ECMO Nursing Guide — GCC

Recognition

• Both drainage and return limbs appear similarly bright (oxygenated)
• Patient SpO₂ low despite high ECMO flow and good oxygenator function
• SaO₂ on drainage sample unexpectedly high (>75%)
• Recirculation fraction = (SrO₂ − SvO₂) / (SpO₂ − SvO₂)

Management

• Reposition cannulae — increase distance between tips
• Reduce ECMO flow temporarily
• Ensure adequate intravascular volume
• Consider position change (e.g., Trendelenburg)
• Imaging to confirm cannula positions (CXR, echo)

UFH Protocol

• Unfractionated heparin (UFH) — continuous infusion
• aPTT target: 55–70 seconds
• Anti-Xa target: 0.3–0.5 units/mL
• ACT target: 180–200 seconds
• Monitor ACT every 4–6 hours
• aPTT or anti-Xa: 6-hourly until stable, then 12-hourly

HIT Surveillance & Management

• Monitor platelet count daily
• HIT suspect: platelet drop >50% from baseline, 5–10 days post-heparin
• Send HIT antibody (anti-PF4/heparin) ELISA
• If HIT suspected: stop all heparin immediately
• Switch to direct thrombin inhibitor: Argatroban
• Argatroban target: aPTT 45–80 seconds (institution specific)
• Bivalirudin: alternative — monitor aPTT or ECT

Oxygenation Targets — VV-ECMO

• PaO₂ 55–80 mmHg acceptable
• Haemoglobin target: 10–12 g/dL (transfuse PRBC if below)
• Optimise ECMO flow before escalating ventilator settings

Lung Rest Ventilation Strategy

Dual Arterial Line Strategy

• Peripheral line: radial artery (right side preferred) — monitors native cardiac output oxygenation
• Central line: femoral or aortic — monitors ECMO circuit perfusion
• Compare SpO₂ from right hand vs lower limb
• If right hand SpO₂ < lower limb SpO₂ = Harlequin

Harlequin Management

• Optimise native lung ventilation (increase FiO₂, PEEP)
• Add venous drainage to jugular (VAV configuration)
• Increase ECMO flow to maximise retrograde oxygenated blood reaching arch
• Consider transition to central cannulation
• Monitor cerebral oximetry (NIRS) if available

Signs of Native Heart Recovery

• Improving pulsatility on arterial waveform — pulse pressure widening
• Aortic valve opening on echocardiogram
• Improving LVEF on serial echo
• Ability to reduce ECMO flow without haemodynamic deterioration
• Decreasing vasopressor requirements
• Improving lactate and SvO₂

Echocardiographic Assessment

• Daily TTE or TOE assessment on VA-ECMO
• LVEF measurement — target improvement to >20–25% before weaning trial
• Assess aortic valve opening — if not opening, LV distension risk
• LV end-diastolic diameter — increasing = distension
• Mitral regurgitation severity
• RV function assessment

Hourly Limb Assessment — VA-ECMO

• Distal pulses: dorsalis pedis, posterior tibial — Doppler if not palpable
• Capillary refill time: <2 seconds normal
• Temperature: compare both limbs — cool = ischaemia
• Colour: pallor, mottling, cyanosis
• SpO₂ probe on great toe of cannulated limb
• Pain/paraesthesia in awake patients
• Document findings hourly — escalate immediately if deteriorating

DPC Management

• Confirm DPC flow — visible pulsatile blood flow
• DPC connected to ECMO circuit return limb via Y-connector
• Keep DPC site clean and patent
• Compartment syndrome: hard, tense calf → escalate urgently
• Rhabdomyolysis: CK, myoglobinuria monitoring

Positioning Guidelines

• HOB 30°: standard position — reduces VAP risk, improves respiratory mechanics
• Central cannula patients: minimal repositioning — log roll ONLY with ECMO specialist present
• Peripheral cannula (femoral): restrict hip flexion on cannulated limb (<30°)
• Prone positioning on VV-ECMO: possible in specialist centres — requires full team

Mobility — VV-ECMO Walking Protocol

• Eligibility: awake, cooperative, haemodynamically stable, peripheral cannulae
• Minimum team: ECMO specialist + 2 nurses + physiotherapist
• Ensure circuit length adequate for ambulation
• SpO₂, HR, MAP continuous monitoring during mobility
• Progressive: dangling → standing → walking

Nutritional Support

• Early enteral nutrition: start within 24–48h of ECMO initiation
• Route: NGT preferred; post-pyloric if gastric intolerance
• ECMO increases metabolic rate — indirect calorimetry if available
• Target: 25–30 kcal/kg/day protein 1.5–2g/kg/day
• Monitor gastric residuals (GRV) — ECMO may reduce GI motility
• Prokinetics (metoclopramide, erythromycin) if high GRV
• Parenteral nutrition if EN not achievable by day 3–5

Metabolic Monitoring

• Blood glucose 6–10 mmol/L — insulin infusion as needed
• Electrolytes: Na, K, Mg, Phosphate, Ca — correct daily
• Drug dosing altered on ECMO — circuit absorbs lipophilic drugs
• Sedatives (midazolam, fentanyl): significantly absorbed — higher doses needed
• Antibiotics: some require dose adjustment (check pharmacy)
• Temperature management: normothermia via heat exchanger

