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Cite as: Archiv EuroMedica. 2024. 13; 1: e1. DOI 10.35630/2024/14/1.109

Received 25 January 2024;
Accepted 20 February 2024;
Published 22 February 2024


Łukasz Czapiewski1 orcid id logo , Grzegorz Ulenberg1 email orcid id logo,
Wojciech Kaczmarek2 orcid id logo, Przemysław Żuratyński 3,4 orcid id logo

1Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Faculty of Health Sciences, Department of Interventional Nursing, Bydgoszcz, Poland
2Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Faculty of Health Sciences, Department of Basic Clinical Skills and Postgraduate Education of Nurses and Midwives, Bydgoszcz, Poland
3Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Faculty of Health Sciences, Department of Emergency Medicine, Bydgoszcz, Poland
4Medical University of Gdańsk, Faculty of Health Sciences with the Institute of Maritime and Tropical Medicine, Department of Emergency Medical Services, Gdansk, Poland

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In today's dynamic medical environment, evolving technologies and advanced life-saving therapies pose new challenges to nursing care. One of the pioneering achievements in this field is veno-venous ECMO (extracorporeal membrane oxygenation) therapy, which plays a key role in the treatment of adult patients with severe respiratory failure. ECMO, also known as artificial respiratory support, is a revolutionary step towards more effective care for critically ill patients. This article is devoted to a deeper understanding of the role of nurses in the care of an adult patient undergoing venovenous ECMO therapy.

Venovenous ECMO therapy is a procedure in which a patient's blood is pumped outside the body, where it is oxygenated, and then reintroduced into the circulation. For adult patients with advanced respiratory failure who do not achieve effective improvement with traditional treatment methods, ECMO often becomes the last resort. However, the complex nature of this therapy requires commitment and expertise from nurses to provide effective patient care.

One of the main challenges that venovenous ECMO therapy poses to nurses is monitoring the patient's precise physiological parameters. Strict control of blood pressure, oxygen levels and organ perfusion becomes crucial to the success of therapy. Nurses therefore act as guardians of physiological stability, constantly reacting to possible instabilities and adjusting the parameters of the device under control.

It is also worth emphasizing that nursing care for a patient undergoing venovenous ECMO therapy is not limited only to technical aspects. The comprehensiveness of this type of treatment is also associated with concern for the patient's psychosocial aspects. Long-term connection to an ECMO device can cause emotional and mental stress in the patient, which makes the support of nurses in the field of psychological care extremely important. Nurses act as both medical professionals and empathetic companions in difficult times, which translates into the overall success of therapy. The article will also focus on nurses' protocols for dealing with a patient undergoing venovenous ECMO therapy. From an excellent understanding of device maintenance to effective communication with the entire healthcare team, nurses play a key role in ensuring safe and effective therapy. As technology advances and life therapies become more advanced, nurses' skills are continually improved to meet the demands of modern medical care.

Keywords: intensive care nursing, ECMO, ARDS


ECMO (extracorporeal membrane oxygenation), i.e. extracorporeal blood oxygenation, is a technique that uses extracorporeal blood circulation to oxygenate it and eliminate carbon dioxide as a result of the action of the oxygenator. Such therapy can be used in the veno-venous system (VV ECMO) or veno-arterial system (VA ECMO). These options differ significantly from each other. VA ECMO therapy provides a bridge between the patient's lungs and heart. Venous blood is collected from the inferior or superior vena cava or right atrium and goes to the oxygenator. The oxygenated blood there returns to the patient through a cannula inserted into a large artery. This therapy is used for potentially reversible or irreversible heart failure. It can also be used as a bridge for patients waiting for a heart transplant. For ECMO therapy, a double-lumen cannula can also be used. The flows in this cannula must be lower, but it allows for physiotherapy and faster mobilization of the patient. This type of cannula is routinely inserted in newborns. VV ECMO therapy is used when there are potentially reversible lung function disorders in which mechanical ventilation alone does not allow for proper gas exchange. In this therapy, blood is taken from the inferior vena cava and after passing through the oxygenator, it goes to the right atrium through a cannula in the superior vena cava. It should be remembered that this therapy does not cure the patient's lungs, but allows the patient to survive when gas exchange disturbances are so great that mechanical ventilation is insufficient. It also allows you to eliminate the risk of lung damage associated with respiratory therapy in patients with severe ARDS (acute respiratory distress syndrome). [1,2,3]

