1 ECMO Services Policy #:

1
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
PURPOSE:
To outline the management of the neonatal patient receiving Veno-Venous ECMO treatment for
pulmonary disease.
SUPPORTIVE DATA:
The ECMO Specialist is a Medial Doctor, a Registered Professional Nurse, a Registered
Respiratory Therapist or a Certified Cardiovascular Perfusionist with a strong critical care
background and who has completed specialized training in the management of the ECMO patient
and the care of ECMO equipment used to support these patients. The ECMO patient is always
assigned to and cared for by a critical care R.N. and an ECMO Specialist.
CONTENT:
Initial Assessment and ECMO Specialist Management
1. Assess efficiency of pump parameters:
a. draw blood gases from all sites including: UAC, RAL, pump arterial and pump
venous.
b. draw pump venous gas to calibrate the SvO2 monitor.
c. draw patient arterial blood gas to assess patient PH, PcO2 and Pao2.
d. adjust pump flow to keep venous saturations above 70%.
e. wean pump FIO2 to keep pump PaO2 between 200-350, if patient on rest
ventilator settings and the patient PaO2 >60.
f. adjust sweep gas to keep CO2 within normal range of 35-45. (increasing
sweep will decrease CO2 and decreasing sweep will increase CO2.)
g. monitor patient arterial gas within 45 minutes of any change in vent
settings, pump flow, pump fio2 or sweep gas titration.
h. zero post bladder, pre-oxygenator and arterial line pressures.
i. observe for signs of recirculation (SvO2 >90, patient color dusky, PaO2 < 45, SaO2 < 85)
If recirculation exists, decrease pump flow slowly while monitoring SaO2 and patient
blood pressure.
2. Assess patient color and perfusion.
3. Assess patient chest rise and breath sounds for baseline compliance and aeration.
4. Check ACT level at least every 30 minutes once it falls below 300 seconds. Increased
diuresis in the patient will cause the ACT level to fall quickly.
5. Start heparin drip once ACT falls below 300 seconds. The heparin drip is standardized
by patient weight and sent by pharmacy when ordered in EPIC by a physician or APN.
2
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
The heparin drip is started at 10units/kg/hour. The ACT should continue to be
monitored closely every 30 minutes and the heparin drip adjusted accordingly
until the desired range is achieved.
7. Advise bedside nurse not to suction patient until the ACT falls below 250 seconds.
8. Adjust ECMO heater as necessary to achieve and maintain normothermia.
Ongoing Assessment and ECMO Specialist Management
1.
2.
3.
4.
5.
6.
Assess patient perfusion and color.
Monitor SVO2 reading.
Adjust pump flow as necessary to maintain venous saturations > 70%.
Maintain mean arterial blood pressures according to physician order.
Replace pump fluids as necessary and judiciously to maintain pump blood flow.
Monitor for signs and symptoms of infection including but not limited to
peripheral vasoconstriction, vasodilation, decreased blood pressure and increasing
venous saturations.
7. Adjust pump flow as necessary to prevent recirculation and keep PaO2 > 60. Call physician
to adjust ventilator settings if PaO2 remains < 60 despite manipulation of pump flows.
8. Monitor ACT level. Titrate heparin drip to maintain ACT levels between 200-220 or
180-200 for an actively bleeding patient.
9. Monitor vital signs.
10. Draw UAC and RAL gases if shunting difference is 10% or higher in pre and post SAT readings.
11. Monitor pump RPM’s and flows.
12. Remove pump fluids as necessary to decrease blood pressure.
13. Monitor post bladder pressure: an increase in negative pressure could indicate a kink/
obstruction prior to the bladder reservoir or a losss of volume. (leak, hemorrhage,
dehydration.)
