ECMO Clinical MasterGuide - Bedside Practice & Quick Reference System

Target Anticoagulation (ACT) 180 – 220 sec

Target Blood Flow Rate 50 – 80 mL/kg/min

Upper Body SpO₂/ABG (VA) Right Radial

Post-Decannulation Bedrest 6 – 12 Hours

CIRCUIT RUN

Extracorporeal Circuit & Physiological Regulator

ECMO drains deoxygenated venous blood, propels it via a centrifugal pump through a membrane lung for O₂ uptake and CO₂ removal, and returns it to the patient. Toggle modes to compare hemodynamic differences.

Current Circuit: VV-ECMO (Veno-Venous)

Femoral Vein ➔ Internal Jugular

Native Organs (Native Lungs)

Ventilator on lung-protective settings (Low VT / Moderate PEEP)

Gas Exchange Support Only

Drainage Line

Venous Blood

PUMP

Membrane Sweep: 4.0 L/min FiO₂: 100%

Return Line

Oxygenated

VV Cannulation Sites: Femoral vein drainage (21-25 Fr) ➔ Internal jugular return (17-21 Fr); native heart generates entire systemic perfusion output.

Harlequin Syndrome (Differential Hypoxemia / North-South Syndrome) Alert: If the native heart recovers while lungs remain compromised, deoxygenated blood from the left ventricle perfuses the coronary arteries, head, and right upper extremity, while ECMO supplies hyperoxygenated blood from below. Always monitor Right Radial Arterial Line & SpO₂!

Transmembrane Pressure (ΔP = Ppost - Ppre): 18 mmHg (Normal < 50)

Progressive increase indicates oxygenator clot formation

Bedside Parameter Tuning Simulator

Blood Flow Rate 4.0 L/min

1.0 L Target: 50–80 mL/kg/min 6.0 L

Sweep Gas Flow (Controls CO₂ Elimination) 4.0 L/min

0.5 L (Retains CO₂) Primary Lever for PaCO₂ 10.0 L (Clears CO₂)

Sweep Gas FiO₂ (Blender Concentration) 100 %

21% (Room Air) Initiate at 100%, titrate per post-mem ABG 100%

Simulated Arterial Blood Gas (ABG) Response

Predicted PaO₂ Impact Adequate (> 75-100 mmHg) Driven by Flow & FiO₂

Predicted PaCO₂ Trend 35 – 45 mmHg (Normocapnia) Driven by Sweep Gas Flow

🫁 Lung Rest Ventilation Strategy:

Tidal Volume: 4–6 mL/kg PBW or < 4 mL/kg ultraprotective
Driving Pressure: < 14 cmH₂O; Plateau Pressure < 25–28 cmH₂O
PEEP: Moderate to High (10–14 cmH₂O) to prevent atelectrauma

When to Initiate ECMO: Indications & Decision Matrix

ECMO is a supportive bridge therapy, not a cure. Criteria require failure of maximal conventional therapy, extreme predicted mortality, and an underlying condition that is reversible or eligible for transplant/VAD.

Severe Respiratory Failure (VV-ECMO)

Isolated Extracorporeal Gas Exchange

ARDS / EOLIA Criteria

🎯 Refractory Hypoxemia Thresholds (EOLIA/CESAR):

PaO₂ / FiO₂ < 80 mmHg sustained for > 6 hours
PaO₂ / FiO₂ < 50 mmHg sustained for > 3 hours

⚡ Severe Respiratory Acidosis / Hypercapnia:

Arterial blood pH < 7.15 with severe CO₂ retention despite maximizing safe ventilator limits (plateau & driving pressure constraints).

Common Underlying Etiologies:

Severe ARDS (Influenza, COVID-19, Pneumonia) Status Asthmaticus Bridge to Lung Transplant / Primary Graft Failure Massive Pulmonary Contusion

Cardiogenic Shock & Circulatory Collapse (VA-ECMO)

Hemodynamic Perfusion + Gas Exchange

Refractory Shock / ECPR

🎯 Hemodynamic Collapse Criteria (Refractory to Inotropes/Vasopressors):

Cardiac Index (CI) < 2.0 L/min/m²
SBP < 90 mmHg or MAP < 65 mmHg
End-organ hypoperfusion: Serum Lactate > 3–4 mmol/L and rising, Oliguria (< 0.5 mL/kg/h)

⚡ Extracorporeal Cardiopulmonary Resuscitation (ECPR Criteria):

Witnessed arrest, immediate high-quality bystander CPR, initial shockable rhythm (VF/VT) preferred, with target CPR Low-Flow Time < 30–60 minutes to cannulation.

