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