ECMO Nursing Guide for GCC | Advanced Critical Care

What is ECMO?

Extracorporeal Membrane Oxygenation — temporary mechanical life support for severe cardiac and/or respiratory failure refractory to conventional therapy

Core Concept

ECMO bypasses the heart and/or lungs by circulating blood through an external circuit containing a membrane oxygenator (artificial lung) and a centrifugal pump. It provides gas exchange and/or haemodynamic support while allowing the native organs time to recover, or as a bridge to transplantation or a ventricular assist device (LVAD).

VV-ECMO — Veno-Venous

Purpose: Respiratory support only
Blood drained from venous system → oxygenated → returned to venous system
Native heart must maintain circulation
Drainage: Right femoral vein
Return: Right internal jugular vein
SpO2 target: 85–95% (acceptable in severe ARDS)
Recirculation is a key concern

VA-ECMO — Veno-Arterial

Purpose: Cardiac + respiratory support
Blood drained from venous system → returned to arterial system
Unloads the heart — reduces preload
Peripheral: Femoral vein → femoral artery
Central: Right atrium → ascending aorta
Provides 60–80% of cardiac output
Higher risk of thromboembolism and stroke

Indications for ECMO

🫁 VV-ECMO Indications

PaO₂/FiO₂ ratio <80 mmHg despite optimal mechanical ventilation
pH <7.2 with PaCO₂ >80 mmHg (hypercapnic respiratory failure)
Severe ARDS (Berlin definition — severe)
MERS-CoV pneumonia / SARS-CoV-2 ARDS (highly relevant in GCC)
Community-acquired severe pneumonia
Pulmonary haemorrhage / status asthmaticus
Bridge to lung transplantation

🫀 VA-ECMO Indications

Refractory cardiogenic shock (MAP <60 despite pressors + IABP)
Post-cardiotomy syndrome (failure to wean from CPB)
ECPR — ECMO-assisted cardiopulmonary resuscitation
Massive pulmonary embolism with cardiac arrest
Myocarditis (fulminant)
Drug overdose with cardiac toxicity
Bridge to cardiac transplant or LVAD

⚠️

Murray Score / RESP Score Use the Murray Lung Injury Score (>3.0) or RESP Score to predict ECMO survival benefit. ELSO guidelines recommend ECMO referral when these thresholds are met before patient deteriorates further.

Contraindications

🚫 Absolute Contraindications

Irreversible condition with no plan for transplant or LVAD (futile)
Severe irreversible CNS damage (anoxic brain injury, massive stroke)
Metastatic/advanced malignancy with poor prognosis
Uncontrolled systemic bleeding with absolute anticoagulation contraindication
Prolonged CPR without ECMO initiation (>60 min without return of perfusion)

⚡ Relative Contraindications

Severe aortic regurgitation (VA-ECMO — increases afterload)
Aortic dissection
Immunocompromised with no reversible cause
Morbid obesity (technical challenges)
Advanced age with multiple organ failure
Heparin-induced thrombocytopenia (HIT) — alternative anticoagulation needed

ECMO Team Structure

👩‍⚕️ ECMO Specialist Nurse

Primary bedside ECMO management
Circuit monitoring and troubleshooting
Patient assessment and safety
Documentation and handover
Family education and support

Highest ICU Pay Grade

🩺 Perfusionist

Circuit priming and setup
Technical troubleshooting
Circuit changes and emergencies
Liaison with surgical team

👨‍⚕️ Intensivist / Cardiac Surgeon

Intensivist: medical management, weaning decisions
Cardiac surgeon: cannulation, surgical decannulation
ECMO physician 24/7 on-call

