**5. Nursing implications for detection and prevention of systemic complications related to ECMO**

The use of ECMO is accompanied by a myriad of potential complications across multiple body systems that are considered calculated risks upon initiation of therapy; however, without it, mortality may increase in conditions like severe acute heart failure [32]. A recent, international, randomized controlled trial (RCT) also suggests a potential mortality benefit with the use of ECMO in severe acute respiratory distress syndrome (ARDS); however, it was found to not be statistically significant [8]. There is abundant literature surrounding the complications of ECMO; but, despite these risks, survival to hospital discharge is greater than 50% [4, 12]. In one recent meta-analysis, the most frequently reported complications associated with ECMO include acute kidney injury (AKI), bleeding, and infection [6]. Specialized RNs have knowledge and understanding of potential complications related to ECMO therapy and can assist with early detection through critical thinking, performing frequent assessments, and reporting them through an open dialog with the team of providers involved.

#### **5.1 Renal and other intraabdominal complications**

The incidence of acute kidney injury (AKI) has been reported as high as 80% of ECMO patients and is associated with a quadrupled mortality risk [13, 34]. Severe fluid

**19**

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

physical exam findings consistent with fluid overload.

of intraabdominal pressure.

**5.2 Hematological complications**

overload is one of the major reasons that renal replacement therapy (RRT) is initiated in this population and is often performed through the ECMO circuit but can also be performed after the pump, which could lower the risk of air embolism not trapped by the oxygenator [34]. Fluid overload is independently associated with increased mortality, prolonged LOS, prolonged ventilator time, and prolonged ECMO time [13, 34].

This consideration can lead providers to assume earlier RRT for therapeutic fluid removal would reduce these comorbidities; however, there is little data to suggest the efficacy of this. In fact, studies suggest increased mortality in ECMO patients who require RRT during their time on pump [16, 37]. Of ECMO patients who suffer AKI, an estimated 46% of survivors require RRT after ECMO is completed [6]. The bedside RN can assist in early identification of AKI by monitoring urine output; measuring strict fluid intake and output; assessing serial serum chemistry values, particularly serum creatinine and trends of electrolyte dyscrasias; and identifying

Abdominal compartment syndrome (ACS) is a known complication of ECMO

Bleeding is the most frequent complication associated with ECMO and affects approximately 30% of the patients receiving the therapy [2]. Bleeding may occur secondary to primary injury such as trauma and surgery or as a result of ECMO itself. Disruption of the red blood cell membrane leads to hemolysis, which is a common complication of patients on ECMO [11]. SIRS and contact between the patient's blood and the ECMO circuit lead to activation of the coagulation cascade,

Large amounts of bleeding will cause losses and consumption of coagulation factors and platelets, leading providers to believe that a heparin overdose may be occurring, thus decreasing the heparin, leading to acute thrombosis of the ECMO circuit or in other places where blood flow may be stagnant [22]. Thrombosis is mainly associated with VA-ECMO and can occur in the atria, ventricles, upper and lower extremity deep vein thrombosis (DVT), pulmonary vasculature, brain, or the ECMO circuit [22]. Unfractionated heparin (UFH) is well known, easily monitored, and easily reversible, allowing its frequent use managing hypercoagulability in the ECMO patient. Institutional guidelines vary; but, systemic anticoagulation with UFH infusion to target aPTT between 50 and 70, with some variations [2]. Despite ease of use, UFH can be associated with complications such as heparin-induced thrombocytopenia (HIT), further contributing to bleeding [22]. Alternatives such as warfarin, lepirudin, or argatroban may also be used in lieu of UFH for anticoagulation in the event of HIT [2]. The ECMO patient provides a unique challenge for providers, who must balance hypercoagulability with coagulopathy with careful but aggressive, administration of blood product transfusions and anticoagulants. It is clear that there is a litany of reasons the patient on ECMO may experience bleeding and bleeding often results in the need for transfusion. Adult patients on ECMO may require 2–3 units of packed red blood cells (PRBCs) and up to 14 units

affecting fibrinolysis, thrombin formation, and platelet function [2].

