The Edge: Moving ECMO Patients, Part 2

The Edge is a monthly blog series developed by EMS World and FlightBridgeED that features top EMS leaders exploring the intricacies of critical care in EMS practice. In this installment Jeremiah Gleitz, BAS, FP-C, CCP-C, completes a 2-part look at extracorporeal membrane oxygenation, or ECMO.

Find Part 1 of this column here.  

Managing ECMO patients in a hospital environment can be challenging enough, but when you introduce the transport environment, it becomes paramount to preplan, communicate with your team, and continuously monitor not only your patient but also your surroundings. Whether you are transporting by ground, rotor wing, or fixed wing, the variables are similar. Let’s return to our patient from last month’s opening scenario.

Upon landing at the airport nearest the sending facility, you prepare the equipment you anticipate needing and load it into the waiting ambulance. You were told the patient was on 9 drips, so you bring an additional 3-channel IV pump. This will give you a spare should there be a failure en route. You have a ventilator; portable oxygen tank; adaptor, so you can plug into the sending facility’s wall O₂ while packaging your patient; your cardiac monitor with invasive monitoring cables; your first-in bags; portable suction for the chest tubes; and additional IV tubing sets. Your perfusionist has her ECMO pump along with a spare circuit. Once loaded it’s a 25-minute ride to the hospital. Prior to leaving the airport, you confirm the airplane will be in a heated hangar upon your return due to the outside temperature. You confirm the ambulance you are riding in has adequate oxygen, working suction, a working inverter, and working heat. 

Once you arrive at bedside, you receive report from the sending RN. This is a 54-year-old gentleman who presented to the ICU this afternoon after undergoing a successful coronary artery bypass graft (CABG). After returning to the ICU, he went into persistent v-fib arrest and was emergently peripherally cannulated at the bedside for venoarterial ECMO. He has since converted to an organized rhythm. Because he requires ongoing ECMO management the sending facility can’t provide, they’ve arranged his transfer to an ECMO center. You are told he is currently on the following medications: norepinephrine, epinephrine, vasopressin, Versed, Nimbex, fentanyl, amiodarone, sodium bicarbonate, and insulin. He is also intubated, on a ventilator, and has a radial arterial line in his right wrist. 

You and your partner begin to assess your patient and divide tasks. At this time you request for additional medications to be mixed by the sending facility pharmacy so you have adequate medications for the transport. Monitoring equipment is transferred, the arterial line is zeroed, and the patient is transitioned to the transport ventilator. Medications are transferred to your IV pumps as well. After discussion with your perfusionist, you determine the team is ready to transition from the sending facility ECMO pump to yours. The circuit is clamped, and transfer occurs without issue. 

Before moving this patient from the ICU bed to your transport litter (which has been secured to the ambulance stretcher), it’s paramount to discuss a game plan. The airway needs to be managed during the move; a provider needs to be solely responsible for immobilizing the cannulation site; you’ll need adequate lifting help; and your ECMO circuit, IV lines, ventilator tubing, cardiac monitor, and cables all need to be free and clear for the transfer. With careful choreography the move is uneventful, and you place warm blankets over your patient. 

For transports via ground ambulance or in a helicopter with its own wheeled stretcher, this is likely to be the only bed-to-bed move until you are at the receiving facility. Since this is a fixed-wing transport, multiple additional moves will take place throughout. 

Once all equipment and your devices are secured to the stretcher and transfer paperwork is obtained, you depart for the ambulance garage. The referring facility is also sending multiple units of blood product in a cooler should they be needed. It’s important to think about the layout of your aircraft or ambulance when packaging your patient and loading equipment so everything remains accessible. 

Loading into the ambulance is another task that needs to be carefully choreographed. Remember, slow is smooth, and smooth is fast. An inadvertent decannulation is catastrophic and likely lethal in the transport environment.

At the Airport

Upon arrival at the airport, you pilot your ambulance into a heated hangar where your aircraft awaits with the loading ramp set up. Unloading from the ambulance is a reverse process and uneventful. With assistance from the EMS crew and your pilot, your patient is loaded into the airplane. You confirm your current oxygen consumption from both the ventilator and ECMO pump and perform an oxygen duration calculation that shows you have plenty on board. All equipment is secured, plugged in, and your patient remains hemodynamically stable, well sedated, and relatively unchanged. 

Shortly after takeoff your pilot advises you are at cruise level, and you rezero your arterial line. Since you have roughly 90 mins left of transport, you draw an ABG and find no significant clinical changes. You recheck your cannulation sites, which you have done after every move thus far, and find them clean, dry, and intact. Throughout the transport you continue to monitor your patient and observe no significant changes. Several of your medications require changing, but with the forethought to obtain them from the sending pharmacy, you are in good shape. 

Upon landing the airplane is pushed into a heated hangar where an uneventful transfer takes place into a waiting ambulance. Once the patient is loaded, you confirm all cannulation sites remain intact. All equipment and additional meds accompany you in the ambulance as you depart for the ECMO center. You call ahead to the receiving CVICU with your patient status and ETA. The unloading process repeats in the ambulance garage and, because you have choreographed these moves with clear communication, is again without problem. Navigating to the CVICU is a task as you weave around stretchers in hallways, around turns, and into elevators. Again the success of the transport stems from communication and teamwork. 

Finally you reach the CVICU. You are met by a receiving team and provide your report. It’s decided you will transfer your patient to the ICU bed and then switch everything else over. Again the plan is choreographed, and the move is flawless. The ventilator is switched, and thanks to a forward-thinking nurse, all medications are set up, primed, and programmed already for a quick transfer. The ECMO pump is moved onto a cart, and the ECMO specialist takes over. 

Conclusion

Many providers will never transport an ECMO patient, but this is a regular scenario for some teams. This patient thankfully provided his crew with an uneventful transport, but things could have gone differently in the blink of an eye—many ECMO transports are not this straightforward. This is where the importance of continuous education, preplanning, and great cross-team communication can make the difference between a catastrophic transport and a successful outcome. 

This patient’s coronary artery bypass graft was repaired by a cardiovascular surgery team the following morning. He had a 4-day run on ECMO prior to decannulation and was discharged home after 11 days neurologically intact.  

Jeremiah Gleitz, BAS, FP-C, CCP-C, is a critical care flight paramedic and regional clinical manager with Life Link III in Minneapolis, Minnesota. He is also an ECMO specialist with the Life Link III mobile ECMO team in collaboration with the Center for Resuscitative Medicine at the University of Minnesota.