The New York Presyterian Medical Center

By Robert Clark,2014-01-29 06:53
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The New York Presyterian Medical CenterNew,the,The,York,new,york

The New York Presbyterian Medical


    Policy and Procedure Manual

    Date issued:

Approved: Approved:

Procedure For Adult ECMO Using Rotaflow pump, Quadrox “D” & “E” pack Circuit

    Purpose: To provide long term cardiopulmonary support for patients requiring extracorporeal membrane oxygenation (ECMO)

    Supplies and Equipment Needed:

    1. ECMO cart which includes the Rotaflow pump console and hand crank, oxygen blender and O2 tank

    2. 1 ea “E” tubing pack which includes a coated tubing pack; rotaflow disposable centrifugal head; Quadrox “D” diffusion membrane oxygenator; (see attached schematic


    3. Heater-cooler device

    4. Cardiotomy reservoir (for priming)

    5. Backup of all the above including an additional oxygenator, pump head, and tubing pack. 6. transducers


    1. The system is assembled by attaching the circuit lines to the oxygenator and recirculating with priming solution after flushing with CO2. Follow usual priming technique. After complete deairing, disconnect the venous side of the loop from the cardiotomy, clamp the cardiotomy outlet and separate the centrifugal pump inlet line at the 3/8” x 3/8” connector. Using an air-

    free technique, connect the venous side of the patient loop to the 3/8” x 3/8” leuer connector on the inlet side of the centrifugal pump to create a closed loop ECMO circuit without the cardiotomy.

    (no albumin in the prime because it may decreases the activity of the bonded tubing). 2. All connections must be tie banded because the coating makes the tubing slippery on the connectors.

    3. For peripheral cannulation, see vascular access cannula selection.

    4. If central cannulation will be continued from cardiopulmonary bypass, then conversion to ECMO will be made using the arterial and venous cannulas already in place. 5. In postcardiotomy patients, no heparin will be given for the first 24 hrs. 6. ACT will be monitored hourly.

    7. After 24 hours if the PT is below 15 seconds, the platelet count is greater than 75,000, and the chest tube drainage has decreased to <1ml/kg/hr, then heparin may be started on order of a physician to maintain the ACT at target 180-200 seconds.

    8. Oxygenator replacement - Since the Quadrox “D” is a non-microporous membrane,

    progressive failure over time due to fluid accumulation within the gas phase of the device is greatly reduced. However, oxygenator performance and line pressure trends should be monitored. The following guidelines are for documenting oxygenator failure that requires replacement:

With venous O2sat > 65% -

    FIO2 of 100% - post oxygenator pO2 < 200 mm Hg

    gas flow 10 L/min - arterial pCO2 > 40 mm Hg

    Procedure for oxygenator changeout -

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    1. Notify physician and nursing staff- tell them that the patient will be off ECMO for 1-2 minutes. Increase ventilator FiO2 to 100%.

    2. Volume load the patient if necessary.

    3. Increase the ACT to > 200 seconds.

    4.Setup a new oxygenator using 3/8” tubing, pigtail and 1/4” recirculation line to existing

     and prime oxygenator. cardiotomy. Flush with CO2

    5. Come off bypass by clamping post centrifugal pump and post oxygenator, and turn console speed control to 0. Isolate patient by clamping the arterial and venous lines to the table.

    6. Remove tubing from both oxygenator inlet and outlet.

    7. Connect new oxygenator into circuit, remove clamp from recirculation line and purge air from the oxygenator into the cardiotomy reservoir. Recirculate until the system is debubbled. Turn off pump and clamp recirculation line and double clamp cardiotomy outlet line. Attach O2 gas line to the new oxygenator. Clamp oxygenator outlet tubing. Remove clamps from the arterial and venous lines to the table.

    8. Turn on the pump and remove the clamp from the oxygenator outlet, and resume ECMO flow rate. Add additional volume as necessary to reach the desired flow rate.

Alternate method:

    Pre-prime Oxygenator using the small single pump stand alone base with a cardiotomy reservoir and 3/8” tubing. Recirculate, deair and clamp oxygenator inlet and outlet tubings

    approximately 4 inches from oxygenator. Using aseptic technique, divide the lines leaving 6” inches of tubing on oxygenator inlet and outlet. Use 3/8” x 3/8” connectors, insert new oxygenator into circuit using an air free technique (either luered connectors with pigtails and 60cc fluid filled syringes or 2 man technique with saline syringe filling and flooding during air-free tubing connection). Confirm air-free connections and air free circuitry, properly reposition clamps, connect gas line, connect water lines, confirm gas flow, and resume ECMO flow and support

Lung Translants: Cardiopulmonary Bypass: Dr. Sonnett

Procedure for adult ECMO


    ECMO for the adult patient provides various methods of cardiac and respiratory support depending on the location of the cannulation sites. In the VV mode, respiratory support is accomplished with the patient's own heart producing pulsatile aortic pressure. In the VA mode, both cardiac and respiratory support is achieved with a non-pulsatile aortic blood pressure. Cannulation can be either perepheral or central depending on operative status.

