© Springer International Publishing Switzerland 2017
Chirine Mossadegh and Alain Combes (eds.)Nursing Care and ECMO10.1007/978-3-319-20101-6_77. Mobilizing the ECMO Patients: Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation (vvECMO)
(1)
Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
This chapter deals with adult venovenous extracorporeal membrane oxygenation (vvECMO) patients who will benefit from proning sessions.
A combination of these therapeutic techniques is used for patients presenting the most severe ARDS, who are particularly frail.
This section describes specificities of these combined therapeutic strategies and presents the nurse’s role for optimized quality care.
Nurses have a decisive part to play in the security and comfort of patients; effectiveness in nursing care is usually associated with training and procedures, so the purpose of this section is to give you an orientation for creating your own protocols.
7.1 Background
Prone positioning (PP)
Prone positioning (PP) for trying to improve oxygenation in patients with acute respiratory failure has been done for a long time (1970s).
During PP, an increase of the posterior pulmonary alveolar recruitment is described, as well as a decrease of inflation in ventral regions [1]; moreover, a homogeneization of ventilation and ventilation/perfusion ratio are also observed.
In addition, there is a reduction in lesions associated with ventilation (VILI), and proning position is effective in 70% of cases.
It is a simple and inexpensive procedure, but little practiced because of the workload and possible complications.
vvECMO
vvECMO for adult pulmonary failure was controversial because of negative results with regard to mortality in several large studies [2, 3].
But, times change and techniques evolve
In 2007, the CESAR [4] study showed a real benefit, in terms of survival, for patients with severe ARDS supported by ECMO.
This study has also shown the benefit of being transferred to referral centers, where an “ECMO-specialized team” is present.
In 2009, the H1N1 pandemic caused a renewed interest in the use of extracorporeal membrane oxygenation (ECMO) for extremely severe ARDS [5].
In 2012, Consensus conférence organized by the French Intensive Care Society [6] concluded: ECMO should be considered in patients with PaO2 to FiO2 ratio lower than 50 mmHg during at least 3 h despite the use of a protective lung strategy including prone positioning.
Very recently, systematic PP performed in ARDS patients with PF ratio lower than 150 has been shown to decrease mortality [7].
Usually, PP is considered before vvECMO.
Some studies have evaluated the effect of PP on lung function for patients under vvECMO [8–12], and they all come to the same conclusions:
PP and vvECMO are probably complementary, because ultraprotective ventilation allowed by vvECMO may reduce overinflation, but probably does not permit ventilation redistribution allowed by PP.
PP can be associated with vvECMO with an improvement in arterial oxygénation, and thereafter facilitation of weaning from vvECMO.
PP during vvECMO can be proposed without compromising the safety of selected patients, and can be implemented by centers experienced in both techniques.
ECMO probably makes PP safer in the most severe patients, because the risk of hemodynamic compromise or of sudden respiratory worsening, while turning the patient, is much less in vvECMO patients.
7.2 Nursing Care Related to vvECMO and Proning
Contraindications for PP under vvECMO are the same as those without ECMO:
Intracranial pressure >30 mmHg
Massive hemoptysis requiring an immediate procedure
Serious facial trauma or facial surgery
Cardiac pacemaker inserted in the last 2 days
Unstable spine, femur, or pelvic fractures
Mean arterial pressure lower than 65 mmHg
Pregnant women
Single anterior chest tube with air leaks
Safety and complications:
The nurse’s main role is to coordinate and organize the procedure, and to avoid complications.
To be performant, nurses have to know the possible side effects.
Most of the time, the proning session last 12–16 h.
Concerning PP position, studies have shown that the main side effects are:
Pressure ulcers
Endo Tracheal Tube (ETT) obstruction
Thoracostomy tube dislodgment
The team also has to keep in mind the side effects of vvECMO:
Bleedings
Thromboembolic risk
Hemolysis
Air embolism
Mechanical complications
Cannula dislodgment
Because of all these side effects, one efficient way to avoid them is to have standardized procedures and checklists (annexe).
It is necessary to think about the patient himself and the ECMO machine.
The environment in the room has to be particularly tidy.
The process is not difficult, but every detail has to be thought of.
The team has to be prepared, informed, and trained.
One more person than that in the usual PP procedure is needed.
This person will be totally dedicated to the ECMO machine and cannulas, which means checking the flow monitoring, checking all the tubing, and maintaining cannulas.
This person will be the referent for mobilization, associated with the one who is in charge of the endotracheal tube (ETT).
Usually, seven people are needed:
One for ETT
One for vvECMO and cannulas
Two on each side
And one for cleaning the mattress, positioning the sheet, helmet and mirror (if needed), and gel supports
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