ECLS Updates GTCAC-AACN FALL SYMPOSIUM November 10, 2016 Sharon Wahl, RN, MSN, CCRN, CCNS

ECMO/ECLS ExtraCorporeal Membrane Oxygenation ExtraCorporeal Life Support

Types of ECLS VA – VenoArterial VV – VenoVenous Provides cardiac and respiratory support VV – VenoVenous Provides respiratory support only

ELSO (ExtraCorporeal Life Support Organization)

Survival Rates

2009 CESAR trial published H1N1 pandemic Advances in technology UK trial, showed improved survival in patients with severe respiratory disease when transferred to ECLS center vs. standard treatment H1N1 pandemic Advances in technology

Candidates for ECLS Indications Contraindications Severe heart or lung failure – consider at 50% mortality risk, indicated at 80% mortality risk Majority of contraindications are relative – evaluate on individual basis Preexisting conditions affecting quality of life – CNS status, inability to anti-coagulate, end stage malignancy Futility Age and ? Size of patient

Patient + Cannula + Pump + Oxygenator + Cannula = ECLS

CIRCUIT

ECLS CANNULATION

VA CENTRAL CANNULATION Drain from the right atrium Return to the ascending aorta Usually cardiac surgery cases with postoperative failure, open chests

Comparison VA ECLS VV ECLS De-oxygenated blood to lungs Nonpulsatile Removes preload Increases afterload Risk of arterial inflow emboli Only way to provide cardiac support Average run 5-7 days In and out right side – oxygenated blood to lungs Normal LV pulsation No effect preload or afterload Microemboli/air to lungs Respiratory support No hemodynamic support Average run 10-14 days

Nursing Considerations

General Nursing Goals Stabilization Comfort and organ rest Prevent and/or manage complications related to ECLS and ICU Understand how ECLS is affecting your patient and provide comprehensive care of patient

Bleeding most common complication All ECLS patients are anticoagulated to maintain patency of circuit Careful transfusion GI prophylaxis Observe cannulation sites Fix coagulopathy Lower PTT goals– observe circuit closely for clots Surgery may be indicated to control bleeding CNS bleed is significant complication

Cerebral hypoxia Oxygenated blood from ECLS circuit mixes with blood ejected from ventricle – blood from ECLS retrograde Location of mixing dependent on ejection fraction of LV and ECMO flow or support Usually mixes in proximal ascending aorta or aortic root As ejection fraction improves the mixing point changes May result in hypoxic blood perfusing proximal aortic branches Degree of lung function is a variable

Mercy Hospital - Coon Rapids, MN April 2013 VA ECMO Admixture

Cerebral hypoxia Use right radial arterial line for ABGs or measure O2 saturations on right hand ABGs drawn from femoral site may appear fully saturated Blood supply to the right hand is most distal from ECLS cannula Increase vent settings if lungs are working Pulmonary recruitment Increase ECLS support, pump flow Add an additional cannula – VAV ECLS Oxygenated blood to the lungs

Monitoring Regional O2 Saturation Gives site specific data on tissue perfusion – regional not global Venous-weighted measure of O2 saturation – Reflects venous oxygen reserve Non-invasive, early warning of ischemia and compromised tissue perfusion

Monitoring Regional O2 saturation General Guidelines Typical values 58-82% Regional O2 saturation (rSO2) of 50 or a 20% decline from baseline are cause for concern and intervention rSO2 of 40 or 25% decline from baseline are associated with ischemic brain injury, neurologic dysfunction and adverse outcomes Monitor trends – wide variance in baseline

LIMB ISCHEMIA Use smaller catheters to cannulate - 15-17 Fr arterial Retrograde perfusion catheter Cannulate posterior tibial artery or SFA and “Y” off arterial cannula 6-8 Fr catheter Reperfusion injury, monitor for compartment syndrome Rooke boots

Pulsatility – VA ECLS Pump-flow is non-pulsatile Arterial line increasingly dampened as pump flow increased Some pulsatility is desirable – recommended 10 mm minimum Stagnation at aortic root LV dilation – leading to pulmonary edema and hemorrhage Difficult to attain with very low EFs

