Recovery, Risks, and Adverse Health Outcomes in Year 1 After Extracorporeal Membrane Oxygenation.

BACKGROUND: Cross-sectional studies suggest that patients treated with extracorporeal membrane oxygenation (ECMO) have adverse health outcomes and high risk for mental health problems after discharge. OBJECTIVES: To describe the recovery of discharged patients during the first year after ECMO. METHODS: In a prospective cohort study, data were collected 3, 6, and 12 months after discontinuation of ECMO and discharge. Postal surveys included the 36-Item Short Form Health Survey, the EuroQol-5-Dimensions-5-Levels health questionnaire, the Hospital Anxiety and Depression Scale, and the Impact of Event Scale-Revised. Telephone interviews were used to track adverse physical outcomes. The Telephone Interview for Cognitive Status questionnaire was administered at the end of each call. RESULTS: Patients in the study experienced more physical than mental adverse health outcomes, and the risk for mental problems was 2 or 3 times the rate expected. Adverse physical outcomes were common. One-quarter of patients remained significantly restricted; some had severe neurological impairments of the lower extremities. On cognitive tests, about half scored inconclusive or mildly impaired. Patients were often admitted to the hospital. CONCLUSIONS: Physical health was more severely impaired than was mental health, and both types improved over time. The EuroQol-5-Dimensions-5-Levels instrument was useful for detecting neurological problems of the lower extremities early and may qualify as a core outcome measure for patients treated with ECMO.

Experience and needs of family members of patients treated with extracorporeal membrane oxygenation.

AIMS AND OBJECTIVES: To explore the experiences of family members of patients treated with extracorporeal membrane oxygenation. BACKGROUND: Sudden onset of an unexpected and severe illness is associated with an increased stress experience of family members. Only one study to date has explored the experience of family members of patients who are at high risk of dying and treated with extracorporeal membrane oxygenation. DESIGN: A qualitative descriptive research design was used. METHODS: A total of 10 family members of patients treated with extracorporeal membrane oxygenation were recruited through a convenient sampling approach. Data were collected using open-ended semi-structured interviews. A six-step process was applied to analyse the data thematically. Four criteria were employed to evaluate methodological rigour. RESULTS: Family members of extracorporeal membrane oxygenation patients experienced psychological distress and strain during and after admission. Five main themes (Going Downhill, Intensive Care Unit Stress and Stressors, Carousel of Roles, Today and Advice) were identified. These themes were explored from the four roles of the Carousel of Roles theme (decision-maker, carer, manager and recorder) that participants experienced. CONCLUSION: Nurses and other staff involved in the care of extracorporeal membrane oxygenation patients must pay attention to individual needs of the family and activate all available support systems to help them cope with stress and strain. RELEVANCE TO CLINICAL PRACTICE: An information and recommendation guide for families and staff caring for extracorporeal membrane oxygenation patients was developed and needs to be applied cautiously to the individual clinical setting.

A qualitative exploration of acute care and psychological distress experiences of ECMO survivors.

OBJECTIVES: To explore the acute care experience of extracorporeal membrane oxygenation (ECMO) patients. BACKGROUND: ECMO is used in life-threatening scenarios of acute lung or heart failure. The patient's experience with ECMO treatment and the psychological distress are unknown. METHODS: Qualitative analysis of semi-structured interviews with ECMO survivors 12 months after discharge were conducted and thematically analyzed. RESULTS: Ten participants treated with ECMO for life-threatening acute heart or lung failure were interviewed. Six themes that captured the ICU experience of ECMO patients were identified including; dealing with crisis, critical care, memory, role of significant others and existence today and tomorrow. Deconditioning was the most frequently reported experience. Patchy factual memories contrasted with detailed delirious memories and paranoid ideations. CONCLUSION: Patients treated with ECMO experienced deconditioning, perceived threats of serious injury or death and delusional episodes with recalls of psychological distress.