14. Monitor pre-oxygenator pressure: a fall in this pressure could indicate lower flows or an
obstruction prior to the oxygenator. A rise in this pressure could indicate higher flows or an
increase in resistance within the oxygenator itself. A higher pump flow in addition to a fall
in the arterial line pressure could indicate a clot in the arterial filter. A sudden pressure drop
between pre-oxygenator pressure and art-line pressure could be indicative of a clot or
obstruction within the oxygenator and or the arterial filter.
15. Monitor arterial line pressure: an increased arterial line pressure indicates higher resistance
(kink/obstruction) in or before the arterial cannula. A decrease could indicate an obstruction
in or prior to the arterial filter.
3
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
16. Transfuse PRBC’s to maintain hemoglobin > or equal to 9.0 per lab results unless
otherwise ordered by a physician. All blood products are to be ordered by a
a physician or APN.
17. Transfuse platelets to keep count > or equal to 50,000. A higher count should be
ordered by a physician. All blood products are to be ordered by a physician or APN.
18. Administer sodium bicarbonate per physician order if base deficit is more negative than
-5. Bicarb may be infused in the ECMO circuit over 1-2 minutes due to the circuit
volume.
19. Administer potassium for level < or equal to 3.5 meq/L. (potassium to be infused per
hospital protocol.)
20. Check ABG within 45minutes following any changes in vent settings, sweep gas,
pump FIO2 or sodium bicarb administration.
21. Open bridge slightly at a minimum of every 30 minutes to prevent stagnation of blood.
22. Adjust sweep gas as necessary to maintain patient CO2 within normal range 35-45.
sweep gas should not be decreased less than 0.1ml/min.
23. Decrease ventilator rate if CO2 less than 35 and sweep gas is at 0.1ml/min.
(Requires a physician order.)
24. Weaning is not necessary unless for purposes of recirculation or to decrease arterial line
pressure below 200 if tolerated.
25. Visually inspect ECMO circuit with a flashlight for air, clots, fibrin strands and examine
all connections for tightness.
26. All prefilled heparin flushes sent from pharmacy should be scanned in the MAR prior to
use.
Every hour and PRN ECMO Specialist Manangement
1. Complete and document all hourly ECMO circuit check and safety parameters that are
included on the ECMO computerized flowsheet.
2. Check ACT level
3. Monitor and document any volume given to or taken from ECMO circuit.
4. Check heater temp...included within hourly flowsheet.
5. Monitor patient temp...collaboratively with bedside RN.
6. Monitor vital signs...collaboratively with bedside RN.
Every four hours and PRN ECMO Specialist Management
4
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
1.
2.
3.
4.
5.
6.
7.
A documented respiratory and cardiovascular assessment in collaboration with bedside RN.
Assess heart sounds and rate in collaboration with bedside RN.
Auscultate breath sounds for equality and aeration.
Assess chest compliance and note the pressure it takes to see adequate chest rise.
Assess pupils and fontanelle in collaboration with bedside RN.
Assess for liver engorgement in collaboration with RN and MD if necessary.
Draw pump venous gas to calibrate the SVO2 monitor every 4 hours and more
frequently if condition or patient warrants. If stable after the first 24 hours on
ECMO, draw pump venous gas and recalibrate SVO2 every 8 hours.
8. Check radial and pump arterial blood gases every 4 hours at a minimum for the first
24 hours and more frequent if condition of patient warrants. If stable after the initial
24 hours on ECMO you may continue to check every 8 hours.
Every six hours and PRN ECMO Specialist Management
1. Draw ECMO labs every 6 hours or otherwise ordered from by the physician.
Every eight hours and PRN ECMO Specialist Management
1. Draw pump and patient ABG to check adequacy of membrane oxygenator and
carbon dioxide removal.
2. Draw pump VBG to recalibrate the SvO2 monitor.
3. Zero post bladder, pre-oxygenator and pump arterial line pressures. Flush lines PRN
if needed.
