Quality Improvement and Nursing Care for Ecmo Patients Journal

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ECMO

Extracorporeal Membrane Oxygenation is a procedure that allows for the oxygenation of a patient through the use of an external machine. Oxygen is required in order to keep a body healthy and alive. The definition of oxygenation is the amount of oxygen in the bloodstream of a patient. If the oxygen level drops below 90% a condition called hypoxemia occurs. Hypoxemia can be very serious and if not addressed within a short period of time can be fatal. Hypoxemia is diagnosed through cyanosis (the skin turning blue). Patients being treated with the EMCO procedure are usually longer-term patients (3-10 days) as compared to the short-term patients who receive a standard cadriopulmonary bypass which is a support that usually only lasts for a number of hours (not days).

Purpose

According to Rodriguez-Cruz et al. The purpose of the ECMO is "to allow time for intrinsic recovery of the lungs and heart; a standards cardiopulmonary bypass provides support during various types of cardiac surgical procedures" (Rodriguez-Cruz, Walters III, Aggarwal, Schwartz, Windle, Mancini, Berger, 2012). Many of the patients for whom ECMO was originally designed for are infants and small children. Selection of the neonates for ECMO must meet certain criteria. According to Rodriguez-Cruz et al. The criteria includes the following; a gestational age of 34+ weeks, birth weight of 2000 g+, no significant coagulopathy or uncontrolled bleeding, no major intracranial hemorrhage, mechanical ventilation for 10-14 days or less, reversible lung injury, no lethal malformations, no major untreatable cardiac malformation, and a failure of maximal medical therapy (Rodriguez-Cruz et al., 2012).

Within the last decade ECMO has been used in adults more than it was initially. Some studies have shown that with new technologies the process has greatly improved and now it can be considered a standard part of severe cardiopulmonary derangement due to disease or injury, but only after the exhaustion of other interventions (Mielck & Quintel 2005; Yang 2011). ECMO is most often used in patients suffering from severe pulmonary failure; but while many experts believe that "treatment with ECMO may save lives" (Perfusion, 2008) ECMO currently does not show any influence in the rate of mortality (due to severe pulmonary failure). Another study touted by Perfusion also showed that "Serious heart failure may be treated with extracorporeal membrane oxygenation (ECMO) when other treatment fails" (Perfusion, 2007).

An additional use or purpose for ECMO takes place when Acute Respiratory Distress Syndrome (ARDS) presents itself. According to one recent article ARDS "still represents a serious problem in clinical routine and is associated with a high mortality" (Perfusion, 2012). According to the Perfusion article there are several concepts that can be employed as well as various special treatments, "but, in some instances, the application of an extracorporeal membrane oxygenation (ECMO) is necessary for both the improvement of oxygenation and the elimination of carbon dioxide (CO2)" (Perfusion, 2012).

Some alternative strategies that are comparative to ECMO include; prone ventilation, high-frequency oscillation ventilation, and (of course) no additional therapy at all. Two other commonly used strategies include mechanical (sometimes known as conventional ventilation and Nitric Oxide treatments.

Nitric oxide is a treatment that can be used to treat ARDS and works by dilating the pulmonary vasculature. However, some experts have reported that "Nitric Oxide is associated with limited improvement in oxygenation, no mortality benefit and may cause harm to the patient" (Adhikari, Burns, Friedrich, Granton, Cook, Meade, 2008). Prone Ventilation, on the other hand is standard mechanical ventilation that takes place with the patient lying flat. Standard mechanical ventilation is what takes place when a ventilator provides the work of respiration for the patient via and endotracheal tube or tracheostomy (Colice, 2007). According to Berryman prone ventilation is particularly beneficial in sputum clearance since it has been found that different areas of the lung are ventilated when comparing ventilation efforts in patient in the normal supine position. One additional method of ventilation includes the high-frequency oscillating ventilation. This treatment is ventilation that requires respiration rates that are very high and small tidal volumes (greater than 60 breathes per minutes and usually below the anatomical dead space (Brower, Krishman, 2000, p. 796). When most of these treatment options

ECMO can also take place as "an extraordinary treatment for profound respiratory failure" (Berryman, 2010, p. 262) especially during times when such treatments might be necessary and conducive to stem certain crisis situations such as recent flu and other virus outbreaks. There are a number of situations when the implementation of ECMO treatments would alleviate concern and suffering, nursing staffs should always be on the lookout for those type of situations.