Extracorporeal membrane oxygenation for critically ill adults.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a form of life support that targets the heart and lungs. Extracorporeal membrane oxygenation for severe respiratory failure accesses and returns blood from the venous system and provides non-pulmonary gas exchange. Extracorporeal membrane oxygenation for severe cardiac failure or for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation (ECPR)) provides gas exchange and systemic circulation. The configuration of ECMO is variable, and several pump-driven and pump-free systems are in use. Use of ECMO is associated with several risks. Patient-related adverse events include haemorrhage or extremity ischaemia; circuit-related adverse effects may include pump failure, oxygenator failure and thrombus formation. Use of ECMO in newborns and infants is well established, yet its clinical effectiveness in adults remains uncertain. OBJECTIVES: The primary objective of this systematic review was to determine whether use of veno-venous (VV) or venous-arterial (VA) ECMO in adults is more effective in improving survival compared with conventional respiratory and cardiac support. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 18 August 2014. We searched conference proceedings, meeting abstracts, reference lists of retrieved articles and databases of ongoing trials and contacted experts in the field. We imposed no restrictions on language or location of publications. SELECTION CRITERIA: We included randomized controlled trials (RCTs), quasi-RCTs and cluster-RCTs that compared adult ECMO versus conventional support. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of all retrieved citations against the inclusion criteria. We independently reviewed full-text copies of studies that met the inclusion criteria. We entered all data extracted from the included studies into Review Manager. Two review authors independently performed risk of bias assessment. All included studies were appraised with respect to random sequence generation, concealment of allocation, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias. MAIN RESULTS: We included four RCTs that randomly assigned 389 participants with acute respiratory failure. Risk of bias was low in three RCTs and high in one RCT. We found no statistically significant differences in all-cause mortality at six months (two RCTs) or before six months (during 30 days of randomization in one trial and during hospital stay in another RCT). The quality of the evidence was low to moderate, and further research is very likely to impact our confidence in the estimate of effects because significant changes have been noted in ECMO applications and treatment modalities over study periods to the present.Two RCTs supplied data on disability. In one RCT survival was low in both groups but none of the survivors had limitations in their daily activities six months after discharge. The other RCT reported improved survival without severe disability in the intervention group (transfer to an ECMO centre ± ECMO) six months after study randomization but no statistically significant differences in health-related quality of life.In three RCTs, participants in the ECMO group received greater numbers of blood transfusions. One RCT recorded significantly more non-brain haemorrhage in the ECMO group. Another RCT reported two serious adverse events in the ECMO group, and another reported three adverse events in the ECMO group.Clinical heterogeneity between studies prevented meta-analyses across outcomes. We found no completed RCT that had investigated ECMO in the context of cardiac failure or arrest. We found one ongoing RCT that examined patients with acute respiratory failure and two ongoing RCTs that included patients with acute cardiac failure (arrest). AUTHORS' CONCLUSIONS: Extracorporeal membrane oxygenation remains a rescue therapy. Since the year 2000, patient treatment and practice with ECMO have considerably changed as the result of research findings and technological advancements over time. Over the past four decades, only four RCTs have been published that compared the intervention versus conventional treatment at the time of the study. Clinical heterogeneity across these published studies prevented pooling of data for a meta-analysis.We recommend combining results of ongoing RCTs with results of trials conducted after the year 2000 if no significant shifts in technology or treatment occur. Until these new results become available, data on use of ECMO in patients with acute respiratory failure remain inconclusive. For patients with acute cardiac failure or arrest, outcomes of ongoing RCTs will assist clinicians in determining what role ECMO and ECPR can play in patient care.

Identification and prevalence of PTSD risk factors in ECMO patients: A single centre study.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is one of the most invasive rescue therapies for acute heart and/or lung failure. Survivors have high rates of adverse mental health outcomes, such as post-traumatic stress symptoms (PTSS) and manifest post-traumatic stress disorder (PTSD). Yet no study to date has identified and explored PTSD risk factors in these patients. OBJECTIVES: The primary aim of this study was to determine and explore post-traumatic stress risk factors for patients treated with ECMO. It also aimed to provide a baseline profile for future hypothesis testing with respect to risk factor exposure, level of exposure and post-traumatic stress outcomes in these patients. METHODS DESIGN: Retrospective cohort study. SETTING: The study was conducted at the Alfred Hospital Melbourne, Australia. PARTICIPANTS: Patients were selected in 2012 from an Intensive Care Unit (ICU) registry that prospectively included all patients admitted to ICU and treated with ECMO. DATA EXTRACTION AND ANALYSIS: Data were extracted from the ICU ECMO registry, ICU and ward charts, progress notes, referrals, drug charts and discharge letters. Data were descriptively analysed. RESULTS: Patients treated with ECMO are exposed to almost all investigated PTSD risk factors. These included psychiatric history (psychiatric comorbidities), admission to ICU and treatment (prolonged ventilation during prolonged ICU stay), and drug therapy (all patients treated with PTSD risk related drugs). CONCLUSION: ECMO patients are exposed to PTSD risk factors such as young age, mechanical ventilation, drug administration, delirium and agitation. Younger age, heterogeneous conditions, profound illness severity and prolonged ICU stay describe the case complexity of patients and may explain these findings. Patients in ICU are increasingly conscious during active treatment and this may have positive or negative psychological effects. "Awake" ECMO in which patients are conscious while on active life support may represent a unique PTSD risk factor in this perspective.

