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.
Ventilator Management on ECMO has been a debatable topic for many years. There have been many approaches to managing the sick lung without ECMO support that still create a lot of debate. But when you add in the complexities of the ECMO system and support processes it becomes even more difficult to find consensus on the best way to adjust ventilator settings. A small percentage of ECMO Centers have begun actually extubating patients on ECMO. Some centers manage the ventilator the same as if the patient were not on ECMO. Some centers perform tracheostomy, some just leave an endotracheal tube in even for prolonged ECMO runs that may last for weeks or months.
A recent article found in Europe PubMed Central entitled International survey on the management of mechanical ventilation during extracorporeal membrane oxygenation in adults with severe respiratory failure. highlights the wide variety of thoughts and practices across the globe.
ELSO (Extracorporeal Life Support Organization) has long recommended “rest” ventilator settings while on ECMO. The ELSO H1N1 Specific Supplements to the ELSO General Guidelines during the H1N1 crisis was to:
- keep plateau pressures under 25
- adjust FiO2 to under 40%
- allow SaO2 in the 70’s and 80’s on VV patients
- keep hematocrit in normal range to aid with oxygen delivery
- early tracheostomy
- minimize sedation
- perform frequent bronchoscope
- consider HFOV at low settings (MAP of 12-14 cmH2O) to help with lung recruitment
The recommendations go on to suggest there is no benefit in attempting recruitment maneuvers until there is some sign of some native gas exchange and aeration on x-ray noted in lung fields. In addition, they mention that some have reported surfactant, prone positioning, fluorocarbon lavage, and percussive ventilation to be beneficial in some patients.
I’m a fan of this approach. I’m a believer in the concept of rest ventilator settings even in the face of complete and total whiteout of the lungs and then allowing TIME for the lungs to begin to recover before forcing recruitment procedures. But there are a lot of smart clinicians out there that take other approaches and have good success as well.
How does your center manage the ventilator on ECMO patients?
Consent and Disclosure in Pediatric Heart Surgery
The trust that families give healthcare workers is immense. To break that trust by lack of communication is heart breaking.
The healthcare community should read this story, perhaps this entire book. We are given a great charge to take care of our patients, and by extension, their families. We have a responsibility to provide accurate, on-time information and to assure that the information is understood clearly.
This effort begins with informed consent. Patients and families should be told the unvarnished truth about their condition. They should also be told the specifics about the procedures or treatments that may or may not fix it. The chance that something could go wrong should also be discussed in clear terms.
Informed consent in ECLS is difficult. Do you obtain consent for every cardiac procedure just in case the patient arrests? Do you obtain consent for every intensive care patient for the potential that there may be a life-threatening event that requires extracorporeal life support?
Even more difficult is the obtaining of consent during duress. Asking for permission to use ECMO as a life saving technology because a parent’s child is at risk of dying (sometimes eminently) almost precludes the answer from being no. Does that parent hear the risk of bleeding or mechanical failure? Do the parents understand that the chance that the lung or cardiac failure may not be reversible and that the clinicians may have to stop ECMO at some point? Probably not. Consent in ECLS is a continuous conversation. Obtaining a signature on a form does not end the conversation. Discussion must be held at least every day so that the family understands the condition of the patient and how things are going. Any untoward complication must be explained in layman’s terms. Employing ancillary personnel, such as chaplaincy, social services or palliative care, to assist in clarifying terms is very important. Hearing things in many ways helps to build understanding and trust.
There are no easy answers regarding conversations and obtaining consent. Perhaps this topic should be discussed in ethics committee or the ECMO supervisory group in your institution. Do you have a separate ECMO consent or do you just fill in the blanks on a generic procedure consent? Have you reviewed your ECMO consent lately? Is it truthful? It is all-encompassing? Does it mention the fact that the patient may die from a complication of ECMO? Does it mention that ECMO may be stopped if it is futile? If not, a thorough review of the language with your ethicists and legal team may be in order.
ECMO does not guarantee survival. It is but one tool in the arsenal of physicians and the healthcare team that can be used to potentially save the life of a patient. To give any other impression is wrong and untruthful. ECMOlogists are in the business of hope – but we must be careful not to overstep the boundaries by saying we WILL save a life.
Spring time – such a lovely time of the year! The cherry trees are blooming, the daffodils are so pretty. It’s time to dust off the winter blahs, think about renewal and growth… Oh – and it’s time to think about the calendar! When are we going to do our annual competencies? Yikes!Annual competencies are a very necessary part of an ECLS Program. Initial training courses are fine for introducing new skills and baseline knowledge. Follow – thru with check-offs for a skill ‘certifies’ your ECMO Specialists in your institution. How do you assure that they stay competent? How does staff demonstrate these skills in a safe but meaningful environment?Annual comps are not just an institutional requirement; there are more and more requirements for documentation of competency on the part of medical staff. The Joint Commission will come through your center and trace back every one who cares for a particular patient. That includes the ECMO Specialist, the ECMO primer and the bedside caregiver.
How do you assure that all these groups of people are up to date with their ECLS knowledge? Do you have education that is just-in-time or planned and prepared materials?
Each of these groups is diverse and requires continuing education in different ways. Bedside nurses may benefit from an on-line learning module. ECMO primers may need an observation of technique with demonstration that all protocols are being followed. The ECMO Specialist requires in depth review of patient populations, high-risk skills and demonstration of competency.
Simulation education is one of the best ways to capture that knowledge. Use of this education tool is becoming more prevalent in health care. Many studies have shown that it is a useful training technique, allowing practice in a safe and controlled environment. Staff feel better prepared for real-life situations after completing simulations.
Do you conduct simulation training in your facility? If not, why not consider hiring ECMO Advantage to come in and provide a tailored educational experience for your team? Not every institution has the facilities or personnel to develop or conduct simulations. We bring the materials, the equipment and experienced trainers to your facility and will provide competencies checks based on your policy and procedures for your entire team.
Preparing for comps is a time consuming part of the ECMO Coordinators job. Finding time in a variety of shifts for all the specialists to be able to attend, scheduling trainers and developing materials is a huge task. Providing simulations for the very first time may be daunting. Call us today. We can help!
Authored by: Micheal Heard