Indications for the use of VV ECMO therapy

The use of this therapy is indicated in patients with acute respiratory failure in whom, despite the use of high levels of oxygen in the breathing mixture and advanced mechanical ventilation techniques, hypoxemia and hypercapnia persist, which may lead to deterioration of the patient's condition or even death. Basic qualification criteria for ECMO therapy is based on the Berlin ARDS criteria and at least one of the following criteria:

Auxiliary criterion:

An alternative is the Murray Scale (LIS) > 3.0. [1,2,4,5]

Contraindications to VV ECMO therapy

In accordance with national guidelines, we distinguish absolute and relative contraindications to the use of extracorporeal blood oxygenation. Absolute contraindications include:

We consider relative contraindications to:

Monitoring a patient undergoing ECMO therapy

The basic parameters that should be monitored during therapy include:

Additionally, if the capabilities of the center where the therapy is carried out allow it, you can monitor:

Therapy-related complications

ECMO therapy is, of course, a great opportunity for patients, but it carries the possibility of complications that are directly related to the patient and technical problems resulting from the operation of the device. The most common complications associated with the patient include:

The most common technical problems and device malfunctions include:

The role and tasks of the nurse during VV ECMO therapy.

The nursing team plays an important role during ECMO therapy. The care of such a patient is the responsibility of people working in intensive care units who know the principles of treatment and are familiar with the operation of the ECMO device. Please remember that the basic supervision of this patient is the same as any other patient in the ICU. Blood pressure, heart rate and possible changes in the ECG, temperature, central venous pressure, and diuresis are monitored. A neurological assessment (assessment of pupils, level of consciousness) and a physical assessment (skin moisture, visible sweating of the patient, assessment of peripheral hypoperfusion) are also performed. Additional activities that should be monitored are related to the therapy device and hazards that may be associated with the treatment. Activities performed on a patient undergoing extracorporeal blood oxygenation can be divided into those related to the device and those related to the patient. Tasks include: to the nursing team related to the device include:

System observation:

Monitoring device pressures

Monitoring blood pressure allows for early detection of dysfunctions in the therapy. It is important to remember that what is important is the evolution of these pressures, not a single measurement. The nursing team's tasks include hourly recording of blood flow, pump revolutions, and pressure before and after the oxygenator. Three pressures are commonly measured

Area of activities of the nursing team in direct patient care

  1. Prevention and early detection of infection.

Like all cannulas, these ECMO devices provide a route for pathogens to enter the patient's body. Their diameter and the place of insertion (the femoral vein causes the risk of contact with stool, and the internal jugular vein increases the risk of water getting into the place of cannula insertion when washing the patient) increase the risk of infection of the patient.

Nursing activities and patient observation should focus on:

  1. Patient skin care

Anti-decubitus prevention is a challenge for the nursing team in most patients in Intensive Care Units (ICU). This is the result of long-term immobilization of the patient in bed. In a patient undergoing ECMO therapy, additional problems will include: pressure of the cannulas on the skin, deep analgosedation, and constant infusion of heparin, which may promote abrasions and hematomas. However, this does not change the fact that skin care should be carried out as for any other patient. It is recommended that:

  1. Other care activities

Nursing care of an adult patient undergoing venovenous ECMO therapy requires special attention, knowledge and commitment from medical staff. Below are some key nursing activities that are important when caring for a patient using this advanced form of respiratory support:

The complexity of venovenous ECMO therapy requires many skills from nurses, from operating advanced equipment to caring for the patient. Continuous improvement in knowledge and practice is necessary to ensure the highest standard of care for patients undergoing this advanced form of therapy.