Offload the left ventricle IABP – decrease afterload allow LV to eject Atrial septostomy Percutaneous transeptal atrial puncture Blood flows from left to right and drains into ECLS cannula Vent left ventricle Cannula from LV to venous drainage cannula

Impella Gaining favor as method to decompress LV when used with ECLS Crosses aortic valve, motor pulls blood through to aorta

VV ECLS

VV ECLS Rate of infusion blood to deoxygenated blood is typically 3:1 Results in lower O2 sat – 80-85% typical for VV ECLS, 85-92% with double lumen cannula Adequate O2 sat if cardiac output and hemoglobin/hematocrit can maintain oxygen delivery Any native lung function will increase O2 sat

Recirculation Oxygenated blood in circuit is taken up by venous drainage catheter Less recirculation with dual lumen cannulas Falling arterial O2 sat with increasing circuit SVO2 Affected by: ECLS pump flow – linear relationship Venous catheter position – positioned high in SVC or low in IVC increases recirculation Native cardiac output – improved output decreases recirculation Right atrial blood volume – increasing intravascular volume can decrease recirculation

Ventilator Management Oxygen delivery is supplied or augmented by ECLS Rest settings on ventilator Low tidal volumes (4-6 ml/kg) Plateau pressures < 35 cm H2O PEEP 5 FiO2 0.21-0.50

SWEEP Increasing sweep flow increases CO2 clearance, does not affect oxygenation

Hemodynamics of Resp Failure on V-V ECLS PVR and SVR decrease – higher mixed venous oxygen saturation in pulmonary arteries Cardiac return increases – improved oxygen delivery to coronary arteries Perfusion improves Decreased vent pressures Patient may initially require inotropes/vasopressors but are usually able to wean off

Sedation In initial stages sedation and paralysis utilized to facilitate ventilator management, decrease O2 demand ELSO recommendations – minimal sedation after 48 hours Trend toward managing patients with less sedation, preferable to not keep paralyzed but as awake and alert as possible May not know neuro status prior to initiation of ECLS – neuro checks frequently, may need CT, EEG – high risk for intracranial hemorrhage, may have hypoxic injury pre-ECLS EEG monitoring for 48-72 hours

MOBILITY

Nutrition Early initiation of feeding associated with improved healing Place feeding tube early – avoid complications associated with anticoagulation

Pressure ulcers Patients are at high risk for pressure ulcers Suspected deep tissue injury (SDTI) have been identified as category of pressure injury May be caused by hypoxic reperfusion vs. pressure Research needed to determine effective prevention and management strategies

KEYS to success Communication Teamwork

Psych/Social Update the family, be responsive to their needs, educate the family Realistic expectations while preserving hope Define goals in terms of a few days at a time Palliative Care and Ethics

Futility Have discussion with family prior to starting ECLS Continue to have some form of this conversation daily Define futility 3 days of no cardiac function in patient who is not candidate for advanced therapies 2 weeks of no lung function in patient who is not transplant candidate Irreversible lung or brain injury Resources available Prolonged support with little chance of success Care giver fatigue

What’s next for ecls?

SEPSIS Historically sepsis has been contraindication for ECLS Treat underlying cause while providing organ blood flow and tissue oxygenation Require high flows on ECLS circuit Wean inotropes once optimal flow achieved Coagulopathy – DIC ROTEM to identifying underlying cause

ECPR Initiation of ECLS during CPR Cannulate for ECLS at bedside – more common in ED Evaluate use of resources vs outcomes

ECPR criteria Criteria Age 18-75 Arrest of cardiac origin – V tach or V fib ETCO2 > 20 ECLS candidacy to be determined by AHF & Intensivist physicians Decision made by 10 minutes into code Goal target time from arrest to initiation of ECMO < 60 minutes

