ECMO Management Clinical Guide

E. Joubert – HuebnerCTCP, EBCP

Chief Perfusionist^Heart Center Eppendorf, HamburgLife Systems Perfusion Service, Hamburg

Precannulation Preperation

Blood Products (Elective)ICU or aneasthesia order blood products

RBC‘sFFPThrombocytes

Blood leukocyte reduction – Blood BankABG, PT, PTT, Fibrinogen – prior heparinFluid maintenanceArterial lineCVP

Precannulation Preperation

MedicationResuscitation drugsHeparin 100 IUHydralazine 0.1 – 0.4 mg/kg/dose IV Q 4-6h PRN (Boston)Aminocaproic Acid (Amicar) – (Boston)

Bolus 100 mg/kg IV x 1Drip 30 mg/kg/hr IV Infusion

THAM 3 ml/kgDopamine drip 50 mg/50 ml D10W (Boston)

ECMO Circuit Prime

Potassium < 8 mEq/LIonized Ca > 0.8 HCO3 22 – 24Sodium > 125 mEq/L

Cannulation

Cardiac ECMO – VA Bypass30 IU/kg Heparin BolusOnce the ECMO is connected aneasthesia, ICU pediatrician is ready to reducevasopressors and administer hydralazine, vasodilators.Once on ECMO platelets and cryoprecipatateare administered.Chest X-ray is ordered – check cannulaposition

Troubleshoot: Loss of Venous Return

Inadequate DrainageGlenn Shunts – should becannulated seperately

Inability to access right atrialvolumeCheck Cannula Position

Occlusion of flowCheck Cicuit Integrity; kinkor clamp?

Achievable flow overshootDecrease Flow

HypovoleamiaGive Volume

RationaleIntervention

Blood Test First 4 Hours

ABG, lactate, glucoseVBGHctPlatelet CountPTFibrinogen levelElectrolytes and ionized calcium

V-A ECMO SupportABGs are obtained once connected to ECMO, ACT. Repeated after adjustments in FiO2 and sweep gas.PaCO2 achieved 40-45 mmHg and pO2 > 60 mmHgACT aim 180 – 200 sec, first checked every 20 min, then every 1 hoursABG every 12 hourspO2 persist low at high FiO2, and Hct is > 35%, flow isincreased in increments of 20 cc/min, and an arterialECMO line ABG is performedpCO2 changes sweep gas is adjustedVBG is obtained when metabolic acidosis persist orflow is reduced

ECMO Circuit

Safety checks, alarm control checked – 4 hourly including

Pre/Post membrane pressurePost membrane blood gasses – only whensudden changes in PaCO2

Patient temperature is tightly controlled –when above 36 degrees heater cooler is puton standby

ECMO Changed

Pre-membrane pressure exceed 350 mmHg– no change in post membrane pressureBlood to gas leak – blood in gas outlet port of oxygenatorImpaired CO2 removel despite maximumsweep gasBoston change system after 120 hours use of Aminocaprioc acid

Respiratory ManagementVentilator Settings

FiO2 0.40PiP/PEEP 25/5 cmH2O frequency 10, Ti 1.0 secsOn VA apneic oxygenation – active air leak. CPAP of 12 cmH2O and decrease until active air leak haveceased.

Suctioning and Hand VentilationGentle chest vibrations and suctioning – 4 hourlyIncreased secretions – suctioning 2-3 hourlyHand ventilation limited to PiP/PEEP 25/5 cmH2O.Patients with air leaks – suctioned off ventilator – no hand ventilation till air leaks resolved

Laboratory TestingACT 1hCBC, platelets, electrolytes. Ionized calcium, lactate, glucose 8hFibrinogen 12 h, 24 h when stableChem 10 h, 12 hABG 12 hLFTs (AST, AlkPhos, LDH, Total Bullirubin, DirectBulirubin, Albumin, Total Protein, Prealbumin) weeklyBlood culture prior antibiotics, 24 hours after, and thereafter only when sepsis is suspected.Trach aspirate prior antibiotics, 24 hours, then onlywhen sepsis is suspected.

Blood Product AdministrationPRBC

20 ml/kg Hct < 35.Cryoprecipitate

1 unit/kg if Fibrinogen < 150 + 10 mg/dL. FFP

10 mL/kg if PT > 17Albumin 5%

Considered Hct > 45 %20% Albumin considered when serum albumin < 2.5.

PlateletsMaintain platelet count + 150 000 mm3. Based on clinicalexperience and publication on intracranial hemorrhage this isjustified. Directly administered to intravenous line. Prior, increase Heparin Perfusor, after half the platelet is givencheck ACT.

Volume ProblemsLarge volumes in association with muscle relaxentsand venodilators can contribute to extraordinaryamounts of peripheral edema and anasarca. Special in septic or disease associated endothelialdamage and capillary leak; liberal fluid administrationto maintain intravascular volume making such edemaunavoidable.PRBC administration – take care for potassium levelsFFP administration – adjust the calcium levelsValued to achieve high hematocrits in early stage of support, if diluting to avoid high potassium effect, onlydilute with FFP.

