A Family Guide to Adult ECMO

by Diane Scarpace, RN

Last Updated August, 1994

Acknowledgments:

ELSO ECMO Parent Manual, 1993

Elaine Braden, RRT, RN

Robert H. Bartlett, MD

Paula Campbell, Surgery Graphics

 Dr. Robert Bartlett, MD was my physician during my ARDS/ECMO crisis.  Without his knowledge and expertise I would not be here today.  He is considered the founder of ECMO, and the University of Michigan's ECMO program is the largest in the country.  We at the ARDS Support Center are deeply grateful to Dr. Bartlett for the use of this guide on our website.    Bob Berendt, Webmaster.

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Dear Family and Friends,

Having a very sick family member being treated in the strange and overwhelming environment of an intensive care unit is an extremely stressful situation.

This booklet will provide you with information, to answer some important questions you may have.

Feel free to ask questions or express your concerns. There are many people to help you cope with this difficult period.

Sincerely,

What is ECMO?

ECMO stands for ExtraCorporeal Membrane Oxygenation. It is the use of an artificial heart-lung machine for patients whose heart or lungs are failing despite all other treatments. The ECMO equipment functions as a heart (pump) and lung (providing oxygen). It takes over the work of these organs so they can rest and heal.

Why ECMO?

ECMO is used for children and adult patients with severe, but reversible heart or lung disorders that have not responded to the usual treatments of mechanical ventilation (ventilator), medicines, and extra oxygen.

• Adults who need ECMO usually have one of the following problems:
• Pneumonia
• Respiratory failure from trauma or severe infections
• Cardiac failure

 

ECMO will not cure these conditions; it does give support and allow time for the lungs/heart to heal.

 

We believe this recovery may lead to the survival of your loved one.

How Long Will ECMO be Needed?

EMCO is continued until the heart or lungs recover or until treatment is not effective; it may be a period of days or weeks.

The length of time on ECMO may be affected by: the type of lung or heart disease, the amount of damage to the lungs before ECMO, and other illnesses or complications.

What Are the Risks of ECMO?

Any person who requires ECMO is very ill and will usually die without it. However, there are risks with this procedure. The ECMO physician will discuss these with you:

 

Bleeding A drug called Heparin is given to prevent the blood from clotting while it travels through the ECMO circuit. The amount of heparin given is monitored closely, but sometimes bleeding occurs. Bleeding can occur anywhere in the body but is most dangerous when it occurs around the brain. This could result in permanent brain damage. If the bleeding becomes too great, any of the following actions may be necessary: Frequent blood transfusions Other operations to control bleeding Discontinue ECMO therapy Blood clots Small blood clots may be introduced into the blood stream of the patient. These clots can cause serious injury to the patient, damaging vital organs such as the brain or kidneys. Malfunction of ECMO equipment Although rare, the equipment required for the ECMO system may fail. An ECMO specialist, at the bedside 24 hours a day, is trained to respond quickly to any malfunction.

Stroke Stroke may occur from bleeding, or blood clots into the brain. If cardiac support is needed, a surgical procedure that involves permanently tying off one carotid artery (blood vessel) is performed. Although there are two carotid arteries that supply blood flow, brain injury, including stroke has occurred in some cases. Other An operation is needed to attach theECMO machine to the patient. This may lead to infection, bleeding, or vocal cord injury. The function of the heart or lungs may not improve during the time of ECMO support. Some patients develop severe blood stream infections that cause irreversible damage to vital organs. Possible Risks- Blood Transfusion Very rarely, serious reactions can occur, including shock, kidney failure and even death. In addition, there is a slight risk of acquiring an infectious disease, such as hepatitis, and a remote risk of AIDS. Improved donor screening and blood testing procedures make such problems unlikely.

What You Can Expect

Starting ECMO: Placing the tubes (catheters) into the blood vessels requires a procedure done at the bedside by a surgeon and an operating room team. Your family member is given medications ahead of time for pain control and sedation. The catheters are connected to the ECMO system.