ECMO Centres in the GCC

Hospital	Country	Programme	Training Available
King Faisal Specialist Hospital (KFSH)	Saudi Arabia (Riyadh)	Adult VV + VA, Paediatric, Neonatal	Yes — ECMO Specialist Certification
Cleveland Clinic Abu Dhabi (CCAD)	UAE (Abu Dhabi)	Adult VV + VA, advanced cardiac ECMO	Yes — international training
Hamad General Hospital (HGH)	Qatar (Doha)	Adult VV + VA, ECPR programme	Developing programme
Sheikh Khalifa Medical City (SKMC)	UAE (Abu Dhabi)	Adult VV + VA, ECPR	Yes — ELSO affiliated
King Abdullah Medical City	Saudi Arabia (Makkah)	Adult VV + VA	Limited
King Hamad University Hospital	Bahrain	Adult VV + VA (growing)	Developing

GCC-Specific Context: MERS-CoV & ECMO

Saudi Arabia documented the world's largest experience with ECMO for MERS-CoV ARDS following the 2012 outbreak and subsequent cases. KFSH Riyadh published landmark data on VV-ECMO survival in MERS patients. This positioned Saudi Arabia and GCC as global leaders in respiratory ECMO for viral pneumonia — a skill set that became critical again during COVID-19. Nurses trained in GCC ECMO centres carry internationally recognised experience.

ECMO Circuit Components

Understanding every component of the circuit is essential for safe bedside management

🔵 Cannulas

Venous drainage cannula: Removes deoxygenated blood from the patient. Large bore (21–25 Fr) to optimise flow
Return cannula: Returns oxygenated blood to the patient. Smaller (15–21 Fr)
Placed under echo and fluoroscopic guidance
Secured with sutures and dressing — nurse checks security q1h
Air bubbles in cannula = emergency

⚙️ Centrifugal Pump

Magnetically driven impeller — no rollers (less haemolysis)
Speed measured in RPM (typically 2000–4000 RPM)
Generates flow — measured in L/min
Preload-dependent: adequate venous return required
Back-rotation alarm = no flow — immediate action required
Battery backup: confirm charged at each shift

🫧 Membrane Oxygenator (Membrane Lung)

Hollow-fibre polymethylpentene (PMP) — modern oxygenators
O₂ transfer across semipermeable membrane
CO₂ removal controlled by sweep gas flow rate
O₂ content in post-membrane blood controlled by FiO₂ of sweep gas
Delta P (inlet minus outlet pressure) = resistance indicator
Rising delta P = oxygenator clotting — plan changeout
Inspect for dark clots, fibrin strands q1h

🌡️ Heat Exchanger

Maintains patient normothermia (36–37°C)
Water flows through to warm/cool blood in circuit
Therapeutic hypothermia: set to 33–34°C post-cardiac arrest
Rapid rewarming can cause haemolysis — avoid
Check water temperature setting at every assessment

📊 Flow Probes & Pressure Monitoring

Flow Probe

Ultrasonic — measures actual blood flow in L/min. Target: 60–80 mL/kg/min. Low flow alarm threshold typically set at 1.0–1.5 L/min.

Pre-membrane Pressure (P-in)

Negative pressure on drainage side. Normal: −20 to −80 mmHg. Very negative (<−100) = drainage problem (cannula position, hypovolaemia, kinking).

Post-membrane Pressure (P-out)

Positive pressure after oxygenator. Delta P = P-in minus P-out. Rising delta P (>50 mmHg increase from baseline) = oxygenator failure / clotting.

Sweep Gas Management

Sweep Gas FiO₂

Controls oxygen delivery through the membrane lung. Higher FiO₂ sweep gas → more O₂ transferred to blood.

Start at FiO₂ 1.0 (100%)
Titrate to post-membrane PO₂ and patient SpO₂
Target post-membrane PO₂ >500 mmHg confirms oxygenator function

Sweep Gas Flow Rate

Controls CO₂ removal. Higher sweep flow → more CO₂ washed out → lower PaCO₂.