Beginning of every eight hour shift safety 0700/1500/2300
Handoff from Specialist to Specialist should include the review of all ECMO parameters and
alarms and documented that they were reviewed together with the oncoming Specialist’s first
circuit check under Protocol in the EMR.
1. Check and adjust high and low RPM’s
2. Check and adjust low flow alarms.
3. Check and adjust high and low venous saturation alarms.
4. Check circuit breaker on ECMO pump and assure that it is in the “ON” position.
5. Check battery charge status on the ECMO pump.
6. Check that all electrical cords are plugged into a red outlet.
7. Assure that 2 emergency tubing clamps are on the patient’s bed and open at all times and
5
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
at least one is hanging on the ECMO pump.
8. Assure that there is an Emergency hand crank safely stable and available on the ECMO
pump’s cart.
9. Assure that emergency ventilator settings are posted visibly. (for neonates rate of 60, PIP
of 35, PEEP of 5 and 100% FIO2, or otherwise ordered by a physician.)
10. EMCO supply cart located in close proximity of patient room.
11. Know the location of the crash cart.
12. Universal precaution equipment including goggles or mask with eye shield at bedside.
13. Secure all tubing and connections from contact with floor or other soiled surface.
14. Make sure that cannulas and tubing are secure.
15. Only fill blood warmer with sterile water and only when needed. There is to be no open
bottles of water at the bedside. Left over water in the bottle that was needed for the
warmer should be discarded. (water level should be seen at the bottom of the screen.)
16. Check pump emergency replacement fluid...lactated ringers for:
a. correct solution (lactated ringers)
b. expiration date
c. tubing expiration date
17. Monitor every hour and PRN the patency of ECMO cannulas, tubing and all other
components of clotting, air, obstruction, kinking, leaking and overall integrity.
18. Do not turn off heparin drip without a physician order.
19. If ACT is at lower end of desired range, monitor ACT’s frequently, alert physician and
and titrate heparin drip accordingly.
20. Do not infuse the following to the ECMO circuit: Cryoprecipitate, Nitroglycerin,
Amphotericin, Nipride, Intralipids, Platelets, Albumin, Fresh Frozen Plasma, Amicar
or Factor VII. If no patient access is available you may infuse platelets, albumin or
fresh frozen plasma post pump head and cryoprecipitate post oxygenator. All attempts
should be made to never infuse amicar or Factor VII to the ECMO circuit. These clotting
adjuncts have a high risk of clotting off the circuit.
21. Monitor all IV fluid infusion sites for patency on the ECMO circuit.
22. Monitor all connections for cracks and stability.
23. Limit visitors to 2 maximum in patient room while on ECMO.
24. Do not reposition patient, change linen or manipulate cannulas without an ECMO
physician present.
25. Medication and IV fluids to be connected to the ECMO circuit must only be done by
the ECMO Specialist. The bedside RN should scan and double check the med, set-up and
program the pump.
6
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
26. When nuclear dye testing is necessary on ECMO, dye should be infused at arterial
pressure line stop-cock port with constant monitoring of dye infusion line for potential
air.
Infection Control ongoing ECMO Specialist Management
1. Utilize proper hand washing technique and all other universal precautions when in
contact with the ECMO patient and ECMO circuit.
2. Gloves must be worn at all times when in contact with blood or blood products.
3. Cap all unused ports with an occlusive cap.
4. Clean all sample ports with alcohol for 15 seconds and allow to dry for 15 seconds prior
to sampling.
5. Change pump replacement fluid (lactated ringers) and tubing per unit and hospital
current protocol.
6. Label all IV flush solutions drawn up in syringes with: name of solution, date and time.
7. Discard all expired flush solutions prefilled from pharmacy.
8. Draw blood cultures from ECMO pump every PM shift.
Emergency Measures ECMO Specialist Management
1. Follow protocol, “Emergency management on ECMO” for:
a. Accidental Decannulation
b. Air or clot in the arterial cannula
c. Any disruption in the ECMO circuit.
d. Removal of a large amount of air from ECMO circuit.
