Resources for Wound Care

A Wound and Stoma Care nurse is a specialty nurse who is able to provide consultation and guidance on wound management for a diverse range of patients with varying medical conditions. We are constantly researching and evaluating new evidence on the management of different wounds. By evaluating all aspects of wound care management, and working closely with all members of the multi-disciplinary team (MDT) such as dieticians, physical therapists, pharmacists and physicians we are able to constantly strive for optimal outcomes for patients receiving medical care. With that in mind, prevention is always better than cure, especially with patients requiring ECLS management. A Thorough assessment of the patient with all members of the MDT prior to ECLS being commenced is vital to ensure positive patient outcomes. Each patient always requires an individual care plan to be devised with input from all MDT members to ensure outcomes and goals are set for the patient so they receive optimal care for recovery. 

Pressure Injury Prevention

  • Specialty Mattress – A low air loss mattress such as a Progressa Bed is optimal for pressure redistribution

  • Patient Repositioning Plan – Discuss with the MDT and create a patient centered plan to ensure every effort is made to prevent any pressure injuries

  • Safe Patient Handling – Use of safe patient handling equipment to minimize trauma to the patient and prevent injury to caregivers
       Jordan Frame
       Slide Sheets
       Airpals
       Wedges
       Use of appropriate number of caregivers to safely manage the patient

  • Medical Device Related Pressure Injury Prevention – Frequently assess the cannula positioning to ensure pressure is minimized to the patient’s skin. The patient is at high risk for pressure, friction and sheer due to cannula contact with the skin (particularly Avalon and internal jugular sites). Careful attention needs to be paid when repositioning the patient.

  • Consult with the Wound and Stomal Care Team – This team will work with you to create a patient specific care plan to ensure skin integrity is maintained and optimized.

Infection Prevention

  • Treat cannula sites as per your medical center’s Central Venous Catheter management policy. The use of antimicrobial biopatch is recommended. 

  • Use chlorhexidine for cannula site care. The use of alcohol can cause the integrity of the cannula to be compromised.

  • Clip excess hair prior to cannula insertion. Hair can be a source of potential infection.

  • Cannula site dressings should be attended to based on your medical center policy. Most ELSO centers and high volume ECLS units place priority in assessment and changing dressings as needed. Some centers require changing every 48 hours with no bio-patch in place, every 7 days with a type of antiseptic (chlorhexidine impregnated or bio-patch) dressing that is still dry, clean and intact. It is understood that these dressings should be changed PRN when damp, moist, bleeding or not fully intact. Dressings should be changed using sterile technique. Generally, a transparent dressing with a bio-patch will be used for easy viewing of the cannulation insertion site. 

  • Open chest central cannulation dressings are typically managed by the cardio-thoracic surgery surgical team.

  • If a wound dressing appears soiled, discuss management with members of your MDT including the Wound and Stomal Care team. 

Cannula Securement
Maintaining positioning of the cannula and ensuring no migration occurs is crucial for patient safety, adequate oxygenation and optimal cardiac output (for VA ECLS). 

  • Use securement devices to ensure no cannula migration occurs. Securement should occur at two sites along the cannula. 

  • Collaborate with the ECMO Specialist, primary nurse and physical therapist to ensure adequate securement is achieved during turns and physical therapy sessions. 

Regular Ongoing Site Assessment

  • Line positioning of ECLS cannulas should be assessed every hour and recorded into your documentation. 

  • In the event of cannula migration:
    Report immediately to the attending provider and ECMO Specialist. 
    Secure the cannula to ensure no further migration – do not attempt to manipulate
    the cannula.

  • Add a Wound LDA for the cannulation site
    The bedside caregiver should document every assessment the status of the insertion site and wound dressing. 
    Take note of any erythema, loose sutures and drainage, documenting accordingly.

  • Report any wound breakdown or drainage to the ECMO Specialist, primary nurse and attending physician. 

Management of Bleeding

  • Cannula site bleeding can occur due to migration of the cannula, leaving a narrower part of the cannula in contact with the arterial entry point, or because of a high anticoagulation level. 

  • In the event that the bedside caregiver notes bleeding from the insertion point: 
    Notify the attending physician and ECMO Specialist for review.

  • Some management options can include:
    If the cannula has migrated – resecurement of proper positioning.
    Use of a thrombotic dressing
    Pressure dressing
    Management and adjustment of anticoagulation
    Vascular surgeon review
    Better securement and suturing of cannula

References

Extracorporeal Life Support: The ELSO Red Book, edited by Roberto Lorusso, ELSO, 2017. 
”Wound Care; 5 Considerations for Wound Management” ECMO Multidisciplinary Care: Cleveland Clinic Abu Dhabi, edited by Mikaela Allen, Veronique Levis, pp. 57-59