Nursing Care in the Post Cardiac Transplant … Lamb, L ECMO case study...Cardiac Transplant...
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Transcript of Nursing Care in the Post Cardiac Transplant … Lamb, L ECMO case study...Cardiac Transplant...
Nursing Care of the Post Cardiac Transplant Extracorporeal Membrane Oxygenation Patient:A Case Study
September 27, 2015
presented by the University of Ottawa Heart Institute 2September 27, 2015
ECMO: A Case Study
Who we areStaff nurses of Cardiac Surgery Intensive Care (CSICU) at the University of Ottawa Heart Institute
● UOHI performs approximately 1450 surgeries per year
presented by the University of Ottawa Heart Institute 3September 27, 2015
ECMO: A Case Study
Introduction
• Overview of ECMO• Case Study
● Patient ● Post-op period● Complications● Nursing Interventions● Family considerations
● Conclusion
presented by the University of Ottawa Heart Institute 4September 27, 2015
ECMO: A Case Study
What is ECMO?
• Extracorporeal Membrane Oxygenation (ECMO)
• Derived from cardiopulmonary bypass (CPB)• First used in paediatric and neonatal
populations• Used in adults for support of reversible cardiac
or respiratory failure
presented by the University of Ottawa Heart Institute 5September 27, 2015
ECMO: A Case Study
presented by the University of Ottawa Heart Institute 6September 27, 2015
ECMO: A Case Study
presented by the University of Ottawa Heart Institute 7September 27, 2015
ECMO: A Case Study
ECMO
• ECMO circuits at UOHI are monitored by a perfusionist.• Monitors and adjusts parameters of
ECMO machine.• Nurse responsible for close monitoring of
patient• Hemodynamics, hygiene, wound care,
family support, coordinating. interdisciplinary team.
• Monitor for early signs of deterioration.• Being proactive
presented by the University of Ottawa Heart Institute 8September 27, 2015
ECMO: A Case Study
Components of ECMO circuit
presented by the University of Ottawa Heart Institute 9September 27, 2015
ECMO: A Case Study
Oxygenation in ECMO
• Oxygenation occurs in the membrane lung(oxygenator) of the ECMO
circuit
• Oxygenation of patients can be affected by
• Oxygenator parameters• Rate of flow• Native lung and heart function
presented by the University of Ottawa Heart Institute 10September 27, 2015
ECMO: A Case Study
Oxygenator Parameters
• Oxygenation in the membrane lung is affected by• Type of membrane lung• FiO2
• Time blood spends in membrane lung• Hemoglobin• Oxygenation of blood before entering the ECMO circuit
presented by the University of Ottawa Heart Institute 11September 27, 2015
ECMO: A Case Study
CO2 Removal
• Removal rates dependent on • Type of membrane lung chosen• Patient’s blood CO2 level
• ECMO flows and sweep gas flows
• Rates of CO2 removal can be adjusted by increasing the surface area of the membrane lung or by adjusting sweep gas flows
presented by the University of Ottawa Heart Institute 12September 27, 2015
ECMO: A Case Study
ECMO Modalities
• 2 kinds of ECMO
• Veno-venous (VV)
• Veno-arterial (VA)
• VV is used to treat refractory respiratory failure
• VA is used for complete cardiopulmonary support in cardiogenic shock and cardiac arrest
presented by the University of Ottawa Heart Institute 13September 27, 2015
ECMO: A Case Study
What is VA ECMO?
• VA oxygenator and pump replaces some or all lung and heart function
• Oxygenated blood is returned to aorta and combined with blood which has passed through the native cardiac circulation• Results in mixing of O2 and CO2 from each source which is delivered
to organs• Forward flow is combination of native cardiac output and ECMO
flows
presented by the University of Ottawa Heart Institute 14September 27, 2015
ECMO: A Case Study
“Stan Plant”
59 year old male with ischemic cardiomyopathy
• Heartmate II Left Ventricular Assist Device (LVAD) inserted in March 2012
• Recurrent GI bleeds• On Coumadin for LVAD
presented by the University of Ottawa Heart Institute 15September 27, 2015
ECMO: A Case Study
Donor
60 year old post head trauma - subdural hematoma
• Echocardiogram showed normal right and left ventricle ejection fraction
• Cardiac catheterization showed normal coronary arteries
presented by the University of Ottawa Heart Institute 16September 27, 2015
ECMO: A Case Study
Post-op Day 4BronchoscopyNitric Oxide startedECMO weaned!
