Nursing Implications in the ECMO Patient

*Alex Botsch, Elizabeth Protain, Amanda R. Smith and Ryan Szilagyi*

## **Abstract**

Effective care and positive outcomes of the extracorporeal membrane oxygenation (ECMO) patient necessitate optimal interdisciplinary management from the healthcare team, including expert care from specially trained registered nurses (RNs). It is incumbent upon the RN caring for the ECMO patient to excel in both time management and assessment skills, as this population often demands care delivery at the pinnacle of intensive care unit (ICU) acuity. Astute and nuanced monitoring of neurological status, bleeding risk with potential (often massive) transfusions, poor hemodynamics, and integrity of the ECMO pump itself are only the few specialized areas of focus that must share priority with traditional nursing considerations involving the critically ill, such as prevention of pressure injuries and bloodstream infections. These high-intensity medical foci must be balanced with ethical considerations, as the ultimate goal of returning the patient to their normal life is not always possible. These demands highlight the dynamic proficiency of the RN caring for the ECMO patient. The following chapter will highlight the importance of specialized nursing care in the critically ill patient supported with ECMO.

**Keywords:** ECMO patient necessitates, interdisciplinary management, importance of specialized nursing care

#### **1. Introduction**

The patient requiring extracorporeal membrane oxygenation (ECMO) for any etiology is almost always managed in the intensive care unit (ICU) and requires care around the clock, which is delivered by a collaboration of physicians, nurses (RNs), respiratory therapists, perfusionists, and many others. Close collaboration between care providers is crucial, particularly between the RN managing hemodynamic medication infusions and the ECMO specialist managing the pump. RNs provide extensive, holistic care for ICU patients and their families, much of it geared toward traditional, clinical care with the additional implications of ECMO therapy, which requires additional specialized training. Acuity, unpredictability, and heavy resource requirements of the ECMO patient, especially when initiating therapy, can necessitate unusual and innovative staffing models, which rely on flexibility and often extra hours and shifts to accommodate individual patient and unit needs.

RNs are essential to the delivery of optimal healthcare and play an integral role in the care of patients admitted to the ICU, so it is important that, when staffed well, RNs reduce the risk of inhospital mortality anywhere from 14 to 36% [10, 29].

A recent expert consensus suggests RN-to-ECMO patient ratios should be at least 1:1 or 1:2 to deliver safe and quality patient care [33]. A recent survey found that RNs were allocated 1:1 in nearly 60% of ECMO centers internationally when also monitoring and intervening on the ECMO circuit [9]. This chapter will further discuss the nursing implications involved in the care of the ECMO patient, the RN's role in prevention of associated complications, and the importance of the holistic approach required at the bedside.