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The Berryman study documented how effective ECMO treatments can be and found that "patients suffering from H1N1 require aggressive treatment and respiratory support, one approach to patient management is through ECMO" (p. 263). The study was conducted as a randomized trial and the participants were "patients with severe but potentially reversible respiratory failure" (p. 262). What was interesting about the study was that out of the 50% of the patients that were remanded to ECMO (as compared to the 50% that received standard ventilation treatments) "63% of the ECMO patients survived as compared to the 47% that survived with standard ventilation treatments" (p. 263).

It can be discerned then that ECMO is effective in a variety of arenas and at different ages, and scenarios. Suffering from heart and lung respiratory illnesses may therefore by a call for the use of ECMO, or at least a consideration thereof.

Treatment and Care

ECMO can be considered as a therapy of last resort, and as such additional care and guidance is needed in the ICU unit where the treatment is being undertaken. The first step is to determine if the patient qualifies for ECMO and if so, whether there are any inhibiting circumstances. The nursing staff is of primary focus during this period of time due to the constant and consistent observation and focus that is necessary. During the Berryman study, "To ensure effective patient care, one nurse managed the patient's direct care, the other monitored the ECMO circuit with close liaison over infusion rates and discussion before parameter/medication changes being made" (p. 264) all evidence of the communication and cooperation that is needed regarding the nurses who are in charge of the patient.

Implications for perioperative nursing are quite extensive, as these procedures can be used during times of surgically necessary or contributed cardiopulmonary distress or loss of function, and as the procedure itself constitutes an initial (and in some views, an ongoing) surgery, perioperative nursing procedures are an essential part of the support and successful carrying out of an ECMO intervention (Mielck & Quintel 2005; Schuerer et al. 2008). Quality improvement in ECMO support through the identification of specific support strategies has been a major cause of improvement to the procedure (Schuerer et al. 2008).

Guidelines

There are a number of guidelines that have been established to assist nursing staffs in the care, monitoring and treatment processes of ECMO. A recent study determined that "The National Institute for Health and Clinical Excellence (NICE) has recently updated its interventional procedure guidance, which summarizes available data on efficacy and safety of this procedure and provides guidance for clinicians wishing to undertake ECMO" (Bastin, Firmin, 2011, p. 1701). Those guidelines can be used as a written aid in implementing ECMO treatment as long as the staff facilitates the normal arrangements for consent. The particular guidelines discussed herein are specifically for the treatment of children who are in respiratory or cardiac failure but other NICE guidelines are available for other ECMO treatments, uses and situations. One of the first steps taken by the medical staff is to determine if the patient qualifies for ECMO treatment. According to NICR guidelines, ECMO is used to "treat respiratory or cardiac failure that is unresponsive to all other measures, but is considered to have a reversible cause" (National Institute, 2011).

These type of situations can also be used to assist post-neonatal children while transitioning from cardiopulmonary bypass to ventilation following heart surgery. Since the National Institute states that 'most children treated with ECMO are very ill and at risk of death', close scrutiny by the nursing staff should take place at all times while the patient is on ECMO treatment. Along with respiratory and cardiac failure, some of the other symptoms that should be watched for include, pneumonia, septic shock, congenital heart disease, cardiomyopathy, severe burns and pulmonary hemorrhage.

The process

ECMO takes place during a very trying time for patients, families and healthcare professionals; it is considered a temporary life support technique (according to NICE) and it involves oxygenation of the blood externally. The method for the oxygenation is through a catheter that is placed in the right side of the heart; this catheter carries blood to a pump, then a membrane oxygenator. The gas exchange of oxygen and carbon dioxide takes place within the oxygenator (NICE, 2011). Once the exchange has taken place the blood is returned to the body via tubing.....

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