Post-op Day 0Heart TransplantECMO started
Post-op Day 1Reopened x 2Open ChestRight arm hyperperfusion
Post-op Day 2Reopened 4th timeECMO weaning not tolerated
Post-op Day 3ReopenedIAPB inserted
Case Study Timeline
presented by the University of Ottawa Heart Institute 17September 27, 2015
ECMO: A Case Study
“Stan Plant’s” Surgery
• Redo-sternotomy
• Removal or automated implantable cardioverter-defibrillator (AICD)
• Removal of Heartmate II
• Orthotopic cardiac transplantation (Bicaval)
presented by the University of Ottawa Heart Institute 18September 27, 2015
ECMO: A Case Study
Intraoperative
• Massive bleeding and hemodynamic instability requiring massive transfusions
• Dobutamine at 10 mcg/kg/min• Mirinone at 0.5 mcg/kg/min• Vasopressin at 4 units/hr• Norepinephrine at 0.7 mcg/kg/min• Epinephrine at 0.15 mcg/kg/min• Insulin at 16 units/hr• Heparin at 250 units/hr
presented by the University of Ottawa Heart Institute 19September 27, 2015
ECMO: A Case Study
Post-op Day 0
• Cardiac transplant completed at 0500• Stan too unstable to leave cardiac
operating room• Nursed by 2 CSICU nurses in
cardiac operating room (COR)• Decided by CSICU physicians/surgeon
that patient required ECMO and procedure started at 0730
presented by the University of Ottawa Heart Institute 20September 27, 2015
ECMO: A Case Study
Post-op Day 0
● Right femoral vein and right axillary artery
● Transferred to CSICU at 1330 from COR
● Transesophageal echo (TEE)
● Right arm beginning to blister from hyperperfusion of ECMO
presented by the University of Ottawa Heart Institute 21September 27, 2015
ECMO: A Case Study
Catch-22 of Anticoagulation and ECMOHemorrhagic and thromboembolic complications
● Bleeding is most common of all ECMO complications
● Primary- surgical and cannulation site● Secondary - Mucous membranes,
gastrointestinal system, pulmonary hemorrhage, intracranial bleed
presented by the University of Ottawa Heart Institute 22September 27, 2015
ECMO: A Case Study
Nursing implications of Anticoagulation
● Cannulation site bleeding
● Close monitoring
● Transfusions and monitoring for hypovolemia
presented by the University of Ottawa Heart Institute 23September 27, 2015
ECMO: A Case Study
Post-op Day 0
At 1630 Stan exhibited hemodynamic decline and bleeding from the chest tubes
● Chest reopened and cleaned out at bedside
● Ruled out tamponade and investigated source of bleeding
● Chest closed afterwards
presented by the University of Ottawa Heart Institute 24September 27, 2015
ECMO: A Case Study
Post-op Day 1
● Still requiring 2:1 nursing● TEE done● Reopened again at 1500 to rule out tamponade
● Chest left open covered with Vi-drape● Blisters on right arm becoming worse due to hyperperfusion
presented by the University of Ottawa Heart Institute 25September 27, 2015
ECMO: A Case Study
presented by the University of Ottawa Heart Institute 26September 27, 2015
ECMO: A Case Study
Assessment of Risk Factors
● Severity of illness/length of stay in ICU
● Exposure to moisture
● Vasopressors shunting blood from periphery to vital organs
● Inability to physically turn patient
presented by the University of Ottawa Heart Institute 27September 27, 2015
ECMO: A Case Study
Nursing Interventions
● Regular skin assessment
● Regular and prn sheet changes
● Begin feeding
● Absorbent dressings to collect drainage from wounds
● Wean vasopressors as tolerated
● Continue lateral rotation therapy
presented by the University of Ottawa Heart Institute 28September 27, 2015
ECMO: A Case Study
Post-op Day 1 (cont’d)
● Vidrape bulging
● It’s an OR in the ICU
● Bleeding from multiple sites
● Platelets transfused
● IV heparin has to be continued
for ECMO circuit patency
● 37 kg of fluid overload!
presented by the University of Ottawa Heart Institute 29September 27, 2015
ECMO: A Case Study
Post-op Day 2
● Second ECMO weaning attempt
● “Renal function stable! Miraculously!”
