HCSS Extracorporeal Membrane Oxygenation (ECMO) specialist/RRT

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 has

successfully completed advanced training to operate ECLS & MCS devices, in

accordance with guidelines established by the Extracorporeal Life Support Organization

(ELSO) & the American Society of ExtraCorporeal Technology (AmSECT). 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, advanced practice

registered nurse, physician assistant or medical school. Completed the annually

required ELSO & AmSECT based didactic education, hands on drills, simulations &

passed annual competency examination(s) for an ES. Completed clinical ECMO

orientations in two patient populations (Adult, Pediatric &/or Neonatal).

MAJOR DUTIES / CRITICAL TASKS:

Communication

· Participates in monthly interdisciplinary ECMO case reviews and in-services to

share information and determine appropriateness of patient care plans.

· Supports ECMO team research through the collection of ECMO-related data,

preparation, and presentation of research abstracts and/or other documentation.

· Utilizes the ECMO flow sheet to maintain ongoing complete and detailed

documentation of patient history and the amount of blood and other fluids

administered and any complications that may occur.

· Provides family/parental education and reinforces medical counseling initiated by

the ECMO physician.

· Provides a clear and concise end of shift report for the oncoming ECMO Specialist

regarding machine settings, patient status, and patient care plans.

Technical Specialist

· Patient Identification: Collaborates with multidisciplinary physician teams to

identify patients indicated for ECLS or MCS therapies and guides care team to

adhere to indications and contraindications as found in hospital 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. · Communication: Collaborates with the ECMO physician and other health care providers involved in the management of the patient to coordinate all tests and evaluations (e.g. head and cardiac ultrasounds and EEGs) and provide care in accordance with the patient’s individualized care plan. Recommends modifications in patient management to the ECMO physician based on the relationship between patient diagnosis and ECMO circuit and/or lab parameters. · 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, cath lab or operating room. Evaluates chest x-rays for endotracheal tube, ECMO cannula, or MCS device position & placement. · Extracorporeal VAD Management (e.g., CentriMag): 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 (e.g., Impella): 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 (e.g., HeartMate 3): 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, reverse citrate, wash, & hemoconcentrate blood components added to the circuit. Will evaluate circuit gasses and · 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. · Weaning and Decannulation from ECMO: Follow guidelines for gradual weaning, assessing patient readiness, and assisting in safe decannulation procedures. · Team Collaboration and Transport: Participate in daily rounds, case reviews, and ECMO transport (in-hospital or inter-facility), ensuring secure patient handling and circuit integrity. · Education and Quality Improvement: Contribute to staff training, continuingeducation, critical incident reviews, and tracking performance indicators (e.g., bleeding events), supporting ECMO program’s quality improvement initiatives. · 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 (SCUF): Implement slow continuous ultrafiltration (SCUF) within the ECMO circuit for fluid removal; monitor ultrafiltration volumes, patient hemodynamics, and electrolyte shifts; manage and troubleshoot technique-specific issues like inadequate fluid extraction or circuit pressures, per ELSO recommendations for fluid overload management. 9 12 · ECMO Circuit Ultrafiltration Techniques (ZBUF): Apply zero-balanced ultrafiltration (ZBUF) in the ECMO circuit to achieve iso-volumic fluid removal while maintaining balance; monitor replacement fluid administration, ultrafiltrate output, and patient volume status; troubleshoot imbalances or circuit complications, aligned with ELSO guidelines for acute kidney injury and fluid management. 9 12 · ECMO Circuit Ultrafiltration Techniques (Countercurrent Hemodialysis): Utilize countercurrent hemodialysis integrated into the ECMO circuit for solute clearance and fluid control; monitor dialysate and blood flow directions, clearance efficiency, and patient responses; manage and troubleshoot diffusion gradients, membrane fouling, or hemodynamic instability, following ELSO protocols for combined ECMO and renal support. 9 12 · Cytokine and Inflammatory Marker Removal (e.g., Using CytoSorb or oXiris Adsorbers): Integrate cytokine adsorbers into the ECMO circuit for removal of cytokines, endotoxins, and inflammatory markers in conditions like sepsis or ARDS; monitor adsorption efficiency, cartridge performance, and patient