TARGETED TEMperature management Can regulate temperature to be whatever you want May warm patient if indicated – exposure Cooling patient: Cerebral protection ECPR patients “Coolit” – intravascular cooling catheter or external gel pads are preferred to cool May have modified goal due to bleeding concerns Circuit cannot rewarm precisely Lower metabolism, sepsis Coagulopathy May consider for circuit changes

Circuit management ECLS circuit is traditionally managed by ECLS specialist – perfusion, RT, or RN Increasing volume of patients - more programs are transitioning to RN managed circuits with backup

RVAD – Biventricular impella PROTEK Duo ABIOMED Impella RP® Double lumen catheter from Tandem Life Right ventricular assist device Inserted percutaneously, pulls blood from right atrium to pulmonary artery http://www.abiomed.com/products/i mpella-rp/

ECLS specialty centers Will certification be required? Current topics ECLS specialty centers Will certification be required? Smaller, smarter, portable systems Standard of care? Algorithms to guide providers when to initiate ECLS

CASE STUDY 39 year old male with no significant medical history presented to outside ED with cough, body aches, headache, chills and congestion x 5 days T-103.6, O2 sat 91% - pain with deep breaths, BP 79/41 Lactate – 4.9, Crt 2.32, EF 40-45% Presented at 0530, intubated at 1000, Vent settings: CMV-18, FiO2 100%, PEEP-12 ABGs @ 1500 – 7.18/51/126/18 O2 sat 90% Levo @ 12 mcg/min, Neo @ 90 mcg/min, Vaso @ .04 units/min – maintaining MAP at 65, systolic 80-90

Case study VA ECMO initiated @ 1752 day of admit Cannulated RFV 25 Fr, RFA 21 Fr Flows 6 – 6.5 liters/min

CASE STUDY Regional O2 saturations To OR with Vascular surgery for fasciotomy, acute ischemia related to spasms Time L) Leg R) Leg 2000 65 60 2100 59 43 2200 30

CASE STUDY – DAY #2 Troponin 28.17 To cath lab – no significant disease, repeat cardiac echo EF < 10% - stress cardiomyopathy Neo off, Levo 0-3 mcg/min, Vaso .04 Units/min – sedation PCV – 8, PEEP – 8, FiO2 – 50%, PIP-25 Blood and sputum cultures from admit positive for Beta Streptococcus group A CRRT started previous evening on return from OR, creatinine peak 2.64, trending down

CASE STUDY – day #6

CASE Study – Day #6 ABGs 7.42/40/252/25 EF 30-35% On/off small dose Nipride, Dobutamine @ 2.5 – weaned off PCV-10, PEEP -10, FiO2 80%, PIP – 31 ECMO flow 6-6.5, sweep – 6.5, FiO2 90% Transitioned to VV ECMO with 31 Fr Avalon in RIJ – dual lumen catheter

CASE study – day #10 Off all vasoactive drips – sedation, paralytics on ECMO flow 4.75, FiO2 100%, Sweep – 9 PCV – 10, PEEP – 5, FiO2 – 100%, PIP – 28 To OR for R) BKA Oxygenator changed – brief asystole arrest requiring atropine, epi, CPR

Case study Decannulated at bedside on Day #23 Transitioned off vent 10 days later and discharged to LTAC

REFERENCES Annich, G.; Lynch, W.; MacLaren, G.; Wilson, J.; Bartlett, R. (Ed.) ECMO Extracorporeal Cardiopulmonary Support in Critical Care, 4th Edition, Extracorporeal Life Support Organization. Extracorporeal Life Support Organization General Guidelines for all ECLS Cases (2013). Retrieved October 28, 2016 from http://www.elso.org/Resources/Guidelines.aspx Peek, G., Mugford, M., Tiruvoipati, R., Wilson, A., Allen, E., Thalanany, M., ….. Elbourne, D. (2009). Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygentation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet, 374, 1351-1363. Rao, A., Preston, A., Strauss, R., Stamm, R., & Zalman, D. (2016), Risk factors associated with pressure ulcer formation in critically ill cardiac surgery patients. Journal of Wound Ostomy Continence Nursing, 43(3), 1-6.