[3]. This can be caused by massive fluid overload, which can be necessary to keep ECMO flows appropriate (read aforementioned suction events) [3]. This significantly positive fluid balance is associated with generalized edema, pleural effusions, and ascites, all of which are known to be causes of ACS. ACS can also compress femoral cannulas, thus diminishing the effectiveness of the ECMO therapy [28]. Clinical assessments significant for the monitoring of abdominal compartment syndrome include physical monitoring of abdomen for tension, distention (diameter), discoloration, and, if the technology is readily available, measurement

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

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

may not exist at all institutions who utilize ECMO support [36].

initiated [1]. Adjustments on the sweep gas flow rates and increased oxygenation settings can be used during physical therapy based on clinician assessment [1]. In the aforementioned study, 167 of the 254 patients supported on ECMO received physical therapy [36]. One hundred and thirty-four of those patients had at least one femoral cannula, while 66 patients had two, 44 of which were on VA-ECMO and 39 of whom were on VA-ECMO with bi-femoral cannulas. Only five patients had a dual-lumen catheter. Only three minor events were recorded during physical therapy: one episode of hypotension and two episodes of arrhythmias. Of the patients who received physical therapy, 109 patients survived hospital discharge, and 26 of those patients were discharged home. The patients who received physical therapy while on ECMO scored higher on their ICU mobility scale (IMS) than the ones who only received physical therapy after decannulation [36]. It is important to note that this was only possible due to a dedicated team of individuals specifically trained for the initiation and completion of physical therapy and mobility in ECMO patients and that the resources necessary to develop this type of team

The Society of Critical Care Medicine developed the ABCDEF (**A**ssess, prevent, and manage pain; **B**oth spontaneous awakening and breathing trials; **C**hoice of analgesia and Sedation; **D**elirium assess, prevent, and manage; **E**arly mobility and exercise; **F**amily engagement/empowerment) bundle as an ICU Liberation Collaborative [25]. A recent study measured the success of this bundle on over 15,000 patients spread across 68 academic, community and federal intensive care units. Patients who received more of the ABCDEF bundle each day showed lower delirium rates, less use of physical restraints, decreased length of mechanical ventilation, avoidance of ICU readmission, increased instances of being discharged to home, and ultimately decreased mortality rates [25]. The significance of this bundle is that it can be applied to every ICU patient regardless of their diagnosis, including the ECMO patient population. Implementing the ABCDEF bundle on ECMO patients potentially increases the likelihood of returning to their baseline function sooner.

**5. Nursing implications for detection and prevention of systemic** 

The use of ECMO is accompanied by a myriad of potential complications across multiple body systems that are considered calculated risks upon initiation of therapy; however, without it, mortality may increase in conditions like severe acute heart failure [32]. A recent, international, randomized controlled trial (RCT) also suggests a potential mortality benefit with the use of ECMO in severe acute respiratory distress syndrome (ARDS); however, it was found to not be statistically significant [8]. There is abundant literature surrounding the complications of ECMO; but, despite these risks, survival to hospital discharge is greater than 50% [4, 12]. In one recent meta-analysis, the most frequently reported complications associated with ECMO include acute kidney injury (AKI), bleeding, and infection [6]. Specialized RNs have knowledge and understanding of potential complications related to ECMO therapy and can assist with early detection through critical thinking, performing frequent assessments, and reporting them through an open dialog

The incidence of acute kidney injury (AKI) has been reported as high as 80% of ECMO patients and is associated with a quadrupled mortality risk [13, 34]. Severe fluid

**complications related to ECMO**

with the team of providers involved.

**5.1 Renal and other intraabdominal complications**

**18**

overload is one of the major reasons that renal replacement therapy (RRT) is initiated in this population and is often performed through the ECMO circuit but can also be performed after the pump, which could lower the risk of air embolism not trapped by the oxygenator [34]. Fluid overload is independently associated with increased mortality, prolonged LOS, prolonged ventilator time, and prolonged ECMO time [13, 34].

This consideration can lead providers to assume earlier RRT for therapeutic fluid removal would reduce these comorbidities; however, there is little data to suggest the efficacy of this. In fact, studies suggest increased mortality in ECMO patients who require RRT during their time on pump [16, 37]. Of ECMO patients who suffer AKI, an estimated 46% of survivors require RRT after ECMO is completed [6]. The bedside RN can assist in early identification of AKI by monitoring urine output; measuring strict fluid intake and output; assessing serial serum chemistry values, particularly serum creatinine and trends of electrolyte dyscrasias; and identifying physical exam findings consistent with fluid overload.

