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
www.ELSO.org Demonstrates High quality standards Specialized equipment and supplies Defined patient protocols Advanced education of all staff members
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.
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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 Administration
Nursing – Bedside ECMO Manager Nursing – ECMO Specialist ECMO Director Perfusionist ECMO Coordinator Respiratory Therapist Physician Registrar Surgeon PI Coordinator Critical Care 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
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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
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The Circuit
ECMO: How? Physiology of Extracorporeal Support It comes full circle… Flow and Sweep
Blood returned to Flow = quantity of blood patient via Drainage via “arterial” venous delivered (L/min) cannula cannula Sweep = Flow rate of oxygen from blender to oxygenator
Flow Flow O2 Blood maintained by warmed to centrifugal normothermia pump
Oxygen and Sweep CO ventilation via 2 membrane oxygenator
ECMO CIRCUITS Rotoflow
Cardiohelp
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Anatomy of an ECMO Circuit
Essential Components: Cannulas Display: SVO2, Hct Venous drainage and Hgb from Tubing tubing: venous sensor Deoxygenated Pump blood draining from the patient. Oxygenator Console Arterial Blood Return Gas Blender Tubing: Oxygenated Blood returning to the Heat Exchanger Heat exchanger patient. “Bridge” Oxygenator Bridge O2 Sat measurement Centrifugal Pump Bubble detectors Venous Oxygen Sensor Monitors and alarms
The artificial endothelium aka – the ECMO circuit
ECMO and Heparin
Anticoagulation Oxygenator is essential to prevent clotting in the ECMO circuit
This makes Centrifugal bleeding the pump #1 risk factor related to ECMO
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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 Kaplan-Meier survival estimates, by allocat conventional management group or consideration for ECMO treatment. 63 % Eligible patients had potentially reversible respiratory failure and 47% met strict entry criteria. Findings: 6 month survival rate 63% versus 47% for control group.
50 100 150 Analysis time (days)
Conventional ECMO
Noah et al.JAMA 2011. Peek Lancet. 2009
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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 time- dependent 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
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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 **
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VA vs VV ECMO
CARDIAC FAILURE PULMONARY FAILURE VenoArterial 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
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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 CTA CHEST/ABDOMEN/PELV 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 A CTA CHEST WWO + ABDOMEN/PELVIS W CONTRAST 6/1/1959 CTA CHEST 125mL iso 370 dws 53 YEAR 2/2/20132/2/2013 3:16:01 AM F 20930779 injury score of ≥ 3.0. APPLIEDAPPLIED LOC: -996.20-996.20 THK: 2 HFS Type II (Hypercapnic) Respiratory Failure with a pH ≤ 7.2. R L
RD: 400 Tilt: 0 Z: 1 mA:mA : 56456 4 C: -585 KVKVp:p: 140 W: 1800 Acq no: 10 DFOV:40x40cmDFOV:40x40cm Compressed 7:1 PaPage:ge: 6969 ofof 121 P IIM: M : 669 9 SESE: : 55 cmcm
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
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Current definition of ARDS aka, the “Berlin Definition”:
Mild ARDS (PaO2 to FiO2 ratio 200 – 300) 20 mortality: 27%
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
Recruitment maneuvers Neuromuscular blockade Inhaled NO / EPO Prone Positioning APRV HFOV / HFPV ECMO
NEED FOR VENILATORY ALI/ARDS Inclusion Criteria SUPPORT PaO2/FiO2 <300 (ALI) PAO2/FiO2 <200 (ARDS) Yes Bilateral Infiltrates Recruitment Maneuver No LA Hypertension Must be approved by physician Acute Onset Conventional CPAP 40 cmH2O for 40 sec No LA Hypertension Ventilation with -OR- ARDSnet Strategy eSIGH 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: Yes Continue P:F ratio >200 ARDSnet On FiO2 < 70% and PEEP < 12 Consider Initial use of VDR for: Strategy Pregnant or obese patient Meeting Ventilation Goals pH >7.25 Inhalation injury Massive Secretions/Lobar No collapse Status Asthmaticus Place on APRV Massive Air leak Consider Consultation or Transfer
Continue Yes Assessment of Patient Improvement APRV No Place on HFOV (or VDR) Consider Transfer
Yes Continue Assessment of Patient Improvement HFOV/VDR See selection criteria – Table 1 No Consider ECMO Transfer
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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
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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)
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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
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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
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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
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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
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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: 0.3 PEEP: 10-15 cmH2O PIP: ~20 (PEEP + 10) F: 4-5 LEH: Mode: Volume Diffusive Respirator (VDR) FiO2: 0.4 PEEP: 12* PIP: 24* F: 15 Percussive Rate = 500 Other: CPAP, MMV, Extubation?
* VDR settings: PEEP = Oscillatory PEEP; PIP = Pulsatile Flow
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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?)
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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
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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
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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
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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
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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 Simulation Lab Roles Bedside RNs Transport RNs ECMO Specialists
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Intra-hospital Transport • Have a plan • Bedside RN is the team leader • Clear hallways • Coordinate with receiving department
Inter-hospital Transport
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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
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Christine Lasich, RN, BSN, CCRN Legacy Emanuel Hospital [email protected]
Thank you!
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