Clinical trial recruitment--a complex intervention?

AIMS AND OBJECTIVES: To discuss the evidence of poor recruitment rates in randomised clinical trials and relate this to existing recruitment methodology before a novel approach to recruitment is suggested. BACKGROUND: Recruitment is crucial to the success of research projects. Effective recruitment leads to effective retention, an increased pool of data and in-time completion of projects. Robust evidence indicates that recruitment remains a challenge in many clinical trials. DESIGN: Discursive article. METHODS: The complexity of recruitment is mandated based on the findings from a literature review that summarises common threats to successful recruitment. Nursing theories and models that incorporate recruitment are critically reviewed before recruiting, and its planning is related to existing complex intervention methodology. CONCLUSION: Threats to sufficient recruitment are inherent in the planning of studies, the recruiting process and triadic relationships between institutions, recruiter and participants. Existing nursing theories and models address important recruitment issues but do not account for all aspects that jeopardise sufficient recruitment. Hence, available frameworks for complex intervention planning and evaluation are useful to guide recruitment and its planning as an umbrella methodology. RELEVANCE TO CLINICAL PRACTICE: Using complex intervention methodology for recruitment and its planning enhances a nurse researcher's awareness of the challenges and pitfalls recruitment poses and may translate to improved recruitment rates and overall success of clinical trials.

Factors influencing health behaviors of younger women after menopause-inducing cancer treatment.

OBJECTIVE: To investigate the health promotion and risk reduction behaviors of younger women previously treated for cancer. DESIGN AND SAMPLE: Guided by the "Precede-Proceed" framework, a mixed-method descriptive investigation of the health behaviors of younger women with cancer treatment-induced menopause in one health jurisdiction in Australia was undertaken. MEASURES: This article reports the results of the qualitative interview component of the study. RESULTS: Of the 85 women who responded to surveys that quantified their health behaviors, 22 consented to interviews that explored how and why these behaviors might occur. CONCLUSIONS: Several predisposing, enabling and reinforcing factors that influenced participants' will or ability to engage with health-promoting behaviors after cancer treatment were identified in the interviews. These include entrenched precancer diagnosis health behaviors, the disabilities resulting from cancer treatments, perceptions of risk, focused intervention by health professionals and the nature of participants' social support. The results indicate a need for flexibility when planning public health initiatives to prepare this cohort for a healthy life after cancer, which accounts for their developmental, knowledge and posttreatment needs.

Using the Precede-Proceed Model of Health Program Planning in breast cancer nursing research.

AIM: In this article, we discuss the use of the Precede-Proceed model when investigating health promotion options for breast cancer survivors. BACKGROUND: Adherence to recommended health behaviours can optimize well-being after cancer treatment. Guided by the Precede-Proceed approach, we studied the behaviours of breast cancer survivors in our health service area. DATA SOURCES: The interview data from the cohort of breast cancer survivors are used in this article to illustrate the use of Precede-Proceed in this nursing research context. Interview data were collected from June to December 2009. We also searched Medline, CINAHL, PsychInfo and PsychExtra up to 2010 for relevant literature in the English language to interrogate the data from other theoretical perspectives. DISCUSSION: The Precede-Proceed model is theoretically complex. The deductive analytic process guided by the model usefully explained some of the health behaviours of cancer survivors, although it could not explicate many other findings. A complementary inductive approach to the analysis and subsequent interpretation by way of Uncertainty in Illness Theory and other psychosocial perspectives provided a comprehensive account of the qualitative data that resulted in contextually relevant recommendations for nursing practice. IMPLICATIONS FOR NURSING: Nursing researchers using Precede-Proceed should maintain theoretical flexibility when interpreting qualitative data. Perspectives not embedded in the model might need to be considered to ensure that the data are analysed in a contextually relevant way. CONCLUSION: Precede-Proceed provides a robust framework for nursing researchers investigating health promotion in cancer survivors; however, additional theoretical lenses to those embedded in the model can enhance data interpretation.