Start sweep flow at 1:1 ratio with blood flow (L/min)
Increase sweep → decreases PaCO₂ (risk of rapid alkalosis)
Decrease sweep → increases PaCO₂
"Sweep flow off" test used in VV-ECMO weaning

Anticoagulation Management

💉 Heparin Anticoagulation Protocol

Standard Monitoring Targets

Parameter	Target Range	Frequency
ACT (Activated Clotting Time)	180–220 seconds	q1–2 hourly
aPTT	60–80 seconds	q4–6 hourly
Anti-Xa	0.3–0.5 IU/mL	q6–12 hourly
Fibrinogen	>1.5 g/L	Daily
Platelets	>50 × 10⁹/L	Daily

Key Nursing Actions

Heparin infusion titrated by ECMO nurse per protocol
Document ACT result and heparin rate change every check
Never stop heparin without medical order — clot risk
HIT: switch to bivalirudin or argatroban
Bleeding: reduce heparin, transfuse FFP/platelets/cryo as ordered
If ACT >300: reduce heparin, re-check ACT in 30 min
If ACT <150: bolus + increase rate per protocol

ECMO Parameter Calculator

Enter patient weight to calculate target ECMO flow range and initial heparin dosing

Patient Weight (kg) ECMO Mode Current ACT (seconds) — optional

Cannula Sizes & Placement

ECMO Mode	Drainage Cannula	Return Cannula	Site	Nurse Check
VV-ECMO	21–25 Fr venous	19–21 Fr venous	R femoral vein → R IJ vein	Groin + neck dressing q2h, no kinking
VV-ECMO Dual-Lumen	Single 27–31 Fr (Avalon Elite)		R IJ vein only	Neck dressing, position confirmation echo
VA-ECMO Peripheral	21–25 Fr venous	15–19 Fr arterial	R femoral vein → R/L femoral artery	Groin bilateral, distal perfusion catheter check q1h
VA-ECMO Central	28–36 Fr atrial	8–10 mm graft	Right atrium → ascending aorta	Sternum open/closed dressing, mediastinal drain output

Patient Positioning on ECMO

🛏️ VV-ECMO Positioning

Head of bed 30–45° (VAP prevention)
Prone positioning possible and beneficial in severe ARDS — ECMO team required
Minimum 2 nurses + perfusionist for proning
Secure ALL lines and cannulas before turning
Prone: check cannula positions after turn
Lateral turns q2–4h for pressure care
Aim for early mobilisation when haemodynamically stable

🚶 VA-ECMO Positioning & Mobility

Usually head of bed 15–30° with femoral cannulas
Femoral cannula: avoid hip flexion >30° to prevent kinking
Central VA-ECMO: more mobility possible
Awake ECMO: physiotherapy while on circuit — evidence growing
Passive range of motion for all limbs daily
Distal perfusion catheter (DPC): check position not kinked with repositioning

Circuit Priming & Changeout

🔄 Nurse's Role in Circuit Management

Circuit Priming (with perfusionist)

Gather circuit (pre-assembled or prime from scratch)
Prime with crystalloid or blood prime for paediatric
De-air the circuit completely — no bubbles
Recirculate and check all connections
Document prime volume for fluid balance
Confirm backup circuit at bedside

Circuit Changeout Indicators

Delta P rise >50 mmHg above baseline
Post-membrane PO₂ declining despite FiO₂ 1.0 sweep
Visible clot in oxygenator head
Haemolysis: rising plasma-free Hb, dark urine
Routine elective change per protocol (varies by centre, typically 7–21 days)
Nurse prepares new circuit with perfusionist; ECMO physician present for changeout

ECMO Monitoring Framework

Systematic head-to-toe assessment plus dedicated ECMO circuit inspection every hour

q1h

Circuit Inspection

q1–2h

ACT Monitoring

q4h

Neuro Assessment

q1h

Limb Check (VA femoral)

Daily

Haemolysis Markers

Daily

Echo (VA-ECMO)

