A structured patient-and-circuit checklist for every ECMO patient: neurology, haemodynamics, pump, oxygenator, anticoagulation, ventilator 'rest', and the daily plan.
At the bedside
Timed steps- 1
Patient: neurology and sedation
Every shiftPupils, GCS/RASS off sedation where possible, focal signs; low threshold for CT head (ICH risk). Aim for light sedation once stable; awake ECMO when possible.
- 2
Haemodynamics and perfusion
Every shiftMAP (VA: usually 65–80 mmHg), pulse pressure (VA: >10 mmHg suggests LV ejection), lactate, urine output, cannulated-limb perfusion with Doppler and NIRS if available. Pre-oxygenator saturation is a venous surrogate on VV but is distorted by recirculation.
- 3
Circuit: pump and flow
Every shiftRecord RPM, blood flow and their relationship (rising RPM for the same flow = drainage problem or circuit resistance). Look/listen for line 'chatter' (shaking drainage line = hypovolaemia or cannula obstruction). Drainage (pre-pump) pressure is normally kept less negative than about −100 mmHg.
- 4
Circuit: oxygenator
Every shiftPre- and post-oxygenator pressures and the gradient across the membrane (rising ΔP = clot); post-oxygenator blood gas daily (PO₂ should be very high on FdO₂ 1.0); inspect connectors and oxygenator with a torch for clot and fibrin; check gas line, blender, heater temperature.
- 5
Anticoagulation and blood
DailyAnti-Xa or aPTT, ACT if used, platelets, fibrinogen, INR, Hb, LDH, plasma free Hb, bilirubin; antithrombin if heparin resistance. Common targets: Hb ≥7–8 g/dL (higher if DO₂ inadequate), platelets >50 × 10⁹/L (higher if bleeding), fibrinogen >1.5 g/L.
- 6
Ventilator 'rest' settings (VV)
DailyPplat <25 cmH₂O (≤30 acceptable), PEEP ≥10, low RR (4–30), FiO₂ 0.3–0.5; avoid hyperoxia and VILI. Track compliance and tidal volume at a fixed driving pressure, plus CXR.
- 7
Echo and imaging
DailyVA: LV size, aortic valve opening, LV/aortic-root smoke or thrombus, RV, pericardial collection. VV: cannula position (dual-lumen jet towards the tricuspid valve), RV function. CXR: cannula position, lung opacity.
- 8
Whole-patient care
DailyInfection screen (heater masks fever), early enteral nutrition, skin and pressure areas, physiotherapy/mobilisation, CRRT integration if used, drug dosing (circuit sequesters lipophilic drugs such as fentanyl, midazolam, propofol), family update.
- 9
Daily goals and weaning screen
DailyCan sweep or FdO₂ be weaned (VV)? Is there native cardiac recovery (VA)? Write today's targets: SpO₂, PaCO₂, MAP, anti-Xa, fluid balance.
