ECLS Team

GOSH
Process
Referral

Transfer

Preparation

Cannulation

Handover

Maintenance
Referral
• Information from local team or Retrieval team/direct to ICU
• ECMO Criteria

• Is there a bed?
• What do you need to know?
- age/weight/blood group
- ventilation /ABG/OI
- sepsis/ inotropes
- relevant history
- neurological assessment – HUSS
Location/transportation/ETA/consent?
Neonatal - ECMO Criteria
oxygenation index > 40
gestational age > 34 weeks
weight > 2 kg
reversible lung disease ( < 10 days high pressure ventilation )
no major intracranial haemorrhage
no lethal congenital abnormalities

ECLS GOSH
 Paediatric ECMO criteria

potentially reversible disease

failure to respond to maximal conventional therapy
no irreversible CNS injury
no major immunodeficiency
oxygenation index > 35

ECLS GOSH
 Cardiac ECMO criteria

failure to wean from CPB

low / failing cardiac output resistant to maximal conventional management
cardiopulmonary dysfunction reversible
cardiac surgery - technically successful
no severe underlying disease
no severe neurological impairment

ECLS GOSH
Transfer
CATS
Local Team
Patient Transfer
Mobile ECMO
Preparation
Bedspace – double O2 outlet/plugboard
- ventilator: conventional +/- HFOV/INO
- drugs prescribed/drawn up
heparin bolus (100u/kg)
paralysis/sedation/antibiotic cover
resuscitation fluid/long line

Personnel - Who do you need to inform?

- perfusionist
NB 40 minutes to prime circuit
- surgeons/theatre staff/cardiology
- haematology 3-4 units
Preparation
Child - supine / head left
- access to RIJ / RCA
- iv access
Circuit - circulating through bridge
- circuit blood gas
- > 10kg ? Clear prime
Surgeon - Surgical Pause
-clear surgical drapes
- heparin bolus- visualisation of vessel
- All lines primed and connected indicates start of ECLS
Drugs Preparation

Fentanyl10mcg/kg

Pancuronium0.1 – 0.2 mg/kg (unless tachycardic then atracurium or

vecuronium if not currently muscle relaxed)

Heparin Bolus x 2 100 units/kg ( given into the central line with a flush
immediately prior to cannulation of the vessel Nacl 0.9% 5mls x 3

Volume as either colloid or blood (as appropriate) already drawn up in 50cc

syringe and attached to the child via a long line
Antibiotics
Antibiotics ( 24 hours ) BNF for children 2012, GOSH antibiotic guidelines 2006

Flucloxacillin
Neonate under 7 days, 25 mg/kg, 12 hourly
Neonate 7- 21 days 25 mg / kg, 8 hourly
21 days – 18 years, 25 mg / kg, 6 hourly

Amikacin
Neonate <28 days, 15mg/kg, one dose only
28 days – 18years, 10mg/kg 12hrly (2 doses)
Renal Impairment, 10mg/kg, one dose only

Teicoplanin ( if already on antibiotics)

Neonates 16 mg / kg, one dose only*
1 month - 18 yrs 10 mg/ kg max 400mg every 12 hours for 2 doses
*for patients <2kg consult GOSH antibiotic policy
If unsure please consult with the clinician leading the care of the baby / child.
 CALCULATIONS
Respiratory ECMO Blood flow=Cal. of Fluids Allowance(%)
100mls/kg ≤ 10kgs
50mls/kg upto 20kgs
20mls/kg thereafter
e.g. 3kg child------- 100% ECMO flows is 300mls/minor 0.3L/min (3x100)
Calculations
Cardiac ECMO
BSA x C. I ( less than 10kgs 2.8, Over 10kgs 2.4) =CO (anticipated )
e.g. BSA 0.14 x 2.8 =0.39
CO (L/min on ECMO) divide by BSA = C.I
e.g. 0.36/0.14=2.5
Equipment-size
Oxygenetor Blood Flow Max Blood Min Gas Flow
Gas
Medos 800 0-0.8 l/min 0.1 l
3 l
Medos 2400 0-2.4 l/min 6 l 0.1 l

Medos 7000 1.0-7.0 l/min 10 l 0.1 l

Cannulation

Two ties also Left

Head Feet

Right
 Commencing ECMO
Correct connections A- A V –V

V – open the clamp on VENOUS line above bridge

B – close the clamp on the bridge

A – open the clamp on ARTERIAL line above bridge

slowly increase blood flow to 120 %

check cardiovascular stability

reduction of inotropes

reduction of ventilation
 Handover
Connections correct; VV/AA

Circuit clear, no bubbles

Transducers connected correctly

Calculate flow- %, set sweep and FiO2

VBG/post membrane within normal limits

Set alarms

Perfusion checklist – sign when happy !

YOU ARE NOW ON ECMO!
 Maintenance

CXR/ECHO: assess cannulae position

Position- head midline/able to maintain ECMO flow

Cannulae secured, tubing not kinked / tight

ACT’s: commence heparin infusion when <350 (20u/kg/hr)

Water heater -?cooling

Optimise clotting/HCT (?clear prime)

ECMO Goals
Maintain adequate tissue oxygenation to allow recovery from short term
cardiopulmonary failure
Adjust ventilator settings allowing for Lung Rest minimizing further
ventilation/oxygen induced lung injury

Resp. Setting Cardiac

PIP 20 22-24
PEEP 10 5-8
Rate 10 20-24
FIO2 0.21 0.4
Adequacy of Support
Tissue Oxygenation
(Not the same as arterial oxygenation)
Oxygen delivery
Oxygen content blood
Arterial oxygen saturation
Haemoglobin
Blood flow – ECMO
Cardiac
SvO2
Generally a good indicator of adequacy of oxygen delivery
sVo2 will fall with decreasing tissue oxygen delivery
Low sVo2
More support needed
PRBC
More ECMO flow
Problems with sVO2 monitoring
Cannot be used with VVECMO
Because of recirculation
ABGs are obtained once connected to ECMO
Affected by intracardiac shuntafter adjustments in FiO2 and gas
Repeated
Patent foramen ovalesweep
PaCO2 achieved 40-45 mmHg and pO2 > 150
Gives a macro picture of oxygen supply and demand
mmHg
ACT150 –in
Ignores potential differences 180 sec, checked
regional (organ)every
blood20flow
min, then
every
hour
PT , PTT , INR
Safety checks
Work though menu on console:
Set alarm limits
Re-zero pressure lines, Venous, Pre/Post membrane
Check through ECMO circuit (tubing, lines etc)
ECMO gas analysis pre (mixed venous) and post oxygenator (arterial)
Check oxygen venous saturation : sVO2 > 70%
Patient temperature is tightly controlled
ABG oxygenator every 12h
Venous blood gas 6-8 h
Check diuresis: hemofylter (100-150 ml /h), dyalisis
Anticoagulation
Systemic heparin
Bolus heparin 100iu/kg at cannulation
Continuous heparin infusion to maintain ACT’s
Procoagulant
Anticoagulant factors
Hypotension
Volume if intravascular volume depleted - Increase preload
Calcium – increase myocardial contractility
Vasopressors – Increase systemic vascular resistance
Always remember…..

Communication
Protocols
Nurses + surgeons + perfusionists + intensivists + cardiology
Questions
?