Equipment Selection and Set-up:

    An adult ECMO bypass tubing pack (E Pack) is used with a Rotaflow centrifugal pump and a Quadrox “D” diffusion membrane oxygenator. Please refer to the diagrams below for

    proper set-up of the E Pack circuit. In extenuating circumstances pigtails may be attached to the leur locks between the centrifugal pump the inlet of the Quadrox “D” oxygenator for

    CVVH for V-V ECMO, but should not be used for V-A ECMO. Pre- and post- membrane pressures should be monitored. The set up is then flushed with CO2 prior to priming. The priming volume of 1200-1500 ml consists of 6% Hextend and lactated ringer’s. 2000 units of CP04-Page 2 of 6

    heparin and 25 ml of sodium bicarbonate is added to the prime. Blood prime should be used if the estimated post-dilutional hematocrit is below 20%. A blood gas on the prime should then be performed and the prime should be adjusted as close to normal physiologic values as possible. After de-airing the circuit, the venous inflow tubing to the cardiotomy reservoir is is removed and connected to the inflow of the centrifugal pump. Recirculation is continued until just before attachment to the cannulae. The cardiotomy reservoir MUST be double clamped or preferably removed from the circuit prior to bypass to ensure a closed system and prevent exsanguination, stagnation with thrombus formation or possible air entrainment.

Vascular Access and Cannula Selection:

    Veno-venous cannulation is the method of choice as long as there is proper cardiac function. choose cannulae sizes which allow for the greatest range of flow for a given BSA. Discuss cannula choices with the surgeon prior to insertion. Peripheral venous drainage can be accomplished via a Biomedicus cannula inserted into the femoral vein, through the IVC and into the right atrium for adequate venous drainage. Pump return to the patient may be accomplished using a biomedicus cannula via the internal jugular vein or various femoral cannulae. Consult the cannula flow selection chart for appropriate sizing of cannulas.

    Veno-arterial cannulation is used when there is combined cardiac and respiratory failure. Venous drainage may be accomplished via femoral vein, internal jugular, or direct right atrial cannulation. Arterial inflow may be accomplished via femoral artery, internal carotid artery, or the ascending aorta. Other cannulation sites may be required as per surgeon’s request. Consult cannula flow chart for appropriate cannulas.

    Distal limb perfusion may be necessary and this can be accomplished be using a luered connector with a short piece of tubing and small distal cannula connected to the primary cannula luered port.

ECMO Initiation and Management During Bypass:

    Prior to cannulation, the patient should be systemically heparinized with 100u per kg. of sodium heparin, with ACT’s >300 seconds. The sterile A-V loop is passed off to the surgical

    field and recircluation is discontinued. Tubing clamps are placed distal to the centrifugal head and distal to the oxygenator. Upon adequate anticoagulation, cannulation is performed by the surgeon. ECMO is initiated by removing both arterial and venous clamps and increasing blood flow to the desired rate. Gas flow is then immediately instituted to the recomended gas to blood flow ratio of 1:1 for the oxygenator used as per manufacturer’s recomendations. Line pressures should be checked immediately to ensure adequate venous drainage and arterial return and to rule out the possibility of arterial dissection. Volume may be given through the ECMO circuit via the pigtail lines, if necessary. However, volume management through patient access lines is preferred. Blood gases are sampled routinely at the bedside and the patient is managed using an alpha-stat protocol to maintain values within normal acceptable ranges. ACT’s are sampled hourly and maintained at >180 sec. All ACT and blood gas samples should be obtained by the nurse via the patient’s arterial line. Blood gases should not be drawn from the pump except for the purposes of checking oxygenator performance or for calibrating the oxygen saturation analyzer. The perfusionist is required to document patient and ECMO pump parameters on the pump record on an hourly basis and all significant events as they occur.

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Weaning and decannulation from the ECMO Circuit:

     Weaning from the ECMO circuit is performed by decreasing pump flow with appropriate ventilator settings, under the authorization of the attending MD. Upon weaning, the heparin drip should be increased to maintain ACT’s > 200-250 sec. Pump flow is discontinued by

    clamping distal to the centrifugal head and oxygenator and cannulas are removed by the surgeon.

     ndReference: ECMO: Extracorporeal Cardiopulmonary Support in Critical Care, 2 ed.J.B.

    Zwischenberger M.D., R. H. Steinhorn M.D. , R. H. Bartlett M.D. ed. Extracorporeal Life Support Org, 2000


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