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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