VV ECMO for CDH Patients

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.

Authored by Charlie Nix, RN – ECMO Advantage Specialist

ECMO Specialist

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.
What now?!?
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.

Blood Conservation Practices Impact ECMO

Blood-Transfusion

Should new blood conservation practices impact ECMO management?  Over the last few years we have seen multiple benefits from blood conservation measures across the OR and ICU environments.  But should we employ these measures to ECMO management?

For many years, and still today, many ECMO order sets will direct caregivers to treat a HCT of < 40 or even 45 with PRBC’s.  Some ECMO programs have lowered the treatment threshold to a HCT of 35.  But how many of you would consider lowering that threshold to 30?  25?  How about 21?

Ok, we all have sat through the lectures on ECMO Physiology and understand that one of our primary goals with ECMO is to deliver oxygen to the tissue and organs.  And one of the key aspects of oxygen delivery is Hgb, right.  So it makes perfect sense to pump the Hgb levels up to give us more “boxcars” to carry the oxygen more efficiently.  And we have all seen that to be effective for many years.  But what if adding those boxcars is actually contributing to the problems we have with coagulopathy, pulmonary edema, fluid shifts, ARDS, infection, compliment reaction?  What if the additional transfusions are actually extending the time a patient needs to be on ECMO, or mechanically ventilated, or even decreasing their chance of survival?

This article in the Korean Journal of Critical Care Medicine provides a nice discussion of the potential for how blood conservation practices impact ECMO.

Is there a role for blood conservation practices in the management of ECMO patients?   I would encourage each ECMO program to re-evaluate their standard ECMO orders sets and consider how blood conservation management practices impact their ECMO patient management.

ECPR Improves Patient Survival

A recent article in the Journal of Thoracic and Cardiovascular Surgery states that ECPR improves patient survival from <20% to 30% with 100% full neurological recovery.

In addition, ECPR made successful organ donation possible for some of the patients that did not survive.
ECPR is the process of initiating ECMO for the purpose of or during the process of cardiopulmonary resuscitation.  There are still a significant number of ECMO centers that do not formally provide this service.  Reasons for not providing ECPR may include a general belief that it does not provide any or enough benefit to justify it’s use, or simply due to the fact that they do not have staff and equipment readily available to respond in the time frame required to make the procedure beneficial.

There have been other articles and reports from single institutions in the past that indicate up to a 55% survival with good neurological outcome in pediatric patients who were supported with ECMO during the course of CPR. In many of the most successful cases, total body hypothermia was used in conjunction with the ECMO support.  ELSO (Extracorporeal LIfe Support Organization) has published Guidelines for ECPR Cases.  Hypothermia is also a part of the ELSO recommendations.

Is ECPR a tool your ECMO Programs uses?

 

 

Ventilator Management on ECMO

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?

 

E-CPR: The Next Frontier in Extracorporeal Life Support?

Heart beat

Extracorporeal Membrane Oxygenation used in the face of cardiac and/or respiratory arrest is not new. However, as ECLS systems become smaller, easier to use and widely available, the expansion of the therapy is inevitable. The challenge will be to decide when and where to initiate E-CPR.The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a single center, prospective, observational study conducted at The Alfred Hospital in Melbourne, Australia. Their experience was recently published in Resuscitation. The CHEER Trial

The results of the study are encouraging as compared to previously published reports. However, caution must be undertaken by centers that read the article and decide that their center should have an E-CPR program. The authors very carefully describe the use of mechanical chest compressions (Autopulse™) and iced saline lavage as well as the use of a team of expert physicians and nurses trained in ECMO. They also comment on the duration of time to place on ECMO as being a significant factor in survival. Their protocol involved emergency services provided in the field to assure that the protocol was started as soon as possible. The authors also describe preventive management of lower limb ischemia with placement of a backflow cannula.