ECMO Bedside Monitoring Parameters

Parameter	Normal Range	Action if Abnormal
ECMO Flow (L/min)	3.5–6.0 L/min adult (60–80 mL/kg/min)	If low: check preload, cannula position, RPM — escalate
RPM	2000–4000 RPM	Sudden drop = pump failure; back-rotation = emergency
Pre-membrane Pressure (P-in)	−20 to −80 mmHg	<−100: check drainage, volume, cannula kinking
Post-membrane Pressure (P-out)	200–350 mmHg	Rising = circuit resistance; >400: oxygenator failure risk
Delta P (P-out minus P-in)	<50 mmHg rise from baseline	Rising delta P = oxygenator clotting — notify ECMO team
Sweep Gas Flow	1:1 with blood flow (L/min)	Adjust per arterial blood gas CO₂ target
Sweep Gas FiO₂	0.21–1.0	Titrate to patient SpO₂ and post-membrane PO₂
Temperature (water circuit)	36–37°C (normothermia)	Adjust for targeted temperature management goals
Blood Flow Colour	Bright red in return limb	Dark/venous colour in return = oxygenator failure

Clinical Monitoring — Patient Parameters

📡 Oxygenation Monitoring

SpO₂ (right hand for VA-ECMO): Right hand reflects pre-ECMO coronary and cerebral oxygenation in peripheral VA-ECMO — critical site
SvO₂ (mixed venous O₂ saturation): Measured in drainage limb; target >65–70% indicates adequate DO₂
SaO₂ vs SvO₂: Wide gap = high O₂ consumption or low flow
Arterial blood gas: q4–6h or with parameter changes
PaO₂/FiO₂ ratio: Track native lung recovery in VV-ECMO
NIRS (near-infrared spectroscopy): Cerebral oximetry — bilateral forehead probes in VA-ECMO; target rSO₂ >50% (or >20% below baseline)

🫀 Haemodynamic Monitoring (VA-ECMO)

Arterial line (radial): Right radial preferred for VA-ECMO — reflects coronary/cerebral perfusion
MAP target: 65–75 mmHg
CVP: Often low due to venous drainage — not reliable
PA catheter: If used, interpret with caution — cardiac output reflects native + ECMO combined
Pulse pressure: Narrow pulse pressure = native heart contribution minimal
Aortic valve opening: Confirm on echo daily — LV distension risk
Vasopressors: Wean as ECMO flow established

⚠️

Harlequin Syndrome (North-South / Differential Hypoxia) — VA-ECMO In peripheral VA-ECMO, oxygenated blood from ECMO enters femoral artery and travels retrograde. Native heart ejects blood from left ventricle (potentially poorly oxygenated due to lung failure). These two streams meet in the aorta — coronary arteries and brain may receive desaturated native heart blood. Sign: right hand SpO₂ LOWER than lower limb SpO₂. Action: optimise mechanical ventilation, consider switching to central cannulation or adding VV component (VAV-ECMO).

Haemolysis Monitoring

🩸 Daily Haemolysis Screen

Marker	Action Level
Plasma-free haemoglobin	>50 mg/dL → investigate cause
LDH	Rising trend → circuit assessment
Urine colour	Port-wine/dark = haemoglobinuria — increase fluids, reduce flow briefly
Haptoglobin	Undetectable = significant haemolysis
Serum bilirubin	Rising with other markers = haemolysis

Causes of Circuit Haemolysis

High RPM with insufficient flow (high shear stress)
Suction events (excessive negative drainage pressure)
Clot in pump head
Kinked cannula creating turbulence
Recirculation in VV-ECMO

💡

Nurse Action: Document urine colour at every hourly check. Send haemolysis screen if urine is dark or patient develops unexplained anaemia.

Interactive ECMO Hourly Assessment Checklist

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CIRCUIT CHECKS

Oxygenator Performance Assessment

🔬 How to Assess Oxygenator Function

Blood Gas Method

Take pre-oxygenator blood gas (from drainage limb port)
Take post-oxygenator blood gas (from return limb port)
Expected: post-membrane PO₂ >400–500 mmHg on FiO₂ 1.0 sweep
Post-membrane PCO₂ should be <40 mmHg
Declining post-membrane PO₂ = oxygenator failure