Abdominal compartment syndrome (ACS) is a known complication of ECMO [3]. This can be caused by massive fluid overload, which can be necessary to keep ECMO flows appropriate (read aforementioned suction events) [3]. This significantly positive fluid balance is associated with generalized edema, pleural effusions, and ascites, all of which are known to be causes of ACS. ACS can also compress femoral cannulas, thus diminishing the effectiveness of the ECMO therapy [28]. Clinical assessments significant for the monitoring of abdominal compartment syndrome include physical monitoring of abdomen for tension, distention (diameter), discoloration, and, if the technology is readily available, measurement of intraabdominal pressure.

#### **5.2 Hematological complications**

Bleeding is the most frequent complication associated with ECMO and affects approximately 30% of the patients receiving the therapy [2]. Bleeding may occur secondary to primary injury such as trauma and surgery or as a result of ECMO itself. Disruption of the red blood cell membrane leads to hemolysis, which is a common complication of patients on ECMO [11]. SIRS and contact between the patient's blood and the ECMO circuit lead to activation of the coagulation cascade, affecting fibrinolysis, thrombin formation, and platelet function [2].

Large amounts of bleeding will cause losses and consumption of coagulation factors and platelets, leading providers to believe that a heparin overdose may be occurring, thus decreasing the heparin, leading to acute thrombosis of the ECMO circuit or in other places where blood flow may be stagnant [22]. Thrombosis is mainly associated with VA-ECMO and can occur in the atria, ventricles, upper and lower extremity deep vein thrombosis (DVT), pulmonary vasculature, brain, or the ECMO circuit [22]. Unfractionated heparin (UFH) is well known, easily monitored, and easily reversible, allowing its frequent use managing hypercoagulability in the ECMO patient. Institutional guidelines vary; but, systemic anticoagulation with UFH infusion to target aPTT between 50 and 70, with some variations [2]. Despite ease of use, UFH can be associated with complications such as heparin-induced thrombocytopenia (HIT), further contributing to bleeding [22]. Alternatives such as warfarin, lepirudin, or argatroban may also be used in lieu of UFH for anticoagulation in the event of HIT [2]. The ECMO patient provides a unique challenge for providers, who must balance hypercoagulability with coagulopathy with careful but aggressive, administration of blood product transfusions and anticoagulants.

It is clear that there is a litany of reasons the patient on ECMO may experience bleeding and bleeding often results in the need for transfusion. Adult patients on ECMO may require 2–3 units of packed red blood cells (PRBCs) and up to 14 units of plasma or cryoprecipitate daily [11]. Additionally, platelet counts of 45,000– 60,000 count/μL are associated with mild to moderate bleeding [11]. Demands on bedside clinicians can be burdensome, as transfusion requirements have been reported to average 45 units of packed red blood cells transfused per adult ECMO patient [11].

Large transfusion volumes are independently associated with increased mortality [11]; despite this, anticoagulation remains the standard practice in patients undergoing ECMO due to thrombotic complications [2]. With the significant risk for bleeding and the subsequent need for anticoagulation, nursing can expect regular and repeated blood draws, transfusions, and anticoagulant titration to be a part of their daily practice in the care of the ECMO patient.

#### **5.3 Infectious complications**

A prospective, 1-day study identified approximately 50% of adult patients in over 1200 ICUs internationally whom were thought to have some form of infection, increasing ICU, and hospital mortality rates by over double that of patients without infection [35]. The literature suggests that from anywhere 13–26% of reported nosocomial infection rate in adults receiving ECMO (particularly VA-ECMO) is significantly associated with infection before initiation of ECMO, prolonged LOS, ECMO duration (particularly >10 days), and prolonged ventilator days [5, 14, 15, 30]. In the ICU patient, respiratory infections are most common; however, with the addition of ECMO, blood stream infections become most prominent [17, 35]. Other reported nosocomial events in ECMO patients include respiratory, urinary, and surgical site infections [17].

