ECMO Troubleshooting - OnePager Summary
ECMO Emergency Protocol - Team should train/practice & have necessary supplies at bedside:
 - Clamp drainage & return lines
 - Call for help
 - Return to pre-ECMO vent settings
 - Exchange of oxygenator or entire circuit may be needed
Circuit Problems:
 • CANNULA DISPLACEMENT - compromises the circuit and can cause an air embolism, major bleed, and reduced blood flows.
 • CIRCUIT THROMBOSIS - Clots in the tubing can increase flow resistance. Clots in oxygenator may also impair gas exchange. Acutely or over time, this may lead to OXYGENATOR FAILURE.
 • CHATTER - visible shaking of the tubing from variable venous drainage when the pump is trying to drain more than what native venous return allows. Pump may repeatedly start/stop causing CUT OUTS. 
 • AIR EMBOLISM - can cause immediate pump, oxygenator, or circuit failure. 
Pump Problems:
 • INADEQUATE FLOW can occur from kinking, cannula malposition, decreased venous return (+/- CHATTER), and CIRCUIT THROMBOSIS (same RPM yielding less LPM flow).
 • PUMP FAILURE may occur from CIRCUIT THROMBOSIS, AIR EMBOLISM, or other insult.
Gas Exchange Problems:
 • HYPOXEMIA is common as oxygenated blood always mixes with deoxygenated native circulation, although this may not reflect insufficient oxygen delivery.
 • HYPERCAPNIA/ACIDOSIS - can worsen with increased CO2 production (e.g. fever) or reduced clearance (worsening function of native lung or membrane lung), or impaired renal compensation.
 • RECIRCULATION - occurs when drainage cannula draws oxygenated blood from the return cannula, reducing the efficiency of the circuit.
Membrane / Oxygenator Problems:
 • RISING TRANSMEMBRANE PRESSURE: At constant flow, this indicates worsening resistance (usually thrombosis) & therefore worsening function, of the oxygenator. 
 • OXYGENATOR FAILURE may occur from AIR EMBOUSM, CIRCUIT THROMBOSIS (most common), or any serious mechanical insult. 
 • POST-CANNULATION SYNDROME is a SIRS-Iike inflammation as blood reacts to the oxygenator at 24-48 hrs of initiation.

by Nick Mark MD @nickmmark and Jonah Rubin, MD @JonahRubinMD


#ECMO #Troubleshooting #problems #diagnosis #differential #management #criticalcare