Aminocaproic Acid (Amicar)Indication

Patients < 37 weeks gestationPost operative bleedingPre-existing IVHSeveryl hypoxic acidotic patients (pH 7.1) (Boston)

Dose and AdministrationLoading Dose : 100 mg/kg (max 5000 gm/dose) IV x over 5 minutes administered CVL just prior to orimmediate after cannulation. Dose should be dilutedwith saline 20 mg/ml.Maintenance Dose: 30 mg/kg/hr (max 1250 mg/hr) continuous infusion via ECMO circiut. Dilute to 125 mg/ml saline.Maximum Daily Dose: 30 g/24 hour

Additional loading dose after ECMO circuitchangeDiscontinue after 72 hours and stableShould be continued throughout ECMO –patients with pre-existing IVHContinued – preterm infants considered high at risk for IVH.Check ECMO system closely for clots, in Boston system is changed after 120 hourswith AMIKAR

Aminocaproic Acid (Amicar)

Nitritional Support

Lipids should ot exceed > 2 g/kg/day to prevent lipid accumulation and embolism in the circuit. Should be administered directly to the patient.TPN may be administered via the circuit.Fluid Management:

Excluding blood products, 80 – 100 ml/kg/dayof volume is generally given.

Hemodiltration

Goal: Normalize fluid balanceIn excessive fluid overload > 10 ml/day in patient not responsive to diuretic therapy.

Urine output less than 0,5 mL/kg/hr> 500 mL positive fluid balance in previous 24 hours24 hours of failed maximum diuretic therapy(eg Furosemide 2mg/kg/dose IV)

Goal: Negative Fluid Balance

No more than 240 cc in any 24 hour period in patients with:

Normal BUN and creatinineUrine output greater than 1.5 mL/kg/hr96 hours of ECMO 24 hours of failed diuretic therapy

Discontinue – hypotension occurs that requires 2 x hemodynamic vasopressors, Blood componenttherapy if necessary.Excessive chatter, of venous line with reduced flows

Associated with ability to weanECMO:

Resolution of pulmonary oedemaDecrease in extracellular fluidDecrease in total body water

Maximize diuresis during ECLSLoop diuretics is appliedRenal dose dopamineHemofiltration parralell to circuitTry to maintain urine output – 1 mL/kg/hr

Analgesia and Sedation

CannulationICU – sedation protocol (medazolam, morphine)

During ECMO SupportAfter 12 hr acute episodes of agitation can betreated with bolus administration of Midazolam0.05 – 0.1 mg/kg which may be repeatedevery 5 min until adequate plain of sedation isreachedContinuous use of Midazolam should beavoided and only instituted when:

Medazolam Management

1. Lorazepam dosage has been increased to 0.2 mg/kg IV Q8h

2. Patient is inadequately sedated according to objective scoring system, includingstimulation of the patient

3. Clinical sedation will be documented Q4h and with titrationClinical sedation score –obtained – ModifiedMotor Activity Assessment Scale (MMAAS)

Additional Sedation Agents

Reserved for patients who are consistentlyunder sedated despite dosing morphine (0.2 mg/kg/hr IV by continuous infusion) and lorazepam (0.2 mg/kg IV Q8h)

Lidocaine 1 mg/kg/dose IV/ETT Q 4h priorsuctioningKetamine 1-2 mg/kg/dose IV Q1h PRNPentobarbital 2-6 mg/kg/dose IV over 3-5 minutes Q 4h PRN

SedationPatients not responsive to sedation using morphine, lorazepam and occational intermittent midazolamshould be evaluated objectively using MMAAS to ensure reliability of observation and reproducibilitybetween observers.Acute decreases in plasma concetration of ofsedation agents can be expected after – significantchanges in blood volumeThe patients usual sedation regimen should then bereinstituted.Additional supplemental boluses may be requiredduring the first 12-24 hours following circuit change.

Muscle Relaxants

Not routinely administered to evaluateneurologic examinations.Indication for use:

Conditioning cyclePatient movement interferes with venousreturnThe threat of accidental de-cannulation

Pancoronium 0.1 – 0.2 mg/kg/dose IV Q1h PRN when indicated

Antibiotics

AmpicillinIf < 14d 150 mg/kg IV Q 12 hIf >14d 50 mg/kg IV Q 6 h

OxacillinIf <14d 50 mg/kg IV Q 12 hIf >14d 50 mg/kg IV Q 6 h

CefataximeIf <14d 50 mg/kg IV Q 12 hIf >14d 50 mg/kg IV Q 8 h

Control Hemodynamic ParametersThe neonate undergoing ECMO is at significant risk forintracranial hemorrhage due to pre-existinghypoxemia/hypotension, anti-coagulation, venous occlusion and arterial ligation. Therefore maintenance of the MAP 35 – 60 mmHg, and prevention of accute blood pressure fluctuations isan imporatnat aspect of the sedation regime. Hemodynamicconsiderations may occasionally alter the selection of sedatingagents as outlined previously: Specifically

Persistant hypotension (< 35 mmHg), fentanyl may be moreappropiate than morphine as opioid. In these patientsbenzodiazepines should also be withheld until adequateblood pressure can be restored.Persistent hypertension (MAP > 60 mmHg) despiteadequate doses of morphine, medazolam for acute periodsof agitation, clinical sedation scoring should be performed.

