HCSS Extracorporeal Membrane Oxygenation (ECMO) RN

JOB SUMMARY:

The ECMO Specialist (ES) is a licensed allied health care professional with a strong clinical background in neonatal, pediatric and/or adult critical care and advanced cardiopulmonary support. The ES has ≥ 2 years ICU experience or completion of an accredited cardiovascular perfusion training program. The ES is responsible for the coordination of clinical care for patients requiring the support of extracorporeal life support (ECLS) & mechanical circulatory support (MCS) devices under the direction & supervision of credentialed ECMO and advanced heart failure physicians. The ES adheres to the policies, guidelines & best practices set forth by the director, manager & coordinator of the ECMO department. The ES plays a key role in device management, patient monitoring, emergency response, and quality improvement initiatives.

Clinical Level Detail

The ECMO Specialist (ES) is a competent technical specialist, preceptor & ECMO primer. The ES is a proficient clinician in two high acuity clinical environments where care of an ECLS or MCS patient is provided (2 ICU's or Any ICU + OR, CVL, Transport etc.) & in two patient populations (Adult, Pediatric &/or Neonatal).

Clinical Level Minimal Experience

The required experience to qualify as an ES is ≥ 2 years’ experience as an ES; or completion of an accredited program in cardiovascular perfusion, nursing, or respiratory therapy. Completed annual required hands-on drills, simulations & passed annual competency examination(s) for an ES. Completed clinical ECMO orientations in two patient populations (Adult, Pediatric &/or Neonatal).

Clinical Level Responsibilities

The ES is trained to independently prime, operate, troubleshoot & manage ECLS & MCS devices. The ES can independently initiate support & manage advanced ECLS & MCS care plans. The ES can independently troubleshoot clinical scenarios. The ES is trained to independently manage ECLS & MCS emergencies and coordinate the allied health care team to implement major interventions. The ES is a clinical preceptor and resource for level I & II specialists. 

MAJOR DUTIES / CRITICAL TASKS:

Programmatic Responsibilities

·     Education: Collaborates with ECMO team leadership and contributes to education, training, precepting & mentoring of all ES I & II team members.     

·     Equipment: Assists leadership with equipment maintenance, cleaning & troubleshooting of ECMO, MCS & ECMO monitoring equipment. Ensures backup ECMO circuit is primed & ready for use each shift.

Technical Specialist Responsibilities

·     Patient Identification: Collaborates with multidisciplinary physician teams to identify patients indicated for ECLS or MCS therapies and in concordance with ECMO physician guides care team to adhere to indications and contraindications as found in program guidelines and policies.

·     Initiation of Support: Coordinates & collaborates with multidisciplinary care team to prepare patient and environment for the timely and safe initiation of ECLS or MCS support.

·     Patient Management & Monitoring on Support: Assess and manage patient clinical needs, including but not limited to patient assessment, hemodynamic monitoring, NIRS, blood gas interpretation, laboratory results, fluid balance, nutrition, respiratory support, neurologic status, infection control, sedation, pain management, hematology, and cardiac function.

·     Documentation: In collaboration with bedside clinician, follows department guidelines for EMR documentation. Utilizes the ECMO flow sheet & EMR to maintain ongoing detailed documentation of the ECMO case. This includes hourly charting in flowsheet, progress & procedure notes, events, complications, physician communication, input & output, medication, blood administration & physical assessment documentation associated with monitoring the delivery of ECMO therapy.

·     Diagnostic Testing: Coordinates with care team to ensure safe execution and delivery of diagnostic testing such as x-ray, ultrasound, echocardiography, EEG including safe and timely transportation to CT, invasive lab or operating room. Evaluates chest x-rays for endotracheal tube, ECMO cannula, or MCS device

position & placement.

·     Extracorporeal VAD Management: Assist the physician during insertion of extracorporeal VAD devices; manage and troubleshoot equipment issues such as pump failures or circuit occlusions; monitor and optimize patient hemodynamics (e.g., flow rates, pressure support) and anticoagulation strategies to prevent thrombosis or bleeding; coordinate discontinuation and removal processes, ensuring safe weaning and device explanation.

·     Percutaneously Inserted VAD Management: Assist the physician during percutaneous insertion; manage and troubleshoot device-specific issues like position migration or suction events; assess patient hemodynamics and anticoagulation protocols; oversee discontinuation, including safe removal and post-removal monitoring.

·     Implanted VAD Management: Assist the physician & VAD coordinator during surgical implantation; manage and troubleshoot equipment such as driveline issues or pump thrombosis; evaluate and fine-tune patient hemodynamics and long-term anticoagulation strategies; facilitate discontinuation through explanation or transition to other therapies, following the guidance of the VAD coordinator.