Common Underlying Etiologies:

Fulminant Myocarditis Acute Myocardial Infarction with Shock Post-Cardiotomy Shock (Failure to wean CPB) Refractory Cardiotoxic Overdose (CCB, Beta-Blocker) Massive Pulmonary Embolism

Contraindications Assessment Checklist

Absolute Contraindications

Irreversible underlying condition with no eligibility for VAD or organ transplantation.
Catastrophic irreversible central nervous system injury (massive intracranial hemorrhage or absent brainstem reflexes).
Uncontrollable active major hemorrhage (ECMO mandates systemic anticoagulation).
Terminal malignancy with severe frailty and life expectancy < 6 months.

Relative Contraindications

Advanced age (typically > 65–70 years; requires strict individual frailty appraisal).
Prolonged high-pressure mechanical ventilation (> 7–10 days with high FiO₂/pressures; lung fibrosis likely irreversible).
Severe peripheral vascular disease (severely limits femoral arterial cannulation).
Severe aortic regurgitation (VA-ECMO causes fatal left ventricular distension and pulmonary edema).

Pre-Cannulation Checklist & Equipment Readiness

Verify all essentials systematically prior to vessel puncture to prevent catastrophic delays.

Readiness Progress 0% (0/16)

1. Patient & Vascular Access

Informed consent verified (or emergency two-consultant approval) Right Radial A-Line placed with clear waveform (mandatory for VA) Baseline bilateral femoral, popliteal, and dorsalis pedis pulses marked Central venous catheter (CVC) & temperature Foley catheter in place

2. Machine & Circuit

ECMO console self-test passed, connected to emergency red outlet & gas blender Circuit primed (Plasmalyte/Normal Saline) and de-aired with zero microbubbles Appropriately sized cannulas and serial vascular dilator sets on tray Distal Perfusion Catheter (DPC, 6–8 Fr) kit ready (mandatory for VA femoral)

3. Bedside Safety Equipment

At least 4 heavy-duty non-serrated tubing clamps at bedside Emergency manual hand crank mounted on machine mast Point-of-care ultrasound (POCUS) + echo probe for guidewire verification High-intensity inspection penlight for fibrin/thrombus assessment

4. Drugs & Blood Bank

Unfractionated Heparin IV bolus (50–100 u/kg) drawn & verified Neuromuscular blocker (Rocuronium) & deep sedation (prevents coughing/bucking) Blood bank check: Packed RBCs (2–4 units on standby), FFP & platelets accessible Emergency vasopressor infusions (Norepinephrine / Epinephrine) dual-line primed

ECMO Critical Care Nursing & Shift Protocols

Focus on four pillars: Cannula security, neurovascular ischemia vigilance, tight anticoagulation titration, and infection prevention.

Cannula & Circuit Security

Anti-Dislodgement Protocols: During patient turns, assign one dedicated staff member to manually secure and stabilize cannulas with both hands.
Tubing Chattering / Shaking: Violent vibration in the drainage line signifies insufficient preload (hypovolemia) or excessive RPM causing vein wall suction. Never increase RPM; decrease speed immediately and assess fluid volume.
Circuit Color Differential: Drainage must appear dark burgundy, return bright scarlet. Matching colors in VV-ECMO suggests significant recirculation.
Scheduled Penlight Inspections: Inspect the oxygenator membrane and connectors every 4 hours for white fibrin strands or microthrombi.

