Prevention of complications is fundamental to successful ECMO care. Many interventions during ECMO carry additional risks. The following is a summary of fundamental precautions to prevent common, severe complications.
Prevention of ECMO Circuit complications
Securing Cannulae
All ECMO lines must be secured at two points with properly adherent skin dressings (Grip-locks with skin preparation). For femoral cannulae, securing of lines should be on the thigh (above the knee) to prevent cannula withdrawal with knee flexion. Initial securing is the responsibility of the cannulator and cannot be delegated. All ECMO line dressings are maintained by bedside nursing staff.
Cannulae Positions
Checked each shift (as part of nursing checklist). Medical staff must also check cannulae positions radiologically when reviewing images. Any change in the position of a cannula must be referred to the ICU Consultant immediately for management.
ECMO cannulae dressings
Sterility must be maintained and insertion sites kept unsoiled. Special attention must be given to jugular vein cannula in particular to prevent contamination and migration. All cannulae dressings are maintained by bedside nursing staff.
Distal perfusion cannula
The placement is mandatory in conjunction with femoral artery cannulation. It must not be delayed in patients considered possible survivors. In ECPR cardiac revascularisation is often judged to be more time-critical than the distal perfusion cannula, however the delay is usually short (<2 hours) and the consultant with the patient is able to monitor the lower limb.
If the percutaneous approach fails an immediate request is made to the vascular surgical unit to assist in placing the cannula.
Procedures
No procedures are to be performed on ECMO patients without the prior consent of the managing Intensivist who has considered the risks of bleeding and alternatives for management. This includes the following:
Suturing
Suturing is NOT used to secure ECMO cannulae. Securing the distal perfusion cannula is done away from the site of the ECMO cannula with a single stitch.
Venepuncture/ vascular access
The need for vascular access and the site should be discussed as well as the performing personnel – this includes blood cultures, arterial lines or any form of central access.
Insertion of nasogastric tubes
At times a trivialised procedure, however this should be performed with great caution. Nasal haemorrhage with an ongoing anticoagulation requirement can represent a clinical challenge. Frictional postpyloric feeding tubes should not be used in ECMO.
Intercostal catheters
Intercostal catheters should not be inserted in patients supported with veno-venous ECMO unless there is mediastinal tension manifesting with haemodynamic instability. Small or asymptomatic pneumothoraces may be managed by a reduction in lung ventilation and increasing fresh gas flow. Pleural effusions should not be drained during ECMO (unless they are impeding venous return or causing ECMO access insufficiency). Tension from massive pleural effusion and/or haemthoraces is uncommon. Thoracotomy may be safer depending on the circumstances and should be considered as an alternative.
Echocardiography
Trans-oesophageal echocardiography should only be performed if transthoracic echo windows are inadequate. Oesophageal tubes should be withdrawn prior to probe insertion.
Surgical interventions
Any surgical intervention may be explored at the bedside or operative intervention in theatre should be discussed with the treating intensivist.
Intra-hospital transports
Whenever possible these should be arranged in-hours. Two ECMO accredited staff must go on all transports. A designated staff member must secure all ECMO lines during transport and patient moves.
General Safety
ECMO clamps
4 ECMO clamps are kept at the bedside at all times. There are a variety of emergencies that require immediate clamping of the circuit to avoid further major complications such as air embolism, circuit rupture, accidental decannulation. Where patients have a jugular line inserted, an ECMO clamp should be available at the “head of the bed”.
Replacement ECMO console and circuit
At all times there is a replacement rotaflow console and Cardiohelp console plugged in outside of cubicle one. The emergency primed circuit on a rotaflow console is kept with the ECPR equipment but can be used for any emergency in the unit e.g. an emergency circuit change.
Avoid Alcohol-basedCleaning Solutions
These solutions (including triclosan) should not come into contact with the ECMO circuit as they may cause cracking of some circuit components (Emergency: circuit rupture). Betadine should be the only antiseptic solution stored in the ECMO patient cubicle. The ICU Consultant should be notified immediately if alcohol solutions come into contact with the circuit. Alcohol and chlorhexidine body wash wipes should not be used on ECMO patients.
Electrical Safety
Do not allow water to enter the ECMO drive unit
- Rotaflow external drive should always face “up” to prevent water entering in the event of a spill.
- Pressurised fluid bags should be sited below the console and drive units
Patient moves and turns
A designated staff member must secure ECMO circuit lines to prevent tension or torsion during patient moves. ECMO accredited staff must be present and available to manage changes in ECMO circuit blood flow during patient turns and moves.
Patients on central ECMO support with surgically placed bypass cannulae via an open sternum should not be turned for pressure care (Jordan Frame pressure care).
What to do when things go wrong?
This guideline is meant to provide a lifeline for the clinician at the bedside however it can not replace the internal backup system and experience at the bedside. The few emergencies that require immediate action at the bedside are covered under Emergency responses. Usually there is time to discuss ECMO related problems and this support is primarily provided by the ECLS consultant (V-consultant) 24/7 (see roster) beyond the duty consultant. The ECMO nurse during day time hours is also an invaluable resource. In addition, these patients will commonly require multidisciplinary input and access to emergency cardiothoracic/ vascular surgery is essential.