Nursing Care in the Post Cardiac Transplant … Lamb, L ECMO case study...presented by the University of Ottawa Heart Institute September 27, 2015 4 ECMO: A Case Study What is ECMO?

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


ECMO: A Case Study

Introduction

• Overview of ECMO• Case Study

● Patient ● Post-op period● Complications● Nursing Interventions● Family considerations

● Conclusion


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


ECMO: A Case Study


ECMO: A Case Study


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


ECMO: A Case Study

Components of ECMO circuit


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


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


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


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


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


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


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


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


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)


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


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


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


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


ECMO: A Case Study

Nursing implications of Anticoagulation

● Cannulation site bleeding

● Close monitoring

● Transfusions and monitoring for hypovolemia


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


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


ECMO: A Case Study


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


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


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!


ECMO: A Case Study

Post-op Day 2

● Second ECMO weaning attempt

● “Renal function stable! Miraculously!”

● Fourth bedside OR

● Right arm hyperperfusion worsening


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


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


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


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


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


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?


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


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


ECMO: A Case Study

A look back


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


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


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


ECMO: A Case Study

In Conclusion

● What is ECMO and how does it work?

● Case Study

● Challenges of ECMO

● Families and ECMO

● Looking back


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

http://www.elso.org/Resources/Guidelines.aspx

http://www.elso.org/Resources/Guidelines.aspx

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

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Nursing Care in the Post Cardiac Transplant … Lamb, L ECMO case study...presented by the University of Ottawa Heart Institute September 27, 2015 4 ECMO: A Case Study What is ECMO?