If the patient is hypertensive and inadequatelysedated (MMAAS scoring) then alteredpharmacokenetics/pharmacodynamics may beproducing inadequate plasma levels and dosages of pioids and benzodiazepines may be increasedincrementally. To increase the level of sedation themidazolam dosage should be increased by 20%.In general opioids can be relied upon to provideanalgesia and benzodiazepines will producesedation, hypnosis, and decreased level of consciousness. Opioid levels should not being increased unlessindicated by objective scoring demonstrating lack of analgesia.

Control Hemodynamic Parameters

Inadequate sedation once the maximumdosesage of lorazepam is achieved; themorphine infusion should be increased by10% following a bolus of the hourly infusiondose.Adequate sedation and hypertension –treated with ant-hypertensive agent.Depending on patient and situation –hydralazine, labetalol, hydrolozine, sodiumnitroprusside

Control Hemodynamic Parameters

Blood Pressure ControlMAP maintained 45 – 65 mmHgMAP range > 80 mmHg or < 30 mmHg – considered urgentCheck List

Pump settings and calibrationExcessive pre-load, afterload, contractilityHypervolemia – diuresis and hemofiltration, dialysisWarming the cold patientWeaning vasopressorsAdministering volume with vasodilatorHyperdynamic state – sedationDecrease excessive ECMO flowTreating sepsisWeaning inotropesAdministering beta-blocker

Antihypertensive Drug Management

Hydralazine 0.1 – 0.4 mg/kg/dose Q 4-6h IVNitroprusside 0.3 -0.5 mcg/kg/min; max 10 mcg/kg/min IVNitroglycerin

0.25-0.5 mcg/kg/min IV cont infusion titrate by 0.5-1 mcg/kg/min Q 3-5 minsUsual dose: 1-3 mcg/kg/min IV usual 5 mcg/kg/min IV butdoses up to 20 mcg/kg/min IV has not been used

Milrinone 50 mcg/kg IV bolus over 20 min, maintenance 0.25-0.75 mcg/kg/minEnalaprilat 5-10 mcg/kg/dose Q 8-24 h IVEsmolol 500 mcg/kg/dose IV load over 1 min; infuse 50-100 mcg/kg/min IVLabetolol 0.25 mg/kg/dose IV 20 minsCaptopril 0.05-0.1 mg/kg/dose Q 8-24 hours, up to 0.5 mg/kg/dose Q 6-24h PG/PJ

Neurologic Evaluation

Head UltrasoundPre-cannulation – 12 hrsPost-cannulation – 24 hrs then 48 hourlySmall intracranial heorrhage – optimizeclotting factors, decrease ACT, applyAminocaroic acid (Amicar). Premature –discontinue ECMO.

Skin Care

Hospital guidelineGel pad – oociputAppropiate bounderiesPrevent hip abduction – nesting the patientInitiate bilateral patient rotationKeep head alignmentSlightly turn patient half hourly to slightlyredistribute pressure points

Conditioning

Conditioning should be considered when thepatient has a calculated compliance of > 0.5 mL/cmH2O with the ventilator set at PiP/PEEP of 30/5 cmH2OShould not be considered when air leakshave not resolved

VA Conditioning- Cardiac Support1. Administer paralatics and sedatives2. Adjust ventilator settings to: f-25,PiP/PEEP 30/5 cmH2O, FiO2

1.0.3. Let the heart start to eject by increasing the ZVP by one at a

time.4. Monitor heart function by Echocardiography5. Reduce ECMO FiO2, and sweep gas flow.6. Connect inotropes and vasopressive drugs to CVP, low dose

regime is started before flow reduction.7. Reduce flow by 10% increments and with the heart ejecting; at

30-40% reduction of ECMO blood flow (20min), with a acceptable CVP for situation, perform ABG, VBG, SpO2 > 90%.

8. At 50% reduction (40 min), if myocardial contractility and respiration and lactate levels are good further weaning can beconsidered.

Weaning ECMO

At ACT 180 sec – 15 – 20 IU heparin beforeweaning below 40% to stop the ECMOACT is elevated to 250-280 secVolume is prepaired. RBC, FFP, Platelets, AlbuminECMO is further reduced, and then stoppedfor up to 5-max 10 min, to evaluatecardiorespiratory function. Hypotension from hypovoleamia isimmediately treated, neonate 10 ml at a time.

Decannulation

Arterial line firstDiscontinue heparin immediately afterdecannulationHypotension is not uncommon after VA ECMOVasopressors, fluidLabs should be obtained, ACT, wean FiO2, obtain SpO2 greater 95%

Post ECMO

Carotid ReconstructionHead UltrasoundCT scanCarotid doppler flow

Prior to DischargeABR (Auditory brainstem evoked repsonse)Eye examPhysical exam with documentation of BPInformation to parents

Patient is Discharged

ECLS Organisation Guidelines follow -up