Prevention of complications, tasks of the nursing team

  1. The risk of bleeding during ECMO therapy is high, therefore the role of the nursing team is a comprehensive assessment of the patient, which will allow for the detection of pathology at an early stage and the implementation of appropriate intervention, the assessment concerns:
  1. Thromboembolic risk

Appropriate continuous anticoagulation prevents bleeding and the formation of thrombin and clots in the system. The nursing team uses a flashlight to observe the system and document any changes detected. This allows you to prevent, among others: ECMO failure or brain damage in the patient. Therefore, you need to acquire the ability to distinguish clots:

  1. Haemolysis

Hemolysis during therapy may be caused by several factors, e.g. chaotic pump operation, membrane damage or cannula clotting. It is most often the result of damage to blood cells, causing them to rupture and bleed. Clinical signs of hemolysis can be observed by the nursing team by observing the urine. Characteristic dark color. If the patient is undergoing renal replacement therapy, the effluent in hemolysis is characterized by a "tea color". Failure to properly monitor the patient may result in the development of other internal or external bleeding, which may lead to the development of DIC syndrome. [20,25,27]

  1. Accidental decannulation

This is a rare complication that occurs mainly when the patient changes position or goes to the toilet. The risk of its occurrence can be minimized by a designated person constantly monitoring the cannulas, drains, oxygenator, and endotracheal tube while performing activities with the patient. Before any manipulations, all fastenings should be checked (presence of sutures in the place of cannulae insertion, proper adhesion of fixing dressings). If decannulation has occurred, clamp the cannulas as quickly as possible with forceps and call a cardiac surgeon and a perfusionist. [20,25,27]

  1. Hypothermia

ECMO therapy, which is often accompanied by renal replacement therapy, results in a large amount of blood leaving the patient's body. This may cause your body temperature to drop. In some situations, lowering the patient's temperature is beneficial; reduces the demand for oxygen and the production of carbon dioxide. If hypothermia becomes unfavorable for the patient it should be; check the operation of the heater-cooler in the ECMO set (in case of problems, call a perfusionist), apply thermal insulation of the ECMO system and active heating of the patient using special devices.[1,4,11,15]


ECMO therapy is hope for patients with heart and/or lung failure. There are many indications for the use of therapy. However, before using it, you must also take into account factors that prevent or significantly limit the effectiveness of the treatment. Caring for a patient undergoing ECMO therapy requires extensive knowledge and experience of the nursing team. In addition to carrying out a large number of medical orders, the nursing team must identify and prevent problems related to the ECMO set, patient care, and intravenous injections, and thoughtfully plan and assess the risk of performing all activities with the patient, and if an adverse event has already occurred, they must detect and resolve it.

Summarizing the article about nursing care of an adult patient undergoing venovenous ECMO therapy, a picture emerges of the comprehensive and extremely demanding role of nurses in this area of ​​medicine. ECMO therapy, an advanced method of artificial respiratory support, is a last resort for patients with severe respiratory failure. A key aspect of nursing care is precise monitoring of the patient's physiological parameters to ensure effective therapy. Nurses also play an important role as psychosocial support, understanding patients' emotional difficulties associated with long-term treatment. Nurse protocols include not only technical operation of the ECMO device, but also effective communication with the medical team. As technology advances and life therapies evolve, nurses' skills are continually improved to meet the challenges of modern medical care. It is worth emphasizing that their involvement is not limited only to technical aspects, but also includes concern for the patient's mental well-being. Understanding the role of nurses in the care of a patient undergoing venovenous ECMO therapy is crucial for effective and contemporary health care in a medical environment, where technologies and therapies are evolving, posing new challenges to nursing care.


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