Nursing Care of the Post Cardiac Transplant Extracorporeal Membrane - - PowerPoint PPT Presentation

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Nursing Care of the Post Cardiac Transplant Extracorporeal Membrane - - PowerPoint PPT Presentation

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Nursing Care of the Post Cardiac Transplant Extracorporeal Membrane Oxygenation Patient: A Case Study September 27, 2015 ECMO: A Case Study Who we are Staff nurses of Cardiac Surgery Intensive Care (CSICU) at the University of Ottawa Heart

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Nursing Care of the Post Cardiac Transplant Extracorporeal Membrane Oxygenation Patient: A Case Study

September 27, 2015

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presented by the University of Ottawa Heart Institute 2 September 27, 2015

ECMO: A Case Study Who we are

Staff nurses of Cardiac Surgery Intensive Care (CSICU) at the University of Ottawa Heart Institute

  • UOHI performs approximately 1450 surgeries per year
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presented by the University of Ottawa Heart Institute 3 September 27, 2015

ECMO: A Case Study Introduction

  • Overview of ECMO
  • Case Study
  • Patient
  • Post-op period
  • Complications
  • Nursing Interventions
  • Family considerations
  • Conclusion
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presented by the University of Ottawa Heart Institute 4 September 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
  • r respiratory failure
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presented by the University of Ottawa Heart Institute 5 September 27, 2015

ECMO: A Case Study

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presented by the University of Ottawa Heart Institute 6 September 27, 2015

ECMO: A Case Study

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presented by the University of Ottawa Heart Institute 7 September 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
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presented by the University of Ottawa Heart Institute 8 September 27, 2015

ECMO: A Case Study Components of ECMO circuit

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presented by the University of Ottawa Heart Institute 9 September 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
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presented by the University of Ottawa Heart Institute 10 September 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
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presented by the University of Ottawa Heart Institute 11 September 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

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presented by the University of Ottawa Heart Institute 12 September 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

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presented by the University of Ottawa Heart Institute 13 September 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

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presented by the University of Ottawa Heart Institute 14 September 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
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presented by the University of Ottawa Heart Institute 15 September 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

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presented by the University of Ottawa Heart Institute 16 September 27, 2015

ECMO: A Case Study

Po Post-op Da Day 4 4

Bronchoscopy Nitric Oxide started ECMO wea eaned ed!

Po Post-op Da Day 0

Heart Transplant ECMO sta tarte ted

Po Post-op Da Day 1 1

Reopened x 2 Open C hest Right arm hyperperfusion

Po Post-op Da Day 2 2

Reopened 4th time EC MO weaning not tolerated

Po Post-op Da Day 3 3

Reopened IAPB inserted

Case Study Timeline

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presented by the University of Ottawa Heart Institute 17 September 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)

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presented by the University of Ottawa Heart Institute 18 September 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
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presented by the University of Ottawa Heart Institute 19 September 27, 2015

ECMO: A Case Study Post-op Day 0

  • Cardiac transplant completed at 0500
  • Stan too unstable to leave cardiac
  • perating 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

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presented by the University of Ottawa Heart Institute 20 September 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
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presented by the University of Ottawa Heart Institute 21 September 27, 2015

ECMO: A Case Study Catch-22 of Anticoagulation and ECMO

Hemorrhagic 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

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presented by the University of Ottawa Heart Institute 22 September 27, 2015

ECMO: A Case Study Nursing implications of Anticoagulation

  • Cannulation site bleeding
  • Close monitoring
  • Transfusions and monitoring for hypovolemia
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presented by the University of Ottawa Heart Institute 23 September 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
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presented by the University of Ottawa Heart Institute 24 September 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
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presented by the University of Ottawa Heart Institute 25 September 27, 2015

ECMO: A Case Study

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presented by the University of Ottawa Heart Institute 26 September 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
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presented by the University of Ottawa Heart Institute 27 September 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
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presented by the University of Ottawa Heart Institute 28 September 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!
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presented by the University of Ottawa Heart Institute 29 September 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
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presented by the University of Ottawa Heart Institute 30 September 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
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presented by the University of Ottawa Heart Institute 31 September 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
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presented by the University of Ottawa Heart Institute 32 September 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
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presented by the University of Ottawa Heart Institute 33 September 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
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presented by the University of Ottawa Heart Institute 34 September 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
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presented by the University of Ottawa Heart Institute 35 September 27, 2015

ECMO: A Case Study Monitoring for signs of infection

ECMO 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?
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presented by the University of Ottawa Heart Institute 36 September 27, 2015

ECMO: A Case Study Infection prevention Nurses 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
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presented by the University of Ottawa Heart Institute 37 September 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
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presented by the University of Ottawa Heart Institute 38 September 27, 2015

ECMO: A Case Study A look back

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presented by the University of Ottawa Heart Institute 39 September 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
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presented by the University of Ottawa Heart Institute 40 September 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
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presented by the University of Ottawa Heart Institute 41 September 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
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presented by the University of Ottawa Heart Institute 42 September 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
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presented by the University of Ottawa Heart Institute 43 September 27, 2015

ECMO: A Case Study Thank you! Any questions?

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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

  • n 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

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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

  • f 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

  • rgans, 34(2), 59-64.

presented by the University of Ottawa Heart Institute September 27, 2015 45

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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