·     ECLS Circuit Priming and Initiation: Prepare and prime ECLS circuits, including pumps, oxygenators, heat exchangers, shunt lines and associated components, ensuring sterility and functionality prior to patient connection.

·     ECLS Circuit Blood Priming: Safely blood primes ECMO circuits for patients as indicated by department guidelines, policies or as requested by cannulating ECMO physician. Maintains competency in strategies to anticoagulate, buffer, correct electrolytes, wash, hemoconcentrate & interpret ECMO circuit blood gases.

·     ECMO Circuit Maintenance: Continuously monitor and maintain ECMO circuit

integrity, including adjusting blood flow rates, monitoring pressure gradients, to prevent complications like hemolysis or clot formation.

·     ECMO Circuit Evaluation: Using in-line tools and blood gas analyses to calculate metrics such as oxygen consumption (VO₂), oxygen delivery (DO₂), oxygen transfer rate, recirculation & sweep gas adjustment rate.

·     ECMO Circuit Troubleshooting: Identify and resolve issues such as circuit leaks, component failures, or suboptimal performance, including elective or emergent component changes when indicated.

·     Anticoagulation Management on ECMO: Monitor and adjust anticoagulation levels to balance the risk of circuit thrombosis and patient hemostasis.

·     Clot Formation Management: Evaluate clot formation through staging (e.g., visual inspection, pressure monitoring), triage severity, and recommend anticoagulation adjustments to mitigate risks of major patient events such as embolism or circuit failure.

·     CVVHD/Hemodialysis Management (e.g., Prismaflex, NxStage, Aquadex): Assist in setup of continuous veno-venous hemodiafiltration (CVVHD) or hemodialysis devices integrated into the ECMO circuit; monitor therapy parameters including dialysate flow, ultrafiltration rates, electrolyte balance, and fluid removal; manage ongoing therapy by adjusting settings for optimal clearance and patient stability; troubleshoot issues such as filter clotting, pressure alarms, or access problems, following hospital guidelines for renal replacement therapy in ECMO patients.

·     ECMO Circuit Ultrafiltration Techniques: Safely crystalloid prime & insert hemofilter into the ECMO circuit shunt line. Implement slow continuous ultrafiltration (SCUF), zero-balance ultrafiltration (ZBUF), or countercurrent hemodialysis (CVVHD) using the ECMO circuit hemoconcentrator. Monitor & document fluid input & output, ultrafiltration volumes, patient hemodynamics, and electrolyte shifts; manage and troubleshoot blood & ultrafiltration flow rates, circuit integration issues and replace or remove hemoconcentrator as indicated.

·     Cytokine and Inflammatory Marker Removal: Safely crystalloid prime & insert cytokine absorbers into the ECMO circuit for removal of cytokines, endotoxins,

and inflammatory markers as ordered by ECMO physician; monitor adsorption efficiency, absorber performance, and patient inflammatory biomarkers; manage and troubleshoot blood flow rate, adsorber saturation & circuit integration issues. Replace or remove cytokine absorber as indicated.

·     Medication Administration to ECMO Circuit: Following physician guidance and orders, administer patient-required medications directly into the ECMO circuit, collaborate with ECMO physician and reports concerning circuit sequestration & drug efficacy. Maintains up to date knowledge & understanding of the

pharmacokinetic effects of all drugs and treatments given to the patient via the ECMO circuit. Examples but not limited to, vasoactive drip titration (e.g., adjusting norepinephrine or vasopressin doses for hemodynamic stability), sedatives, analgesics, antibiotics, and other supportive agents; monitor drug levels and effects, troubleshooting suboptimal responses or interactions.

·     Blood Product Administration to ECMO Circuit: Following physician guidance & orders, administer blood products (e.g., packed red blood cells, platelets, fresh frozen plasma, cryoprecipitate) via the ECMO circuit to maintain target blood count parameters and physician guided platelet & coagulation cascade functionality; monitor transfusion effects on circuit function and patient hemostasis; troubleshoot & monitor for transfusion-related complications & reactions.

·     ECMO Circuit Flow Management: Manage all ECMO circuit flows. Follow guidelines to set alarms, interpret changes in pressures, communicate concerns with ECMO physician & care team, coordinate appropriate interventions to resolve deviations greater than 10% from physician-ordered patient flow.

·     Troubleshooting ECMO System Alarms: Interpret and troubleshoot ECMO system alarms, triaging the need for planned, staged or emergency interventions. Communicate with care team and ECMO leadership to implement component, circuit or equipment exchanges in a safe and timely manner.

