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NO DISCLOSURES - UW Blogs Network
4/23/2015 ECMO Strategies for Refractory Respiratory Failure: The Who, How and Why Christine Lasich RN, BSN, CCRN Randall/Emanuel Severe Cardio-pulmonary Failure and ECMO (RESCUE) Center. The Extracorporeal Life Support Organization 2013 Award for Excellence in Life Support Demonstrates High quality standards Specialized equipment and supplies Defined patient protocols Advanced education of all staff members www.ELSO.org NO DISCLOSURES No financial relationships to disclose Any reference to a specific brand or product is not intended as an endorsement, but rather a reflection of the device or product with which we are familiar. 1 4/23/2015 OBJECTIVES Describe the clinical indications for ECMO support and discuss how ECMO supports oxygenation and ventilation Describe nursing actions required to prepare a patient for initiation of ECMO Identify the unique multisystem nursing considerations for adult patients on ECMO The ECMO team Clinical Nursing – Bedside Nursing – ECMO Specialist Perfusionist Administration ECMO Manager ECMO Director Respiratory Therapist ECMO Coordinator Physician Registrar Surgeon Critical Care PI Coordinator Interventional Radiology ECMO Bedside Educator Palliative Care/Social Worker ECMO Specialist Educator PT/OT/Speech Therapy Dietitian Extracorporeal Membrane Oxygenation (ECMO): What? Mechanical cardiopulmonary or pulmonary support May be configured Venoarterial (VA) or Venovenous (VV) Lungs no longer primary site of oxygenation and ventilation 2 4/23/2015 The Cannulas The Pump Centrifugal pumps Most prevalently used Improved performance with less complications Preload and afterload dependent The Oxygenator Hollow fibers (<0.5mm in diameter) coated with polymethylpentene Allow diffusion of gas but not liquid. As blood flows through the oxygenator, “sweep gas” (oxygen) is piped through the inside of the hollow fibers Oxygen and CO2 diffuse across membrane 3 4/23/2015 The Circuit ECMO: How? Physiology of Extracorporeal Support It comes full circle… Flow and Sweep Flow = quantity of blood Blood returned to patient via “arterial” cannula Drainage via venous cannula delivered (L/min) Sweep = Flow rate of oxygen from blender to oxygenator Flow maintained by centrifugal pump Blood warmed to normothermia Oxygen and ventilation via membrane oxygenator ECMO CIRCUITS Flow O2 Sweep CO2 Rotoflow Cardiohelp 4 4/23/2015 Anatomy of an ECMO Circuit Essential Components: Cannulas Tubing Pump Oxygenator Gas Blender Heat exchanger “Bridge” O2 Sat measurement Bubble detectors Monitors and alarms Display: SVO2, Hct and Hgb from venous sensor Venous drainage tubing: Deoxygenated blood draining from the patient. Console Arterial Blood Return Tubing: Oxygenated Blood returning to the patient. Heat Exchanger Oxygenator Bridge Centrifugal Pump Venous Oxygen Sensor The artificial endothelium aka – the ECMO circuit ECMO and Heparin Anticoagulation is essential to prevent clotting in the ECMO circuit Centrifugal pump Oxygenator This makes bleeding the #1 risk factor related to ECMO 5 4/23/2015 Extracorporeal Membrane Oxygenation (ECMO) Does not “cure” anything It takes over the work of the heart or lungs while they heal ECMO: Why? Improving efficacy and outcomes with advent of new technology Increasing patient volumes = more experience = more informed practice Conventional Ventilation of ECMO for Severe Adult Respiratory Failure (CESAR) 180 patients randomized to either conventional management group or consideration for ECMO treatment. Kaplan-Meier survival estimates, by allocat 63 % Eligible patients had potentially reversible respiratory failure and met strict entry criteria. 47% Findings: 6 month survival rate 63% versus 47% for control group. 