Visual Inspection

Inspect oxygenator housing against a light source
Dark streaks or clumps = thrombus formation
Fibrin strands visible = early clotting — monitor closely
White discolouration of fibres = plasma leakage
Document findings with photo if possible
Escalate to ECMO physician if deteriorating

Echocardiography in ECMO

🖥️ Daily Echo Assessment — VA-ECMO

LV function: Track ejection fraction — improving EF = native recovery (weaning signal)
Aortic valve opening: Must open at least intermittently; failure to open = LV distension risk → unloading strategy (IABP, Impella, surgical vent)
LV distension: Sign of afterload mismatch — can cause pulmonary oedema and LV clot
Cannula positions: Confirm tip positions with each echo
Pericardial effusion: Post-cardiac surgery — tamponade risk
RVOT obstruction: Can cause suction alarms in VV-ECMO (septal shift)
Nurse role: Assist with echo (patient positioning, connection of pads), document findings, escalate LV distension signs

ECMO Complications Overview

Complications are common — early recognition by the bedside nurse is critical. Average incidence in ELSO registry: major bleeding 30%, thrombosis 18%, neurological 8%

🚨

Emergency Situations — Know These Responses Accidental decannulation: apply direct pressure immediately, call for help, prepare clamping. Circuit failure: clamp both limbs, initiate manual ventilation/CPR as appropriate. Air embolism: clamp lines, position patient left lateral Trendelenburg, call ECMO team stat.

Circuit Complications

🔴 Clot Formation

Where: Pump head, oxygenator, tubing junctions, cannula tips
Signs: Rising delta P, dark streaks in oxygenator, low flow despite normal RPM, haemolysis
Action: Optimise anticoagulation, inform ECMO team, prepare for elective circuit change
Prevention: Maintain ACT in target range, avoid long periods of low flow (<1 L/min)

💨 Air Embolism

Cause: Disconnection on drainage side (negative pressure sucks air in), inadequate priming, port manipulation
Signs: Visible bubbles in circuit, sudden flow loss, patient deterioration
Emergency action:
1. Clamp both limbs immediately
2. Call ECMO team STAT
3. Stop pump if large air bolus
4. Position patient left lateral Trendelenburg (VA-ECMO)
5. De-air circuit before resuming

⚙️ Pump Failure

Back-rotation alarm = retrograde flow = life-threatening
Clamp arterial limb immediately to prevent arterial backflow
Switch to backup pump if available
Maintain CPR if cardiac arrest patient
Battery check at every shift — ensure fully charged

🧬 Oxygenator Failure

Progressively rising delta P
Declining post-membrane PO₂
Plasma leakage (white discharge from gas outlet)
Plan elective circuit change before emergency
Have backup oxygenator at bedside on prolonged ECMO runs

Patient Complications

🩸 Bleeding — Most Common Complication

Occurs in ~30% of ECMO patients. Caused by systemic anticoagulation + ECMO-induced coagulopathy (acquired von Willebrand syndrome, consumptive thrombocytopenia, fibrinogen depletion)

Bleeding Sites to Monitor

Cannula insertion sites (groin, neck, wrist)
Oropharynx / nasopharynx — avoid NGT if possible
Surgical sites (post-cardiac surgery)
Pulmonary haemorrhage (worsening ventilator oedema)
Intracranial haemorrhage (CT head if neuro changes)
GI bleeding (haematemesis, melaena)
Retroperitoneal bleeding (femoral cannula)

Management

Reduce heparin infusion per protocol
Transfuse: packed red cells, FFP, platelets, cryoprecipitate
Tranexamic acid (physician order)
Avoid IM injections on ECMO
Minimise blood draws — use circuit ports when possible
Gentle suctioning — limit frequency
Hold pressure for all venepunctures (minimum 10 minutes)

🧠 Neurological Complications

Stroke: Higher risk in VA-ECMO (arterial circuit, emboli, differential hypoxia)
Intracerebral haemorrhage: Anticoagulation-related
Seizures: Metabolic or structural
Nurse action: q4h neuro assessment: GCS, pupils, focal neurology
NIRS monitoring: bilateral — sudden drop alerts to ischaemia
Report any new neuro findings immediately
EEG if unexplained encephalopathy or seizure suspicion

