Ações de cuidado e diagnósticos de enfermagem ao paciente com oxigenação por membrana extracorpórea: translação do conhecimento / Acciones de cuidado y diagnósticos de enfermería para pacientes con oxigenación por membrana extracorpórea: traslación del conocimiento / Care actions and nursing diagnoses for patients with extracorporeal membrane oxygenation: knowledge translation

Resumo Objetivo mapear diagnósticos e ações de enfermagem para o cuidado ao paciente adulto com oxigenação por membrana extracorpórea, considerando um protocolo e um sistema informatizado de prescrição e a inclusão de novas ações de cuidados, em um processo de translação do conhecimento à prática clínica. Métodos estudo descritivo e exploratório, com mapeamento cruzado entre um protocolo assistencial e sistema informatizado de um hospital universitário, no período de 2014 a 2018. Foram realizados dois encontros com a chefia de enfermagem e membros do time de oxigenação por membrana extracorpórea para validar as ações. Resultados diagnósticos mais comuns utilizados nos 45 prontuários dos pacientes com oxigenação por membrana extracorpórea foram: Risco de infecção (100%); Ventilação espontânea prejudicada (93,33%); Síndrome do déficit de autocuidado (93,33%). Conclusão e implicações para a prática o mapeamento incluiu 25 novas ações associadas a 14 diagnósticos de enfermagem no sistema informatizado, visando a disseminação do conhecimento e sua aplicação em cuidados reais a pacientes com oxigenação por membrana extracorpórea.

Resumen Objetivo mapear diagnósticos y acciones de enfermería para el cuidado de pacientes adultos con oxigenación por membrana extracorpórea, considerando un protocolo y un sistema de prescripción computarizado y la inclusión de nuevas acciones de cuidado, en un proceso de traslación del conocimiento a la práctica clínica. Métodos estudio descriptivo, exploratorio, con mapeo cruzado entre un protocolo de atención y un sistema informatizado en un hospital universitario, de 2014 a 2018. Posteriormente se realizaron dos reuniones con la gerente de enfermería y miembros del equipo de oxigenación por membrana extracorpórea para validar acciones. Resultados los diagnósticos más frecuentes utilizados en los 45 prontuarios de pacientes con oxigenación por membrana extracorpórea fueron: Riesgo de infección (100%); Deterioro de la ventilación espontánea (93,33%); Síndrome de déficit de autocuidado (93,33%). Conclusión e implicaciones para la práctica el mapeo incluyó 25 nuevas acciones asociadas a 14 diagnósticos de enfermería en el sistema informatizado, con el objetivo de difundir el conocimiento y su aplicación en la atención real al paciente con oxigenación por membrana extracorpórea.

Abstract Objective to map diagnoses and nursing actions for the care of adult patients with extracorporeal oxygenation membrane, considering a protocol and a computerized prescription system and the inclusion of new care actions, in a process of translating knowledge to clinical practice. Methods descriptive and exploratory study, with cross-mapping between a care protocol and a computerized system of at a university hospital, from 2014 to 2018. Two meetings were held with the nursing manager and members of the extracorporeal oxygenation membrane team to validate the actions. Results most common diagnoses used in the 45 medical records of patients with extracorporeal membrane oxygenation were: Risk of infection (100%); Impaired spontaneous ventilation (93.33%); Self-care deficit syndrome (93.33%). Conclusion and implications for practice The mapping included 25 new actions, associated with 14 nursing diagnoses in the computerized system, aiming to disseminate knowledge and its application in real care for patients with extracorporeal oxygenation membrane.

Enfoque de enfermería a la persona en situación crítica sometida a oxigenación por membrana extracorpórea: scoping review / Nursing approach to the person in critical situation submitted to extracorporeal membrane oxygenation: scoping review / Abordagem de enfermagem à pessoa em situação crítica submetida a oxigenação por membrana extracorporal: scoping review

La Oxigenación con Membrana Extracorpórea (ECMO en inglés) es un tipo de soporte artificial cardiopulmonar usado para tratar el fallo respiratorio severo ya que permite la oxigenación extracorpórea. Además, en pacientes con fallo cardíaco severo o que han sufrido un infarto, esta técnica provee circulación sistémica. Sin embargo, la ECMO conlleva algunos riesgos, por ejemplo, coagulopatías. El enfermero tiene un papel clave en esta situación. OBJETIVO: Dejar clara la función científica de los enfermeros en relación con el paciente crítico en tratamiento con ECMO. MÉTODO: Llevamos a cabo un estudio usando las bases de datos de la plataforma EBSCO host y siguiendo la metodología propuesta por el Instituto Joanna Briggs. Con base en los descriptores de la MeSH, hemos seleccionado estudios publicados entre el 2009 y 2019, escritos en portugués e inglés. RESULTADOS: Se han incluido 5 estudios en esta revisión. El análisis de los artículos nos permitió verificar que la labor del enfermero se basa en la monitorización, supervisión, dirección y coordinación del cuidado de los pacientes críticos sometidos a ECMO. También se apreció que el uso de protocolos adecuados, la formación de equipos multidisciplinarios y la comunicación adecuada entre los componentes del equipo contribuye a un abordaje eficaz, seguro y de calidad para tratar a los pacientes sometidos a ECMO. CONCLUSIÓN: El papel del enfermero es fundamental para la calidad y seguridad de los cuidados prestados a los pacientes críticos sometidos a ECMO