50 100 Analysis time (days) Conventional 150 ECMO Noah et al.JAMA 2011. Peek Lancet. 2009 6 4/23/2015 EOLIA trial ECMO to rescue lung injury in severe ARDS (EOLIA) Ongoing international randomized controlled trial Daniel Brodie ECMO: Where? Regional Referral Program ECMO care requires a trained, multidisciplinary team ECMO patients have improved outcomes when cared for at experienced, high volume centers “..., advanced critical care for profound ARDS, including ECMO, represents the type of timedependent and high-reliability practice that might best be provided in a focused setting in which the provider and systems aspects of performance would benefit from a high density of experience.” Michaels et al. (2013) Why Transfer? CESAR TRIAL: “We recommend transferring of adult patients with severe but potentially reversible respiratory failure, …, to a center with an ECMO-based management protocol to significantly improve survival without severe disability.” - Peek et al. 2009 JAMA: “For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non– ECMO-referred patients.” – Noah et al. 2011 7 4/23/2015 Who Needs ECMO? • Refractory ARDS • Pneumonia • Sepsis • Severe respiratory failure • Shock • Near Drowning • Bridge to transplant • Trauma ECMO Contraindications ** All Contraindications are relative ** Related to patient’s premorbid condition: Age and size Contraindication to anticoagulation Chronic condition associated with poor outcome Underlying terminal condition not related to ARDS Limitations to care (code status) Related to treatment of current illness: Greater than 7 - 10 days on mechanical ventilator with peak airway pressure > 30 cmH2O and/or FiO2 > 0.8 ** Must have an endpoint to care ** 8 4/23/2015 VA vs VV ECMO CARDIAC FAILURE VenoArterial PULMONARY FAILURE VenoVenous VenoArterialECMO Cardiac May be applied for management of cardiac and/or respiratory failure Blood access via central vein and central artery, primarily femoral Controls up to 80% of patient’s total cardiac output (CO) VenoArterialECMO Indications Patients who cannot wean from cardiac bypass Refractory cardiogenic shock o Bridge to VAD o Bridge to transplant o ECPR Must have endpoint to care 9 4/23/2015 VenoVenousECMO Respiratory Provides pulmonary support only Relies on the patient’s native heart function to circulate the newly oxygenated blood “IV Oxygen” Blood access via femoral and / or internal jugular vein H CT A C HEST/A BDO C TA BDOMEN/PELV MEN/P ELV VenoVenousECMO 11/ Indications Severe Refractory Respiratory Failure from potentially reversible cause. Type I (Hypoxemic) Respiratory Failure (severe) with P:F <80 on FiO2 >90% with a Murray lung injury score of ≥ 3.0. 6/1/1959 6/1/195 9 53 YEA R F A CT A C HE ST WWO + A BDOMEN/P ELV IS CHE BDO MEN/PELV IS W C ONTRA ST ST C TA C HEST 5mL iso 3370 70 dws CTA HEST 12 1 25mL 22/2/2 /2 /2 013 3:16:01 A M M 20 93077 9 9307 79 A D APPLIE PP LIED LO C: -99 6.2 0 -9 96.20 THK: 2 HFS Type II (Hypercapnic) Respiratory Failure with a pH ≤ 7.2. R L RD: RD: 400 Tilt: 0 mA mA: 564 56 4 KV p: p: 140 A cq no: 10 10 Page: 669 9 of of 121 P Z: 1 C: -5 -585 W: 180 0 18 00 DFOV :4 0x40cm 0x40c m C ompressed 7:1 cm IM: 69 SE : 5 Acute Respiratory Distress Syndrome (ARDS) No effective pharmacological treatment Cornerstone to therapy remains supportive care with mechanical ventilation ARDS Network recommendations for volume and pressure limited ventilation strategies associated with decreased mortality Despite ARDSnet strategy, some patients continue to decline 10 4/23/2015 Current definition of ARDS aka, the “Berlin Definition”: Mild ARDS (PaO2 to FiO2 ratio 200 – 300) mortality: 27% 20 Moderate ARDS (PaO2 to FiO2 ratio 100 – 200) mortality: 32% Severe ARDS (PaO2 to FiO2 ratio < 100) mortality: 45% 28% of all ARDS is “severe” ARDS Definition Task Force, Raneri VM, Reubenfeld