Routine Cannula Care

• Aseptic non-touch technique for all dressing changes
• Dressing change: 48-hourly (or sooner if soiled/loose)
• Transparent dressing preferred — visible exit site inspection
• Exit site inspection: daily — redness, discharge, haematoma, movement
• Cannula secured with sutures + additional fixing — document
• Never remove or reposition cannulae without ECMO specialist
• Mark cannula depth/position at commencement — reassess each shift

Infection Prevention

• Full barrier precautions for cannula access
• CHG (chlorhexidine gluconate) dressings at exit sites
• CHG bathing: daily whole-body wash
• Exit site swabs if infection suspected
• Blood cultures (peripheral + central) if fever or unexplained deterioration
• Remove unnecessary venous catheters — minimise infection sources

Awake ECMO Patients

• ECMO machine noise — constant anxiety trigger
• Immobility (circuit limitations)
• Fear of circuit disconnection or emergency
• ICU delirium — assess with CAM-ICU daily
• If intubated — cannot verbalise fears
• Communication aids: letter boards, tablets, eye gaze devices
• Regular psychological assessment
• Sleep hygiene: noise reduction, light management, sedation minimisation

Family Support

• Pre-visit preparation: ECMO is alarming — explain circuit, alarms, appearance before first visit
• Show family photos of the circuit and equipment in advance
• Assign family liaison nurse — consistent communication
• Daily family meetings with ECMO/ICU team
• Involve family in care (hand-holding, speaking to patient)
• Spiritual support: hospital chaplain, Imam access in GCC ICUs
• Allow Arabic Quranic recitation — contributes to patient comfort

MERS-CoV ECMO Experience

• Middle East Respiratory Syndrome Coronavirus — endemic in Arabian Peninsula
• Severe MERS-CoV ARDS: P/F ratio <80 — VV-ECMO indication
• Saudi Arabia accumulated significant VV-ECMO experience for MERS
• Outcomes data published from KFSHRC and other Saudi centres
• Infection control: ECMO for MERS required full PPE — N95, gown, gloves, eye protection
• Circuit management with aerosolisation precautions

COVID-19 ECMO Experience

• GCC hospitals established/expanded ECMO programmes during COVID-19 pandemic (2020–2022)
• Qatar (HMC) and UAE treated international patients on ECMO
• ELSO COVID-19 guidelines followed across GCC
• VV-ECMO for COVID-ARDS: P/F <80 despite optimal proning and ventilation
• Extended ECMO runs (weeks to months) — unique nursing challenges
• Nursing staff rapidly trained and upskilled during pandemic

Mobile ECMO Team Composition

• ECMO specialist physician (intensivist/cardiac surgeon)
• ECMO specialist nurse
• Perfusionist or ECMO technician
• Additional transport nurse/paramedic
• Transport: ground ambulance (short distance), helicopter or fixed-wing aircraft (inter-emirate/cross-border)

Transport Nursing Considerations

• Transport ECMO console — battery-powered, certified for air transport
• Adequate drug and blood product supply for transport duration
• Secure all connections before movement
• Ventilator transport settings — anticipate vibration effects
• Communication with receiving team pre-arrival
• Documentation: ECMO parameters logged throughout transport

ELSO Guidelines — GCC Adoption

• Extracorporeal Life Support Organisation (ELSO) — international standards body
• GCC centres following ELSO guidelines for circuit management, anticoagulation, weaning
• ELSO registry participation — data submission from major GCC centres
• ELSO training courses offered at GCC centres

Nurse Specialist Training Pathway

• ICU registered nurse with ≥2 years critical care experience
• ECMO theory training: circuit physics, pathophysiology, pharmacology
• Simulator training: circuit management, emergency scenarios
• Supervised clinical practice: minimum case numbers
• Competency assessment: annual recertification
• ECMO Coordinator role in major GCC centres

Withdrawal of ECMO Support

• Islamic bioethics: preservation of life is paramount; extraordinary measures not obligatory if futile
• Fatwa (religious ruling) may be sought by family in difficult decisions
• Family consensus preferred — extended family may be involved
• Hospital ethics committee involvement for complex cases
• Palliative care team integration — increasing across GCC
• Documentation of decision-making process essential

Religious & Family Support in ECMO ICU

• Prayer: Adhan (call to prayer) and Quranic recitation — important comfort measure for Muslim patients
• Qibla (direction of Mecca) orientation for bed placement where feasible
• Family visitation: infection control requires limiting visitors, but flexibility for dying patients
• Female patients: maintain modesty during ECMO care procedures
• Ramadan: fasting exempted for critically ill patients — but family may wish to participate in care during Iftar/Suhoor times
• Hospital chaplaincy/Imam service available in all major GCC hospitals

Indications

• Congenital heart disease post-operative repair — most common indication in GCC tertiary paediatric cardiac centres
• Failure to wean from cardiopulmonary bypass
• Post-operative low cardiac output syndrome
• Neonatal respiratory failure (CDH, MAS, PPHN)
• Paediatric myocarditis
• Paediatric ARDS (including MERS-CoV and COVID-19)

Paediatric Nursing Considerations

• Weight-based flow calculations (target: 100–150 mL/kg/min neonates)
• Blood prime circuit for neonates/small children — reduces haemodilution
• Temperature regulation more critical — neonates hypothermia risk
• Developmental care: touch, voice, gentle stimulation within circuit limits
• Family presence: parents at bedside — ECMO education essential
• Play therapy and psychological support for older children on ECMO