2. Follow procedure, “ Emergency Removal from ECMO.”
Standing Orders ECMO Specialist Management
A physician or APN will implement the ECMO Management Protocol order upon initiation of
ECMO treatment. Any change to these standing orders will be ordered by a physician or an
advanced practice nurse and documented by the bedside nurse and ECMO Specialist either in the
patient’s flowsheets or kardex. The ECMO Specialist will practice within the
guidelines of the following orders:
7
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
1. Transfuse PRBC’s to keep hemoglobin > or equal to 9.0. To be ordered by a physician or
APN.
2. Transfuse platelets to keep count > or equal to 50,000. To be ordered by a physician or APN.
3. Lactated Ringers for pump replacement fluid. 10 ml per kg initially and then report to
physician.
4. Titrate heparin drip to maintain ACT 200-220 or 180-200 seconds for an actively bleeding
patient.
5. Administer Potassium rider for a level < or equal to 3.5.
6. Administer Sodium Bicarbonate for a level more negative than -5.
7. Draw labs according to “ECMO-Care of the Patient” nursing protocol.
MD communication ECMO Specialist Management
1. Collaborate daily with ECMO physician on:
a. anticipated discontinuation of ECMO support.
b. plan for the day
c. chest x-ray and other diagnostic findings.
2. Notify MD of:
a. abnormal assessment
b. abnormal lab values
c. decreasing blood pressure despite increases in pump flows or volume given.
d. increasing ACT with the heparin requirement down to 3 units/kg/hr.
e. notable air or clotting in the circuit.
f. loss of integrity of circuit.
g. falling venous saturations despite increase in pump flow.
h. need for repositioning of patient, linen change or manipulation of cannulas.
i. any emergency or potential emergency situations.
j. Continued recirculation despite decreasing flows.
Bedside RN Communication ECMO Specialist Management
1. Collaborate with bedside RN on:
a. cardiorespiratory status and assessment
b. patient temperature
c. ACT level and heparin adjustment.
d. lab results
8
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
e. Intake and Output
f. roles in an emergency situation.
g. family interaction
h. need for medication and blood product administrations
DOCUMENTATION:
1. Document assessments and interventions in appropriate unit based record.
2. Record family teaching.
3. Treatment team members will be notified of relevant changes in patient status.
4. Assure protocol is initiated on the Plan of Care if appropriate.
REFERENCES:
.
Short, Williams, Rycus. ECMO Specialist Training Manual 3rd edition, 2010. Extracorporeal Life
Support Organization.
Van Meurs, K, Lally, K.P., Peek, G., Zwischenberger, J.B. ECMO -Extracorporeal Cardiopulmonary Support
In Critical Care. 3nd Edition, 2006. University of Michigan Press.
Zwischenberger, J., Steinhorn, R., Bartlett, R. Extracorporeal Cardiopulmonary Support in
Critical Care. Second edition 2000, University of Michigan Press
AUTHOR:
Dan Byron, BS RRT
ECMO Coordinator
DISTRIBUTION:
ECMO Department
NICU
PICU/CCU
REVIEWED BY:
M. Reynolds, M.D.
D. Goodman, M.D.
R. Rozenfeld, M.D.
E. Preze, RN MSN, Director of Cardiac Nursing/ECMO
T. Gentile, BS RRT
9
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol
APPROVAL:
Pediatric Surgery/ECMO Division Head and ECMO Coordinator
APPROVAL DATE:
03/2011
REVIEW DATE:
03/2014
10
ECMO Services
Policy #:
Effective Date: 03/2011
Policy and Procedure
Manual
Approved By:
Marleta Reynolds, MD
Patient care is revised to
meet the individual
patient’s needs
Policy/Procedure/Protocol:
Dan Byron BS, RRT
ECMO Coordinator
V-V Neonatal ECMO Specialist Management Protocol