GD, et al: Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33 ECMO: When? Hypoxia becomes refractory to conventional management ALI/ARDS Inclusion Criteria PaO2/FiO2 <300 (ALI) PAO2/FiO2 <200 (ARDS) Bilateral Infiltrates No LA Hypertension Acute Onset No LA Hypertension Recruitment maneuvers Neuromuscular blockade Inhaled NO / EPO Prone Positioning APRV HFOV / HFPV ECMO NEED FOR VENILATORY SUPPORT Yes Conventional Ventilation with ARDSnet Strategy Recruitment Maneuver Must be approved by physician CPAP 40 cmH2O for 40 sec -OReSIGH with PEEP 10cm above LIP set PEEP above Lower Inflection Point at end of maneuver Consider CT scan: evaluate for reversible issues Consider for Recruitment Maneuvers Optimize Cardiovascular Status/Swan-Ganz prn Address anatomical issues: PTX, effusions, etc Evaluate for Proning, Paralytics, Nitric Oxide Assessment of Patient Improvement: Continue ARDSnet Strategy Yes P:F ratio >200 On FiO2 < 70% and PEEP < 12 Meeting Ventilation Goals pH >7.25 No Place on APRV Consider Consultation or Transfer Continue APRV Consider Initial use of VDR for: Pregnant or obese patient Inhalation injury Massive Secretions/Lobar collapse Status Asthmaticus Massive Air leak Yes Assessment of Patient Improvement No Place on HFOV (or VDR) Consider Transfer Continue HFOV/VDR Yes Assessment of Patient Improvement See selection criteria – Table 1 No Consider ECMO Transfer 11 4/23/2015 KEY POINTS Increased ventilator days and high ventilator settings are associated with higher mortality. Preferred fewer than 7 intubated days The longer the patient has been sick, the longer they will be on ECMO. Early referral saves lives! Before going on ECMO Baseline labs **Type and Crossmatch** Hct and coags Anticipate fluid / blood volume resuscitation Place all lines and tubes prior to initiation of anticoagulation Central Lines Peripheral IV Foley Catheter Feeding tube Transformation Intensive Care to Operating Room 12 4/23/2015 COMMUNICATION Blood bank Respiratory Therapy Pharmacist Operating Room staff X-Ray Family Supplies Anticoagulation Heparin Monitoring for effect: ACT (goal ~1.5x normal, 180-220 seconds) Heparin level (0.2-0.4) Optimize AT III (>80) Direct Thrombin Inhibitors Argatroban Bivalirudin PTT (45-75) 13 4/23/2015 Cannulation: Going on ECMO May be performed in ICU or OR Full sterile prep and OR team present Deep sedation / paralysis essential Heparin bolused (50-100 units / kg) prior to cannula placement Coordination between surgeon, perfusion and bedside RNs This is a critical time. The room needs to be quiet for clear communication And we’re on…. ECMO flow slowly increased to maximum tolerated, then decreased to lowest level required for adequate support. Sit back and watch the red blood flow… What could go wrong? Patient is bolused with approximately 1liter of saline from ECMO circuit This essentially empties blood from the heart temporarily 14 4/23/2015 Code situations Bedside Nurse Manages the Patient Full ventilator support Titrate vasoactive drugs May need blood and products Prepare code cart and ACLS drugs May need to emergently switch to VA Complications Vessel injury Thrombus Lung injury Equipment Malfunction Occurs less than 5% Air emboli Emergencies 15 4/23/2015 Bleeding Emergencies • Time to call the blood bank • Know your institution’s resources and policies ECMO is initiated Oxygenation improves immediately Perfusion improved Myocardial function improved Pulmonary pressures decrease Wean inotropes and vasoactive drips Rest settings on ventilator Diagnostic Procedures Labs ABG guides ECMO therapy PTT 45-75 Chest X-ray Cannula placement Occasional tests Echocardiogram EKG Ultrasound CT 16 4/23/2015 Multisystem care of the ECMO patient Cardiovascular / Hemodynamic Respiratory Hematologic Considerations Neurologic / Sedation Renal