ECMO Management

Clinical Guide
E. Joubert Huebner
CTCP, EBCP
Chief Perfusionist^Heart Center Eppendorf, Hamburg
Life Systems Perfusion Service, Hamburg

Precannulation Preperation
Blood Products (Elective)
ICU or aneasthesia order blood products

RBCs
FFP
Thrombocytes

Blood leukocyte reduction Blood Bank

ABG, PT, PTT, Fibrinogen prior heparin
Fluid maintenance
Arterial line
CVP

Precannulation Preperation
Medication
Resuscitation drugs
Heparin 100 IU
Hydralazine 0.1 0.4 mg/kg/dose IV Q 4-6h
PRN (Boston)
Aminocaproic Acid (Amicar) (Boston)

Bolus 100 mg/kg IV x 1

Drip 30 mg/kg/hr IV Infusion

THAM 3 ml/kg
Dopamine drip 50 mg/50 ml D10W (Boston)

ECMO Circuit Prime

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

Cannulation
Cardiac ECMO VA Bypass
30 IU/kg Heparin Bolus
Once the ECMO is connected aneasthesia,

ICU pediatrician is ready to reduce

vasopressors and administer hydralazine,
vasodilators.
Once on ECMO platelets and cryoprecipatate
are administered.
Chest X-ray is ordered check cannula
position

Troubleshoot: Loss of Venous Return

Intervention

Rationale

Give Volume

Hypovoleamia

Decrease Flow

Achievable flow overshoot

Check Cannula Position

Inability to access right atrial

volume

Glenn Shunts should be

cannulated seperately

Inadequate Drainage

Check Cicuit Integrity; kink

or clamp?

Occlusion of flow

Blood Test First 4 Hours

ABG, lactate, glucose
VBG
Hct
Platelet Count
PT
Fibrinogen level
Electrolytes and ionized calcium

V-A ECMO Support

ABGs are obtained once connected to ECMO, ACT.

Repeated after adjustments in FiO2 and sweep gas.

PaCO2 achieved 40-45 mmHg and pO2 > 60 mmHg
ACT aim 180 200 sec, first checked every 20 min,
then every 1 hours
ABG every 12 hours
pO2 persist low at high FiO2, and Hct is > 35%, flow is
increased in increments of 20 cc/min, and an arterial
ECMO line ABG is performed
pCO2 changes sweep gas is adjusted
VBG is obtained when metabolic acidosis persist or
flow is reduced

ECMO Circuit
Safety checks, alarm control checked 4

hourly including
Pre/Post membrane pressure
Post membrane blood gasses only when
sudden changes in PaCO2
Patient temperature is tightly controlled
when above 36 degrees heater cooler is put
on standby

ECMO Changed
Pre-membrane pressure exceed 350 mmHg

no change in post membrane pressure

Blood to gas leak blood in gas outlet port of
oxygenator
Impaired CO2 removel despite maximum
sweep gas
Boston change system after 120 hours use of
Aminocaprioc acid

Respiratory Management
Ventilator Settings
FiO2 0.40
PiP/PEEP 25/5 cmH2O frequency 10, Ti 1.0 secs
On VA apneic oxygenation active air leak. CPAP of
12 cmH2O and decrease until active air leak have
ceased.
Suctioning and Hand Ventilation
Gentle chest vibrations and suctioning 4 hourly
Increased secretions suctioning 2-3 hourly
Hand ventilation limited to PiP/PEEP 25/5 cmH2O.
Patients with air leaks suctioned off ventilator no
hand ventilation till air leaks resolved

Laboratory Testing
ACT 1h
CBC, platelets, electrolytes. Ionized calcium, lactate,

glucose 8h
Fibrinogen 12 h, 24 h when stable
Chem 10 h, 12 h
ABG 12 h
LFTs (AST, AlkPhos, LDH, Total Bullirubin, Direct
Bulirubin, Albumin, Total Protein, Prealbumin) weekly
Blood culture prior antibiotics, 24 hours after, and
thereafter only when sepsis is suspected.
Trach aspirate prior antibiotics, 24 hours, then only
when sepsis is suspected.

Blood Product Administration

PRBC

20 ml/kg Hct < 35.

Cryoprecipitate
1 unit/kg if Fibrinogen < 150 + 10 mg/dL.
FFP
10 mL/kg if PT > 17
Albumin 5%
Considered Hct > 45 %
20% Albumin considered when serum albumin < 2.5.
Platelets
Maintain platelet count + 150 000 mm3. Based on clinical
experience and publication on intracranial hemorrhage this is
justified. Directly administered to intravenous line. Prior,
increase Heparin Perfusor, after half the platelet is given
check ACT.