Extracorporeal Membrane Oxygenation (ECMO) corresponds to a form of mechanical cardiopulmonary support used to treat severe respiratory failure, since it allows extracorporeal gas exchange. Additionally, in patients with severe heart failure, or experiencing cardiorespiratory arrest, this technique also provides systemic circulation. Nevertheless, ECMO carries some risks, such as clot formation. It is in this context that the nurse has a key role. OBJECTIVE: To map the available scientific evidence about the nurses' approach to the critically ill person subjected to ECMO. METHOD: We conducted a scoping review, using databases accessed through the EBSCOhost platform and following the methodology proposed by the Joanna Briggs Institute. Through the combination of appropriate MesH descriptors, we selected articles published between 2009 and 2019, written in Portuguese or English. RESULTS: Five studies were included in the review. Their analysis allowed us to verify that the nurse's approach focuses on the monitoring, surveillance, management and coordination of the care provided to critically ill patients subjected to ECMO. It was also found that the adoption of adequate protocols, the training of the multidisciplinary teams and an efficient communication between team members contributed to an effective, safe and high-quality performance when facing patients subjected to ECMO. CONCLUSION: An appropriate nursing approach is essential to ensure the provision of care with quality, and safety, to the patient subjected to ECMO

A Oxigenação Extracorporal por Membrana (ECMO, na sigla inglesa) corresponde a um suporte cardiopulmonar mecânico utilizado para tratar a insuficiência respiratória grave, ao permitir trocas gasosas extracorporais. Adicionalmente, em pacientes com insuficiência cardíaca grave, ou em paragem cardiorrespiratória, esta técnica também providencia circulação sistémica. Contudo, a ECMO acarreta alguns riscos, como a formação de coágulos. É neste contexto que o enfermeiro desempenha uma função primordial. OBJETIVO: Mapear a evidência científica disponível sobre a abordagem dos enfermeiros à pessoa em situação crítica submetida a ECMO. MÉTODO: Realizou-se uma revisão abrangente da literatura (scoping review), recorrendo a bases de dados acedidas através da plataforma EBSCOhost e seguindo a metodologia proposta pelo Joanna Briggs Institute. Mediante a conjugação de descritores MesH apropriados, foram selecionados estudos em Português, ou Inglês, e publicados entre 2009 e 2019. RESULTADOS: Foram incluídos cinco estudos na revisão. A sua análise permitiu averiguar que a abordagem do enfermeiro se centra na monitorização, vigilância, gestão e coordenação dos cuidados prestados à pessoa em situação crítica submetida a ECMO. Verificou-se, ainda, que a adoção de protocolos adequados, o treino das equipas multidisciplinares e uma comunicação eficiente entre os membros de equipa, contribuem para uma atuação eficaz, segura, e de qualidade, perante os doentes submetidos a ECMO. CONCLUSÃO: Uma abordagem apropriada, por parte do enfermeiro, é fundamental para garantir a prestação de cuidados com qualidade, e segurança, ao doente submetido a ECMO

Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant: Considerations for Critical Care Nursing Practice.

TOPIC: Candidates waiting for lung transplant are sicker now than ever before. Extracorporeal membrane oxygenation has become useful as a bridge to lung transplant for these critically ill patients. CLINICAL RELEVANCE: Critical care nurses must be prepared to care for the increasing number of lung transplant patients who require this advanced support method. PURPOSE OF PAPER: To provide critical care nurses with the foundational knowledge essential for delivering quality care to this high-acuity transplant patient population. CONTENT COVERED: This review describes the types of extracorporeal membrane oxygenation (venovenous and venoarterial), provides an overview of the indications and contraindications for extracorporeal membrane oxygenation, and discusses the role of clinical bedside nurses in the treatment of patients requiring extracorporeal membrane oxygenation as a bridge to lung transplant.

Extracorporeal Life Support in Adult Patients: A Global Perspective of the Last Decade.