Circuit anticoagulation (standard)
Unfractionated heparin (UFH)
- Dose
- Bolus 50–100 units/kg at cannulation; infusion about 7.5–20 units/kg/h titrated to target
- Range
- 7.5–20 units/kg/h
- Preparation
- 25,000 units in 50 mL NS = 500 units/mL
- Target
- anti-Xa 0.3–0.7 units/mL (or aPTT ~1.5–2.5 × baseline) per unit protocol; lower targets if bleeding
- Worked example
- 70 kg at 10 units/kg/h = 700 units/h = 1.4 mL/h of 500 units/mL
ECMO round checklist (bedside chart)
| Domain | Check | Typical target / red flag |
|---|---|---|
| Neuro | Pupils, GCS/RASS, CAM-ICU | New asymmetry → CT head |
| Haemodynamics | MAP, pulse pressure (VA), lactate, urine output | MAP 65–80 (VA); lactate falling; UO >0.5 mL/kg/h |
| Gas exchange | Right radial ABG (VA), patient ABG, post-oxygenator ABG | SaO₂ ≥85–88% on VV; post-oxy PO₂ high; PaCO₂ corrected slowly |
| Pump | RPM, flow, chatter, drainage pressure | Stable RPM:flow; drainage pressure less negative than about −100 mmHg |
| Oxygenator | ΔP pre/post, clots, sweep, FdO₂, gas line | Rising ΔP or visible clot = plan change |
| Anticoagulation | Anti-Xa/aPTT, platelets, fibrinogen, antithrombin | Per unit protocol (often anti-Xa 0.3–0.7 units/mL) |
| Haemolysis | Plasma free Hb, LDH, urine colour | pfHb >50 mg/dL (0.5 g/L) is significant |
| Cannulae | Sites, sutures, dressing, depth marks, limb perfusion | Bleeding, migration, ischaemia |
| Ventilator | Rest settings, compliance | Pplat <25, PEEP ≥10, FiO₂ ≤0.5 |
| Infection | Temperature (heater-controlled), WBC, cultures, line days | Fever may be masked |
| Nutrition/renal | Enteral feed, fluid balance, CRRT | Avoid fluid overload |
| Plan | Weaning trial? Family update? Exit strategy? | Documented daily |
Calculators for this topic
Infusion rate from per-kg-per-hour dose
Pump rate for drugs dosed per kg per hour (insulin U/kg/h, midazolam mg/kg/h, propofol mg/kg/h, fentanyl mcg/kg/h, dexmedetomidine mcg/kg/h).
PaO₂/FiO₂ ratio
Oxygenation ratio with ARDS severity bands (Berlin; PEEP ≥ 5 cmH₂O).
Driving pressure
Plateau pressure − PEEP (volume control, passive patient).
Static respiratory system compliance
Vt ÷ (Pplat − PEEP).
Mean arterial pressure
(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).
Low flow or 'chattering' circuit
Step 1 of ~5
Troubleshooting falling ECMO flow with drainage-line vibration.
Reduce RPM until chatter stops; keep minimum safe flow; call ECMO specialist
Based on Tonna JE, Abrams D, Brodie D, et al; Farkas J. Educational use; follow local protocol.
Pathophysiology
Pressures in a centrifugal circuit. Pre-pump (drainage) pressure is negative; the more negative, the greater the suction on the vein (haemolysis, chatter, cavitation). Pre-oxygenator pressure is the highest in the circuit; post-oxygenator pressure reflects return-cannula resistance and patient afterload. The gradient across the oxygenator rises as the membrane clots.
Evidence
- ELSO VV 2021 gives ventilator 'rest' ranges (Pplat <25 recommended, ≤30 acceptable; PEEP ≥10; RR 4–30; FiO₂ 0.3–0.5) and notes variable transfusion practice (some target Hb >7 g/dL, others up to 12 g/dL; restrictive practice may be considered).
- ELSO Anticoagulation 2021: heparin first-line; DTIs (bivalirudin, argatroban) for HIT or heparin resistance; no single monitoring test is perfect, so centres should use a consistent protocol combining tests.
- Daily structured checklists are expert-consensus practice to reduce missed complications.
Controversies
- Haemoglobin target on VV ECMO (7 g/dL vs higher) — oxygen delivery depends on both Hb and flow.
- Anti-Xa vs aPTT vs viscoelastic tests (TEG/ROTEM) for monitoring.
- Low-dose or anticoagulation-free VV ECMO in bleeding patients is increasingly used with modern coated circuits.
🇮🇳 India notes
- Anti-Xa assays may not be available 24/7 in many Indian labs; agree an aPTT/ACT-based fallback protocol.
- Plasma free Hb is not routinely available in many hospitals — use LDH, bilirubin and urine-colour trends as surrogates.
- Oxygenators and circuits are expensive; early recognition of rising ΔP allows a planned (safer) change.
References
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.