Their results are encouraging for both outside hospital cardiac arrest and in hospital cardiac arrest patients, and by all accounts should be considered when decisions about starting an E-CPR program are being made. Nevertheless, purchasing an ECLS blood pump and having the initiative is not enough. The significant factor that most institutions fail to consider is the staff. If the team is not adequately trained and experienced, the availability of E-CPR may not contribute to increased survival for their patients.

Training physicians to insert cannulas and ECMO Specialists to initiate and manage the ECLS system is not an easy task. If the team is new to ECMO as a therapy, the groundwork doesn’t even exist yet for building these new skills upon.

Additionally, the increased burden on resources with initiating an E-CPR program can be overwhelming. Most ECMO centers have a limited number of ECLS Systems and staff who are trained to care for these patients. How do you offer a new service to a high-risk population and assure that you are not depriving other populations of the service? How many patients code in your institution on a daily basis? Do you offer E-CPR to every one? Institutions need to have in place appropriate protocols and procedures for patient selection and use of ECMO in all populations.

E-CPR is a valuable tool. It most definitely will save lives. Assure that your team is approaching this ‘new frontier’ with wisdom and the education to give your patients the best possible outcomes.

ECMO and Consent: The Importance of Communication

Consent and Disclosure in Pediatric Heart Surgery

care hands

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.

Annual Competency Checks for ECMO/ECLS Teams

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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

Vital Updates: The ECLS Conference

 

IMG_3063I’m in Keystone Colorado – attending the 31st Annual CHNS Symposium on “ECMO and the Advanced Therapies for Respiratory Failure Conference”. While the conference has many competing distractions (skiing anyone?) the chance to hear the latest information that leading ECLS Centers and experts are presenting here is too vital to miss.

Very often I hear; “Is it really necessary to attend outside continuing education? Will it really help my clinical practice?” The answer? Yes! The chance to hear the current status of patient care, or what are large ECLS Centers doing with novel patient populations, or how have things changed in providing bedside care is rare. Not only are you able to listen to the lectures; you are able to hear and participate in the discussions, hear others experiences and perhaps even speak directly to the presenters. These opportunities are valuable! For example, anticoagulation is a HUGE topic in ECLS – how to, when to, why to – are all questions that asked repeatedly in just about every ECMO program, and there are still no specific answers. The use of antithrombin III – perhaps your ECMO program is considering using it? At this meeting, a review of the use of ATIII in patients was presented. A review of the literature with specific findings of its’ impact was discussed. The lecture included a comprehensive overview of the differences between human plasma antithrombin versus recombinant antithrombin; with costs, dosages and testing described. You could have researched and detailed all this information yourself, and perhaps come to a conclusion about how you wish to implement this into your practice. But having the opportunity to listen to a lecture and hear the discussion generated at the end offers a completely different perspective. What if you already had some basic ideas about what you wanted to do? Then you could talk not only to the expert lecturer, but also to many other ECMO programs and gather their specific protocols and experience. That type of ‘immediate education’ is incredibly efficient!

Which brings up Networking. Extracorporeal life support is a very dynamic field. Every patient affords a learning occasion. Issues are discovered for the very first time or incidents that have never arisen before may happen. Attending a conference that specializes in ECMO allows practitioners a real-time moment for discussion about your particular patient. Experts in the field are readily available and willing to talk about anything you might want to. Perhaps the issue or event that happened in your institution is new and with your experience you may help another ECMO center in the future. Which is what ECLS conferences are all about – leaning how to provide the best possible care we can to our patients.

If you are new to the field of ECLS – Welcome! The group of professionals you now belong to is amazing! If you haven’t been to an ECMO conference yet – you should! Come meet others who share your new passion and perhaps pick up a few new tidbits of information to take back to your home ECMO Center to share and discuss. You’ll make some new friends that will be life-long. You will discover a fraternity of medical professionals unlike any other! If you’re not sure when and where the next conference is – visit www.elso.org There is a complete listing of all upcoming meetings. I hope to see you at the next one!

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