**2. Nursing implications for cannula site management**

Nursing care should include monitoring of the ECMO circuit as nurses and associated staff, such as respiratory therapists and perfusionists, are at the bedside with the patient continually. ECMO cannulae require the same, if not more, attention that any peripheral or central venous catheter would, including assessment for erythema, purulence, adequacy of securement, and dressing integrity. It is significantly important to monitor for fixation of the ECMO cannulae. Initial placement of ECMO cannulae is usually confirmed by echocardiography and the position reaffirmed by radiographs [19]. Thus, ensuring the securement and stability of the cannulae by routine and repeated physical assessment is integral, as misplaced cannulae, loose sutures, or distant lashing straps can lead to specific complications such as inadequate flows or cannula dislodgment [28]. Ideal placement of lashing straps and appropriate securement of cannulae can be seen in **Figure 1**.

It is particularly important for the nurse and other bedside clinicians to be mindful of the integrity of the pump, as mispositioning of cannulae or hypovolemia can result in end-organ injury [11]. Suction events involve disruption of flow secondary to venous collapse onto the drainage cannula and can result in thrombus formation [11]. The occurrence of thrombi in the pump or oxygenator can be recognized by a visible thrombus, an increasing pressure decrease across the oxygenator, or a low post-oxygenator pCO2 [11].

#### **Figure 1.**

*Appropriate lashing strap distance demonstrating safe securement and appropriate tension on the ECMO cannulae.*

**15**

**Figure 2.**

*lower extremity.*

*Nursing Implications in the ECMO Patient DOI: http://dx.doi.org/10.5772/intechopen.85982*

upper extremity cyanosis [28].

There are additional considerations that the nurse caring for the ECMO patient will need to exercise specific to the therapy. Disruption of innate circulatory flow secondary to ECMO can result in limb ischemia. Thus, it is important to monitor limbs, especially those distal from cannulation sites. Clinical judgment, pulse palpation, and Doppler sonography of limb vessels are effective tools for this purpose [28]. Another modern tool for monitoring tissue oxygenation in lower extremities in ECMO patients is near-infrared spectroscopy [28]. The nurse may also note that clinicians will often place distal perfusion catheters to help prevent or treat distal limb ischemia, as demonstrated in **Figure 2** [28]. Harlequin syndrome can present in patients with venoarterial (VA) cannulation, where the heart has recovered but the lungs are still poorly functioning. The hallmark assessment finding for this is

Vessel perforation may take place on insertion; but, symptoms may not present immediately [28]. The most serious complication is a large retroperitoneal hematoma; but, considerable local bleeding at the insertion site is also possible, and site assessment, as well as assessment of the abdomen, flanks, and inguinal areas for ecchymosis, hypotension, and acutely worsening anemia, is necessary [28]. Additional assessment findings may include bulging or swelling at the insertion site, most consistent with pseudoaneurysm. Mild insertional hematomas may be mitigated and controlled by application of manual pressure, with subsequent monitoring of flows and distal pulses, both of which are imperative for clinical safety. Infection is an associated risk of ECMO therapy as well and linked to greater likelihood of mortality. In one study, patients on ECMO experienced an overall mortality of 68.3:75.6% in patients with infections and 67.1% in patients without infections [30]. The use of steroids in acute respiratory distress syndrome (ARDS) or adrenal insufficiency, body temperature control, and multiple blood transfusions after cardiac operations for coagulopathy during ECMO can interfere with the presentation of infection in patients undergoing ECMO [30]. Thus, routine inspection and care of all invasive lines, including ECMO catheters, become integral. Implementing standard decolonization practices set forth by the nurse's institution is appropriate

for ECMO catheters, such as antimicrobial scrubs and occlusive dressings.

*Left femoral artery perfusion catheter in place providing flow from the arterial ECMO cannula to the left* 

#### *Nursing Implications in the ECMO Patient DOI: http://dx.doi.org/10.5772/intechopen.85982*

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

**2. Nursing implications for cannula site management**

and appropriate securement of cannulae can be seen in **Figure 1**.

approach required at the bedside.

post-oxygenator pCO2 [11].

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

Nursing care should include monitoring of the ECMO circuit as nurses and associated staff, such as respiratory therapists and perfusionists, are at the bedside with the patient continually. ECMO cannulae require the same, if not more, attention that any peripheral or central venous catheter would, including assessment for erythema, purulence, adequacy of securement, and dressing integrity. It is significantly important to monitor for fixation of the ECMO cannulae. Initial placement of ECMO cannulae is usually confirmed by echocardiography and the position reaffirmed by radiographs [19]. Thus, ensuring the securement and stability of the cannulae by routine and repeated physical assessment is integral, as misplaced cannulae, loose sutures, or distant lashing straps can lead to specific complications such as inadequate flows or cannula dislodgment [28]. Ideal placement of lashing straps

It is particularly important for the nurse and other bedside clinicians to be mindful of the integrity of the pump, as mispositioning of cannulae or hypovolemia can result in end-organ injury [11]. Suction events involve disruption of flow secondary to venous collapse onto the drainage cannula and can result in thrombus formation [11]. The occurrence of thrombi in the pump or oxygenator can be recognized by a visible thrombus, an increasing pressure decrease across the oxygenator, or a low

*Appropriate lashing strap distance demonstrating safe securement and appropriate tension on the ECMO* 

**14**

**Figure 1.**

*cannulae.*

There are additional considerations that the nurse caring for the ECMO patient will need to exercise specific to the therapy. Disruption of innate circulatory flow secondary to ECMO can result in limb ischemia. Thus, it is important to monitor limbs, especially those distal from cannulation sites. Clinical judgment, pulse palpation, and Doppler sonography of limb vessels are effective tools for this purpose [28]. Another modern tool for monitoring tissue oxygenation in lower extremities in ECMO patients is near-infrared spectroscopy [28]. The nurse may also note that clinicians will often place distal perfusion catheters to help prevent or treat distal limb ischemia, as demonstrated in **Figure 2** [28]. Harlequin syndrome can present in patients with venoarterial (VA) cannulation, where the heart has recovered but the lungs are still poorly functioning. The hallmark assessment finding for this is upper extremity cyanosis [28].

Vessel perforation may take place on insertion; but, symptoms may not present immediately [28]. The most serious complication is a large retroperitoneal hematoma; but, considerable local bleeding at the insertion site is also possible, and site assessment, as well as assessment of the abdomen, flanks, and inguinal areas for ecchymosis, hypotension, and acutely worsening anemia, is necessary [28]. Additional assessment findings may include bulging or swelling at the insertion site, most consistent with pseudoaneurysm. Mild insertional hematomas may be mitigated and controlled by application of manual pressure, with subsequent monitoring of flows and distal pulses, both of which are imperative for clinical safety.

Infection is an associated risk of ECMO therapy as well and linked to greater likelihood of mortality. In one study, patients on ECMO experienced an overall mortality of 68.3:75.6% in patients with infections and 67.1% in patients without infections [30]. The use of steroids in acute respiratory distress syndrome (ARDS) or adrenal insufficiency, body temperature control, and multiple blood transfusions after cardiac operations for coagulopathy during ECMO can interfere with the presentation of infection in patients undergoing ECMO [30]. Thus, routine inspection and care of all invasive lines, including ECMO catheters, become integral. Implementing standard decolonization practices set forth by the nurse's institution is appropriate for ECMO catheters, such as antimicrobial scrubs and occlusive dressings.

#### **Figure 2.**

*Left femoral artery perfusion catheter in place providing flow from the arterial ECMO cannula to the left lower extremity.*
