Frequently Asked Questions - Professional Tips

Information for ecp service providers
Blanket the patient

 

ECP Clinical Application Specialists suggest covering the patient’s lower extremities with a blanket during IECP therapy. This actually has two interesting benefits: first, the warmth from the blanket may serve to vasodilate the vasculature of the lower extremities. As vascular volume is one of the important factors affecting the degree of augmentation, the peripheral vasodilatation secondary to the warmth may, in fact, enhance the therapeutic effect of IECP therapy. Second, the blanket serves to muffle the sound of the valves which is particularly important in a multi-system treatment setting.
Choose the fabric

 

Some of ECP therapists noted that encouraging patients to wear cotton shirts/tops (instead of polyester-blends or nylon-blends) had a very positive impact on reducing ECG artifact. They also discovered that emptying shirt pockets of pens, etc., also helped.
ECG Synchronisation

 

Positive R-waves are easier for the ECP treatment systems to “read”. Reversing the positions of the positive and negative ECG electrodes can provide a positively deflected R-wave. Don’t forget - thorough skin prep before applying the electrodes is important for good skin contact and a stable ECG.
Weigh the Patient in treatment clothes

 

Weigh the patient before each ECP treatment hour in his/her treatment pants to minimize differences due to different clothing. Change in body weight is a very reliable alert to changes in fluid status. An increase in weight greater than two pounds over night or four pounds in a week may indicate exacerbation of heart failure, as would a five pound change in weight from the pre-treatment baseline. It’s best to hold treatment and notify the physician of the changes. ECP therapy can be administered once the physician has examined the patient and the clinical status is deemed stable. Rapid, shortened breaths or a wet cough may also be indicative that the patient is experiencing fluid overload. Do not begin ECP therapy; notify the physician, place the patient in a high sitting position, and monitor the patient’s oxygen saturation level.
Managing ECG artifact in female patients

 

Obese, female patients can be a challenge when attaining a stable ECG. An effective ECG lead placement (after thorough skin prep with alcohol and NuPrep, and the addition of ECG Conductive Gel to a good stress test electrode) is: White lead directly on the bone of the right shoulder, Black lead directly on the bone of the left shoulder, Green lead on the upper sternum, above the breasts. The addition of a tight-fitting sports bra can also be effective for reducing tissue movement and decreasing ECG artifact.
Use Nitro-glycerine

 

Some of the experienced ECP clinicians worldwide prefer Nitro paste to the sublingual or spray nitroglycerin for improving augmentation.
Handling Tachycardia

 

Ativan (Lorazepam) 0.5mg can be given sub-lingually to patients that present with anxiety and tachycardia. Within 5 minutes of administration, the patient is usually calmer and the heart rate is decreased. But it’s something to keep in mind for those patients that come to treatment anxious and have a rapid heart rate.
Check the Blood Sugar

 

Check the diabetic patients’ blood sugar levels daily before starting ECP therapy. If the level is less than 80, the patient can be routinely given something to eat and drink.
Adjusting the Cuffs

 

If the proper size cuffs prove too long for a patient and the lower thigh cuff extends over the patient’s knees:
 
a. Apply the calf cuffs first, placing a piece of sheepskin behind the patient’s knees and securing it with the upper edge of the calf cuff.
 
b. Apply the lower thigh cuff, positioning the lower edge over the top edge of the calf cuff (and the sheepskin), behind the patient’s knees. This will minimize the possibility of skin irritation, and any discomfort behind the knee from pressure of the lower thigh cuff.
Coping the cold weather

 

During the Cold weather mainly in the Northern parts of the country, cold hands are a problem and that makes getting a stable finger plethysmograph tracing a challenge. Here are some things to try: Encourage your patients to put their gloves on in the house before going outside. Actually, mittens are even better preservers of warmth than gloves. Warm a 250 cc bag of saline in the microwave and have the patient hold it before treatment starts. For really frosty digits, keep the warmed saline in the patient’s hand, position the plethysmograph and wrap a towel around everything to keep those fingers warm and plethysmograph friendly. Heating pads also work very well and can be applied before or throughout ECP treatment.
Administering ECP Therapy in the Prone Position

 

For patients having history of lumbar surgeries and chronic back pain you can try initially to put support under his knees to minimize lumbar strain, if it does not help then you can try the prone position. Wrap the cuffs with the patient lying on his back (without the hoses attached to the treatment table), and then turn him on his abdomen. Long hoses have to be used on all the cuffs. Initially his torso can be supported with a foam wedge, with his head rested on his forearms. A small pillow can be placed under his shins. The ECG electrodes should be placed posterior to avoid artifact from the pressure of lying on his torso. This position is well tried and will do well, and the biggest and best surprise would be that the augmentation will be just as good.
IECP should be done before dialysis or after?

 

Generally, it is preferable to have the patient receive IECP therapy before dialysis as the increased intravascular volume enhances diastolic augmentation and venous return. Conversely, the increased vascular volume could potentially reduce systolic unloading and induce pulmonary congestion. Therefore, it is important to take into account the patient’s cardiac status. For example, a CHF patient is probably not a good candidate for pre-dialysis IECP therapy, but a patient with an EF of 40 percent or greater might tolerate pre-dialysis treatment. A trial IECP therapy session to evaluate the patient's tolerance of the treatment will provide important information for managing the course of therapy. Whether pre- or post-dialysis, pre- and post-IECP lung auscultation, monitoring oxygen saturation, and adjusting timing to maximize systolic unloading help  minimize adverse responses to IECP for dialysis patients.

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