🦵 Limb Ischaemia — VA-ECMO Femoral

Cause: Arterial cannula in femoral artery obstructs distal limb perfusion
Incidence: Up to 20% without distal perfusion catheter (DPC)
DPC: 6–8 Fr sheath placed antegrade in superficial femoral artery at time of cannulation
Hourly check — 6 Ps:
Pain, Pallor, Paraesthesia, Paralysis, Pulselessness, Poikilothermia
Doppler of dorsalis pedis / posterior tibial q4h
Urgent: loss of Doppler signal → escalate immediately

🔵 Infection — ECMO-Associated Bacteraemia

Incidence: 10–20% of ECMO runs >7 days
Sources: cannula site, intravascular lines, ventilator-associated pneumonia
Common organisms: CONS, Staphylococcus aureus, gram-negative rods, Candida
Daily circuit inspection: dressings, entry points, exit sites

Prevention Bundles

Aseptic dressing changes q48–72h or when soiled
Chlorhexidine daily bathing
VAP bundle compliance
CLABSI bundle for all lines
Daily review of need for all intravascular devices
Blood cultures if temperature >38.5°C or haemodynamic deterioration

⚡ Harlequin Syndrome (North-South / Differential Hypoxia)

Unique to peripheral VA-ECMO with concurrent lung failure

Mechanism

ECMO return blood (well oxygenated) enters via femoral artery → travels retrograde up aorta
Native LV ejects blood (poorly oxygenated — lung failure) anterograde
These streams compete at the mixing point in descending aorta
Upper body (heart, brain) may receive deoxygenated native blood

Recognition & Action

Sign: Right hand (pre-ductal) SpO₂ < lower limb SpO₂
NIRS drop: Cerebral rSO₂ falls
Action 1: Maximise mechanical ventilation (FiO₂, PEEP)
Action 2: Increase ECMO flow
Action 3: Consider central cannulation or adding VV component (VAV-ECMO)
Document right hand SpO₂ separately in all VA-ECMO patients

Emergency Response Protocols

🚨 Accidental Decannulation

Apply DIRECT FIRM PRESSURE to the cannula site immediately
Call for help — activate ECMO emergency response
Clamp circuit tubing to stop pump pulling air
Assess patient: consciousness, pulse, blood pressure
Begin CPR if pulseless
Surgeon and ECMO team to bedside for emergency recannulation decision

💔 Complete Circuit Failure

Clamp BOTH arterial and venous limbs of the circuit
Switch to manual ventilation / initiate CPR if needed
Call ECMO team stat — activate emergency changeout protocol
Prepare backup circuit (should already be at bedside)
Document time of failure and all interventions
Maintain IV access and medications during circuit change

ECMO Weaning — Principles

Weaning from ECMO requires evidence of native organ recovery. Process differs significantly between VV and VA modes.

When to Consider Weaning

VV-ECMO: improving native lung compliance and oxygenation, PaO₂/FiO₂ improving on low ECMO support, CXR improving

VA-ECMO: improving LVEF on echo (>20–25%), widening pulse pressure on arterial line, aortic valve opening reliably, lactate normalising, vasopressor weaning

VV-ECMO Weaning Protocol

Step down sweep gas FiO₂ gradually from 1.0 → 0.21 over hours/days; monitor SpO₂ and ABG response
Reduce sweep gas flow gradually (e.g., 6 → 4 → 2 → 1 L/min); monitor PaCO₂ — rising CO₂ = lung not yet ready
Trial off: Stop sweep gas entirely (or clamp gas tubing). Blood still flows through circuit but no gas exchange — pure native lung trial. Continue 1–4 hours.
Pass criteria: SpO₂ >92%, PaO₂ >60 mmHg, pH >7.3 on ventilator settings of FiO₂ <0.6, PEEP ≤10
Fail criteria: SpO₂ <85%, rising CO₂, haemodynamic compromise — resume full ECMO support

