrated the feasibility of its use as an adjunct to ultra-lung protective ventilation (3-4 ml/kg IBW) in ARDS patients. At blood flows of 450 ml/min to 1000 ml/min, ECCO2R assists in the removal of CO2, thereby allowing the clinician to reduce excessive ventilator pressures that contribute to ventilator induced lung injury. The multicenter, international, randomized control trial SUPERNOVA denoted a 73% survival rate at 28 days and a 62% survival rate at hospital discharge for those enrolled. While consideration must be given to documented and potential serious adverse events associated with ECCO2R (brain hemorrhage, pneumothorax), it appears to be a viable adjunct therapy for the treatment of profound respiratory acidosis in ARDS patients. Full article can be found here.
Post submitted by: Jeliene LaRocque RRT-NPS, RRT-ACCS, ECMO Advantage Specialist
ECMO Advantage is making comprehensive ECMO training easier! Many of our clients say they simply can’t commit five consecutive days to attend a comprehensive ECMO training course. We have heard you! Learners can now take two 3-Day sessions weeks or even months apart. Our traditional 5-Day ECMO Specialist Training Course has been converted into two 3-Day sessions called Mastering ECMO Fundamentals and Application of ECMO Fundamentals. This new structure benefits the learner by allowing more time to deepen understanding of the content, making it easier to apply in the clinical setting. Plus, there is an additional day of simulation that will further strengthen critical thinking skills and technical expertise. ECMO Advantage continues to offer the traditional 5-day ECMO Specialist training course at your institution or at EC², our independent ECMO simulation center.
Mastering ECMO Fundamentals is a 3-Day session designed to provide comprehensive core curriculum focused on the fundamental principles of extracorporeal life support. This session will introduce the learner to key ECMO principles as described in the ELSO guidelines. Upon completion of this session the learner will have a deeper understanding of physiology and pathophysiology of extracorporeal life support and its clinical application.
Application of ECMO Fundamentals is a 3-Day session designed to employ the technical aspects required to manage an extracorporeal life support system. This is accomplished through the use of various scenario-based simulations in which the learner will perform emergent and non-emergent procedural skills and utilize their knowledge and critical thinking skills to address clinical alterations in care of the patient on extracorporeal support.
ECMO Advantage also offers training and simulation sessions customized to your specific needs. Contact Us to learn more about our customized services.
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“Miracles happen here everyday”. So many great hospitals across the country can say that. Here is a story from a hospital in Tacoma, Washington about a patient they supported on ECMO in 2016. Congratulations to the team at Mary Bridge Children’s and Madigan Army Medical Center! Keep up the good work!
Always fun to see reports like this. Congrats to Kason and his family as well as the TEAM at Wolfson Children’s. Keep up the good work!
Would your ECMO Program consider VV ECMO for CDH Patients? There is much discussion surrounding the most appropriate type of ECMO for a patient with congenital diaphragmatic hernia (CDH). Take below as an example case study and see the reasons why one would argue VV may be a very appropriate form of ECMO for this diagnosis.
A neonate is being admitted to your facility with respiratory failure secondary to a diagnosis of Left congenital diaphragmatic hernia. The patient is on HFOV, INO, Dopamine at 20 mcg/kg/min, and Epi at 0.2 mcg/kg/min. Despite being on maximal vent settings your patient’s Oxygen Index remains >40 with pre-ductal sats in the 70’s. ECHO shows no heart defects, good squeeze, but severe PPHN. The new attending physician with very little ECMO experience is debating whether to place the patient on VV or VA ECMO. From your experience you explain to the physician the pros of VV ECMO.
1. You maintain the native heart function by maintaining natural blood flow through the lungs.
2. The patient does not truly need heart support in the form of VA ECMO as the patient’s heart is structurally intact and has good function.
3. Oxygen is a very powerful drug and once the heart and body is adequately oxygenated you will most likely be able to dramatically wean down, if not off of, the vasoactive dips.
4. By using VA ECMO you risk the heart going into stun.
5. Only one vessel will have to be to be manipulated with VV ECMO and carotid artery will not have to be ligated once the patient is weaned off ECMO.
6. VV ECMO can adequately supply the oxygen needed to fully support this patient as long as an adequate size cannula can be placed. Some ECMO Centers may also consider a cephalad cannula for added drainage.
7. Studies have shown VA ECMO for CDH’s had higher neurologic morbidity than VV ECMO.
The physician has listened to your advice and has decided to place the patient on VV ECMO with a double lumen cannula. Cannulation is uneventful and the patient is now on full flow of 150ml/kg/min with his sats in the 90’s. The patient has been transitioned from HFOV to conventional vent. Epi was turned off almost immediately and over the next several hours Dopamine was weaned down to 8mcg/kg/min.
So, now you’re an ECMO SPECIALIST! Fresh out of training at a newly established ECMO Center. All nine pages of the ELSO GUIDELINES for TRAINING ECMO Specialists have been faithfully followed. The initial training, simulation, and precepting has been completed. But that nagging fear about your own readiness for the responsibility of “flying alone” won’t go away.
Begin with the self-reminder that you are not alone. You have access to expert opinions. And remember that many ECMO issues are time sensitive but not always truly emergent. You’ll generally have the opportunity to review policy, refer to your training manual and notes, or call the ECMO Coordinator/Perfusionist/Physician/ECMO Director,etc.
Next, self-assess your readiness by answering the following questions.
Can you manage the worst case emergencies?
- Protect the patient by isolating from the ECMO circuit
- Recognize and eliminate air (and stop the source).
- Respond appropriately to blood spurting from the circuit or cannula site(s).
- Recognize and repair/replace failed equipment or components (hand cranking if necessary).
Can you recognize and respond to decreased venous return?
Can you recognize and respond to recirculation on VV ECMO?
As a new ECMO Specialist you should have gained the confidence in both comprehension and planned response to these events during ECMO training. Greater comfort at the bedside will only be gained with time and experience, but at a minimum the new ECMO Specialist absolutely needs to have practiced and memorized this core knowledge. If you find you can’t answer these questions with an unqualified “yes!”, then seek out additional education and/or simulation training. When all answers are positive, then as a new ECMO Specialist you are ready to sit alone.
Congratulations on your new beginning as an ECMO Specialist!!
Authored by Richard Toney, RN, ECMO Advantage Specialist
ECMO Advantage offers training and simulation experiences for ECMO Teams to help them be prepared and feel comfortable in their ability to care for ECMO patients. Please contact us to learn more.