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Extracorporeal Membrane Oxygenation (ECMO): Initiation and Management– Pediatric/Neonatal – Inpatient

Extracorporeal Membrane Oxygenation (ECMO): Initiation and Management– Pediatric/Neonatal – Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Respiratory, Related


1



Extracorporeal Membrane Oxygenation (ECMO): Initiation
and Management– Pediatric/Neonatal – Inpatient –
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
INTRODUCTION .................................................................................................................................4
SCOPE ................................................................................................................................................4
DEFINITIONS ......................................................................................................................................4
TYPES OF ECMO .................................................................................................................................4
ECMO CIRCUIT ...................................................................................................................................5
ECMO Circuit Overview .................................................................................................................................... 5
How ECMO Works ............................................................................................................................................ 6
RECOMMENDATIONS .........................................................................................................................8
Indications for ECMO ........................................................................................................................................ 8
Table 2. General Indications and Contraindications for ECMO ............................................................................. 8
Indications for Extracorporeal Cardiopulmonary Resuscitation (ECPR) ........................................................... 9
Table 3. Indications and Contraindications for ECPR ............................................................................................ 9
Placing a Pediatric Emergent ECMO Page ...................................................................................................... 10
Initiation of ECMO .......................................................................................................................................... 11
Venoarterial ECMO (V-A) .................................................................................................................................... 11
Venovenous ECMO (VV) ...................................................................................................................................... 12
Table 4. Patient Management Parameters ......................................................................................................... 13
Table 5. ECMO Circuit Blood Gas Management .................................................................................................. 13
Table 6. Ventilator “Rest” Settings ...................................................................................................................... 13
Circuit and Patient Management ................................................................................................................... 14
ECMO Circuit Management ................................................................................................................................ 14
Monitoring the patient on ECMO ........................................................................................................................ 14
Table 7. Labs and interventions for Patient and ECMO Circuit Monitoring ........................................................ 16
What to do when ECMO circuit fails and when to hand-crank ...................................................................... 17
Sedation and Analgesia................................................................................................................................... 18
Infection Control of ECMO Circuit and Patient Prophylaxis ........................................................................... 19
Infection Control and ECMO Circuit Management .............................................................................................. 19
Obtaining Blood and Yeast Cultures in ECMO Patients ....................................................................................... 19
Antimicrobial Prophylaxis ................................................................................................................................... 20
Anticoagulation Management for Pediatric ECMO ........................................................................................ 21
Baseline monitoring of ECMO UFH infusion ........................................................................................................ 21
Initiation of UFH infusion for ECMO .................................................................................................................... 21
Initial Monitoring of UFH infusion for ECMO ...................................................................................................... 22
Antithrombin III (ATIII) Replacement .................................................................................................................. 23
Additional clinical monitoring ............................................................................................................................. 24
Transfusion support for Pediatric ECMO ........................................................................................................ 25
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2


Transfusion for ECMO initiation and management ............................................................................................ 25
Hemofiltration and Renal Replacement Therapy ........................................................................................... 26
In-line hemofilter ................................................................................................................................................. 26
CRRT Machine to ECMO Circuit ........................................................................................................................... 29
Weaning and Termination .............................................................................................................................. 31
METHODOLOGY ............................................................................................................................... 33
COLLATERAL TOOLS & RESOURCES ................................................................................................... 35
APPENDIX A. CENTRIFUGAL PUMP CIRCUIT CHECKLIST ...................................................................... 37
APPENDIX B. MONITORING THE PATIENT ON ECMO ......................................................................... 38
APPENDIX C. ECMO TROUBLESHOOTING .......................................................................................... 40
VA ECMO Troubleshooting ............................................................................................................................. 40
VV ECMO Troubleshooting ............................................................................................................................. 41
Troubleshooting the ECMO Circuit ................................................................................................................. 42
APPENDIX D. MONITORING UNFRACTIONATED HEPARIN WITH ACT .................................................. 44
REFERENCES .................................................................................................................................... 46




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3


Content Expert:
Name: Sushant Srinivasan, MD – Pediatric Critical Care
Phone Number: (608) 265-4366
Email Address srinivasan8@wisc.edu

Contact for Changes:
Name: Katherine Le, PharmD – Center of Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-5898
Email Address: kle@uwhealth.org

Workgroup Members:
Monica Bogenschutz, PharmD – Pharmacy Inpatient Services
Paula Clark – Special Coagulation Laboratory
Joseph Connor, MD – Transfusion Medicine
Robin Grimes – Transfusion Services Laboratory
Georgios Kirvassilis, MD – Pediatric Anesthesiology
Jillian Koch, RRT – ECMO Coordinator
Donna Lawler, MT(ASCP)SH
CM
– Special Coagulation Laboratory
Nicole Lubcke, PharmD – Pharmacy Inpatient Services
Charles Leys, MD – Pediatric General Surgery
Ryan McAdams, MD – Neonatology
Kari Nelson, NP – Pediatric Cardiothoracic Surgery
Thomas Raife, MD – Blood Bank/Transfusion Medicine
Allison Redpath, MD – Pediatric Nephrology
Anne Rose, PharmD – Pharmacy Inpatient Services
Deb Soetenga, MS, RN, CCNS – Pediatric Critical Care
Tom Steffens, MPS, LP, CCP – Perfusion Services
Josh Vanderloo, PharmD – Drug Policy Program
Michael Wilhelm, MD – Pediatric Critical Care
C. Lydia Wraight, MD – Neonatology
Rhonda Yngsdal-Krenz, RRT – Pediatric Respiratory Therapy

Reviewer(s):
Nicholas Kuehnel, MD – Pediatric Emergency Medicine
Joan Watson, RN – Renal Nursing

Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 10/26/17)

Release Date: October 2017 | Next Review Date: July 2019

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4


Introduction
Extracorporeal Membrane Oxygenation (ECMO) is the use of extracorporeal gas exchange
and/or hemodynamic assistance to provide temporary life support in patients with reversible
pulmonary or cardiac failure. ECMO is similar to cardiopulmonary bypass and has also been
referred to as extracorporeal carbon dioxide removal, extracorporeal heart assist, extracorporeal
lung assist and extracorporeal life support (ECLS).
Scope
Intended User(s): Physicians, Advanced Practice Providers, Nurses, Respiratory Therapists
(RT), ECMO Specialists, Perfusionists, Pharmacists

Objective(s): To provide basic ECMO information and guidance on managing ECMO patients
in the Pediatric Intensive Care Unit (PICU)

Target Population: Neonatal and pediatric patients with a reversible and (potentially)
survivable disease, disorder or injury who meet criteria for ECMO

Clinical Questions Considered:
• What indications and contraindications should be considered when placing a neonatal or
pediatric patient on ECMO?
• What ventilator “rest” settings may be used and target patient management parameters
to consider upon ECMO initiation?
• What labs and interventions are used and how often should they be conducted when
monitoring the ECMO circuit and patient?
• What antibiotics should be considered for prophylaxis and for long?
• How is unfractionated heparin used and monitored when anticoagulating a patient on
ECMO?
• What to consider when initiating hemofiltration or renal replacement therapy in a
pediatric ECMO patient?
• What is the general process for weaning a pediatric patient from ECMO?
Definitions
• Neonate – a patient from birth to 28 days old
• Pediatric – a patient from 29 days to 18 years old
Types of ECMO
The two most common types of ECMO are venovenous (VV) and venoarterial (VA). In VV
ECMO, blood is removed from one or two large veins, circulated externally through the ECMO
circuit (with membrane lung and pump) and then returned to the venous side of circulation. In
VV ECMO, since blood is returned to the venous circulation, systemic perfusion depends on the
patient’s own cardiac output. Therefore VV ECMO is predominantly used for pulmonary
support.
1


In contrast to VV ECMO, with VA ECMO, blood is returned to the body into systemic arterial
circulation.
1
In VA ECMO, both the patient’s lungs and heart are bypassed and cardiac output is
supported by the ECMO pump.
2
Table 1 summarizes key differences between VV and VA
ECMO.


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5


Table 1- Differences between venovenous and venoarterial ECMO
3,4

VV ECMO VA ECMO
• Does not provide cardiac support to
assist systemic circulation
• Requires only venous cannulation
• Higher perfusion rates may be required
• Elevates mixed venous PO
2

• Achieves lower arterial oxygen tension
(PaO
2
)
• ECMO circuit is in series to the heart and
lungs

• Provides cardiac support to assist systemic
circulation
• Requires arterial and venous cannulation
• Lower perfusion rates may be adequate
• Decreases pulmonary artery pressures
• Achieves higher arterial oxygen tension
(PaO
2
)
• ECMO circuit is in parallel to the heart and
lungs
ECMO Circuit
ECMO Circuit Overview
The standard ECMO set-up or “circuit” consists of a mechanical blood pump, a gas-exchange
device (i.e., membrane lung/oxygenator), and a heat exchanger. A centrifugal pump (versus a
roller pump) is typically used at UW Health for pediatric patients. A CDI
®
System 500 blood
parameter monitor may be also incorporated into the circuit during initial ECMO circuit set-up.

The CDI
®
500 blood parameter monitor is an in-line blood gas monitoring device used during
ECMO. It provides continuous blood gas and electrolyte measurements for pO
2
, pCO
2
, pH,
SvO2, hematocrit, hemoglobin, bicarbonate and potassium, as well as temperature.

The components are all connected together with polyvinyl chloride tubing between the venous
access cannula and either the venous (VV) or the arterial infusion canula (VA), as depicted in
Figure 1.
5


The appropriate ECMO circuit size is determined by the weight of the patient; the larger the
circuit membrane surface, the greater potential for gas exchange. However, a larger membrane
surface area also means higher platelet consumption and circuit priming volume. Since a circuit
is not always primed with blood, a high priming volume relative to the patient’s circulating blood
volume will result in hemodilution.
4



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6


Figure 1. Schematic overview of ECMO Circuit


How ECMO Works
Deoxygenated blood is drained from the venous cannula directly to the centrifugal pump.
4
A
venous cannula with largest lumen and shortest length possible is typically used.
1
The ECMO
pump (i.e., centrifugal pump) creates a negative pressure to pull venous blood from the patient.

The ECMO pump then propels blood through the membrane lung (“oxygenator”) where oxygen
is constantly being delivered. In the membrane lung, a non-microporous hollow fiber membrane
separates two compartments; one with the patient’s blood and the other the gas containing
compartment.
4
(See Figure 2)
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7



As the patient’s blood flows past one side of the membrane, oxygen diffuses from the gas
containing compartment into the blood cells. Carbon dioxide is concurrently removed or “swept
out” from the blood into the gas compartment by a ventilating gas (i.e., “sweep gas”). The
sweep gas is regulated by a flow meter connected to the membrane lung.
4
The gas exchange
capability of the membrane lung (i.e., oxygenator) is described as “rated flow” or “maximal
oxygen delivery.”

The amount of oxygen delivered to the patient’s blood and the amount of carbon dioxide
removed from the blood are dependent upon the partial pressure gradient for the gases across
the membrane lung. The oxygen delivered to the patient’s blood is determined by the amount of
oxygen in the sweep gas and the available surface area for diffusion. Maximal O
2
delivery is
the amount of oxygen delivered per minute when running at rated flow (calculated as outlet
minus inlet O
2
content.
6


The amount of carbon dioxide removed from the blood is determined by the sweep gas flow and
the surface area. Increasing the sweep gas flow rate will increase carbon dioxide removal,
however oxygenation will not be affected at all.
Figure 2. How ECMO Works


The ECMO circuit is much more efficient at removing carbon dioxide because of the solubility
and diffusion properties of carbon dioxide relative to oxygen. Thus carbon dioxide removal will
exceed oxygen delivery when the circuit is planned for full support.
6,7


As blood moves through the ECMO circuit, heat is lost, thus a heat exchanger is used to keep
the blood warm prior to returning to the patient’s body via the arterial or venous infusion
cannula. At UW Health, the Quadrox-d
®
oxygenator (i.e., membrane lung) is used and the heat
exchanger is integrated into the device. This allows for better body temperature control without
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8


the need for additional components.
5
In general, the temperature of the water bath for the heat
exchanger is maintained <40°C, usually at 37°C.
6

Recommendations
Indications for ECMO
UW Health is a member of the Extracorporeal Life Support Organization (ELSO), an
international consortium of health care centers dedicated to the development of extracorporeal
life support (ECLS) techniques. ECLS is another term for ECMO. According to ELSO,
indications for ECMO are acute severe heart or lung failure with high mortality risk despite
optimal conventional therapy. ECLS can be considered at 50% mortality risk and indicated in
most circumstances of high mortality risk.
6
Key to ECMO survival and morbidity outcomes is
implementation prior to the development of irreversible organ injury.
8
Table 2 lists general
indications and contraindications to consider for ECMO. (UW Health Moderate quality of evidence,
weak/conditional recommendation)

Table 2. General Indications and Contraindications for ECMO
6,9,10

Indications for ECMO Contraindications for ECMO
• Underlying disease process is
treatable and potentially
reversible
• Oxygenation index > 30
• PIP/AMP >30
• Air leak/barotrauma
• Hemodynamic or respiratory
failure refractory to conventional
therapy
• Arrhythmia refractory to
conventional therapy


• Gestational age < 34 weeks
• Birth weight < 1.6 kg
• Multisystem organ failure of > 3 organ systems
• Severe Disseminated Intravascular coagulation (DIC)
• IVH ≥ grade 3 or irreversible brain damage
• Irreversible lung disease and/or Persistent pulmonary
hypertension of the newborn (PPHN)
• Recent neurosurgical procedures or intracranial bleeding
(within 10 days)
• Ongoing hemorrhagic condition/evidence of uncontrolled
bleeding or coagulopathy
• Irreversible cardiopulmonary failure
• Do not resuscitate order
• Parental refusal for use of mechanical support

Relative Contraindications
• Birth weight < 2 kg
• IVH > grade 2
• Cardiac lesion (coarctation)*
* Congenital diaphragmatic hernia (CDH) and congenital heart disease patients will be considered on a case-by-case
basis for ECMO depending on the type of cardiac lesion and severity of the CDH. For additional guidance on CDH
patients, refer to the Congenital Diaphragmatic Hernia-Neonatal Guideline.

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9


Indications for Extracorporeal Cardiopulmonary Resuscitation (ECPR)

Extracorporeal cardiopulmonary resuscitation (ECPR) is defined by the American Heart
Association (AHA) as the initiation of cardiopulmonary bypass during the resuscitation of a
patient in cardiac arrest.
11
In ECPR only VA-ECMO is employed.
The AHA does not recommend routine use of ECPR for patients in cardiac arrest but
recommends that, in settings where ECPR can be rapidly implemented, ECPR “may be
considered for select patients for whom the suspected etiology of the cardiac arrest is potentially
reversible during a limited period of mechanical cardiorespiratory support.”
11
(AHA Class IIb, LOE
C-LD)While no distinct inclusion criteria are given, the AHA guideline notes that criteria to
consider for ECPR include conventional CPR for more than 10 minutes without return of
spontaneous circulation (ROSC). The ELSO guideline on ECPR also does not give succinct
indications but states that all contraindications for ECMO use (e.g., gestational age < 34 weeks)
apply to ECPR patients.
6


At UW Health, ECPR can be initiated for pediatric patients in the Pediatric Intensive Care Unit
(PICU), Operating Room (OR) or Pediatric Cardiac Catheterization Lab. Table 3 summarizes
criteria to consider for ECPR in pediatric patients at UW Health. Refer to section “Placing a
Pediatric Emergency ECMO Page” for information on the initiation of emergent ECMO or ECPR.

Table 3. Indications and Contraindications for ECPR
12,13

VA Contraindications for ECPR
• Monitored or witnessed in-hospital cardiac
arrest with initiation of prompt and effective
CPR
• No recovery of cardiac function within 20
minutes of the initiation of CPR

• Do not resuscitate (DNR) order
• Parental refusal for use of mechanical
support
• All other general contraindications for
ECMO use (see Table 2)


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10


Placing a Pediatric Emergent ECMO Page
















If ECMO is needed for a pediatric patient in an emergent situation, such as ECPR, an
Emergent ECMO page should be sent.

The Emergency ECMO page will be sent to the following individuals:
• PICU attending and fellow
• All pediatric general surgeons
• All pediatric cardiothoracic surgeons
• All pediatric cardiac anesthesiologists
• Pediatric ECMO Director
• PICU Medical Director
• ECMO Coordinator
• All pediatric respiratory therapists in house
• University Hospital Charge Respiratory Therapist
• All Pediatric Cardiothoracic Surgery Physician Assistants
• PICU Pharmacist on call
• All pediatric cardiac physician assistants and nurse practitioners

The following outlines the procedure for sending out the page:
• Send Emergent ECMO page (pager 4844) with following information:
o patient’s medical record number
o location (PICU/OR/Cath lab)
o patient’s weight
o call back number
• Call the AFCH OR Charge Nurse at 608-890-7200
o Perfusion should be notified by OR at this point
• Physician and nursing staff who are on-call that received page and are not
already at bedside should call PICU (608-263-8049) and say, “I’m [your name],
received ECMO page, and will be there in [X] minutes.” No patient details
should be discussed to avoid tying up phone lines.
• The Health Unit Coordinator (HUC) should note the time of the Emergent
ECMO page is sent, who calls and the time of the call back.
o The HUC needs to ensure a pediatric surgeon and perfusionists have
called back.

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11


Initiation of ECMO

For CDH patients who will be placed on ECMO, it is recommended that in the peri-operative
period, the ACT goal should be determined by the surgeon. (UW Health Low quality of evidence,
weak/conditional recommendation)

It is also recommended that a pressure relieving surface be placed under high pressure areas
(i.e., occiput, ears.) when the OR team is cannulating the patient for ECMO.
14,15
(UW Health Low
quality evidence, weak/conditional recommendation)

Once the cannulation is complete, it is recommended that nursing complete a new Braden Q
score due to the change in level of care.
16
(UW Health Low quality evidence, weak/conditional
recommendation) It is also recommended that a wound care consult be placed. (UW Health Low
quality of evidence, weak/conditional recommendation)
Venoarterial ECMO (VA)
Once cannulated for VA ECMO, flow is gradually increased slowly over 1-10 minutes depending
on patient condition and age. The younger the patient is, the slower the rate of increase. This
rate is increased to a calculated flow of 100 – 120 mL/kg/min. In general it is recommended
that the FiO2 of the ECMO blender be set at 1.0 and the sweep gas rate equal to the blood flow
rate (1:1 ratio) when starting ECMO. (UW Health Low quality of evidence, weak/conditional
recommendation)

As pump flow is increased, hemodynamic instability and decreased venous drainage may occur.
This volume shift may be replaced with packed red blood cells (PRBC), 5% albumin, pump
prime contents, or crystalloid. Careful attention should be made as to not fluid overload the
patient. Possible causes of poor venous return should be excluded such as cannula
malposition. In addition, if a patient is acutely hypotensive when going on ECMO and is not
responsive to increasing the flow, consider calcium administration to augment native contractility
and cardiac output. (UW Health Low quality of evidence, weak/conditional recommendation)

Aliquots of 5 – 10 mL/kg of fluid may be given to treat hypovolemia. During the initial phase of
full support, small changes in flow rate may be required to optimize systemic hemodynamics
and general patient management targets in Table 4. Suggested ECMO circuit blood gas
parameters are listed in Table 5. Ventilator settings may be reduced to “rest settings” during
this time as well (Table 6.) It is very important to avoid hypertension in the neonate to reduce
the risk of bleeding, especially intracranial bleeding when anticoagulated. As hemodynamic
stability ensues, cardiovascular drugs may be weaned and disconnected as tolerated.


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12


Venovenous ECMO (VV)
Prior to initiating VV ECMO, inotropic support may be increased until an increase in blood
pressure is seen. This technique is employed due to hypotension that may occur from the
“wash-out” effect that initiating ECMO has on a patient. Also, careful attention must be made
that the ECMO circuit prime has a normalized ionized calcium and potassium level given the
limited ability in VV ECMO to support hemodynamics. Failure to do this can result in cardiac
arrest during VV ECMO initiation. If the patient is acutely hypotensive when going on ECMO
and is not responsive to increasing the flow, consider calcium administration. (UW Health Low
quality of evidence, weak/conditional recommendation)

Pump flow is initiated at 50 mL/kg/min in a neonatal or pediatric patient and increased SLOWLY
by 10-15 mL/kg/min and increased over 5-15 minutes to a flow of 120 -150 mL/kg/min. It is
recommended that the FiO2 of the ECMO blender be set at 1.0 and the sweep gas rate equal to
the blood flow rate (1:1 ratio) when starting ECMO. (UW Health Low quality of evidence,
weak/conditional recommendation)

“Recirculation” is a phenomenon that occurs only in VV ECMO. A portion of blood that has
been oxygenated in the circuit will flow directly from the re-infusion site and be taken up by the
venous drainage catheter instead of going to the patient. (See Figure 3 for schematic diagram
of recirculation.) This amount of redundant flow is defined as the recirculation fraction and is
estimated as
6
:
Recirculation (R) = SvO2
(preOxy)
– SvO2
(pt)
/(SvO2
(postOxy)
– SvO2
(pt)
)


Figure 3. Schematic diagram of recirculation in VV ECMO (with double lumen catheter)
6





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13


Due to possible recirculation, oxygenation is assessed by monitoring:
1. The trend in venous saturation.
2. Changes in pulse oximetry.
3. Saturation of a cephalad catheter if employed.
4. Total oxygen uptake across the membrane.

Because VV ECMO provides no direct circulatory support it can be difficult to achieve the same
level of oxygen delivery as during VA ECMO. Increasing the hemoglobin may enhance oxygen
content and thus delivery. If fluid boluses are required, PRBC infusion is the product of first
choice, but careful attention should be made to avoid fluid overloading the patient. (UW Health
Moderate quality evidence, weak/conditional recommendation) Possible causes of poor venous
return should be excluded. See Appendix C. ECMO Troubleshooting for possible actions.

Aliquots of 5 – 10 mL/kg of fluid may be given to treat hypovolemia. During the initial phase of
full support, small changes in flow rate may be required to optimize flow to achieve general
patient management targets listed in Table 4. Suggested ECMO circuit blood gas parameters
are listed in Table 5. Ventilator settings may be reduced to “rest settings” during this time as
well (Table 6). As hemodynamic stability ensues, cardiovascular drugs may be weaned and
discontinued as tolerated.
Table 4. Patient Management Parameters

VA VV Notes
HCT > 25 >30
17
Goal to minimize transfusion unless bleeding
Can adjust targets if bleeding or inadequate
oxygen delivery
Plts >75 K/µL >75 K/µL Goal to minimize transfusions unless bleeding
Sats >90 >80
Flows 100-120 mL/kg/min 100-150 mL/kg/min

Adequate flow to be determined by SVO2 and
NIRS values; lactate
pH 7.35 – 7.45
18
7.30 -7.40 Adjust per patient condition
PaO2 < 300 <120 Goal is to avoid hyperoxia
pCO2 35 – 45 mm Hg
18
40 – 50 mm Hg
Table 5. ECMO Circuit Blood Gas Management

Premembrane (Venous) Postmembrane
pH 7.30 –7.40 7.40 – 7.50
PCO
2
45 – 55 30 – 40
PO2 35 – 45 mm Hg
18
> 200 mm Hg
Saturation > 65% 100%

Table 6. Ventilator “Rest” Settings
18-21

Setting Notes
Fi02 0.21- 0.30
Intermittent mandatory
ventilation (IMV)
4 – 10 breaths per
minute

Peak inspiratory pressure (PIP) 20 – 30 cm Limit PIP to avoid alveolar overdistention
Positive End-expiratory Pressure
(PEEP)
5-12 cm H
2
O CPAP/High PEEP 10-12 cm to maintain
functional residual capacity (FRC) can
often shorten bypass time.

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14


Circuit and Patient Management
ECMO Circuit Management

Temperature
The ECMO circuit water bath should be adjusted to achieve the desired patient temperature
which should not exceed 37.5°C.
18
(UW Health Moderate quality evidence, weak/conditional
recommendation)

Given the complexity of the ECMO circuit though, it is important to be vigilant and conduct
precise, thorough and consistent management of the circuit. Appendix A gives an example of a
circuit checklist, usually conducted by the ECMO Specialist, with checks that should be
completed hourly, every 8 hours and daily. Targets for ECMO circuit blood gases are given in
Table 5.
Monitoring the patient on ECMO
Neuromonitoring
Neurologic injury is a significant risk factor for morbidity and mortality in ECMO patients and
remains an important predictor of survival post-ECMO. Patients are at risk for seizures,
intraventricular hemorrhage, cerebral infarction and brain death. There is no gold standard for
neurologic monitoring in ECMO and the most commonly employed methods are head
ultrasound (in infants with an open fontanelle) and EEG.
22
The following are neuromonitoring
guidelines for pediatric ECMO patients at UW Health:
1. It is recommended to obtain a daily head ultrasound starting on the first day of
cannulation for any pediatric ECMO patient less than 12 months of age and/or with an
open fontanelle.
18,19
(UW Health Low quality evidence, strong recommendation)
2. Recurrent and comprehensive neurological assessments (e.g., pupillary size, response
to light, response to pain) must be done frequently (e.g., every 2 hours) on patients.
23,24

(UW Health Low quality evidence, strong recommendation)
3. An electroencephalogram (EEG) is recommended for neonatal and pediatric ECMO
patients who are under heavy sedation or neuromuscular blockade where a neurological
assessment is limited. (UW Health Low quality evidence, weak/conditional recommendation)
4. It is recommended to initiate and maintain cerebral near-infrared spectroscopy (NIRS)
monitoring in all ECMO patients.
25
(UW Health Low quality evidence, strong recommendation)

Cardiovascular monitoring
1. Chest x-ray is recommended daily to check cannula placement and integrity.
18,19
(UW
Health Low quality evidence, strong recommendation)
2. Wean vasopressors, as allowed, for VA-ECMO patients following ECMO initiation. (UW
Health Low quality evidence, weak/conditional recommendation)
3. Ensure adequate cardiac output and oxygenation by heart rate, respiratory rate, blood
pressure, pH, paO2, PaCO2, lactate, and mixed venous oxygen saturation.
4. Monitor for limb ischemia by comparing temperature of extremities/warmth, skin color,
presence/absence of edema and peripheral pulses (using Doppler and/or NIRS
monitoring, if necessary).
6,26

5. It is recommended to initiate and maintain renal NIRS monitoring in all ECMO
patients.
25,27
(UW Health Low quality evidence, strong recommendation)
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15


6. It is recommended to monitor mixed venous blood from CDI Blood Monitoring system.
(UW Health Low quality evidence, strong recommendation)

Skin care
1. Verify wound consult has been ordered and/or completed. (UW Health Very low quality
evidence, weak/conditional recommendation)
2. The medical team should be consulted prior to any repositioning the patient and to what
level to raise the head of the bed to. (UW Health Low quality evidence, strong
recommendation)
3. The ECMO Specialist should assist whenever the patient is repositioned or the head of
the bed is raised. (UW Health Low quality evidence, strong recommendation)
4. For patients > 2 years of age, when possible, place on a turn and repositioning device.
28

(UW Health Low quality evidence, weak/conditional recommendation)
5. It is recommended that nursing and ECMO Specialist assess cannulation site for
drainage and skin integrity issues related to the cannulas and findings and treatments be
discussed with medical team.
6
(UW Health Low quality evidence, strong recommendation)
6. When possible, high risk areas for pressure ulcer development should be assessed
(e.g., occiput, ears, elbows, sacrum, scapula for redness, non-blanching or other signs
of skin breakdown.)
7. It is recommended to assess for skin integrity issues within skin folds and check for
moisture and signs of yeast infection. (UW Health Low quality evidence, strong
recommendation) If moisture is found, it may be treated with InterDry
®
moisture wicking
fabric. For yeast infection treatment, an anti-fungal is recommended. (UW Health Low
quality evidence, strong recommendation)
8. Place patient on absorbant pads to wick moisture away from skin. (UW Health Low quality
evidence, strong recommendation)

Table 7 outlines labs and interventions to conduct to aid in monitoring the patient while on
ECMO and their recommended frequency. Appendix B outlines assessments and
interventions for monitoring the patient which may fall under nursing care.


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16


Table 7. Labs and interventions for Patient and ECMO Circuit Monitoring
29

Monitoring Intervention General Frequency and Comments
Chest radiography Daily
Electrocardiogram Once post-cannulation (for cardiac patients)
Cranial ultrasonography Daily
Activated clotting time Every hour upon initiation; once stable, then as needed
Antifactor-Xa (anti-Xa)
Check within 6 hours of heparin initiation then every 6 hours when
stable
Pre-membrane blood gas
(pre-oxygenator)
Every 8 hours for first 24-48 hours until stable and then daily or as
needed thereafter (with no changes in circuit FiO2 and sweep)
Post-membrane blood gas
(post-oxygenator)
Every 8 hours for first 24-48 hours until stable and then daily or as
needed thereafter (with no changes in circuit FiO2 and sweep)
Patient blood gas
(including hemoglobin, electrolytes,
lactate, and ionized calcium)
Every 4 hours
Glucose monitoring test Every 4 hours
Complete blood cell count (CBC)
with platelets
Once daily and as needed
If blood product replaced, full blood (vs whole CBC)
hemoglobin/hematocrit and platelets redraw 1 hour after transfusion
completion
Basic Metabolic Panel
(Sodium, potassium, chloride,
total carbon dioxide, anion gap,
glucose, BUN, creatinine,
calcium)
Every 12 hours (calcium, magnesium, phosphorus, re-check based
on replacement needs)
PT/INR and Fibrinogen
Every morning; if infusion of blood products (e.g., cryoprecipitate,
fresh frozen plasma) redraw 4 hours after infusion completion
Blood culture
(bacteria and yeast)
Daily (starting on Day 1 of ECMO

* For patients not placed on ECMO emergently (e.g., ECPR), yeast
culture may be obtained starting on Day 3

It is recommended to draw blood from patient versus drawing from the heparinized circuit to
avoid falsely elevated anti-Xa or ACT levels. (UW Health Low quality of evidence, strong
recommendation)
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17


What to do when ECMO circuit fails and when to hand-crank

If the ECMO circuit fails (e.g., pump stops or power failure), it is considered an emergent
situation. Staff should be ready and prepared to support the patient as if it were a “code.” It is
recommended to: (UW Health Low quality evidence, strong recommendation)
• Call for help
• Be prepared to perform CPR if necessary and support the patient with emergency code
drugs and ventilator settings (e.g., shift patient back to pre-ECMO ventilator settings)
4


If there is a loss of power (e.g., regional electric service down), all possible electrical sources for
the pump (i.e., hospital generator and batteries) should be exhausted before hand-cranking the
pump. (UW Health Low quality of evidence, strong recommendation) Other situations where it may be
necessary to hand-crank the pump include:
• catastrophic pump failure (i.e., pump just stops)
• decoupling of the pump head (i.e., typically occurs only when running very high flows)

Per the manufacturer, an unusually high-pitched sound typically indicates when pump failure is
occurring. If this occurs, it is recommended to replace the centrifugal blood pump immediately.
Pump replacement may also be necessary if the pump vibrates or makes a grinding noise which
continues upon use.
30
In an emergency situation, before hand-cranking the pump, ensure that
arterial/venous clamps are removed prior to initiating flow support. (UW Health Low quality
evidence, strong recommendation)

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18


Sedation and Analgesia

While some ECMO patients may be awake and calm for decannulation, many ECMO patients
will be deeply sedated throughout their ECMO run.
31
It is recommended that a sedation goal be
set for a pediatric ECMO patient and analgesia and medications be administered as outlined in
the UW Health Pediatric Inpatient Pain and Agitation Continuous Infusion Titration Practice
Protocol.
32
(UW Health Low quality evidence, strong recommendation) It is important to note that due
to the ECMO circuit adsorbing some medications, patients may require higher total amounts of
medication (e.g., more frequent boluses or have medication titrated more rapidly) to achieve
analgesic and sedation goals.

Paralysis should also be avoided in ECMO patients, if possible, except during cannulation and
decannulation.
21
(UW Health Low quality evidence, strong recommendation) Cardiac patients on
ECMO may also receive muscle relaxants throughout their ECMO run.
31


Opiates
The two most commonly used opiates are fentanyl and morphine.
2,31,32
Fentanyl poses a unique
challenge with ECMO patients because of its adsorption into the ECMO circuit. While fentanyl
adsorption may be less with newer ECMO component materials, circuit adsorption nevertheless
occurs and the amount adsorbed can significantly reduce the expected analgesic effect.
33

Moreover, neonatal patients can also develop tachyphylaxis to fentanyl’s analgesic effect,
further requiring dose escalation to maintain a patient’s comfort.
2
Morphine is the preferred
opiate when hemodynamically feasible, as circuit adsorption and tachyphylaxis are less
problematic.
33
(UW Health High? quality of evidence, weak/conditional recommendation.)

Sedatives
The two most commonly used sedatives are midazolam and lorazepam.
2,32
Midazolam, like
fentanyl, can also be significantly adsorbed into the ECMO circuit. It is also metabolized by
cytochrome P4503a4/5 to an active metabolite, a process that is prolonged in critically ill
children.
2
Lorazepam can also be adsorbed into the ECMO circuit but not necessarily to the
extent of midazolam. Because the solubility of lorazepam in water though is poor it requires the
parenteral formulation to contain polyethylene and propylene glycol. Due to possible
intravenous toxicities associated with propylene glycol, midazolam tends to be preferred and
clinicians should be aware that ECMO patients may require higher dosages to achieve desired
sedation status.
33
(UW Health Low quality evidence, weak/conditional recommendation)


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19


Infection Control of ECMO Circuit and Patient Prophylaxis
When a patient is placed on ECMO, there is significant risk for infection during bypass. In
January 2010, ELSO reported that 6.1% and 18.7% of all neonatal and pediatric ECMO cases
were complicated by a culture-proved infection.
34
Moreover, ELSO leadership recognized a
need amongst its members for more direction on the diagnosis and treatment of infections of
patients on ECMO and established an ELSO Infectious Disease Task Force. The following is a
summary of task force recommendations on infection control practices of the ECMO circuit.
Infection Control and ECMO Circuit Management
It is recommended that the ECMO circuit be cared for and treated like a protected central line
used for hyperalimentation, such that “breaking into the line” unnecessarily is strongly
discouraged. (UW Health Low quality evidence, strong recommendation) This lessens the change
for contamination of the circuit. Blood gases from the circuit for calibration of monitoring
technology may be necessary and when possible, sample from patient sites (e.g., arterial lines)
are preferred versus routine sampling from the circuit itself.
6


In addition, once a patient is stable on ECMO, consider removal of unnecessary lines, access
and devices. (UW Health Low quality evidence, weak/conditional recommendation) This should be
balanced against the risk of bleeding given anticoagulation of the patient. The insertion of
indwelling long term IV access (e.g., tunneled or cuffed catheters) is discouraged.
6


The use of needleless hubs is strongly encouraged for all connection and access sites,
including connections to stopcock access ports. (UW Health Low quality evidence, strong
recommendation) These are preferred from a user safety perspective and because they can be
more reliably sterilized with prep solutions versus stopcock Luer-Lock ports.
6
It is also
recommended to keep all stopcocks and needless connectors sterilely covered.
35
(UW Health
Low quality evidence, strong recommendation)

Intermittent drug and electrolyte boluses should be administered to the patient directly whenever
appropriate access is possible to avoid unnecessary “breaks” to the circuit.
6
(UW Health Low
quality evidence, strong recommendation)

It is strongly advised to avoid rooming a patient on ECMO with another patient with highly
resistant organism(s), grossly contaminated wounds, or serious infections.
6
(UW Health Low
quality evidence, strong recommendation)
Obtaining Blood and Yeast Cultures in ECMO Patients
Given the potential for nosocomial infection in an ECMO patient, it is important to monitor
patients for infection. Thus, it is recommended to obtain a blood culture daily on a pediatric
patient starting on the day of ECMO initiation. (UW Health Moderate quality of evidence, strong
recommendation)

It is recommended to obtain a yeast culture daily on pediatric ECMO patients starting on day 3.
If there is concern regarding sterility status of ECMO cannulation, it is recommended to obtain
yeast culture in patients starting on day 1 of ECMO.
36
(UW Health Moderate quality of evidence,
strong recommendation)



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20


Antimicrobial Prophylaxis

Antibiotic agent selection and duration
While the ELSO Infectious Disease Task Force recommends avoiding routine use of antibiotic
prophylaxis in ECMO patients without specific culture or physiologic evidence of ongoing
infection, per the Task Force, this recommendation does not necessarily apply to cardiac
patients with transthoracic cannulation through open chests, given this patient group’s
documented increased risk of infection.
6


For pediatric ECMO patients at UW Health, the following antibiotics are recommended
depending on the cannulation site and procedural initiation.

For pediatric patients with clean neck cannulation (i.e., cannulation occurred in sterile
environment):
• No concern for MRSA: cefazolin for surgical prophylaxis, to be discontinued 24 hours
post-cannulation
36
(UW Health Low quality of evidence, weak/conditional recommendation)
• For history of MRSA or concern for MRSA: substitute with vancomycin (UW Health Low
quality of evidence, weak/conditional recommendation)

For pediatric patients with open chest cannulation:
• No concern for MRSA: cefepime for surgical prophylaxis, to be discontinued 24 hours
after decannulation (UW Health Low quality of evidence, weak/conditional recommendation)
• For history of MRSA or concern for MRSA: add vancomycin (UW Health Low quality of
evidence, weak/conditional recommendation)

For additional information and suggested dosing, refer to the UW Health Surgical and
Interventional Radiology Antimicrobial Prophylaxis clinical practice guideline.

Antifungal usage
The ELSO Task Force recommends “cautious but aggressive” use of antifungal prophylaxis in
patients who are at particularly high risk (e.g., prolonged open chest on multi-drug antibiotic
therapy, or significantly immunocompromised.) Therefore it is recommended to initiate anti-
fungal prophylaxis on day 3 of ECMO for pediatric patients. (UW Health Moderate quality of
evidence, strong recommendation) Fluconazole has been reported as the preferred anti-fungal
agent by certain ECMO centers and if used, clinicians should be cognizant of drug
interactions.
36,37



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21


Anticoagulation Management for Pediatric ECMO
Anticoagulation in ECMO is typically achieved with intravenous unfractionated heparin (UFH).
Intravenous UFH has an immediate onset of action but requires monitoring and infusion rate
adjustments in order to achieve a targeted therapeutic range.
38
It is also a high alert medication
at UW Health.

Per the UWHC Policy 8.33 High Alert Medication Administration, an additional double-check is
required for all boluses when IV pump programming is outside of the established IV pump
decision support software (Alaris Guardrails®) limits, with each new bag of heparin hung, and at
every shift change.

Historically, the activated clotting time (ACT) was used to monitor the anticoagulation level by
UFH in ECMO due to its low cost and ability to be done rapidly at the bedside using whole
blood.
39
This test, however, is subject to significant variability due to influence from factors in
addition to heparin, and correlates poorly with the dose of heparin given in pediatric ECMO
populations. There is literature to suggest that monitoring UFH infusions in ECMO with
antifactor Xa levels may improve time to therapeutic range and warrant less testing.
40-42
Two
small pediatric studies have demonstrated a more positive correlation with heparin dosed in
ECMO with anti-Xa versus dosing with ACT or activated partial thromboplastin time
(aPTT).
40,43,44
A recently published single-center study has also showed a correlation between
using an anti-Xa based monitoring protocol and decreased blood product administration,
decreased hemorrhagic events, and decreased need to replace the ECMO circuit.
45


The ACT may be appropriate to use in specialized neonatal and pediatric populations (e.g.,
congenital diaphragmatic hernia patients.)
10-11
Refer to Appendix D for guidance on utilizing
ACT to monitor UFH once a patient is stable.
Baseline monitoring of ECMO UFH infusion
1. Collection of baseline PT/INR and ACT prior to initiating the UFH infusion if not already
available is reasonable (UW Health Moderate quality of evidence, strong recommendation)
2. For CDH patients, in the peri-operative period, the ACT goal should be determined by the
surgeon, in consultation with the Pediatric Intensivist. (UW Health low quality of evidence,
weak/conditional recommendation)
3. Collection of baseline CBC and platelet count prior to initiating the UFH infusion if not
already available is recommended (UW Health High quality of evidence, strong recommendation)
Initiation of UFH infusion for ECMO

Table 8. Initial Dosing of ECMO UFH infusion
Patient Status
Bolus Dose Maximum Bolus
Initial Infusion
High Bleed Risk
(Examples: underlying
coagulopathy, pre-existing trauma,
existing head bleed, etc.)
None N/A 40 units/kg/hr
Standard Bleed Risk
100 units/kg 10,000 units 40 units/kg/hr

1. Initial bolus doses are reasonable for standard bleed risk patients (UW Health Low quality of
evidence, weak/conditional recommendation)
2. Bolus doses should be based on actual body weight and rounded to the nearest 100 units
for ease of preparation (UW Health High quality of evidence, strong recommendation)
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22


3. Initial starting rate and heparin concentration should be based on patient’s actual body
weight at the time of infusion initiation to minimize fluid volume administered to the patient.
(UW Health High quality of evidence, weak/conditional recommendation) See Table 9.

Table 9. Concentration of ECMO UFH infusion
Patient Actual Body
Weight
Heparin amount per
infusion bag
Volume

Diluent
<10 kg 12,500 units 250 mL D10W
10-25 kg 30,000 units 250 mL D5W
26-49 kg 62,500 units 250 mL D5W
>49 kg 87,500 units 250 mL D5W

Table 10. Suggested laboratory monitoring schedule for ECMO
45

Condition ACT Anti-Xa
Initiation
Q1H until first anti-Xa is resulted Obtain within 6 hours of heparin
initiation
Stable (see Appendix D) Q6H
Bleeding or
Clotting
(see Appendix D) Q 4 to 6 hours or at discretion of
primary attending physician
Initial Monitoring of UFH infusion for ECMO
1. Obtain the ACT every hour upon heparin initiation until first anti-Xa is resulted. Once patient
is stable, ACT may be checked as needed. (UW Health Moderate quality of evidence, strong
recommendation)
2. The anti-Xa level should be checked within 6 hours of heparin initiation and when patient is
stable, obtain every 6 hours. See Table 10 (UW Health Moderate quality of evidence, strong
recommendation)
3. Monitoring the anti-Xa level is recommended for maintenance titration of the UFH infusion
(UW Health Moderate quality of evidence, weak/conditional recommendation)
4. Suggested therapeutic anti-Xa target range for standard bleed risk patients is 0.3 – 0.7
45

(UW Health Moderate quality of evidence, strong recommendation) See Table 11
5. For high bleed risk patients, suggested target therapeutic range is 0.2 – 0.4. (UW Health
Moderate quality of evidence, weak/conditional recommendation) See Table 12
6. To avoid confusion, do NOT titrate the UFH infusion with both anti-Xa levels and ACT and/or
aPTT (UW Health Very low quality of evidence, weak/conditional recommendation)
Table 11. Standard bleed risk ECMO UFH titration nomogram by anti-Xa
Heparin Level by Anti-Xa
(international units/mL)
Bolus/Hold Infusion Rate Change
< 0.1 Consider bolus 40 units/kg ↑ by 3 units/kg/hr
0.10 – 0.19 Consider bolus 20 units/kg ↑ by 2 units/kg/hr
0.2 – 0.29 None ↑ by 1 unit/kg/hr
0.3 – 0.7
17
None
NO CHANGE
Therapeutic Range
0.71 – 0.8 None ↓ by 1 unit/kg/hr
0.81 – 1.6 Hold infusion x1 hr ↓ by 2 units/kg/hr
> 1.7 Hold infusion x1.5 hr ↓ by 3 units/kg/hr


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23



Table 12. High bleed risk ECMO UFH titration nomogram by anti-Xa (Target 0.2–0.4)
Heparin Level by Anti-Xa
(international units/mL)
Bolus/Hold Infusion Rate Change
< 0.1 Consider bolus 20 units/kg ↑ by 2 units/kg/hr
0.1 – 0.19 None ↑ by 1 unit/kg/hr
0.2 – 0.4 None
NO CHANGE
Therapeutic Range
0.41 – 0.6 None ↓ by 1 unit/kg/hr
0.61 – 1 None ↓ by 2 units/kg/hr
> 1 Hold infusion x 1 hr ↓ by 3 units/kg/hr

Re-starting Heparin infusion after hold

1. If the infusion is held for an elevated level and restarted, check anti-Xa 4 hours after the
infusion was restarted. It is not recommended to check the anti-Xa sooner than 4 hours
given the half-life of heparin and if obtained too soon, may result in a falsely elevated anti-
Xa result. (UW Health Moderate quality of evidence, weak/conditional recommendation)
2. If the infusion is held for a procedure, restart at the previous infusion rate and check an anti-
Xa 4 hours after the infusion was restarted (UW Health Moderate quality of evidence,
weak/conditional recommendation) Suggested laboratory monitoring for ECMO UFH initiation,
stable conditions, and active bleeding or clotting is shown in Table 10. (UW Health Moderate
quality of evidence, weak/conditional recommendation)
3. It is recommended to contact the physician responsible for the heparin infusion after each
lab result for infusion titration orders (UW Health High quality of evidence, weak/conditional
recommendation)
Antithrombin III (ATIII) Replacement
Neonates and pediatric patients have lower levels of antithrombin III (ATIII) than adults. ATIII
levels typically seen in adults are usually not reached until 6 months – 1 year of age.
46,47

Acquired ATIII deficiency can be caused by ECMO and in some cases may need repletion to
achieve adequate activity levels;
48
however, there is a lack of evidence demonstrating benefit in
replacing ATIII.
49,50

1. Monitoring ATIII activity is reasonable when there is evidence of or concern for heparin
resistance (e.g., rate of infusion >60 units/kg/hr) (UW Health Moderate quality of evidence,
weak/conditional recommendation)
2. ATIII should only be replaced if the following criteria are both met:
51
(UW Health Moderate
quality of evidence, strong recommendation)
• rate of heparin infusion >60 units/kg/hr AND
• ATIII activity is <50% in patients less than 30 days and <85% in patients greater
than or equal to 30 days.
a. Target ATIII activity for replacement should be within normal range for patient age. (UW
Health Moderate quality of evidence, weak/conditional recommendation).
b. Suggested weight-based dosing for ATIII
48
:
50-100 units/kg, rounding to the nearest vial size available in pharmacy.

Suggested dosing for ATIII based off on target ATIII:
49

AT III dose = (Target value – ATIII level)/1.4, rounding to the nearest vial size.

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24


For example, if using ATIII to supplement to 100%, ATIII dose = ([100-ATIII level]/1.4)
rounding to nearest vial
c. Infusing ATIII slowly over an extended period may result in more consistent levels. If line
time is a concern, then it may be administered over 20 minutes. (UW Health Low quality of
evidence, weak/conditional recommendation).
d. After ATIII replacement, ATIII activity may be repeated the following morning with AM
labs to determine if the ATIII activity is within the 50-100% target range. (UW Health Low
quality of evidence, weak/conditional recommendation) ATIII activity is typically not repeated
until the following morning to prevent administration of multiple doses in a short time
frame. Ideally, ATIII replacement would be infused over longer times to better mimic
normal physiology and to prevent the ECMO circuit from eliminating it when it is given as
a bolus.
3. Following replacement of ATIII, titration of the UFH infusion by anti-Xa should be continued
per guideline. It is reasonable to consider checking levels every 4 hours until anti-Xa is
within usual therapeutic range (UW Health Moderate quality of evidence, weak/conditional
recommendation)

Additional clinical monitoring
45

1. Hemoglobin/hematocrit and platelets must be followed every 8 hours after initiating ECMO
UFH therapy until these levels are determined to be stable or until UFH is discontinued.
Once stable, the frequency of monitoring may be reduced to every 24 hours. (UW Health High
quality of evidence, strong recommendation)
2. If blood product replacement is necessary, hemoglobin/hematocrit and platelets should be
re-drawn 1 hour after completion of transfusion (UW Health Moderate quality of evidence,
weak/conditional recommendation)
4. PT/INR and fibrinogen may be followed daily while receiving ECMO UFH therapy (UW Health
Low quality of evidence, weak/conditional recommendation)
5. If blood product replacement with FFP or cryoprecipitate is necessary, PT/INR and
fibrinogen should be re-drawn 4 hours after completion of transfusion (UW Health Moderate
quality of evidence, weak/conditional recommendation)
6. Inspect line/surgical/wound sites for bleeding at least every 8 hours and check patient for
symptoms indicating bleeding such as new hematomas or enlargement of hematoma, new
bruising or extension of bruising. Contact MD if any signs of bleeding. (UW Health High quality
of evidence, weak/conditional recommendation)
7. Thromboelastography (TEG) may be performed as needed for bleeding and thrombotic
complications in order to assist clinicians by providing a framework for blood product
replacement in ECMO patients (UW Health Low quality of evidence, weak/conditional
recommendation)
a. If TEG is ordered in an ECMO patient receiving UFH, both “TEG – Patient not on
Heparin” and “TEG – Patient on Heparin” lab tests should be ordered (UW Health High
quality of evidence, weak/conditional recommendation)
b. TEG should only be ordered by a provider with the ability to interpret the results. (UW
Health High quality of evidence, weak/conditional recommendation)

Table 13. Suggested clinical monitoring parameters for ECMO
45

Condition PT/INR Fibrinogen Hemoglobin/Platelets AT III TEG
Stable Every morning
Q8H for the first
24hours then every
morning
If UFH infusion
> 60 units/kg/hr N/A
Bleeding or
Clotting
Treat and redraw
after 4 hr
Treat and redraw after
1 hr
PRN
PRN
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25


Transfusion support for Pediatric ECMO
Transfusion for ECMO initiation and management
To facilitate timely transfusion support, the following should be communicated appropriately
between the clinical ECMO team and the blood bank if blood products are needed for ECMO
initiation:
52
(UW Health Low quality of evidence, weak/conditional recommendation)
• ECMO urgency (standby versus emergent case)
• Fresh red blood cell (RBC) units (less than 7 days) to prime ECMO circuit if needed
• Verify consent for transfusion is signed prior to transfusion
• Blood type and antibody screening results (if known)
• Do blood products need to be washed and/or irradiated?

Priming the ECMO circuit with blood is typically needed for patients weighing < 18 kg.
Following the circuit priming with solution, 2 RBC units are used to avoid hemodynamic
instability and hemodilution caused by the priming solution.
52


Fresh and irradiated blood products are indicated when there is strong concern for patient’s
immune status (i.e., risk for transfusion-associated graft-versus-host disease). Washing blood
is also recommended if blood is older than two weeks, especially for neonatal patients. (UW
Health High quality of evidence, weak/conditional recommendation) It is also recommended that if the
patient is a heart/lung transplant candidate, the ordering physician should make an attempt to
request CMV-negative blood product. (UW Health Low quality of evidence, strong recommendation)

Patients may also require transfusions once on ECMO as the use of a centrifugal pump (pump
type predominantly used at UW Health) can cause hemolysis, resulting in anemia.
According to the UW Health Indications for Blood Product Transfusion Pediatric/Neonatal
guideline, transfusion of platelets is indicated for ECMO patients to maintain a platelet count
greater than 75 K/μL. Per the guideline as well, cryoprecipitate is indicated for active bleeding
or anticipated major surgery/invasive procedure (e.g., ECMO) with fibrinogen < 100 mg/dL or
dysfibrinogenemia.

For patients with significant bleeding, the following targets may be considered:
17,53

Target
Platelet count 75,000/mm
3

Fibrinogen concentration > 100 mg/dL
HCT VA-ECMO: >25
VV-ECMO: >30


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26


Hemofiltration and Renal Replacement Therapy

Acute kidney injury (AKI) is serious concern for ECMO patients and is considered an
independent risk factor for mortality for pediatric patients requiring ECMO. Renal replacement
therapy (RRT) options during ECMO can include peritoneal dialysis and continuous renal
replacement therapy (CRRT). Table 14 lists some of the advantages and disadvantages these
modalities for AKI in ECMO. Indications for RRT include acute kidney injury, fluid overload, and
electrolyte abnormalities.
54
(UW Health Moderate quality of evidence, weak/conditional
recommendation)

Table 14. Advantages/disadvantages of RRT modalities for AKI in ECMO
55

RRT modality Advantage Disadvantage
CRRT
• Could be joined with ECMO circuit
• Continuous removal of toxins
• Hemodynamic stability
• Tight and easy control of fluid
balance
• Gentle solute removal avoiding
disequilibrium syndrome
• Potentially allows blood
purification therapies for systemic
inflammation
• Patient immobilization
• Increased risk of hypothermia
• High costs
Peritoneal dialysis
(PD)
• Hemodynamic stability
• Technically simple
• Lower costs

• Requires specific intraperitoneal
catheters
• Risk of peritonitis
• Impairs diaphragmatic
movements, potentially prolonging
weaning from ECMO
• Less efficient
ultrafiltration/clearance

If the patient already has a PD catheter, PD may be used as the RRT modality however CRRT
is the most common modality used. PD may be considered however if it is anticipated that the
patient will require prolonged pump time, there is concern for amount of nephrotoxic agents
patient has already been exposed to and it is presumed that the patient will have oliguric AKI.
In this scenario, placement of a PD catheter (if one is not already in place) when the patient is
not very fluid overloaded may be easier for the patient versus CRRT.

CRRT in ECMO allows for the ability to make rapid changes to target fluid balance and provides
good solute clearance. The two most common methods of CRRT with ECMO are 1) use of an
in-line hemofilter with ultrafiltration controlled by an IV pump or 2) a traditional CRRT device
connected to the ECMO circuit.
56


Some pediatric ECMO centers use a standard of removing no more than 3 mL/kg/hr (6-7% of
dry weight/day) of fluid on CRRT based on the patient’s dry weight.
20,54
Given this maximal
removal rate, the degree of fluid overload at CRRT initiation may impact ECMO duration for the
patient.
54

In-line hemofilter
Hemofiltration uses a microporous fiber in which blood flows through. The pores of the
hemofilter are of a size sufficient to allow free water to pass through. The hemofilter is typically
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placed after the pump (to provide forward blood flow through the hemofilter) and and returns to
the pre-pump stopcock (to maintain the membrane lung’s use as a clot and air trap in case of
complications.)
56
(See Figure 4)

The hemofilter blood flow rate can be derived by subtracting the flow delivered to the patients
from the total ECMO blood flow rate. The hemofilter blood flow rate could be adjusted via the
stopcock or other flow-restricting device however there is potential for hemolysis and thrombus
formation due to turbulent flow, thus this should be limited to use in practice.
56


Use of the hemofilter alone provides the patient with slow continuous ultrafiltration (SCUF) only
and DOES NOT constitute renal replacement therapy. Ultrafiltrate production may be controlled
with an intravenous pump in this circuit set-up. This method, however, should be used with
caution because when using intravenous infusion pumps for regulating ultrafiltrate on ECMO,
error in fluid management has been reported and there is a risk of electrolyte imbalance too with
this method. Ultrafiltrate production should be monitored by weighing or measuring the actual
volume removed.
56,57


It is important to note that the use of an in-line hemofilter (SCUF) in the ECMO circuit mostly
removes fluid. Electrolytes and other solute removal is negligible due to low UF rate and lack of
diffusive clearance. Moreover, the ability to ultrafiltrate is much less with an in-line hemofilter
versus doing CRRT which can ultrafiltrate faster and in larger volumes. If the care team feels
that optimized fluid removal as well as clearance of uremic toxins and balancing of electrolytes
would be beneficial for the patient, it is recommended to consult Pediatric Nephrology for
initiation of CRRT. (UW Health Low quality evidence, strong recommendation)


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Hemofilter configuration with centrifugal pump in ECMO

Figure 4. Hemofilter in line with ECMO

Initiation of hemofilter in ECMO circuit:
1. Extreme care must be taken to ensure no air in the hemofilter AND the UF line. Proper
priming is ESSENTIAL. Make sure there are no open ports on the venous line
stopcocks as air can be drawn in if opened.
2. Add a stopcock to the pre-pump (venous line) site. Insure stopcock is pre-primed with
fluid.
3. Attach inlet of hemofilter to the bridge stopcock.
4. Attach outlet of hemofilter to pre-pump stopcock
5. Note flowrate on pump console
6. Open bridge stopcock to hemofilter
7. Open pre pump stopcock
8. Watch for air. If air seen, IMMEDIATELY close pre-pump stopcock, remove and re-
prime hemofilter
9. Observe any change in patient pump flow rate.
10. Adjust flow rate equivalent to flow prior to the addition of the hemofilter
11. After 2-3 minutes of monitored flow through hemofilter, turn on the infusion pump to the
desired UF rate ordered
12. Monitor hourly output (UF) of the hemofilter, as measured by the Alaris pump, on the
ECMO flow sheet. (Note: Input and output typically recorded by Nursing and values
communicated to ECMO Specialist.)
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Continuous Renal Replacement Therapy (CRRT)
If a standard one-port hemofilter is set up, CRRT may be performed if ordered. The purpose of
running replacement fluid in conjunction with hemofiltration (known as continuous venovenous
hemofiltration or CVVH) is to optimize fluid management, clear uremic toxins, and balance
electrolytes in patients who have developed AKI while on ECMO. Replacement fluid is
administered into the ECMO circuit prior to the hemofilter or patient. The replacement fluid rate
is infused at a rate ordered by Renal Service (usually 2000-3000 mL/min/1.73 sq m).
Ultrafiltrate is removed at the same time with the ultrafiltrate removal pump (i.e., Alaris pump).
This pump is adjusted to achieve either an even or negative fluid balance per hour. In certain
circumstances where positive fluid balance is desired, the ultrafiltrate removal pump will be run
at a rate lower than the replacement fluid infusion pump as. Nursing will record RRF as an input
and UF as an output on and communicate information to ECMO Specialist.
CRRT Machine to ECMO Circuit

When to Use a CRRT machine over In-line Hemofilter
A CRRT machine (e.g., NxStage
®
device) can be connected in-line to the ECMO circuit and the
following modalities may be performed: CVVH, CVVHD, and CVVHF. Of the three, CVVH is
the most commonly used. For CRRT device set-up with ECMO, refer to Figure 5. CRRT may
be indicated over in-line hemofilter in the ECMO circuit when there is:
• Failure to remove adequate fluid (e.g., high amount of fluids being delivered for
medications or nutrition and in-line hemofilter cannot keep up with ultrafiltration)
• Concern for diuretic ototoxicity (e.g., furosemide)
• Hyperkalemia
• Worsening uremia

CRRT Device Set-up with ECMO Circuit
The CRRT device should be placed so that the flow goes from post membrane to pre
membrane lung so that any clot or air will be trapped in the membrane lung instead of being
sent to the patient and to avoid venous admixture due to the shunt (i.e., the inlet line of the
CRRT machine is connected after the centrifugal pump and its outlet line before the membrane
lung.)
56-59


It is recommended that the NxStage
®
be set-up and primed by Renal team nurses. (UW Health
Very Low quality of evidence, strong recommendation)

When the CRRT machine is connected, the following changes are made to the ECMO circuit:
1. Moving the air bubble sensor to post membrane position
2. ACT draws from the post membrane pigtail
3. No pre-membrane gases will be drawn
4. Bridge will remain open.

The Perfusionist is responsible for connecting the NxStage
®
to the ECMO circuit and monitoring
its initial function. Because of heparinization of the ECMO circuit anticoagulates the entire
circuit, additional anticoagulation is not typically done for the CRRT circuit in series with ECMO.



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The ECMO circuit blood flows are much greater than circuit blood flows that the NxStage
®
circuit
demands. This creates positive pressure throughout the circuit. Normally arterial pressure is a
negative value and venous pressure is a positive value. The NxStage
®
system has default
pressure alarm settings for arterial and venous pressure which reflect this and also cannot be
adjusted. To avoid positive arterial pressure nuisance alarms, it is recommended for the arterial
pressure monitoring to be disabled by the Renal Team nurse.
57
(UW Health Low quality of
evidence, strong recommendation) Venous pressure will continue to be monitored and should not
exceed 400 mm/mg since there is no way to decrease the amount of positive pressure in the
ECMO circuit. (UW Health Low quality of evidence, weak/conditional recommendation) The ordered
blood flow rate on the NxStage
®
circuit may need to be adjusted to keep the venous pressures
below 350 mm/mg too.

The bedside nurse and the Renal team nurse will be responsible for operating the NxStage
®

device. If flow were to cease on the ECMO circuit, the NxStage
®
must be stopped until ECMO
flow is re-established. For additional guidance on nursing responsibilities and procedures for
CRRT with ECMO Circuit, refer to Nursing Policy 3.11AP Continuous Renal Replacement
Therapy Using the NxStage System One Machine.


Figure 5. Diagram of ECMO circuit with NxStage
®
device connected


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Weaning and Termination

The purpose of weaning is to provide a means to assess a patient’s ability to be removed from
ECMO support. By increasing the patient’s ventilator support and subsequently decreasing the
ECMO support, clinical staff can assess whether or not a patient can be supported
conventionally.

It is strongly recommended that before trying to wean patient from ECMO there is a
decannulation plan in place, if the weaning is successful. (UW Health Very low quality of evidence,
strong recommendation)

The following outlines the general process for weaning from VA-ECMO and VV-ECMO.

Weaning from VA ECMO
60

1. Add bridge and stopcocks and tubing near cannula sites
2. Remove or clamp the LA vent if present
3. Adjust inotropes to prepare for the wean
4. Adjust/optimize ventilator for wean (e.g., FiO2, ventilator rate)
5. Place pulse oximeter post-ductal for trending
6. Optimize fluid balance
7. For cardiac patients, attach pacing cables to the pacing wire. Connect patient to a
temporary pacemaker.
8. Discuss upcoming wean with Cardiologist on service and order bedside echocardiogram
(ECHO).
9. Decrease ECMO flows incrementally by 10-20 mL/kg/min to approximately 50
mL/kg/min.
10. When flows are decreased, clamp the lines between the 2 stopcocks in the arterial and
venous line of the circuit. Open the bridge.
11. Clamp trial (7-10 min at a time), “Flush” the cannulas with heparin solution and continue
clamp trial.
12. Turn off sweep gas and heparin drip.
13. Obtain ABG, lactate and SVO2 (if available) every 10-15 minutes for 1 hour then and
monitor NIRS every 15 mins for 1 hour and then as needed.
14. If trial is successful, discuss proceeding with decannulation plan with pediatric surgeon.

If weaning trial fails

If trial fails, the Perfusionist will unclamp the arterial line, clamp the bridge, and unclamp the
venous line. Turn sweep gas and patient heparin drip back on. Adjust temperature. Flush the
blood from the bridge using saline. Adjust inotropes and ventilation to ECMO rest levels.



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Weaning from VV ECMO
10,60

1. Optimize ventilation
2. Decrease ECMO FiO2 incrementally while obtaining blood gases from the patient
3. Decrease sweep gas as necessary to maintain proper patient blood gas values
4. When ready to trial off, turn off sweep gas flow while maintaining ECMO blood flow (at
this point, the patient is technically off ECMO.)
5. If tolerating the clamp trial, obtain ECHO
6. Obtain ABG, lactate and SVO2 (if available) every 10-15 minutes for 1 hour then and
monitor NIRS every 15 mins for 1 hour and then as needed.
7. If trial is successful, discuss proceeding with decannulation plan with pediatric surgeon.


Terminating ECMO Support and Care

If the decision is made to stop ECMO and patient death is likely to occur immediately thereafter,
the medical team and staff should use the usual end-of-life approach with family and be mindful
of the family’s wishes.

Non-essential personnel should be removed prior to terminating ECMO and the Pediatric
Intensivist should be present. (UW Health Very low quality evidence, strong recommendation) Once
appropriate provision of analgesics and sedative medications is done, two clamps can be
placed on each cannula in proximity to each other (2-3 cm apart). The tubing should be cut
between the clamps so that the family may hold the patient and allow for removal of all
equipment.
23
(UW Health Low quality evidence, strong recommendation)











Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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Methodology
Development Process
Each guideline is reviewed and updated a minimum of every 3 years. All guidelines are
developed using the guiding principles, standard processes, and styling outlined in the UW
Health Clinical Practice Guideline Resource Guide. This includes expectations for workgroup
composition and recruitment strategies, disclosure and management of conflict of interest for
participating workgroup members, literature review techniques, evidence grading resources,
required approval bodies, and suggestions for communication and implementation.

Methods Used to Collect the Evidence:
The following criteria were used by the guideline author(s) and workgroup members to conduct
electronic database searches in the collection of evidence for review.

Literature Sources:
• Electronic database search (e.g., PubMed)
• Databases of systematic reviews (e.g., Cochrane Library)
• Hand-searching journals, external guidelines, and conference publications
• Medical textbooks and clinical references
• ELSO guidelines
• UW Health ECMO Specialist Handbook 2017

Time Period: May 2017 to October 2017

The following is a list of various search terms that were used individually or in combination with
each other for literature searches on PubMed: Pediatric, ECMO, Weaning, Ventilator setting,
antibiotic prophylaxis, ECMO monitoring, ECPR, renal replacement, neuromonitoring, sedation,
anticoagulation, transfusion, pressure ulcer prevention, antithrombin replacement.

Methods to Select the Evidence:
Literary sources were selected with the following criteria in thought: English language, subject
age (i.e., birth-18 years), publication in a MEDLINE core clinical journal and strength of expert
opinion (e.g., ELSO sponsored or affiliated, author from nationally recognized ECMO center).

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations such as ELSO and/or create recommendations internally via a consensus process
using discussion of the literature and expert experience/opinion. If issues or controversies arose
where consensus could not be reached, the topic was escalated appropriately per the guiding
principles outlined in the UW Health Clinical Practice Guideline Resource Guide.

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 6).


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Figure 61. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations for or Against Practice
Strong
The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.


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American College of Cardiology/American Heart Association Level of Evidnce Grading


Collateral Tools & Resources
The following collateral tools and resources support staff execution and performance of the
evidence-based guideline recommendations in everyday clinical practice.

Metrics
• Number of ECMO patients who survived to discharge
• Percentage of patients who developed infection while on ECMO
• Percentage of patients with intracranial hemorrhage
• Percentage of patients with circuit clot
• Percentage of patients with air in circuit

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Related Guidelines
Indications for Blood Product Transfusion – Pediatric/Neonatal – Inpatient/Ambulatory
Pressure Ulcer Prevention and Treatment Guideline at a Glance (Nursing Practice Guideline)

Order Sets & Smart Sets
IP – ECMO Initiation – Pediatric – Procedure [2214]
IP – ECMO- Pediatric – Post-Cannulation [2215]
IP – ECMO Heparin Anticoagulation – Pediatric – Supplemental [5816]

Patient Resources
Health Facts For You #5760- ECMO: Extracorporeal Membrane Oxygenation

Policies
• UWHC Policy 8.39AP: Repair or Replacement of Essential Equipment in Case of
Breakdown (Adult & Pediatric)
• UWHC Policy 2.3.13: Safe Transport of Sedated and/or Intubated Children in University
Hospital (and AFCH)
• UWHC 2.04: Blood and Blood Components – OR
• UW Nursing Policy 3.11AP- Continuous Renal Replacement Therapy (CRRT) Using the
NxStage System One Machine (Adult and Pediatric)

Protocols
Pain and Agitation Continuous Infusion Titration – Pediatric – Inpatient [5]
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Appendix A. Centrifugal Pump Circuit Checklist
Date am pm noc
ECMO Specialist:

Check drainage cannula site for bleeding, kinks

Check venous side stopcock of bridge for closure

Observe centrifugal pump for clots or abnormal vibrations/noise

Verify air bubble detector connection and module status – must be
on

Check ACT stopcock for leaks or turning difficulty, replace if needed

Check for clots on the inlet of the membrane and note on flowsheet

Note color of gas outlet condensation of the membrane

Verify oxygen connection to membrane

Verify FiO2 and sweep rate to membrane

Check arterial side stopcock of bridge for proper position

Check CDI shunt for clots/flow

Check hemofilter for clots/flow

Check reinfusion cannula site for bleeding, kinks

Check water level and flow through warming unit

Check temperature of warming unit and patient temperature

Discard blood units > 4 hours old

Verify 250 mL Albumin 5% available in room

Verify hand crank availability

Verify extra membrane and centrifugal pump availability on cart

Record irregularities on ECMO doc flowsheet

Record clot formation on ECMO clot diagram

Notify perfusionist on-call for abnormal observations


Hourly Check:

Draw ACT

Document vital signs and pump parameters set forth by the doc
flowsheet

Keep careful documentation of fluid I & O

Q 8 hours (or shift change)

Perform Hemocron EQC

Fill out ECMO SBAR & Daily Summary

Inspect line/surgical/wound sites for bleeding and check patient for
symptoms indicating bleeding (e.g., new hematomas, new bruising)

Q day shift

Replace ACT stopcock

Replace other circuit stopcocks per guideline




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Appendix B. Monitoring the Patient on ECMO
6,18,24,26


Assessment Intervention
Neurologic
• Pupil checks at regular intervals
(more often if using
neuromuscular blockade)
• Glasgow Coma Scale or similar
measure of receptive and motor
function
• Pain and sedation scoring
• Administer narcotics and anxiolytics as
needed
• Elevate the head of the bed, maintaining
patient’s head in mid-line position to
encourage venous return
• Provide periods of stimulation and quiet
time
• Provide means of distraction (e.g.,
television, music)
• Provide comforting, restful environment
(e.g. pressure relief mattress, dry bedding)
• Secure lines and tubes
• Utilize additional staff as needed to support
patient’s psychological needs
Respiratory
• Respiratory assessment at
regular intervals (e.g., breath
sounds, presence/absence of
effort, distress)
• Assess for air leak if chest tube
in place

• Avoid elevated PIP during manual
ventilation with suctioning
• Maintain secure airway
• Suction airway at regular intervals as
needed
• Chest physiotherapy with attention to
presence of air leak and bleeding risk
• Position changes at regular intervals based
on comfort, skin integrity, and need for
mobilization of secretions; consider prone
positioning
• “Lung conditioning”
• Oral care at regular intervals (remove
drool, blood and clots and clean with
smooth mouth sticks used with water only)
Circulatory
• Warmth of extremities
• Pulses (may be absent on VA
support at high blood flows)
• Blood volume
• Color of extremities (pink,
dusky, mottled)
• Urine output
• Presence/absence of edema
• Administer vasoactive infusions via patient
line (not via the ECMO circuit)
• Maintain adequate blood volume
• Position patient to promote optimal
perfusion of extremities and minimize
dependent edema

GI and
Nutrition
• GI assessment at regular
intervals (e.g., assess for
abdominal distention or
tenderness, quality of bowel
sounds, tolerance enteral
feeding, character of NG
draining and stool pattern, blood
in stool)
• Nutritional assessment (e.g.,
daily weight if possible,
calculation of protein and caloric
intake)
• Maintain NG/OG tube for feeding and/or
decompression
• Maintain gastric or jejunal tube for feeding
• Administer enteral or parenteral feedings
• Promote normal stooling pattern
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Assessment Intervention
Fluid balance
• Evaluate for edema, skin
turgor and electrolyte status
• Maintain accurate intake and
output measurements
• Daily weights, if feasible
• Maintain urinary catheter
• Calculate intake and output, noting
positive or negative fluid balance
• Maintenance of hemofiltration or dialysis
circuit
• Evaluation of electrolyte status
• Prevent complications of edema through
patient positioning and skin care
Skin
• Evaluate for signs of skin
breakdown or decreased
perfusion
• Asses skin integrity around IV
and cannula sites
• Frequent repositioning of patient with
close examination of the back of the
head, heels and sacrum
• Maintain sterile dressings on IV sites
• Avoid infection of cannula sites with
regular inspection and topical antiseptics
Anticoagulation
• Assess for signs of active
bleeding at IV, incisional and
cannula sites; gastric, chest or
endotracheal tubes; urinary
and umbilical catheters; and
operative site drains
• Prevent bleeding by maintaining existing
IV lines, avoid insertion of new IV lines
and careful handling of mucus
membranes (suctioning, oral care, NG
tube placement)
• Monitor platelet count, hematocrit, ACT,
anti-Xa, and coagulation parameters
• Replace blood loss with appropriate
blood products as needed
Infection
Control
• Assess for signs of infection • Daily white blood count and cell blood
culture
• Check integrity of cannula dressing
• Assess insertion point of cannulas
looking for redness, swelling, bleeding or
potential infection



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Appendix C. ECMO Troubleshooting
VA ECMO Troubleshooting

Symptom Possible Intervention Rationale
Hypotension Give volume Hypovolemia
Increase flow Cardiovascular instability
Chest radiograph Cannula malposition, cannula kinking,
vessel perforation, pneumothorax,
tamponade, bleeding
Assess level of
pain/sedation
Patient may be over sedated
Check bridge stopcocks Recirculation of flow back to venous
side
Hypertension Slow rate of flow increase Patient responding to volume
Assess level of
pain/sedation
Patient alert despite paralysis
Wean inotropes CV function improving with ECMO
Vasodilatory drugs In particular for VA ECMO
Withdraw volume Hypervolemia
Low or falling SpO
2

Increase flow O2 delivery low
Check gas sweep rate &
FiO2 to membrane
No oxygen delivery through membrane
Chest radiograph Pneumothorax or tamponade
Check ventilator connection Insufficient flow
Transfusion
Loss of venous
return
Give volume Hypovolemia
Decrease flow ECMO flow too high (overshoot)
Chest radiograph Pneumothorax or tamponade
Check cannula position Kinked cannula would reduce flow
Check circuit integrity Occlusion to flow (kink, clot)




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VV ECMO Troubleshooting

Arterial
Saturation
Venous
Saturation
Interpretation Management
Increasing Increasing or
stable
Patient condition improving Wean ECMO FiO2
Decreasing Decreasing or
stable
Patient condition declining Check catheter position and
pump flow. Try to increase flow
Decreasing Increasing Increased recirculation Evaluate cannula position, adjust
head position, add or subtract
shoulder roll, apply gentle traction
to cannula.
Decreasing Increasing Increased recirculation
most likely due to changing
cannula position
Evaluate cardiac output and
cannula position, consider giving
volume.
Decreasing but
stable
Stable Poor ventilation. PaCO2 is
increased
Check ABG. Adjust sweep gas
flow or mix. If off ECMO adjust
ventilator support.
Stable Increasing Over ventilation, PaCO2 is
decreased
Check ABG. Adjust sweep gas
flow or mix. If off ECMO adjust
ventilator support.
Decreasing and
decreased BP
Increasing Worry about compromised
cardiac output
Consider pericardial effusion if
pulse pressure is decreased.



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Troubleshooting the ECMO Circuit
4,6,26

Problem Symptoms Causes Solutions
Poor Venous
Return
• Pump cutting out
• Venous line chatter
• Hypovolemia
• Inadequate siphon
• Kinked venous line
• Kinked cannula
• Patient awake
• Pneumothorax
• Small cannula for pt size
• Give volume
• Reduce flow rate
• Raise bed
• Straighten line out
• Check bladder box function
• Change patient head position
• Sedate
• Check X-ray
• Place additional venous cannula
Increased
Transmembrane
Pressure or
membrane failure
• Transmembrane
pressure difference
>150
• Premembrane
pressure limit
alarming
• Reduced flow @
high RPM (adult
ckt)

• Clots in the membrane
• Transmembrane
pressure difference
trend rising
• Acute clot formation in
membrane
• Re-zero and flush pre and post
membrane transducers
• Aspirate any clot in pre and post
membrane stopcocks
• Temporarily reduce flow by 10 mL/kg,
consider ventilating pt.
• Adjust alarm upward (no > than 400
mm Hg)
• Replace membrane or circuit
ICU Power
Failure

Patient Transport
Battery power
alarming
• Power lost in the unit
• Power cord
disconnected
• Power cord not
connected to red outlet
• Power strip circuit
breaker tripped
• Observe battery discharge meter
• Plug into emergency hospital power;
use batter or uninterruptible power
supply (ups)
4

• Check for hand crank availability
• Re-plug power cord into outlet (gas)
• Hand crank if pump not working
• Obtain new pump console for
replacement
• Reset circuit breaker
Pump Stops
(no alarms)
• No forward
movement of pump
• Digital display
reading “---“ or “0”
• Directional knob hit
• Flow control knob set to
zero

• Reset knob
• Turn flow rate back up slowly
(accelerator)
• Reset pump power switch (ignition)
• Hand crank
Membrane
condensation
pink/foamy
Frothy fluid coming
out of gas exit port
• Membrane blood to gas
leak
• Tear in membrane
• Remain on ECMO if possible
• Watch for air in the arterial line
• Prepare to terminate ECMO and
ventilate pt
• Replace circuit immediately
Air in arterial line
(air bubble
detector alarm)
• Air bubble detector
alarming

• Bubbles seen
• Air bubble detector
inadvertently opened
• Gross air entrapment
from infusions,
membrane rupture, or
line disconnection
• Reseat detector housing and reset
alarm

• Immediately come off ECMO,
ventilate and resuscitate pt, re-prime
circuit and recirculate through bridge,
aspirate all air from circuit, and re-
establish ECMO support
Air in venous line
• Bubbles seen • Correct source of problem, aspirate
air
Clots in circuit
• Blood, fibrin clots
seen where tubing
connects to cannula
• Dark zones or
streaks seen
• Low flows
• Insufficient anti-
coagulation
Tubing not inserted all
the way into cannula
connector
• Increase anti-coagulation, monitor
clots- if increase, may need to replace
connection
• Un-tie banded tubing connection with
cannula
• Insert tubing well and secure
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Troubleshooting the ECMO Circuit (continued)
Problem Symptoms Causes Solutions
Hemolysis
• Hematuria
• Hemofilter effluent
pink
• DIC

• Pump failure
• Kinks in circuit
• Clots in circuit
• Check ACT, platelets, fibrinogen for
DIC picture
• Check serum hemoglobin, bilirubin
• Check blood temperature
• Check circuit for kinks, excessive clots,
circuit pressures > 300 mmHg
• Change pump head, membrane,
and/or entire circuit
• Treat with mannitol and alkalinize urine
Accidental
decannulation
• Partial removal on
venous side, air
entrainment can be
seen
• With complete
decannulation,
cannula will be out
of body with
bleeding from
cannulation site and
possible pumping of
air or blood

• Cease ECMO and stop pump flow (i.e.,
clamp); increase ventilator settings
• Page surgeon for immediate
replacement of cannula and to control
bleeding
• Apply direct pressure on site
• Replace volume losses with available
blood products and crystalloid

Membrane
lung/
oxygenator
failure
• Failure to remove
CO2 or add
adequate levels of
oxygen despite
increasing sweep
gases and FiO2;
• May see blood or
serum leaking from
gas exhaust port

• Change the entire ECMO circuit
Poor Post
membrane
Oxygenation
• Low SaO2 post
membrane
• Low pt SaO2
• Disconnected O2 line to
membrane
• Low FiO2 on Blender
• Leak in Air/Oxy blender
or tubing
• Disconnected Air and/or
Oxygen line to wall
• Reconnect

• Turn FiO2 to 100%
• Replace tubing segment

• Connect to wall source
• Obtain standalone O2 tank and
connect to membrane
High Venous
Saturation
(SvO2)
SvO2 > 80%
• Mild hypothermia
• O2 demand decreased
• Bridge not properly
closed
• Patient improving
• Warm pt to 37° C
• Watch for acidosis or multi system
organ failure
• Close bridge stopcock

• Consider weaning
Low Venous
Saturation
(SvO2)
SvO2 < 60%
• Clot forming on sensor
site
• Blood flow too low
• Low HCT
• Low SaO2
• Increased O2 demand
• Low native cardiac output
(VV)
• Consider sensor replacement
• Increase flow rate
• Transfuse RBC’s, diurese
• Increase pump FiO2


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44


Appendix D. Monitoring Unfractionated Heparin with ACT

Table 1. Suggested laboratory monitoring schedule for ECMO
45

Condition ACT
Initiation Q1H until first anti-Xa is resulted or as physician directed
Stable PRN
Bleeding or Clotting Q1H or PRN

1. It is recommended to contact the physician responsible for the heparin infusion after each
lab result (e.g., ACT, anti-Xa) for infusion titration orders (UW Health High quality of evidence,
weak/conditional recommendation)
2. Upon initiation of the UFH infusion, ACT levels should be checked every hour until the first
anti-Xa level is resulted or as physician directed. (UW Health Moderate quality of evidence,
weak/conditional recommendation)
3. The UFH infusion rate may be adjusted using ACT. The suggested titration nomogram
listed is in Table 2. (UW Health Low quality of evidence, weak/conditional recommendation)

Table 2. Titration of ECMO UFH infusion by ACT for CDH patients on ECMO
ACT Bolus/Hold Infusion Rate Change
< 180 seconds Consider bolus 20 units/kg ↑ by 2 units/kg/hr
180 – 220 seconds
17,52

(for CDH patients 180-200 seconds)

None
NO CHANGE
Therapeutic Range
201 – 250 seconds
(for CDH patients 201-250 seconds)
None ↓ by 2 units/kg/hr
> 250 seconds Hold infusion until ACT < 250 ↓ by 3 units/kg/hr

1. Contact the physician responsible for the heparin infusion after each lab result (ACT, Anti-
Xa) for infusion titration orders (UW Health Low quality of evidence, weak/conditional
recommendation)
2. The ACT level may be used for monitoring and titration of UFH infusion in CDH patients on
ECMO. (UW Health Low quality of evidence, weak/conditional recommendation)
3. Suggested monitoring of the ACT for initiation, stable conditions and active bleeding or
clotting is outlined in Table 3 (UW Health Low quality of evidence, weak/conditional
recommendation)
4. If ACT results are inconsistent (e.g., consistently low, consistently high), refer to Table 4-
Troubleshooting ECMO circuit with regards to ACT.

Table 3. Suggested laboratory monitoring schedule for patients on ECMO
Condition ACT
Initiation Q1H x 4 hours or until first anti-Xa resulted or as directed by physician
Stable Q2H X 24 hours then Q4H (if stable)
Bleeding or Clotting Q1 H

1. Do NOT titrate the UFH infusion with ACT and anti-Xa levels or aPTT. Anti-Xa levels and
aPTT may be used to identify heparin resistance. (UW Health Low quality of evidence,
weak/conditional recommendation)
2. If the infusion is held for elevated level or procedure and restarted, check an ACT 1 hour
after the infusion was restarted and monitor as outlined in Table 3. (UW Health Low quality of
evidence, weak/conditional recommendation)
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

45


Table 4. Troubleshooting ECMO circuit with regards to ACT
Problem Symptoms Causes Solutions
Persistently
low ACT’s
• Increased urine
output
• Platelets transfused
• Cryo transfused
• RBC transfused
• FFP transfused
• Pump flow rate
down
• CDH repair on
ECMO
• No response to
heparin bolus
• Drip rate high
• Diuretics given, heparin
excreted

• Platelet count >100K
• Fibrinogen > 150K
• HCT > 40
• PTT > 106
• Slower circulation of flow
causing clot formation
• Amicar infusion

• Anti-thrombin III
deficiency
• Check concentration of
heparin

• Increase heparin drip rate

• Bolus Heparin
• Bolus Heparin
• Increase heparin drip rate
• Increase heparin drip rate
• Increase heparin drip rate

• Increase heparin drip rate

• Transfuse FFP
• Obtain new heparin infusion bag
Persistently
High ACT’s
• Decreased urine
output
• Sudden rise in ACT
• Active bleeding
• Hypothermia
• Drip rate low
• Hypovolemia
• Heparin drip
concentration incorrect
• Low Platelets
• Low Fibrinogen
• Low clotting factors
• DIC
• Temp < 36° C
• ACT drawn from port
containing heparin
• Check concentration of
heparin
• Transfuse accordingly
• Replace heparin drip with a new
solution
• Transfuse Platelets
• Transfuse cryoprecipitate
• Transfuse FFP
• Institute hemorrhage protocol
• Warm patient to 37° C
• Draw ACT from fresh pigtail
• Obtain new heparin infusion bag
Inconsistant
ACT’s
ACT’s rising and falling
each measurement
• Active bleeding
• Bad Cuvette lot
• Broken ACT machine

• Operator Error
• Follow bleeding protocol
• Obtain new box of cuvettes
• Check QC on ACT machine
• Change out machine
• Have another ES draw and run ACT





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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

46


References
1. Chung DH. Atlas of Pediatric Surgical Techniques A Volume in the Surgical Techniques Atlas
Series - Expert Consult. London : Elsevier Health Sciences, 2010.; 2010.
2. Holmes AP. NICU Primer for Pharmacists. Bethesda, US: ASHP; 2015.
3. Makdisi G, Wang IW. Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving
technology. J Thorac Dis. 2015;7(7):E166-176.
4. Mary Fran H. Nursing care of the critically ill child. Third edition. St. Louis, Mo. : Elsevier/Mosby,
[2013] ©2013; 2013.
5. Lequier L, Horton SB, McMullan DM, Bartlett RH. Extracorporeal membrane oxygenation
circuitry. Pediatr Crit Care Med. 2013;14(5 Suppl 1):S7-12.
6. Annich GM, Extracorporeal Life Support O. ECMO : extracorporeal cardiopulmonary support in
critical care, red book. [Ann Arbor, Mich.?]: Extracorporeal Life Support Organization; 2012.
7. Rollins MD, Hubbard A, Zabrocki L, Barnhart DC, Bratton SL. Extracorporeal membrane
oxygenation cannulation trends for pediatric respiratory failure and central nervous system injury.
J Pediatr Surg. 2012;47(1):68-75.
8. Maslach-Hubbard A, Bratton SL. Extracorporeal membrane oxygenation for pediatric respiratory
failure: History, development and current status. World J Crit Care Med. 2013;2(4):29-39.
9. Kirpalani HN. Manual of Pediatric Intensive Care. Shelton : PMPH USA, Ltd., 2009.; 2009.
10. Brogan TV, Lequier L, Lorusso R, MacLaren G, Peek GJ, Extracorporeal Life Support O.
Extracorporeal life support : the ELSO red book. 2017.
11. Brooks SC, Anderson ML, Bruder E, et al. Part 6: Alternative Techniques and Ancillary Devices
for Cardiopulmonary Resuscitation: 2015 American Heart Association Guidelines Update for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18
Suppl 2):S436-443.
12. Wolf MJ, Kanter KR, Kirshbom PM, Kogon BE, Wagoner SF. Extracorporeal cardiopulmonary
resuscitation for pediatric cardiac patients. Ann Thorac Surg. 2012;94(3):874-879; discussion
879-880.
13. Kane DA, Thiagarajan RR, Wypij D, et al. Rapid-response extracorporeal membrane oxygenation
to support cardiopulmonary resuscitation in children with cardiac disease. Circulation.
2010;122(11 Suppl):S241-248.
14. Baharestani MM, Ratliff CR. Pressure ulcers in neonates and children: an NPUAP white paper.
Adv Skin Wound Care. 2007;20(4):208, 210, 212, 214, 216, 218-220.
15. Peterson J, Adlard K, Walti BI, Hayakawa J, McClean E, Feidner SC. Clinical Nurse Specialist
Collaboration to Recognize, Prevent, and Treat Pediatric Pressure Ulcers. Clin Nurse Spec.
2015;29(5):276-282.
16. Butler CT. Pediatric skin care: guidelines for assessment, prevention, and treatment. Pediatr
Nurs. 2006;32(5):443-450.
17. Saini A, Spinella PC. Management of anticoagulation and hemostasis for pediatric extracorporeal
membrane oxygenation. Clin Lab Med. 2014;34(3):655-673.
18. Freitag-Koontz MJ, Ryder S. Monitoring and evaluating the infant on venoarterial extracorporeal
membrane oxygenation. J Perinat Neonatal Nurs. 1992;5(4):68-86.
19. Schumacher RE. Extracorporeal Membrane Oxygenation. In: Donn SM, Sinha SK, eds. Manual
of Neonatal Respiratory Care. Cham: Springer International Publishing; 2017:543-549.
20. Smith AH, Hardison DC, Worden CR, Fleming GM, Taylor MB. Acute renal failure during
extracorporeal support in the pediatric cardiac patient. Asaio j. 2009;55(4):412-416.
21. Gehrmann LP, Hafner JW, Montgomery DL, Buckley KW, Fortuna RS. Pediatric Extracorporeal
Membrane Oxygenation: An Introduction for Emergency Medicine Physicians. J Emerg Med.
2015;49(4):552-560.
22. Bembea MM, Felling R, Anton B, Salorio CF, Johnston MV. Neuromonitoring During
Extracorporeal Membrane Oxygenation: A Systematic Review of the Literature. Pediatr Crit Care
Med. 2015;16(6):558-564.
23. Schwartz SM, Schmidt A. Medical and nursing care of the child on mechanical circulatory
support. Pediatr Crit Care Med. 2013;14(5 Suppl 1):S43-50.
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

47


24. Krause KD, Youngner VJ. Nursing diagnoses as guidelines in the care of the neonatal ECMO
patient. J Obstet Gynecol Neonatal Nurs. 1992;21(3):169-176.
25. Wong JK, Smith TN, Pitcher HT, Hirose H, Cavarocchi NC. Cerebral and lower limb near-infrared
spectroscopy in adults on extracorporeal membrane oxygenation. Artif Organs. 2012;36(8):659-
667.
26. Mossadegh C. Monitoring the ECMO. In: Mossadegh C, Combes A, eds. Nursing Care and
ECMO. Cham: Springer International Publishing; 2017:45-70.
27. Hazle MA, Gajarski RJ, Aiyagari R, et al. Urinary biomarkers and renal near-infrared
spectroscopy predict intensive care unit outcomes after cardiac surgery in infants younger than 6
months of age. J Thorac Cardiovasc Surg. 2013;146(4):861-867.e861.
28. Edger M. Effect of a Patient-Repositioning Device in an Intensive Care Unit On Hospital-Acquired
Pressure Injury Occurences and Cost: A Before-After Study. J Wound Ostomy Continence Nurs.
2017;44(3):236-240.
29. Holcomb GW, III. Ashcraft's Pediatric Surgery Expert Consult. 6th ed. London : Elsevier Health
Sciences, 2014.; 2014.
30. Medtronic. Medtronic Affinity CP Manual. In. Minneapolis, MN2015.
31. Anton-Martin P, Modem V, Taylor D, Potter D, Darnell-Bowens C. A retrospective study of
sedation and analgesic requirements of pediatric patients on extracorporeal membrane
oxygenation (ECMO) from a single-center experience. Perfusion. 2017;32(3):183-191.
32. Zalieckas J, Weldon C. Sedation and analgesia in the ICU. Semin Pediatr Surg. 2015;24(1):37-
46.
33. Harthan AA, Buckley KW, Heger ML, Fortuna RS, Mays K. Medication Adsorption into
Contemporary Extracorporeal Membrane Oxygenator Circuits. The Journal of Pediatric
Pharmacology and Therapeutics : JPPT. 2014;19(4):288-295.
34. Bizzarro MJ, Conrad SA, Kaufman DA, Rycus P. Infections acquired during extracorporeal
membrane oxygenation in neonates, children, and adults. Pediatr Crit Care Med. 2011;12(3):277-
281.
35. O'Horo JC, Cawcutt KA, De Moraes AG, Sampathkumar P, Schears GJ. The Evidence Base for
Prophylactic Antibiotics in Patients Receiving Extracorporeal Membrane Oxygenation. Asaio j.
2016;62(1):6-10.
36. Kao LS, Fleming GM, Escamilla RJ, Lew DF, Lally KP. Antimicrobial prophylaxis and infection
surveillance in extracorporeal membrane oxygenation patients: a multi-institutional survey of
practice patterns. Asaio j. 2011;57(3):231-238.
37. Gardner AH, Prodhan P, Stovall SH, et al. Fungal infections and antifungal prophylaxis in
pediatric cardiac extracorporeal life support. J Thorac Cardiovasc Surg. 2012;143(3):689-695.
38. Garcia DA, Baglin TP, Weitz JI, Samama MM. Parenteral anticoagulants: Antithrombotic Therapy
and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e24S-43S.
39. Swaiman KF. Swaiman's Pediatric Neurology Principles and Practice. 5th ed. London : Elsevier
Health Sciences, 2011.; 2011.
40. Liveris A, Bello RA, Friedmann P, et al. Anti-factor Xa assay is a superior correlate of heparin
dose than activated partial thromboplastin time or activated clotting time in pediatric
extracorporeal membrane oxygenation*. Pediatr Crit Care Med. 2014;15(2):e72-79.
41. Bembea MM, Schwartz JM, Shah N, et al. Anticoagulation monitoring during pediatric
extracorporeal membrane oxygenation. Asaio j. 2013;59(1):63-68.
42. Esper SA, Levy JH, Waters JH, Welsby IJ. Extracorporeal membrane oxygenation in the adult: a
review of anticoagulation monitoring and transfusion. Anesth Analg. 2014;118(4):731-743.
43. Cameron P. Textbook of Adult Emergency Medicine Expert Consult - Online and Print. 4th ed.
London : Elsevier Health Sciences UK, 2014.; 2014.
44. Bolton JM, Gunnell D, Turecki G. Suicide risk assessment and intervention in people with mental
illness. Bmj. 2015;351:h4978.
45. Northrop MS, Sidonio RF, Phillips SE, et al. The use of an extracorporeal membrane oxygenation
anticoagulation laboratory protocol is associated with decreased blood product use, decreased
hemorrhagic complications, and increased circuit life*. Pediatr Crit Care Med. 2015;16(1):66-74.
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

48


46. Appel IM, Grimminck B, Geerts J, Stigter R, Cnossen MH, Beishuizen A. Age dependency of
coagulation parameters during childhood and puberty. J Thromb Haemost. 2012;10(11):2254-
2263.
47. Jacobs DS, Oxley DK, DeMott WR. Jacobs & DeMott laboratory test handbook : with key word
index. Hudson (Cleveland), Ohio: Lexi-Comp; 2001.
48. Stockton WM, Padilla-Tolentino E, Ragsdale CE. Antithrombin III Doses Rounded to Available
Vial Sizes in Critically Ill Pediatric Patients. J Pediatr Pharmacol Ther. 2017;22(1):15-21.
49. Byrnes JW, Swearingen CJ, Prodhan P, Fiser R, Dyamenahalli U. Antithrombin III
supplementation on extracorporeal membrane oxygenation: impact on heparin dose and circuit
life. Asaio j. 2014;60(1):57-62.
50. Wong TE, Nguyen T, Shah SS, Brogan TV, Witmer CM. Antithrombin Concentrate Use in
Pediatric Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study. Pediatr Crit Care
Med. 2016;17(12):1170-1178.
51. Wong TE, Delaney M, Gernsheimer T, et al. Antithrombin concentrates use in children on
extracorporeal membrane oxygenation: a retrospective cohort study. Pediatr Crit Care Med.
2015;16(3):264-269.
52. Yuan S, Tsukahara E, De La Cruz K, Kelly RB. How we provide transfusion support for neonatal
and pediatric patients on extracorporeal membrane oxygenation. Transfusion. 2013;53(6):1157-
1165.
53. Giglia TM, Massicotte MP, Tweddell JS, et al. Prevention and treatment of thrombosis in pediatric
and congenital heart disease: a scientific statement from the American Heart Association.
Circulation. 2013;128(24):2622-2703.
54. Selewski DT, Cornell TT, Blatt NB, et al. Fluid overload and fluid removal in pediatric patients on
extracorporeal membrane oxygenation requiring continuous renal replacement therapy. Crit Care
Med. 2012;40(9):2694-2699.
55. Villa G, Katz N, Ronco C. Extracorporeal Membrane Oxygenation and the Kidney. Cardiorenal
Med. 2015;6(1):50-60.
56. Askenazi DJ, Selewski DT, Paden ML, et al. Renal replacement therapy in critically ill patients
receiving extracorporeal membrane oxygenation. Clin J Am Soc Nephrol. 2012;7(8):1328-1336.
57. Bridges BC, Askenazi DJ, Smith J, Goldstein SL. Pediatric renal replacement therapy in the
intensive care unit. Blood Purif. 2012;34(2):138-148.
58. Santiago MJ, Sanchez A, Lopez-Herce J, et al. The use of continuous renal replacement therapy
in series with extracorporeal membrane oxygenation. Kidney Int. 2009;76(12):1289-1292.
59. Chen H, Yu R-G, Yin N-N, Zhou J-X. Combination of extracorporeal membrane oxygenation and
continuous renal replacement therapy in critically ill patients: a systematic review. Critical Care.
2014;18(6):675.
60. Jenks CL, Raman L, Dalton HJ. Pediatric Extracorporeal Membrane Oxygenation. Crit Care Clin.
2017;33(4):825-841.

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