Hourly Neurovascular & Limb Surveillance

Q1H Neurovascular Checks: Compare cannulated vs. non-cannulated limb: dorsalis pedis pulses (Doppler if needed), skin temperature, color, capillary refill (< 2s).
DPC Patency: Palpate the distal perfusion cannula pulsation. Pallor, coolness, or tense swelling suggests early acute compartment syndrome.
Q1H GCS & Pupil Evaluation: Heparinized patients are at high risk for intracranial hemorrhage (ICH). Sudden pupillary asymmetry requires emergency non-contrast head CT.
Differential Hypoxemia (Harlequin) Vigilance: In VA-ECMO, continuously cross-reference right radial SpO₂ with lower extremity arterial values to safeguard cerebral and coronary perfusion.

Anticoagulation & Bleeding Control

Target Titration: Maintain ACT 180–220 s; Anti-Xa 0.3–0.7 IU/mL; aPTT 50–70 s via continuous Heparin infusion per protocol.
Coagulation Thresholds: Maintain Platelets > 50–80 × 10⁹/L and Fibrinogen > 1.5–2.0 g/L to prevent consumptive coagulopathy.
Bleeding Site Inspection: Monitor cannula insertion sites for hematoma formation, endotracheal suctioning for frank alveolar hemorrhage, and urine/NG secretions.
Atraumatic Suctioning: Avoid forceful tracheal suctioning; use closed inline suction catheters with minimal negative pressure to prevent airway mucosal hemorrhage.

Infection Control & Dressing Protocols

Cannula sites represent major bloodstream infection (CRBSI) gateways. Cleanse insertion sites with 2% chlorhexidine in alcohol and apply sterile, semi-permeable transparent dressings. Perform a 15-second "scrub the hub" on all stopcocks prior to access. Avoid routine circuit access.

Micro-turns & Pressure Ulcer Prevention

Large rotational turns pose extreme decannulation risks. Utilize pressure-relieving air mattresses and execute 15–30 degree micro-turns every 2 hours. Position gel pads under the occiput, sacrum, and cannula contact points along the thighs.

ECMO Catastrophes & Bedside Emergency Troubleshooting

Remain calm during alarms. Follow sequential emergency algorithms systematically.

SCENARIO 1 Frequency: Very High

Violent Tubing Chattering & Sudden Flow Drop

🔍 Root Causes: Severe hypovolemia (insufficient preload), patient coughing/bucking, increased intra-abdominal pressure, or suction collapse of the inferior vena cava against drainage side holes.

🛠️ Immediate Management Steps:

Immediately decrease pump RPM: Relieve negative suction pressure and release vena cava collapse.
Administer rapid crystalloid bolus (250–500 mL): Expand intravascular volume.
Verify tubing is free of mechanical kinking or positional patient compression.
Deepen sedation or administer neuromuscular blockade if patient is coughing or straining vigorously.

SCENARIO 2 High Risk

Membrane Lung Microthrombosis / Rapid Rise in ΔP

🔍 Warning Signs: Transmembrane pressure ΔP exceeds 50–60 mmHg and continues rising, post-membrane PaO₂ declines, and plasma-free hemoglobin surges due to mechanical hemolysis.

🛠️ Immediate Management Steps:

Immediately check coagulation markers (ACT / aPTT / Anti-Xa) to rule out under-anticoagulation.
Inspect both inlet and outlet faces of the oxygenator with a bright penlight for clot burden.
Alert the perfusionist and on-duty ICU consultant to prepare for emergent oxygenator exchange.

CRITICAL EMERGENCY Lethal Event

Accidental Decannulation or Tubing Rupture with Air Ingress

🚨 5-Second Reflex Action Protocol:

Clamp Tubing Immediately: Grab 2 heavy clamps and clamp the drainage line nearest to the patient; grab 2 clamps for the return line!
Stop the Blood Pump (STOP PUMP): Prevent air from being propelled into the arterial circulation or tearing vessels.
Apply Firm Manual Pressure: Compress the bleeding vascular insertion site directly with sterile gauze.
Activate Emergency Code Blue (Call for Senior Help): Transition patient to full ventilator and inotropic support.

SCENARIO 4 Mechanical / Electrical Failure

Console Blackout or Motor Drive Failure

🔍 Clinical Threat: In VA-ECMO, pump cessation results in retrograde arterial blood flow back into the low-pressure venous circuit, precipitating exsanguination and cardiac arrest.