● Fourth bedside OR
● Right arm hyperperfusion worsening
presented by the University of Ottawa Heart Institute 30September 27, 2015
ECMO: A Case Study
Post-op Day 3
● How high can you go?● Patient still requiring large doses of
vasoactive meds● Intra-aortic balloon pump (IABP) inserted
presented by the University of Ottawa Heart Institute 31September 27, 2015
ECMO: A Case Study
Post-op Day 3● Did the IABP work?● Patient converted from normal sinus rhythm to atrial fibrillation
● Third ECMO weaning attempt● ECMO flow to 1 L/min - not tolerated
● Overall vasopressor requirements decreasing ● Right arm hyperperfusion
● Managed with frequent dressing changes
presented by the University of Ottawa Heart Institute 32September 27, 2015
ECMO: A Case Study
Post-op Day 3 (cont’d)
● PRBC 7 units● Albumin 1000 mL● FFP 2 units● Platelets 2 adult doses● Cryoprecipitate 30 units● Cell saved 4 times
presented by the University of Ottawa Heart Institute 33September 27, 2015
ECMO: A Case Study
Post-op Day 4 Morning
● Bronchoscopy at bedside● How is the arm?● Fourth ECMO weaning attempt
● Doesn’t tolerate initial ECMO weaning - MAP 45● Inhaled nitric oxide administered
presented by the University of Ottawa Heart Institute 34September 27, 2015
ECMO: A Case Study
Why are ECMO patients prone to infection?Multiple Risk Factors
● Duration of ECMO ● Illness severity pre-ECMO● Steroid use● Prolonged ventilation● Open chest/surgery/cannulation● Inability to move/hygiene
presented by the University of Ottawa Heart Institute 35September 27, 2015
ECMO: A Case Study
Monitoring for signs of infectionECMO skews objective measures like body temperature and white blood cell count (WBC)
● Thorough nursing assessments
● How does the patient look and feel?
● What has changed?
presented by the University of Ottawa Heart Institute 36September 27, 2015
ECMO: A Case Study
Infection preventionNurses are first line workers in preventing infections
● Apply transparent dressing to cannula insertion sites
● Use ventilator-associated pneumonia (VAP) prevention measures
● Meticulous hand hygiene
● Catheter care
● Antibiotics
● Stress ulcer prophylaxis
presented by the University of Ottawa Heart Institute 37September 27, 2015
ECMO: A Case Study
Post-op Day 4 (cont’d)Afternoon
● Fifth ECMO weaning attempt - SUCCESS!
● Stan remains critically ill
● Large doses vasoactive drugs
● Secretions improved post-bronchoscopy
● Patient continues to diurese
presented by the University of Ottawa Heart Institute 38September 27, 2015
ECMO: A Case Study
A look back
presented by the University of Ottawa Heart Institute 39September 27, 2015
ECMO: A Case Study
Final tally of blood products received during ECMO
● PRBCs 49 units● FFP 21 units● Platelets 23 doses● Cryo 40 units● Albumin
● 5% 5500 mL● 25% 300 mL
presented by the University of Ottawa Heart Institute 40September 27, 2015
ECMO: A Case Study
How did it end for Mr. Plant?
● Long-term CSICU patient● Hospitalized for 281 post-op
days● CSICU 171 days● Ward 62 days● Rehab 48 days
● Walked into his home
presented by the University of Ottawa Heart Institute 41September 27, 2015
ECMO: A Case Study
Caring for the family of the ECMO patient
● Family-centered model of care
● Kubler-Ross model of five stages of grief
● Denial, anger, bargaining, depression, and acceptance
● Therapeutic relationships with family
● Families want clear, understandable, and honest information
● Challenge making connection
presented by the University of Ottawa Heart Institute 42September 27, 2015
ECMO: A Case Study
In Conclusion
● What is ECMO and how does it work?
● Case Study
● Challenges of ECMO
● Families and ECMO
● Looking back
presented by the University of Ottawa Heart Institute 43September 27, 2015
ECMO: A Case Study
Thank you! Any questions?
References
Allen, S., Holena, D., Mccunn, M., Kohl, B., & Sarani, B. (2011). A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ECMO) in critically ill adult patients. Journal of Intensive Care Medicine, 26(1), 13-26.
Annich, G.A., Lynch, W.R., MacLaren, G., Wilson, J.M., Bartlett, R.H. (2012). ECMO: Extracorporeal cardiopulmonary support in critical care, fourth edition. Ann Arbour Michigan: Extracorporeal Life Suppot Organization.