·     Troubleshooting Ancillary Equipment Functionality & Alarms: Address alarms from any device connected to the ECMO circuit, triaging the need for

replacement and coordinating with ECMO leadership & patient care team to replace equipment in a safe and timely manner.

·     ECMO Transport: Safely lead and coordinate inter-facility and intra-facility ECMO transport. Ensure safe patient handling, circuit integrity, ECMO equipment functionality and ordered ECMO flows are maintained.

·     Weaning, Withdrawal & Decannulation from ECMO: Assess patient readiness for weaning & follow guidelines & physician orders to safely wean ECMO flow (V-A/V-PA) or sweep gas (V-V). Coordinate patient care team to safely transition patient off ECMO and ensuring vent settings are no longer in “ECMO rest settings” and inotropic support is available. Assist ECMO physician in decannulation procedure. Compassionately support family and coordinate with ECMO physician and care team to withdraw ECMO when end of life measures are ordered.

Emergency Responses

The ECMO Specialist will master the necessary skills with repeated clinical drills until meeting the ECMO director, manager, and/or coordinators’ expected time and best practice goals in response to ECMO emergencies. These guidelines & goals are set to minimize loss of flow & reduce risk of secondary harm that may occur during the interruption of extracorporeal life support therapy.

Emergency response training includes, but not limited to:

·     Power failure: Ensure equipment is connected to generator backed red outlet. If power failure is extended ensure backup equipment is readily available to swap consoles prior to battery depletion.

·     Equipment Failure & Hand Cranking: Triage the need for emergency hand cranking, coordinating with the allied health care team to start emergency ventilation & patient management strategies. Hand crank to maintain goal-directed flow using visual indicators of RPM’s and patient vital signs. Coordinate the replacement of failed ECMO system components.

·     Blood Pump Failures: Rapidly triage and differentiate blood pump failures (clotted cone, decoupling), mitigate loss of flow possible, clamp circuit if not and safely & rapidly replace failed blood pump or circuit.

·     Air Entrainment: Detect and eliminate air bubbles in the circuit using bubble detectors and de-airing techniques, clamp ECMO circuit, isolate patient from air embolism, remove air from circuit and re-establish flow. Replace entire circuit if unable to clear air from a mass air entrainment. Investigate and identify the cause of air entrainment and resolve prior to initiating flow to the patient & through the circuit.

·     Cannula Dislodgement: If an ECMO cannula dislodges, clamp dislodged cannula, coordinating with the care team & ECMO physician for immediate

surgical intervention while maintaining patency of functioning cannula and attempting to salvage ECMO circuit. Prepare backup circuit for circuit exchange if indicated. Support cannulating physician with re-insertion or exchange of dislodged cannula and safely initiating ECMO.

·     Cannula Malpositioning or Impedance of Flow: Manage cannula malpositioning or flow impedance by interpreting circuit pressures to identify the cannula with increased impedance. Reposition patient or attempt to correct cannula malpositioning to re-establish goal flow. If impedance is unresolvable, contact cannulating physician. Coordinating patient stabilization, positioning and diagnostic imaging to further investigate impedance. Prepare for surgical interventions, mechanical thrombectomy, or cannula exchange if indicated.

·     Uncontrolled Hemorrhage: Manage acute or uncontrolled bleeding by administering fluids or blood products to ECMO circuit to maintain goal flow and stopping anticoagulation. Assist care team by utilizing ECMO circuit as a method of rapid & mass transfusion.

·     Advanced Life Support (ACLS, PALS, BLS): Collaborate with the multidisciplinary team to stabilize hemodynamics of the patient and adjust ACLS & PALS algorithm to augment the support capabilities of the current ECLS or MCS strategy.

·     Circuit Exchange: Triage the need for planned or emergent circuit exchange and coordinate with the allied health care team safely complete a full circuit exchange if indicated.

·     Circuit Tubing or Component Fracture, Rupture or Failure: Respond to circuit

tubing or component fracture, rupture or failure by clamping affected sections, replacing tubing or component and restoring circuit integrity to minimize loss of support & prevent blood loss or air entrainment.

·     Circuit Obstruction of Flow: Detect and correct obstruction of flow by evaluating circuit pressures, identifying problem location and visually inspecting for kinks, clamps or thrombus. Repositioning tubing, components, holders & brackets to restore optimal flow. If obstruction is unresolvable due to internal

obstruction/thrombosis, triage the need use push-pull techniques for mechanical thrombectomy or to replace section, component or entire circuit and execute appropriate action to restore goal flow.

·     Oxygenator Failure: Manage oxygenator failure by monitoring blood flow & gas exchange metrics (e.g., rising pressure drops or reduced oxygenation and/or ventilation), triaging for immediate or planned replacement & coordinating oxygenator or circuit change-out procedure with care team.