Volume Problems
Large volumes in association with muscle relaxents

and venodilators can contribute to extraordinary

amounts of peripheral edema and anasarca.
Special in septic or disease associated endothelial
damage and capillary leak; liberal fluid administration
to maintain intravascular volume making such edema
unavoidable.
PRBC administration take care for potassium levels
FFP administration adjust the calcium levels
Valued to achieve high hematocrits in early stage of
support, if diluting to avoid high potassium effect, only
dilute with FFP.

Aminocaproic Acid (Amicar)

Indication
Patients < 37 weeks gestation
Post operative bleeding
Pre-existing IVH
Severyl hypoxic acidotic patients (pH 7.1) (Boston)
Dose and Administration
Loading Dose : 100 mg/kg (max 5000 gm/dose) IV x
over 5 minutes administered CVL just prior to or
immediate after cannulation. Dose should be diluted
with 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

Aminocaproic Acid (Amicar)

Additional loading dose after ECMO circuit

change
Discontinue after 72 hours and stable
Should be continued throughout ECMO
patients with pre-existing IVH
Continued preterm infants considered high
at risk for IVH.
Check ECMO system closely for clots, in
Boston system is changed after 120 hours
with AMIKAR

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/day

of volume is generally given.

Hemodiltration
Goal: Normalize fluid balance
In 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
hours
24 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 creatinine

Urine output greater than 1.5 mL/kg/hr
96 hours of ECMO
24 hours of failed diuretic therapy

Discontinue hypotension occurs that requires 2 x

hemodynamic vasopressors, Blood component

therapy if necessary.
Excessive chatter, of venous line with reduced flows

Associated with ability to wean

ECMO:
Resolution of pulmonary oedema
Decrease in extracellular fluid
Decrease in total body water

Maximize diuresis during ECLS

Loop diuretics is applied

Renal dose dopamine
Hemofiltration parralell to circuit
Try to maintain urine output 1 mL/kg/hr

Analgesia and Sedation

Cannulation
ICU sedation protocol (medazolam,
morphine)
During ECMO Support
After 12 hr acute episodes of agitation can be
treated with bolus administration of Midazolam
0.05 0.1 mg/kg which may be repeated
every 5 min until adequate plain of sedation is
reached
Continuous use of Midazolam should be
avoided 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, including
stimulation of the patient
3. Clinical sedation will be documented Q4h
and with titration
Clinical sedation score obtained Modified
Motor Activity Assessment Scale (MMAAS)

Additional Sedation Agents

Reserved for patients who are consistently

under 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 prior
suctioning
Ketamine 1-2 mg/kg/dose IV Q1h PRN
Pentobarbital 2-6 mg/kg/dose IV over 3-5
minutes Q 4h PRN

Sedation
Patients not responsive to sedation using morphine,

lorazepam and occational intermittent midazolam

should be evaluated objectively using MMAAS to
ensure reliability of observation and reproducibility
between observers.
Acute decreases in plasma concetration of of
sedation agents can be expected after significant
changes in blood volume
The patients usual sedation regimen should then be
reinstituted.
Additional supplemental boluses may be required
during the first 12-24 hours following circuit change.

Muscle Relaxants
Not routinely administered to evaluate

neurologic examinations.
Indication for use:
Conditioning cycle
Patient movement interferes with venous
return
The threat of accidental de-cannulation

Pancoronium 0.1 0.2 mg/kg/dose IV Q1h

PRN when indicated

Antibiotics
Ampicillin

If < 14d 150 mg/kg IV Q 12 h

If >14d 50 mg/kg IV Q 6 h

Oxacillin

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

Cefataxime

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

Control Hemodynamic Parameters

The neonate undergoing ECMO is at significant risk for

intracranial hemorrhage due to pre-existing

hypoxemia/hypotension, anti-coagulation, venous occlusion and
arterial ligation. Therefore maintenance of the MAP 35 60
mmHg, and prevention of accute blood pressure fluctuations is
an imporatnat aspect of the sedation regime. Hemodynamic
considerations may occasionally alter the selection of sedating
agents as outlined previously: Specifically
Persistant hypotension (< 35 mmHg), fentanyl may be more
appropiate than morphine as opioid. In these patients
benzodiazepines should also be withheld until adequate
blood pressure can be restored.
Persistent hypertension (MAP > 60 mmHg) despite
adequate doses of morphine, medazolam for acute periods
of agitation, clinical sedation scoring should be performed.

