Susan Bachmeier, MSN, RN, NEA-BC, really puts it about as aptly as can be said: When adults get prescribed extracorporeal membrane oxygenation (ECMO) treatment at Wake Forest University Baptist Medical Center, Winston-Salem, NC, it can often mean their last chance at life itself.
An advanced form of life support used to restore lung function in those patients experiencing cardiac and/or respiratory failure, ECMO treatment, which is more commonly seen in underdeveloped neonates and pediatrics, requires a high level of care that utilizes a multidisciplinary approach and constant monitoring, and can cause a myriad of complications if protocols are not followed stringently at all times.
"It's very advanced practice," said Bachmeier, director of nursing at Wake Forest, a facility that offers one of only a few adult ECMO programs along the East Coast. "There is a very complex set of skills that needs to be maintained to take care of these patients, and not every nurse gets an opportunity to experience it."
Conducted through the use of a special machine that pumps and oxygenates blood, ECMO provides continuous support of the lungs until individuals can breathe on their own. This is accomplished by the use of cannulae placed in large blood vessels that draw blood into the pump and through an oxygenation chamber that removes carbon dioxide, adds oxygen, and returns the blood to the patient.
Indications for ECMO include profound hypoxia despite maximum ventilator support, severe barotraumas, cardiac arrest, and failure of maximal medical therapy. The treatment is available via two modes: venovenous (VV) and venoarterial (VA).
VV ECMO, the more common method of the two, involves the insertion of a double-lumen catheter that drains blood from the inferior vena cava, a large vein that delivers blood to the right atrium of the heart, to the ECMO circuit for oxygenation before sending it back into the patient.
VA ECMO is used primarily in postoperative cardiac surgery patients, such as those with an inability to come off cardiopulmonary bypass despite maximal conventional therapy. In VA ECMO, the cannula ends in the right atrium with the tip near the level of the tricuspid valve. This cannula drains blood from the right side of the heart and delivers it to the ECMO circuit for oxygenation. Blood is returned to the body through a cannula placed in the right internal carotid artery.
"It's not so much that their hearts and lungs are damaged, they're compromised," said Melanie Williamson, RN, CCRN, manager of the cardiothoracic ICU (CTICU), where the adult ECMO program is performed. "Most of our patients are those with adult respiratory distress syndrome, and we occasionally have heart surgery patients who are not able to come off the pump to support their own cardiopulmonary system while their heart is recovering."
A care plan that generally requires about 5-10 weeks for recovery, ECMO is often administered during a general ICU stay and after the use of a respirator proves not to be enough to restore health. Though typically needed among older adults who've acquired pneumonia or are facing complications following heart or lung surgery, distress also can be seen during routine surgeries - albeit rarely.
"Any surgery can cause lung failure postoperatively," Williamson said. "We've seen patients who've had routine hip surgeries who've ended up with massive clots in their lungs and severe respiratory failure, and they need to go on ECMO."
In 2009, the ECMO program as a whole (Wake Forest also has separate neonatal and pediatric departments) admitted 26 patients, 14 of whom were related to existing pulmonary conditions. As of August 2010 the unit had already seen 22 adult patients, 18 of whom were pulmonary. Since its inception in January 1996, the facility has cared for more than 450 neonatal, pediatric, and adult patients.
Focus on Adults
While several types of ECMO exist, the two most common forms used among adult patients at Wake Forest (neonates and pediatrics require differing care) are VA and VV.
As such, ECMO protocols are determined based on results of patients' lab work, such as hemoglobin, fibrinogen and platelet counts. Although anticoagulant drugs such as heparin are given to prevent blood clotting, bleeding out and sepsis remain ongoing concerns with this patient population during treatment, particularly as a result of cannulation sites that can become problematic if a patient bleeds or the site becomes infected.
"Bleeding is a big complication because these patients are highly anticoagulated," said Kimberly Rogers, BSN, RN, CCRN, a nursing educator at Wake Forest. "If they've had any surgery or injury, that precipitates the bleeding much more, so we're pretty vigilant on anything that can cause bleeding."
Furthermore, equipment tubing can become kinked and result in restricted blood flow and/or prevent the oxygenator from properly removing carbon dioxide from the blood, further increasing the chance of morbidity.
"You have to be careful of their cannula sites and protect those sites when you're positioning and repositioning your patients," Rogers added. "Those are routes for infection we have to keep clean just like any other central line we would take care of. And their propensity to bleeding is so high, we can't administer intramuscular medications to these patients [for pain relief]."
A Niche Market
In housing what's said to be not just one of the only but one of the busiest adult programs in the area, Wake Forest has become renowned for its ECMO care. In April 2010 the facility was designated as a center of excellence by the Extracorporeal Life Support Organization, an international consortium of healthcare professionals and scientists dedicated to the development and evaluation of novel therapies for support of failing organ systems.
"This is a bit of a niche market for us, and we're proud of that," Bachmeier said. "Having people who are at their last chance of living, it's rewarding to think we're responsible for that."
To qualify to work within Wake Forest's ECMO program, "you have to display that you have critical-thinking skills, that you manage well in a crisis situation and that you have sound judgment in taking care of patients who are very sick," Williamson said. "(You) need to know what to look for and anticipate complications. It requires a lot of diligence. For example, if the blood is supposed to be red coming from the arterial side, and it's black, you know the oxygenator is compromised. The only way you know that is if you have a working knowledge of the equipment."
The adult program offers 11 beds and as many as five patients can be seen simultaneously for ECMO treatment. The number of patients is limited strictly to availability of equipment.
Dealing With Death
Despite the risks involved, survival rates for this patient population are said to be successful. Still, due to factors such as age and comorbid conditions, adult ECMO is not always a life-saving possibility. There are times when the healthcare team has to discuss with patients and their families the fact that they simply cannot recover from their distress.
In these instances, Wake Forest offers chaplain services and emotional support - sometimes through the visits of former patients who've survived but can still relate to the struggle.
"When a patient is taken off ECMO and dies, you try to remove yourself, but you never can," Williamson said. "These are patients who stay on the unit for at least a week most times. You're bonding with them and their families, and when you see them cry you can't help but feel sorry for them."
But the joy of helping those patients who do come off the pump healthy is enough to keep anyone dedicated to the unit, they say.
"This type of care can be very rewarding," Rogers said. "We have adult patients who have stayed in touch with us, and we have an ECMO picnic each year to get patients and families together to celebrate a life they probably wouldn't have if it wasn't for this program. It's stuff like that that makes you want come back to work the next day and do it all over again."
Joe Darrah is senior associate editor at ADVANCE.