Auborn, C., Cheng, A.C., Pilcher, D., Leong, T., Magrin, G., Cooper, D., Scheinkestel, C.& Pellegrino, V. (2013). Infections acquired by adults who receive extracorporeal membrane oxygenation: risk factors and outcomes. Infection control and hospital epidemiology, 34(1), 24-30.
Bombino, M., Redaelli, S., & Patroniti, N. (2014). Patient Care During ECMO. In Sangalli, F., Patroniti, N., & Pesenti, A. (Eds.), ECMO-Extracorporeal Life Support in Adults (pp. 345-359). Milano: Springer.
Clements, L., Moore, M., Tribble, T. & Blake J. (2014). Reducing skin breakdown in patients receiving extracorporeal membrane oxygenation. Nursing Clinics of North America, 49, 61-68.
Connelly, J., Weaver, B., Seelhorst, A., Beaty, C., Mcdonough, M., Nicolson, S., & Tabbutt, S. (2012). Challenges at the bedside with ECMO and VAD. World Journal for Pediatric and Congenital Heart Surgery, 3(1), 67-71.
Courtin, A., Sanchez, L., Sinquet, J., Gaudard, P., Eliet, J., Barge, F., & Colson, P. (2012). ARDS and ECMO, an update on critical care nursing. Open Journal of Nursing, 2, 301-306.
Esper, S.A., Levy, J.H., Waters, J.H., & Welsby, I.J. (2014). Extracorporeal membrane oxygenation in the adult: a review of anticoagulation monitoring and transfusion. Anesthesia-Analgesia, 118(4), 731-743.
presented by the University of Ottawa Heart Institute September 27, 2015 44
References
Extracorporeal Life Support Organization. (2014). ELSO anticoagulation guidelines. Available from: http://www.elso.org/Resources/Guidelines.aspx
Extracorporeal Life Support Organization. (2014). ELSO Guidelines for ECMO Centres, version 1.8. Available from: http://www.elso.org/Resources/Guidelines.aspx
Gattinoni, L., Carlesso, E., & Langer, T. (2011). Clinical review: Extracorporeal membrane oxygenation. Critical Care, 15, 243.
Gay, S., Ankney, N., Cochran, J., & Highland, K. (2005). Critical Care Challenges In The Adult ECMO Patient. Dimensions of Critical Care Nursing, 24(4), 157-162.
Guttendorf, J., Boujoukos, D.R., Rosenzweig, M.Q., Hravnak, M. (2014). Discharge outcomes in adults treated with extracorporeal membrane oxygenation. American Journal of Critical Care, 23(5), 365-376
Hsin, Y., Ko, W., Tsai, P., Sun, C., Chang, Y., Lee, C. & Chen, Y. (2010). Infections occurring during extracorporeal membrane oxygenation use in adult patients. The Journal of Thoracic and Cardiovascular surgery, 140(5), 1125-1132.
Hsu, M., Chiu, K., Huang, Y,. Kao, K., Chu, S. & Liao, C. (2009). Risk factors for nosocomial infection during extracorporeal membrane oxygenation. Journal of Hospital Infection, 73, 210-216.
Lan, C., Tsai, P., Chen, Y. & Ko, W. (2010). Prognostic factors for adult patients receiving extracorporeal membrane oxygenation as mechanical circulatory support- a 14 year experience at a medical center. Artificial organs, 34(2), 59-64.
presented by the University of Ottawa Heart Institute September 27, 2015 45
References
Sangalli, F., Patroniti, N., & Pesenti, A. (Eds.). (2014). ECMO-Extracorporeal Life Support in Adults. Milano: Springer.
Schmidt, M., Brechot, N., Hariri, S., Giguet, M., Luyt, C.E., Makri, R.,LePrince, P., Trouillet, J.L., Pavie, A., Chastre, J. & Combes, A. (2012) Nosocomial Infections in adult cardiogenic shock supported by venoarterial extracorporeal membrane oxygenation. Clinical Infectious Diseases, 55(12), 1633-1641.
Tulman, D., Stawicki, S., Whitson, B., Gupta, S., Tripathi, R., Firstenberg, M., ... Papadimos, T. (2014). Veno-venous ECMO: A synopsis of nine key potential challenges, considerations, and controversies. BMC Anesthesiology, 14(65).
Zangrillo, A., Landoni, G., Biondi-Zoccai, G., Greco, M., Greco, T., Frati, G., ... Pappalardo, F. (2013). A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. Critical Care and Resuscitation, 15(3), 172-178.
presented by the University of Ottawa Heart Institute September 27, 2015