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Hands-On ECMO Training

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ECMO Transport Curriculum

Breakout Sessions for Transport of the ECMO Patient

○     Preparation for Transport – Planning/Training Considerations

  • Interfacility Transport Environment – In general there is a lack of space, time, and resources while traveling and transport is much more difficult than rounding on a patient in an ICU room, need to maximize preparation and listen to EMS crew as they are experts
  • Infusion Triage Concepts and Essentials to Consider – These patients are usually on many drips, if possible eliminate any redundant or unnecessary ones as every drip makes the transfer longer
    • Condense pressors, evaluate need for inotropes, stop insulin, maintenance fluids,
    • Convert drips from hospital based mcg/kg/min to EMS based ml/min drip rate
    • Taking it with You! – Sweet talk pharmacy into getting narcotics/sedatives/paralytics boluses
    • Skill Performance – Discuss inhaled eporostenol and its role in the ECMO patient, reconstitute epoprostenol and set up drip (HANDS ON)
    • Blood Products – Get blood products from sending hospital as unlikely to have any on your ambulance or airplane…what to look for.
  • Lines/Tubes/Introducers – This is actually a special assessment that the team should perform carefully at the bedside. If the resuscitation team can have a “de-pantser” then the transport team should have “lines and tubes police”
    • Confirm arterial line in right arm for VA ECMO
    • Sutures in place
    • No kinks
    • Organized accordingly prepared for the position of the Vent/ECMO/IV pumps….this is where planning comes
  • Ready! Set! Go! (“game on”) – Moving the patient and leaving the hospital
    • Circuit Splicing – May need to splice circuit into your transport machine, can discuss but likely out of scope
    • Is there enough gas? – Get blood gas, calibrate ECMO display’s hct and scvo2 (HANDS ON)
    • ACT – Discuss ACT and other markers of anticoagulation, much more important for VA than VV, no clear standard of care so follow institutional protocol
  • Packaging Takes Time – Moving the patient ALWAYS takes longer than physicians think it will/should, listen to the EMS crew as they are the experts at this
    • Encourage sending physician(s) to help, not just stand in doctor poses with arms folded
    • Mechanical Ventilation – No clear standard of care for vent settings but likely minimal contribution to gas exchange, can have hemodynamic and pulmonary edema effects, clamp ET tube before disconnecting ventilator
    • Assessment – Ensure cannulae are well secured (should have purse strings and several distal points of suture, use clear tape and tegaderms, examine for any bleeding and call surgeon if needed)
    • Check distal perfusion catheter flows and pulses after moving if applicable

○     Physiology and the Transport Environment

  • Review of the Gas Laws and their impact on the ECMO patient
  • Vibration
  • Temperature variations on the patient

○     Administering Medications During Transport

  • Sedation/analgesia
  • Paralytics
  • Pressors
    • Push-dose pressors?

○     Important Stuff to Learn

  • Positioning the ECMO device in transport vehicles
    • Pump Failure! – Handcrank operations
    • Above, below, or phlebostatic-level?
  • High venous pressure alarm during transport
    • Discuss the concept and what it means, describe tactile chugging that can occur
    • Show how it looks on the cardiohelp display (HANDS ON)
    • Have team go through potential causes and guide them as needed:
    • Are the pressures calibrated correctly?
      • Has the atmospheric pressure decreased because you are in an airplane and the “0” pressure is incorrectly calibrated?
      • Can show how to calibrate pressure but more practical to ignore and know your pressure reading is somewhat off
      • Also don’t forget to calibrate arterial line while you’re at it so you don’t have undetected hypotension
  • Is cannula too small?
    • Have team look at cannula sizes, can check typical pressures for given cannula online
    • Can add another cannula but unlikely during transport, consider decreasing flows if oxygenation will tolerate
  • Has hypovolemia developed?
    • Check for any signs of bleeding, examine cannula sites
    • Check cardiohelp display for Hct, dropping could mean bleeding but unlikely in acute setting while increasing could be volume contraction through 3rd spacing
    • Consider empirically giving volume
    • Consider decreasing PEEP to improve venous filling
  • Is there kinking?
    • Examine cannulae for kinking and reposition patient’s extremities
  • Actual answer: pneumothorax that got much bigger from pressure change in airplane causing increased intrathoracic pressure and decreased venous filling

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