inflammatory biomarkers; manage and troubleshoot adsorber saturation or circuit integration issues, based on supportive literature and ELSO-aligned practices for immunomodulation in ECMO. 1 15 · Medication Administration to ECMO Circuit: Administer patient-required medications directly into the ECMO circuit, accounting for circuit sequestration and pharmacokinetic alterations; this includes, but is 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 per ELSO and AmSECT guidelines. 7 12 · Blood Product Administration to ECMO Circuit: Administer blood products (e.g., packed red blood cells, platelets, fresh frozen plasma, cryoprecipitate) via the ECMO circuit to maintain target hemoglobin, platelet counts), and coagulation factors; monitor transfusion effects on circuit function and patient hematology; troubleshoot transfusion-related complications like hemolysis or clotting · 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, following ELSO and AmSECT guidelines for thrombosis prevention and management. 13 24 27 · ECMO System Flow Management: Manage ECMO system flow, including alarm triage, interpretation, and troubleshooting to resolve deviations greater than 10% from physician-ordered goals while ensuring stable hemodynamics · Troubleshooting ECMO System Alarms: Interpret and troubleshoot ECMO system alarms, triaging the need for planned or emergency component and system replacement strategies for all hospital-owned devices used in extracorporeal life support or mechanical circulatory support, aligning with AmSECT standards for perfusion safety and ELSO circuit guidelines. 1 20 26 · Troubleshooting Equipment Alarms: Address alarms from any device connected to the ECMO circuit, triaging the need for replacement and coordinating with the allied health care team to replace equipment in a safe and

timely manner, per AmSECT and ELSO recommendations for equipment management and patient safety. 1 20 26 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 to minimize interruption of therapy, follow guidelines and prevent any secondary patient injuries for all circuit emergencies, including but not limited to: · Power or Equipment Failure: Respond to ECMO circuit power or equipment failures by activating backup systems and hand-cranking if necessary, ensuring minimal interruption of continuous therapy. · Air Entrainment: Detect and eliminate air bubbles in the circuit using bubble detectors and de-airing techniques. · Cannula Dislodgement: Stabilize and reposition dislodged cannulas, coordinating with the team for immediate surgical intervention while maintaining patency of functioning cannula. · Patient Bleeding or Hypotension: Manage acute bleeding or hypotensive episodes by adjusting flow rates, administering fluids or blood products, and optimizing anticoagulation strategies. · 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 · Blood Pump Failures: Rapidly triage and differentiate blood pump failures (clotted cone, decoupling) and address the failed and address blood pump failures by replacing the failed blood pump · Circuit Tubing Fracture or Rupture: Respond to circuit tubing fractures or ruptures by clamping affected sections, replacing tubing, and restoring circuit integrity to prevent blood loss or air entry, following ELSO circuit management and AmSEC safety standards. · Circuit Tubing Kinks or Occlusions: Detect and correct circuit tubing kinks or occlusions by repositioning tubing or replacing segments, restoring optimal flow, as per ELSO bedside troubleshooting and AmSECT perfusion guidelines. 9 13 16 · Oxygenator Failure: Manage oxygenator failure by monitoring gas exchange metrics (e.g., rising pressure drops or poor oxygenation), triaging for immediate replacement, and executing change-out procedures to maintain support, aligned with ELSO circuit guidelines and AmSECT standards. 1 9 12 · Heat Exchanger Failure: Address heat exchanger failure by assessing temperature control issues, isolating the component, and replacing it to prevent thermal dysregulation, following ELSO and AmSECT equipment management protocols. 1 12 · Blood Path Circuit Component Failure and Replacement: Triage blood path circuit component failures (e.g., filters, connectors), determining emergency versus planned replacement strategies, and performing replacements to sustain circuit function, per ELSO and AmSECT guidelines. 1 12 20 · Equipment Failure Related to Any Device Connected to the ECMO Circuit: Respond to failures in connected equipment (e.g., monitors, heaters) by isolating the issue, activating backups, and coordinating repairs or replacements, ensuring patient safety as outlined in ELSO and AmSECT standards. 1 5 20 26 · Circuit Clot Emergency Removal Techniques: Apply emergency clot removal techniques when flow through cannulas, pump, or oxygenator is compromised. Whether through aspiration, component replacement, or emergent surgical intervention. · Cannula Dislodgment, Malpositioning, or Impedance of Flow: Manage cannula dislodgment, malpositioning, or flow impedance by using techniques to identify the failing cannula, isolate if necessary and preserve patency of the remaining functional cannula. Coordinating patient stabilization, positioning and/or emergent surgical intervention. · Triaging Need to Initiate Emergency Hand Cranking: Triage the need for

emergency hand cranking, coordinating with the allied health care team to maintain goal-directed flow, and replacing failed motor, cables, or ECMO system components, ensuring minimal interruption of support.