COVID-19 Procedure: Daily Management and Monitoring of ECMO Audit:

COVID-19 Procedure: Daily Management and Monitoring of ECMO Audit

This process template is part of our COVID-19 Procedures pack. 

It is built as a reproduction of the procedures outlined in the Handbook of COVID-19 Prevention and Treatment (2020) produced by The First Affiliated Hospital, Zhejiang University School of Medicine (FAHZU). 

FAHZU had great success in combatting the novel Coronavirus COVID-19 and this handbook outlines best-practices, procedures, and useful charts for hospitals and medical centers to practically employ. 

The items contained within the handbook were compiled according to clinical experience. 

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You can find the full handbook embedded below.

Process Street is not a medical institution and the items contained in this process template are illustrative and not intended to be understood as medical advice. Please refer to the attached PDF document for any and all medical or operational recommendations. 

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Check ECMO equipment hourly

ECMO equipment should be managed by ECMO perfusionists and the following items should be checked and recorded every hour:

  • 1
    Pump flow rate/rotation speed
  • 2
    Blood flow
  • 3
    Oxygen flow
  • 4
    Oxygen concentration
  • 5
    Ensure that the temperature controller is flowing
  • 6
    Temperature setting and actual temperature
  • 7
    Preventing clots in circuit
  • 8
    No pressure to the cannulae and the circuit tubing is not kinked, or no "shaking" of ECMO tubes
  • 9
    Patient's urine color with special attention to red or dark brown urine
  • 10
    Pre & post membrane pressure as required by the doctor

Monitor equipment during shifts

The following items during every shift should be monitored and recorded:

  • 1
    Check the depth and fixation of cannula to ensure that the ECMO circuit interfaces are firm
  • 2
    The water level line of the temperature controller
  • 3
    The power supply of the machine and the connection of the oxygen
  • 4
    The cannula site for any bleeding and swelling
  • 5
    Measure leg circumference and observe whether the lower limb on the operation side is swollen
  • 6
    Observe lower limbs, such as dorsalis pedis artery pulse, skin temperature, color, etc.

Perform daily monitoring duties

Post membrane blood gas analysis.

Maintain anticoagulation balance

The basic goal of ECMO anticoagulation management is to achieve a moderate anticoagulation effect, which ensures that certain coagulation activity under the premise of avoiding excessive activation of coagulation. That is to maintain the balance among anticoagulation, coagulation and fibrinolysis.

The patients should be injected with heparin sodium (25-50 IU/kg) at the time of intubation and maintained with heparin sodium (7.5-20 IU/kg/h) during the pump flow period.

The dosage of heparin sodium should be adjusted according to APTT results which should be held between 40-60 seconds. During the anticoagulation period, the number of skin punctures should be reduced as less as possible.

Operations should be taken gently. The status of bleeding should be observed carefully.

Implement the "ultra-protective lung ventilation" strategy

Implement the "ultra-protective lung ventilation" strategy to avoid or reduce the occurrence of ventilator-related lung injury.

It is recommended that the initial tidal volume is< 6 ml/kg and the intensity of spontaneous breathing is retained (breathing frequency should be between 10-20 times/min).

Monitor patient status

Closely observe the vital signs of patients, maintain MAP between 60-65 mmHg, CVP < 8 mmHg, 5pO2 > 90%, and monitor the status of urine volume and blood electrolytes.

Follow transfusion procedures

Transfuse through the post membrane, avoiding infusion of fat emulsion and propofol.

Evaluate the ECMO oxygen generator every shift

According to the monitoring records, evaluate the ECMO oxygenator function during every shift.

Sources:

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