Control Hemodynamic Parameters

If the patient is hypertensive and inadequately

sedated (MMAAS scoring) then altered

pharmacokenetics/pharmacodynamics may be
producing inadequate plasma levels and dosages of
pioids and benzodiazepines may be increased
incrementally. To increase the level of sedation the
midazolam dosage should be increased by 20%.
In general opioids can be relied upon to provide
analgesia and benzodiazepines will produce
sedation, hypnosis, and decreased level of
consciousness.
Opioid levels should not being increased unless
indicated by objective scoring demonstrating lack of
analgesia.

Control Hemodynamic Parameters

Inadequate sedation once the maximum

dosesage of lorazepam is achieved; the

morphine infusion should be increased by
10% following a bolus of the hourly infusion
dose.
Adequate sedation and hypertension
treated with ant-hypertensive agent.
Depending on patient and situation
hydralazine, labetalol, hydrolozine, sodium
nitroprusside

Blood Pressure Control

MAP maintained 45 65 mmHg
MAP range > 80 mmHg or < 30 mmHg considered urgent
Check List

Pump settings and calibration

Excessive pre-load, afterload, contractility
Hypervolemia diuresis and hemofiltration, dialysis
Warming the cold patient
Weaning vasopressors
Administering volume with vasodilator
Hyperdynamic state sedation
Decrease excessive ECMO flow
Treating sepsis
Weaning inotropes
Administering beta-blocker

Antihypertensive Drug Management

Hydralazine 0.1 0.4 mg/kg/dose Q 4-6h IV
Nitroprusside 0.3 -0.5 mcg/kg/min; max 10 mcg/kg/min IV
Nitroglycerin

0.25-0.5 mcg/kg/min IV
cont infusion titrate by 0.5-1 mcg/kg/min Q 3-5 mins
Usual dose: 1-3 mcg/kg/min IV usual 5 mcg/kg/min IV but
doses up to 20 mcg/kg/min IV has not been used
Milrinone 50 mcg/kg IV bolus over 20 min, maintenance 0.250.75 mcg/kg/min
Enalaprilat 5-10 mcg/kg/dose Q 8-24 h IV
Esmolol 500 mcg/kg/dose IV load over 1 min; infuse 50-100
mcg/kg/min IV
Labetolol 0.25 mg/kg/dose IV 20 mins
Captopril 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 Ultrasound

Pre-cannulation 12 hrs
Post-cannulation 24 hrs then 48 hourly
Small intracranial heorrhage optimize
clotting factors, decrease ACT, apply
Aminocaroic acid (Amicar). Premature
discontinue ECMO.

Skin Care
Hospital guideline
Gel pad oociput
Appropiate bounderies
Prevent hip abduction nesting the patient
Initiate bilateral patient rotation
Keep head alignment
Slightly turn patient half hourly to slightly

redistribute pressure points

Conditioning
Conditioning should be considered when the

patient has a calculated compliance of > 0.5

mL/cmH2O with the ventilator set at
PiP/PEEP of 30/5 cmH2O
Should not be considered when air leaks
have not resolved

VA Conditioning- Cardiac Support

1.
2.
3.
4.
5.
6.
7.

8.

Administer paralatics and sedatives

Adjust ventilator settings to: f-25,PiP/PEEP 30/5 cmH2O, FiO2
1.0.
Let the heart start to eject by increasing the ZVP by one at a
time.
Monitor heart function by Echocardiography
Reduce ECMO FiO2, and sweep gas flow.
Connect inotropes and vasopressive drugs to CVP, low dose
regime is started before flow reduction.
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%.
At 50% reduction (40 min), if myocardial contractility and
respiration and lactate levels are good further weaning can be
considered.

Weaning ECMO
At ACT 180 sec 15 20 IU heparin before

weaning below 40% to stop the ECMO

ACT is elevated to 250-280 sec
Volume is prepaired. RBC, FFP, Platelets,
Albumin
ECMO is further reduced, and then stopped
for up to 5-max 10 min, to evaluate
cardiorespiratory function.
Hypotension from hypovoleamia is
immediately treated, neonate 10 ml at a time.

Decannulation
Arterial line first
Discontinue heparin immediately after

decannulation
Hypotension is not uncommon after VA
ECMO
Vasopressors, fluid
Labs should be obtained, ACT, wean FiO2,
obtain SpO2 greater 95%

Post ECMO
Carotid Reconstruction

Head Ultrasound
CT scan
Carotid doppler flow

Prior to Discharge

ABR (Auditory brainstem evoked repsonse)

Eye exam
Physical exam with documentation of BP
Information to parents

Patient is Discharged
ECLS Organisation Guidelines follow -up