VA-ECMO Weaning Protocol

Daily echo assessment: Confirm improving LVEF, aortic valve opening, no LV distension
Gradual flow reduction: Reduce ECMO flow in steps (e.g., 4 → 3 → 2 → 1 L/min) over hours; maintain anticoagulation, monitor haemodynamics
At 1 L/min: Maintain for 15–30 min with close echo and haemodynamic monitoring
Pass criteria: MAP >65 on minimal/no vasopressors, CI >2.2 L/min/m², PCWP <18 mmHg, LVEF >20–25% on echo
Never stop blood flow completely without clamping — clot risk. Flow must stay >1 L/min or circuit clamped.
Fail criteria: Rising lactate, hypotension, LVEF not improving — return to full support

Decannulation

🏥 VV-ECMO — Bedside Decannulation

Can be performed at bedside in most centres
ECMO team present: nurse, ECMO physician, perfusionist
Stop pump, clamp lines, remove cannulas
Large-bore cannulas: manual pressure 30–60 minutes
Purse-string sutures if placed at cannulation — tie down
Pressure dressing applied
Post-decannulation monitoring: haemostasis hourly × 4h
Resume therapeutic anticoagulation per plan (DVT prophylaxis)

🔪 VA-ECMO — Surgical Decannulation

Peripheral VA: usually requires surgical repair of femoral artery — operating theatre or bedside with surgical team
Central VA: always operating theatre — sternotomy
Surgeon oversees arteriotomy closure
Distal perfusion catheter removed simultaneously
Vascular surgeon on standby for femoral repair
Post-decannulation: hourly limb checks continue × 12h
Haemostasis: pressure dressing + compression, heparin management

Post-ECMO Care

🔁 After Decannulation — Nursing Priorities

Immediate (0–24 hours)

Continue hourly haemostasis checks at decannulation sites
Doppler limb checks post-VA decannulation q1–4h × 24h
Anticoagulation transition: physician order (may restart heparin → bridge to warfarin or DOAC)
Arterial line management (may decannulate once stable)
Ventilator management — now on native lungs fully
Reassess haemodynamics off ECMO support

Extended Monitoring (24–72h)

Late vascular complications: pseudoaneurysm, AV fistula at cannulation site
Rebound pulmonary hypertension (post-VV)
Late stroke (embolic) — neuro checks continue q4h × 48h
Coagulopathy resolution monitoring — daily FBC, coagulation screen
Renal function: acute tubular necrosis common post-ECMO
Liver function: hepatic congestion in VA-ECMO

ECMO Rehabilitation

🏃 Early Mobilisation on ECMO — Growing Evidence

Awake ECMO (avoiding sedation + mechanical ventilation) and early physiotherapy is increasingly practiced, particularly in lung transplant bridge patients

Evidence-Based Practice

Passive range of motion: start day 1
Sitting to chair: possible with dual-lumen VV cannula (RIJ only)
Ambulation: achieved in select patients on ECMO bridge to transplant
Reduces ICU-acquired weakness
Improves patient outcomes and transplant candidacy

Safety Requirements for Mobilisation

ECMO flow stable ≥ target during activity
No arrhythmias at rest
Cannulas well secured — extra skin sutures if mobilising
Minimum 4 staff: nurse, physiotherapist, ECMO specialist, physician
Portable ECMO console with battery backup
Stop activity: SpO₂ fall >5%, haemodynamic instability

ECMO Withdrawal — Ethical Considerations

💛

When Recovery Does Not Occur If ECMO fails to achieve weaning despite optimal management and no viable bridge option (transplant/LVAD not feasible), the ECMO team together with patient/family and ethics committee may consider compassionate withdrawal. The nurse plays a key role in: family communication and support, ensuring comfort care is maximised, coordinating palliative care team, supporting staff wellbeing during withdrawal. This is one of the most emotionally demanding situations in critical care nursing.

ECMO Nursing Guidefor GCC