Metabolic / Gastrointestinal Skin Family Recovery vs. Futility Decannulation Cardiovascular and Hemodynamic Considerations VV: Pt. dependent on native hemodynamic physiology Support with inotropes, vasoactives, fluid, blood etc. as indicated MAP >65 VA: ECMO flow provides primary hemodynamic support May require fluid / blood / vasopressors to augment Maintain MAP 50-70 Additional Hemodynamic Considerations Trend markers of perfusion / native heart function Lactate ABGs SvO2 Continuous pulse contour analysis (PiCCOTM, FloTracTM) – VV only Echocardiography Urine output, skin color/temp, cap refill, etc. Pulmonary artery catheters? Pt. temp controlled by heat exchanger 17 4/23/2015 Treating the Underlying Problem Infection Abx Antiviral therapy (H1N1) Inflammation Plasmapharesis IVIG Trauma Surgical repair *Infectious Disease and Pharmacy input is crucial* Respiratory Considerations The lungs are no longer the primary site of oxygenation and ventilation!!! 3 R’s Rest Recover Recruit Rest Reducing pressure and FiO2 ELSO Recs: Mode: pressure control FiO2: PEEP: PIP: F: 0.3 10-15 cmH2O ~20 (PEEP + 10) 4-5 LEH: Mode: Volume Diffusive Respirator (VDR) Other: CPAP, MMV, Extubation? FiO2: 0.4 PEEP: 12* PIP: 24* F: 15 Percussive Rate = 500 * VDR settings: PEEP = Oscillatory PEEP; PIP = Pulsatile Flow 18 4/23/2015 What is the VDR? A pneumatically powered, pressure limited, time-cycled, high frequency flow interrupter. Delivers smaller, percussive tidal volumes at rates that range between 300-700 oscillations per minute at lower pressures. Enhances oxygenation, promotes CO2 clearance and facilitates mobilization of secretions while minimizing barotrauma Increased secretion clearance necessitates vigilant oral care and secretion maintenance by RN staff * Kunugiyama SK, Schulman CS. High-Frequency percussive ventilation using VDR-4 ventilator: an effective strategy for patients with refractory hypoxemia. AACN Advanced Crit Care. 2012;23(4):370-389 Recruit Recruitment maneuvers Positional Therapy Bronchoscopy Aggressive diuresis Ventilator recruitment maneuvers Initiated once lungs begin to show recovery Additional Respiratory Considerations Pulmonary Hypertension Management IV agents: Epoprostenol (Flolan), Nitroglycerin Inhaled agents: Nitric Oxide, Epoprostenol Tracheostomy Pneumothorax (To drain or not to drain?) 19 4/23/2015 Hematologic Considerations Systemic anticoagulation essential Bleeding is a major complication of ECMO Visible versus occult Common bleeding sites: Intracranial Mucous membranes Cannulation Sites Central lines and PIVs Surgical sites GI Tract **ICH on ECMO usually extensive and fatal** Minimize Hemolysis Monitor Plasma Free Hgb Bleeding Management (Focus on prevention) Vigilant monitoring Coagulation studies Plts, PT/INR, Fibrinogen, Viscoelastography (TEG™ / Rotem™) Cannula sites, IVs, mucous membranes, neuro exam Maintain Coagulation factors at acceptable levels Platelets ≥ 50,000* INR ≤ 2.2 Fibrinogen ≥ 100,000 Minimize venipuncture, fingersticks, insertion of tubes/drains, etc. When Intervention is Required: (Bleeding Management continued) Return coagulation status to normal D/C anticoagulant infusion (if necessary) Thrombostatic dressings OR as last resort 20 4/23/2015 Neurologic Considerations Maintain sedation and analgesia with least amount required to provide effective support & maintain safety Daily awakening trials as soon as tolerated Neuromuscular blockade? **Note: Some medications shown to have increased adsorption to circuit and oxygenator** Neuro Assessment Sedated and paralyzed? Hourly pupil response assessment Train of four Low threshold for Head CT with neuro change Pupilometry Near Infrared Spectroscopy (NIRS) Bispectral index monitor (BIS) Renal Considerations Euvolemia is the goal Diurese aggressively Hemofiltration