Extracorporeal life support (ECLS) is an external medical device to treat critically ill patients with cardiovascular and respiratory failure. In a nutshell, ECLS is only a "bridging" mechanism that provides life support while the heart and/or the lungs is recovering either by therapeutic medical interventions, transplantation, or spontaneously. Extracorporeal life support has been developed since 1950s, and many studies were conducted to improve ECLS techniques, but unfortunately, the survival rate was not improved. Because of Dr Bartlett's success in using ECLS to treat neonates with severe respiratory distress in 1975, ECLS is made as a standard lifesaving therapy for neonates with severe respiratory distress. However, its use for adult patients remains debatable. The objectives of this study are to outline and provide a general overview of the use of ECLS especially for adult patients for the past 10 years and to elaborate on the challenges encountered by each stakeholder involved in ECLS. The data used for this study were extracted from the ELSO Registry Report of January 2018. Results of this study revealed that the number of ECLS centers and the use of ECLS are increasing over the year for the past decade. There was also a shift of the patient's age category from neonatal to adult patients. However, the survival rates for adult patients are relatively low especially for cardiac and extracorporeal cardiopulmonary resuscitation cases. To date, the complications are still the major challenge of ECLS. Other challenges encountered by the stakeholders in ECLS are the limited amount of well-trained and experienced ECLS teams and centers, the limited government expenditure on health, and the lack of improvement and development of ECLS techniques and devices. Further studies are needed to evaluate the value of ECLS for adult patients.

Management of Extracorporeal Membrane Oxygenation for Obstetric Patients: Concerns for Critical Care Nurses.

Critical care nurses are faced with many challenges, and one that is particularly stressful is caring for obstetric patients. This care can become more complex when the obstetric patient requires extracorporeal membrane oxygenation. It is imperative that critical care nurses have knowledge about this unique population, the expected physical changes of pregnancy, and the management of extracorporeal membrane oxygenation. Obstetric patients present unique challenges, and care is focused on the woman and her family. The purpose of this paper is to provide information for critical care nurses regarding care of obstetric patients who receive extracorporeal membrane oxygenation.

Cuidados a pacientes em uso de oxigenação por membrana extracorpórea / Care for patients using extracorporeal membrane oxygenation

Objetivo: analisar as evidências acerca da assistência de Enfermagem a pacientes em uso de oxigenação por membrana extracorpórea. Método: trata-se de um estudo bibliográfico, tipo revisão integrativa, com busca de artigos publicados em periódicos científicos de 2008 a 2018 e indexados nas bases de dados LILACS, MEDLINE e Scopus e no Centro LatinoAmericano e do Caribe de Informação em Ciências da Saúde (BIREME), analisados pela técnica de Análise de Conteúdo e apresentados em formas de figuras. Resultados: selecionaram-se nove artigos com a análise que agrupou os resultados nas seguintes categorias: Deambulação/Mobilização; Gerenciamento dos circuitos; Cuidados gerais de Enfermagem; Monitorização hemodinâmica, posição prona; Monitorização do estado de sedação; Controle da anticoagulação e monitoração do sangramento. Conclusão: entende-se que a assistência de Enfermagem repercute diretamente na melhora do quadro clínico de pacientes que utilizam este tipo de suporte hemodinâmico, sendo primordial para a sua completa recuperação. Devem-se proporcionar capacitações específicas para que os enfermeiros possuam habilidades e competências suficientes para assistir o paciente de maneira segura e eficaz.(AU)

Objective: to analyze the evidence about nursing care for patients using extracorporeal membrane oxygenation. Method: this is an integrative review bibliographic study, searching for articles published in scientific journals from 2008 to 2018 and indexed in the LILACS, MEDLINE and Scopus databases, and the Latin American and Caribbean Center for Science Information. Health (BIREME), analyzed by the Content Analysis technique and presented in figure forms. Results: nine articles were selected with the analysis that grouped the results into the following categories: Ambulation / Mobilization; Circuit management; General nursing care; Hemodynamic monitoring, prone position; Sedation status monitoring; Anticoagulation control and bleeding monitoring. Conclusion: it is understood that nursing care directly affects the improvement of the clinical condition of patients using this type of hemodynamic support, being essential for their complete recovery. Specific training should be provided so that nurses have sufficient skills and competencies to assist the patient safely and effectively.(AU)

Objetivo: analizar las evidencias sobre el cuidado de Enfermería para pacientes que usan oxigenación con membrana extracorpórea. Método: este es un estudio bibliográfico de revisión integradora, que busca artículos publicados en revistas científicas de 2008 a 2018 e indexados en las bases de datos LILACS, MEDLINE y Scopus, y en el Centro Latinoamericano y del Caribe de Información en Ciencia de la Salud (BIREME), analizadas por la técnica de Análisis de Contenido y presentadas en forma de figuras. Resultados: se seleccionaron nueve artículos con el análisis que agruparon los resultados en las siguientes categorías: Ambulación / Movilización; Gestión de circuitos; Cuidados generales de Enfermería; Monitoreo hemodinámico, posición prono; Monitorización del estado de la sedación; