Daily Care: Invasive Procedures:

Patients will often require a broad spectrum of invasive procedures while on ECMO. Because of the inherent bleeding risk, special consideration must be taken before proceeding.

  • Because of the inherent bleeding risk, patients on ECMO should not have their lines placed by junior trainees with limited experience; they are NOT ideal learning cases.

Arterial Line Insertion:

  • Anticoagulation does not need to be held for arterial line insertion.
  • If the patient is on V-A ECMO, the ideal place for an arterial line is the right radial or brachial artery.
  • Femoral arteries may be used, but the blood gas value will not properly represent cerebral oxygenation in a patient on V-A ECMO.
  • V-V ECMO patients may have radial, brachial, or femoral arterial lines.
  • Because of the inherent bleeding risk, care should be taken to minimize the number of needle passes by using ultrasound if necessary.

Central Venous Cahteter Insertion:

  • Anticoagulation does not need to be held for central venous catheter insertion.
  • The perfusionist should be by the bedside during central venous catheter insertions.
  • Because of bleeding risk, ideally compressible sites (internal jugular vein, or femoral vein) should be used.
  • The subclavian is not an ideal choice for a central venous catheter in an ECMO patient because the area is noncompressible, but if absolutely necessary it may be used.
  • Because of the centrifugal pump, ECMO patients are at risk of developing venous air emboli, and the consequences of this are dire.
  • During needle insertion, the perfusionist should temporarily reduce flow in order to prevent the entrainment of air through the needle.
  • Because of the inherent bleeding risk, care should be taken to minimize the number of needle passes by using ultrasound if necessary.

Bronchoscopy:

  • Anticoagulation does not need to be held for patients receiving bronchoscopy.
  • Care should be taken to avoid trauma to the endothelium, as patients are prone to bleeding.

Chest Tube Insertion:

  • Should we hold anticoagulation??
  • Patients on ECMO are followed by thoracic or cardiovascular surgery services at TGH, and they should be involved for any chest tube insertion.

Patients Requiring Surgery:

  • Patients requiring surgery often need their anticoagulation held.
  • Usually anticoagulation reversal can be accomplished by turning off the heparin infusion and waiting about 2 hours.
  • The decision on when to restart anticoagulation should happen in discussion with the surgical team.

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