🛠️ Immediate Management Steps:

If retrograde flow alarm sounds, single-clamp the arterial return line immediately to stop backflow.
Retrieve the manual hand crank from the machine mast and slot it into the centrifugal drive head.
Release the clamp and initiate hand cranking at target RPM (gauge markings).
Inspect red emergency power connections and verify backup battery switches.

Decannulation & Post-ECMO Critical Care

The first 24 hours post-decannulation represent a highly vulnerable transition. Prioritize vascular hemostasis, cardiopulmonary rebound vigilance, and deep vein thrombosis prophylaxis.

1. Hemostasis & Immobilization

Direct Manual Compression: Following percutaneous decannulation, maintain direct manual compression proximal to the puncture site for 30–45 minutes, followed by compression dressing or mechanical clamps (e.g., FemoStop).

Strict Flat Bedrest: Patients must remain on strict flat bedrest with the cannulated limb immobilized for 6 to 12 hours. Avoid hip flexion.

Vascular Doppler Surveillance: Monitor for hematoma expansion or bruits, remaining vigilant for pseudoaneurysms or arteriovenous fistulas.

2. Cardiopulmonary Rebalancing

Ventilator Uptitration: Upon ECMO cessation, adjust ventilator settings upward from rest parameters to therapeutic ventilation. Monitor ABGs frequently to evaluate PaO₂/FiO₂ ratio.

Hemodynamic Recalibration: Weaning from VA-ECMO drops left ventricular afterload while increasing venous return. Titrate Norepinephrine / Dobutamine and perform bedside echocardiography.

Lactate Clearance: Serial lactate and urine output checks every 2–4 hours to identify occult rebound hypoperfusion early.

3. Anticoagulation Transition

Cessation Timing: Discontinue heparin infusion 2–4 hours prior to decannulation, confirming ACT < 150–160 seconds or normalized aPTT before pulling cannulas.

Protamine Reversal: Have Protamine ready at bedside if rapid heparin reversal is required for refractory puncture bleeding.

DVT Prophylaxis: Resume prophylactic anticoagulation (e.g., LMWH Enoxaparin) 12–24 hours post-decannulation once hemostasis is secure to prevent deep vein thrombosis.

4. Infection Control & Rehab

Cannula Tip Culture: Aseptically transect the distal 5 cm of the explanted cannula tip and send for quantitative microbiological culture.

Sepsis Biomarkers: Track core temperature, WBC, CRP, and procalcitonin closely.

Graduated Physical Therapy: Once hemostasis is stable for 24 hours, physical therapy initiates passive range-of-motion exercises advancing toward sitting, combating ICU-acquired weakness.

Bedside Oxygenation Index Calculator (P/F Ratio & ARDS Severity)

Aids in VV-ECMO indication decision making

Arterial Oxygen Tension PaO₂ (mmHg)

Ventilator Fraction of Inspired O₂ (FiO₂ 0.21 - 1.0)

Calculated P/F Ratio

60 mmHg Severe ARDS / Consider VV-ECMO

Extracorporeal Circuit & Physiological Regulator

Native Organs (Native Lungs)

Bedside Parameter Tuning Simulator

Simulated Arterial Blood Gas (ABG) Response

When to Initiate ECMO: Indications & Decision Matrix

Severe Respiratory Failure (VV-ECMO)

Cardiogenic Shock & Circulatory Collapse (VA-ECMO)

Contraindications Assessment Checklist

Pre-Cannulation Checklist & Equipment Readiness

ECMO Critical Care Nursing & Shift Protocols

Cannula & Circuit Security

Hourly Neurovascular & Limb Surveillance

Anticoagulation & Bleeding Control

Infection Control & Dressing Protocols

Micro-turns & Pressure Ulcer Prevention

ECMO Catastrophes & Bedside Emergency Troubleshooting

Violent Tubing Chattering & Sudden Flow Drop

Membrane Lung Microthrombosis / Rapid Rise in ΔP

Accidental Decannulation or Tubing Rupture with Air Ingress

Console Blackout or Motor Drive Failure

Decannulation & Post-ECMO Critical Care

Bedside Oxygenation Index Calculator (P/F Ratio & ARDS Severity)

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