Care provided by the specialized RN remains inherently important in the prevention of infection, particularly when caring for lines and their cannulation sites with thorough hand, cannulation site, and patient hygiene and the application of impermeable site dressings. Protocols preventing ventilator-acquired pneumonia (VAP) are common practice and include interventions like hand hygiene, meticulous oral care with chlorhexidine gluconate solution, endotracheal tube cuff pressure control, and control of sedation [27]. Further management of routine line and cannulation site management are further discussed earlier in this chapter under Section 2.

#### **5.4 Cardiopulmonary complications**

Cardiopulmonary complications are often resultant of high left ventricular (LV) afterload, especially on prolonged ECMO (particularly VA-ECMO), which can lead to pulmonary edema [21]. Other cardiac sequelae include aortic valve regurgitation, biventricular failure, and LV thrombus which have been treated with a variety of modalities including intra-aortic balloon pump (IABP) and other percutaneous and surgical procedures to shunt elevated LV pressures [24]. Additional lung complications significantly associated with ECMO include pulmonary hemorrhage, hemorrhagic pulmonary infarct, pulmonary calcifications, and fibrinous pleuritis [18]. The bedside RN can assist with early detection of these complications by close assessment of vasopressor and inotrope requirements, endotracheal secretions, monitoring the ventilator for peak and plateau pressures, and ensuring daily chest radiographs and frequent echocardiograms which are ordered to monitor progression of cardiopulmonary disease.

#### **5.5 Neurological complications**

A study reviewing nearly 24,000 patients on ECMO revealed 10.9% of incidence of nearly equal prevalence of seizure, stroke, or intracranial hemorrhage (ICH) [23].

**21**

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

event of catastrophic neurologic injury.

interests or maybe even personal preferences.

These patients who suffered ICH while on ECMO had increased mortality, while strokes and ICH alike both demonstrated increased LOS and increased likelihood of requiring placement in a skilled nursing facility (SNF) or long-term acute care hospital (LTACH) upon discharge [23]. Other sources suggest up to 50% of patients on ECMO demonstrate severe neurological sequelae [19]. Intracranial hemorrhage has been identified in as high as 40% of non-survivors of ECMO, and thrombotic

The clinical suspicion for stroke may be obscured in ECMO patients given the multitude of other systemic or metabolic derangements usually encountered in ICU patients [19]. The bedside RN becomes integral to monitoring subtle neurologic indicators such as pupilometer and bi-spectral index, which can read zero in the

With the advent of advancing ECMO technology comes an expanded library for indications of use. VA and VV support are commonly being utilized for bridge-totransplant and respiratory or cardiac failure. Additionally, ECMO therapy is being utilized as bridge to support the body through a medical emergency in the form of extracorporeal cardiopulmonary resuscitation (ECPR). With the introduction of high-tech innovation, critical care nursing frequently encounters stressors due to resource scarcity, increased workloads, and moral distress related to carrying out aggressive life-sustaining treatments that may conflict with the patient's best

ECMO is a costly, resource-intensive therapy requiring commitment from the patient, family, and multiple disciplines. The impact of caring for an ECMO patient puts a mental and physical strain, not only on the patient and family but the entire medical team involved in the patient's care. Providing the intense, complex nursing care impacts not only the nursing staff or ECMO provider but the entire nursing unit caring for the patient. Institutions employing the use of ECMO in treating complex, critically ill patients as one of their only means of survival must have a process that addresses the moral and ethical dilemmas that arise from caring for the critically ill. Common questions are "Who receives ECMO treatment?", "When should support cease?", and "What is the goal of therapy, *quantity* or *quality* of life?" Allocation of nursing resources has become undoubtedly one of the most challenging aspects in caring for patients and families. Nursing staff ratios, complexity of patients, and the mental and physical impact on the bedside nurse become compounded when one critically ill patient draws a majority of a unit's resources. ECMO patients can begin their treatment with significantly unstable hemodynamic parameters requiring multiple blood transfusions, circulatory support with several vasoactive medications, and frequent lab draws pulling a majority of the nursing unit's resources for the care of one patient. This places an enormous burden on the nursing staff to be creative and flexible with patient care assignments. RN:patient ratios may be less than desirable, ultimately impacting the care provided to other patients on the unit as well. Everyone, from the unit manger to housekeeping, plays

a hands-on role in supporting the entire unit as well as the ECMO care team.