CRRT if necessary Directly into circuit HD Catheter 21 4/23/2015 Gastrointestinal / Metabolic Considerations Place post-pyloric feeding tube pre-ECMO if possible Early consult from dietician Enteral nutrition as soon as tolerated TPN until tube feed tolerated at goal rate Probiotic supplements GI continuity Stress ulcer prevention Blood glucose management per hospital critical care insulin management protocol Skin Care Considerations Eyes Mucous membranes Blisters Pressure points Q 2 hour turning and ROM essential Continence management Family Care Considerations Include family as much as possible Allow family presence in rounds Include in plan of care Honest and direct communication Early palliative care consult 22 4/23/2015 Futility Possibility of stopping for futility should be discussed with family at outset of therapy Promptly discontinue ECLS when there is irreversible organ damage and no option for transplant Definition of irreversible damage depends on the institution and available resources Arbitrary timeframes for recovery are discouraged Signs of Recovery Hemodynamic stability Patient tolerates decreasing ECMO Flow and Sweep Evidence of clearing on CXR and bronchoscopy Pulmonary “step-up” Trial off VV: Wean flow and sweep to minimal settings Set ventilator to acceptable settings “cap off” oxygenator Maintain ECMO blood flow while monitoring SaO2, PO2 and CO2. VA: Reduce flow. Clamp access and return lines Monitor SaO2, PO2 and CO2. If VA for cardiac support, ECHO very helpful 23 4/23/2015 Decannulation May be performed at bedside if vascular repair not required Anticoagulant off for 30-60 minutes Get “comfortable” Program Considerations Education and team maintenance Intra-hospital Transport Inter-hospital Transport ECMO Education and Team Maintenance Formal ECMO education process ECMO handbook for bedside nurses Skills, drills, simulation, lecture, online SLMs Collaborate with Pt. care champions Additional mandatory CEUs Roles Simulation Lab Bedside RNs Transport RNs ECMO Specialists 24 4/23/2015 Intra-hospital Transport • • • • Have a plan Bedside RN is the team leader Clear hallways Coordinate with receiving department Inter-hospital Transport 25 4/23/2015 For additional information: www.elso.org References Annich,., G.M., Lynch., W.R., MacLaren, G., Wilson, J.M., Bartlett, R.H. (2012). ECMO Extracorporeal Cardiopulmonary Support in Critical Care (4th ed.). Ann Arbor, MI: Extracorporeal Life Support Organization. ARDS Definition Task Force, Ranieri V.M., Rubenfeld, G.D., et al. (2012). Acute respiratory distress syndrome: the Berlin definition. JAMA 307 2526-2533 Bibro C, Lasich C, Rickman R, et al. Critically ill patients with H1N1 influenza A undergoing extracorporeal membrane oxygenation. Crit Care Nurse. 2011;31:e8-e24 ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support Extracorporeal Life Support Organization, Version 1.3 November 2013 Ann Arbor, MI, USA www.elsonet.org ELSO Adult Respiratory Failure Supplement to the ELSO General Guidelines Version 1.3 December 2013 Ann Arbor, MI, USA www.wlsonet.org Holleran, R. (2010). ASTNA: Patient Transport, principles and practice (4th ed). Mosby, INC. Michaels, A.J., Hill, J.G., & Long,., W.B., Young, B.P. Sperley, B.P., Shanks, T.R., Morgan, L.J. (2013). Adult refractory hypoxemic acute respiratory distress syndrome treated with extracorporeal membrane oxygenation: the role of a regional referral center. The American Journal of Surgery,205(), 492-499 Noah MA, Peek GJ, Finney SJ, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A (H1N1). JAMA 2011;306:1659-1668 Peek GJ, Mugford M, Tiruviopati R, et al. Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet. 2009;374(9698):1351-1363 26 4/23/2015 Christine Lasich, RN, BSN, CCRN Legacy Emanuel Hospital [email protected] Thank you! 27