While your family member is being supported by ECMO, the ventilator will remain on at very low settings in order to "rest" the lungs.

Pain medication is given on a regular basis to prevent any discomfort. Attempts are made to maintain your family member in an alert, awake state. However, this is not always possible. Many patients do require heavy sedation and paralyzation to decrease the amount of oxygen used by the muscles.

ECMO patients are placed on a special bed. You will notice the bed rotate side to side. This decreases pressure on the skin to prevent damage and helps move the secretions in the lungs. It is elevated because gravity plays a part in the amount of blood that can safely travel through the ECMO system.

We follow a daily routine that includes a morning chest X-ray and blood tests at different times throughout the day. The ECMO circuit is used for drawing blood and for giving medications. The lungs are suctioned regularly since the patient's cough mechanism is not effective.

Nutrition is provided through specially formulated solutions administered through the veins or through a tube into the stomach.

As the heart or lungs improve, the amount of ECMO support will be decreased over a period of time. As signs of improvement continue, a "trial off" ECMO is begun. If this is successful, then ECMO is discontinued. The patient will remain on the ventilator for support for several days or weeks, until further improvement takes place.

The ECMO Team

We understand that this is a very stressful time for you and you may not remember all of our explanations. Please don't be afraid to ask us the same question more than once. We are here to help:

 

Attending Physician	The primary physician in charge of your family member's care. Our physicians are known worldwide for their research and for the development of ECMO.
ECMO Fellow	This surgeon is specializing in the treatment of severe respiratory failure and is the primary manager of patients requiring ECMO, under the guidance of the attending physician.
ECMO Specialists	The management of ECMO equipment the minute-to-minute monitoring of ECMO patients is done by these specially trained nurses and respiratory therapists.
Critical Care Nurses	Nurses provide care and comfort for your loved one. They will often be your first line of information for the many questions that you have.
Respiratory Therapists	These professionals are specialists in ventilator management, make recommendations to other team members and assist with procedures.
Resident Physicians	Surgical residents are medical doctors who are obtaining specialty training in surgery. Much of the around-the clock-bedside medical care, under the supervision of the attending physician and ECMO fellow, is carried out by the resident physicians.
Social Worker	The social worker can help you with: Accommodations or lodging Financial concerns: Insurance, parking, or meals. Emotional issues such as coping with a life threatening illness.
Clinical Care Coordinator	The clinical coordinator is a nurse who serves as a resource for you during and after a hospital stay. She will help answer any questions or concerns about the plan of care, prepare you to go home, and be available for follow-up.

How ECMO Works

ECMO substitutes for the function of the lungs and heart by pumping blood out of the body; oxygen is added to the blood and carbon dioxide is removed before it is returned to the patient. This process allows the heart and lungs to rest and recover.

Types of ECMO:

There are two types of ECMO therapy; venoarterial (V-A) and venovenous (V-V). The terms V-A and V-V refer to the blood vessels used during the ECMO procedure.

V-A ECMO is used in people with blood pressure or heart functioning problems. A catheter is placed in both a Vein and an Artery. This method gives excellent support for the heart in addition to the lungs.

In V-V ECMO, catheters are placed so that blood travels from a Vein and back to another Vein. The advantage of VV is that the carotid artery does not need to be tied off as in V-A . Occasionally, patients start out on V-V and need to be changed over to V-A ECMO.

A large catheter drains blood out to a pump. This blood is dark because it contains very little oxygen.

A steady amount of blood is pumped through the ECMO machine each minute. This is referred to as the flow rate. As your family member improves, the flow rate can be decreased and more of the blood will get oxygen through the lungs.

The pump pushes blood through a membrane lung where gas exchange occurs; oxygen is added and carbon dioxide is removed. The size of the lung is based on the size of the patient. Sometimes two lungs are needed for adults.

The blood is then warmed by a heat exchanger , before it is returned to the body.

This blood is bright red because it contains oxygen.

You will also see other tubing and ports for blood withdrawal and drug administration, as well as safety features, such as a pump regulator or "bladder box" and a backup power supply.