Let’s assume that the decision has been made to place a particular patient on ECMO. Obviously, at this point there are many things to consider. ECMO has numerous settings and adjustments, just as our mechanical ventilators do, and each of those needs to be optimized for your patient.
Additionally, you will need to be careful of potential complications, just as we are with mechanical ventilators. And you will need to think ahead about weaning and decannulation of your patient. The patient cannot stay on ECMO forever, and the sooner we move them back to conventional ventilation, the sooner they will have an opportunity to breathe on their own and leave the critical care setting. Careful monitoring of the patient on ECMO, and making adjustments to changes in patient condition, are both keys to the success of this modality.
In this assignment, you will discuss key aspects of ECMO management, demonstrating your learning about this important aspect of managing patients in the critical care setting.
Management of the Patient on ECMO
Management of the patient receiving ECMO involves strategies for multiple body systems, listed below:
Pulmonary Management During ECMO
ECMO is generally intended for temporary use while awaiting pulmonary recovery. It is very important to keep the patientâ€™s lungs inflated and free of pneumonia during ECMO. Typical ventilator settings during ECMO are FIO2 of 30%, Peak Inspiratory Pressure (PIP) of 20 cm H2O, a Positive End-Expiratory Pressure (PEEP) of 5 cm H2 O, and SIMV of 10-20 breathes per minute. Pulmonary hygiene is very important during ECMO, requiring frequent changes in patient position, suctioning, and daily CXR to identify any problems early.
Cardiovascular System Management During ECMO
Systemic fluid volume needs to be carefully monitored during ECMO to avoid fluid overload. Urinary output and physical assessments of the patient can provide a reference to the patient’s fluid volume status. Additionally, it is helpful to measure central venous pressure and the mean arterial blood pressure during ECMO. Cardiac output can be enhanced with inotropic agents if needed.
Central Nervous System Management during ECMO
Central nervous system complications from ECMO are the most serious type, generally related to the degree of hypoxia and acidosis which the patient experienced prior to receiving ECMO. Avoiding paralytic agents is advisable, and performing regular neurologic examinations is essential to identify problems early on.
Renal System Management during ECMO
During the first 48 hours on ECMO, a reduced urinary output is common. This is believed to be due to ECMO triggering an acute inflammatory response in the kidneys. The diuretic phase, which usually begins within 48 hours, is often one of the earliest signs of recovery, a very positive sign for the patientâ€™s survival. If reduced urinary output persists longer than 72 hours, diuretics should be utilized to reduce edema.
Infection Control during ECMO
Strict aseptic precautions are important during ECMO. The circuit should be cultured at least once per week, and necessary actions taken.
Weaning or Trial Period Without ECMO
A weaning trial period without ECMO should be attempted if the patient demonstrates adequate gas exchange and is on reasonable ventilatory settings and the patient tolerates a pump flow of 10-20 mL/kg/min with a minimum of 200 mL/min. Well managed ECMO saves lives without a doubt. Specifically, prior to ECMO when the patient’s lungs were in such poor condition that the patient could not oxygenate or ventilate, that patient would die, just that simple. ECMO does a remarkable thing, it does the work of the patient’s lungs (and heart if necessary) while the patient recovers and can begin to breathe effectively again. ECMO is an exciting specialty in the RT field. Who knows, you might even become the ECMO specialist in your own hospital someday.
Advance Ventilatory Modes
There are several special ventilatory techniques that have come along as advancements in the science of ventilation. Among these are airway pressure release ventilation (APRV), high-frequency oscillatory ventilation (HFOV), neutrally adjusted ventilatory assist (NAVA), and Heliox therapy. You will learn about how these special modes actually function, and protocols for their application to patients. You will learn when you should recommend these modes for patients.