How do we reduce some of the ethical or moral dilemmas nurses experience caring for complex, critically ill patients? Communication is the key in healthcare. An integral part of communication is developing and maintaining a team not isolated to healthcare workers but also including the patient and family. Early involvement of the palliative care team and social work is crucial to providing consistent support to the patient and family. Interdisciplinary daily rounds including the bedside nurse,

events have been identified in approximately 15% of ECMO courses [2].

**6. Nursing implications in ethics and ECMO withdrawal**

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

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

part of their daily practice in the care of the ECMO patient.

**5.3 Infectious complications**

surgical site infections [17].

**5.4 Cardiopulmonary complications**

sion of cardiopulmonary disease.

**5.5 Neurological complications**

of plasma or cryoprecipitate daily [11]. Additionally, platelet counts of 45,000– 60,000 count/μL are associated with mild to moderate bleeding [11]. Demands on bedside clinicians can be burdensome, as transfusion requirements have been reported to average 45 units of packed red blood cells transfused per adult ECMO patient [11]. Large transfusion volumes are independently associated with increased mortal-

ity [11]; despite this, anticoagulation remains the standard practice in patients undergoing ECMO due to thrombotic complications [2]. With the significant risk for bleeding and the subsequent need for anticoagulation, nursing can expect regular and repeated blood draws, transfusions, and anticoagulant titration to be a

A prospective, 1-day study identified approximately 50% of adult patients in over 1200 ICUs internationally whom were thought to have some form of infection, increasing ICU, and hospital mortality rates by over double that of patients without infection [35]. The literature suggests that from anywhere 13–26% of reported nosocomial infection rate in adults receiving ECMO (particularly VA-ECMO) is significantly associated with infection before initiation of ECMO, prolonged LOS, ECMO duration (particularly >10 days), and prolonged ventilator days [5, 14, 15, 30]. In the ICU patient, respiratory infections are most common; however, with the addition of ECMO, blood stream infections become most prominent [17, 35]. Other reported nosocomial events in ECMO patients include respiratory, urinary, and

Care provided by the specialized RN remains inherently important in the prevention of infection, particularly when caring for lines and their cannulation sites with thorough hand, cannulation site, and patient hygiene and the application of impermeable site dressings. Protocols preventing ventilator-acquired pneumonia (VAP) are common practice and include interventions like hand hygiene, meticulous oral care with chlorhexidine gluconate solution, endotracheal tube cuff pressure control, and control of sedation [27]. Further management of routine line and cannulation site management are further discussed earlier in this chapter under Section 2.

Cardiopulmonary complications are often resultant of high left ventricular (LV) afterload, especially on prolonged ECMO (particularly VA-ECMO), which can lead to pulmonary edema [21]. Other cardiac sequelae include aortic valve regurgitation, biventricular failure, and LV thrombus which have been treated with a variety of modalities including intra-aortic balloon pump (IABP) and other percutaneous and surgical procedures to shunt elevated LV pressures [24]. Additional lung complications significantly associated with ECMO include pulmonary hemorrhage, hemorrhagic pulmonary infarct, pulmonary calcifications, and fibrinous pleuritis [18]. The bedside RN can assist with early detection of these complications by close assessment of vasopressor and inotrope requirements, endotracheal secretions, monitoring the ventilator for peak and plateau pressures, and ensuring daily chest radiographs and frequent echocardiograms which are ordered to monitor progres-

A study reviewing nearly 24,000 patients on ECMO revealed 10.9% of incidence of nearly equal prevalence of seizure, stroke, or intracranial hemorrhage (ICH) [23].

**20**

These patients who suffered ICH while on ECMO had increased mortality, while strokes and ICH alike both demonstrated increased LOS and increased likelihood of requiring placement in a skilled nursing facility (SNF) or long-term acute care hospital (LTACH) upon discharge [23]. Other sources suggest up to 50% of patients on ECMO demonstrate severe neurological sequelae [19]. Intracranial hemorrhage has been identified in as high as 40% of non-survivors of ECMO, and thrombotic events have been identified in approximately 15% of ECMO courses [2].

The clinical suspicion for stroke may be obscured in ECMO patients given the multitude of other systemic or metabolic derangements usually encountered in ICU patients [19]. The bedside RN becomes integral to monitoring subtle neurologic indicators such as pupilometer and bi-spectral index, which can read zero in the event of catastrophic neurologic injury.
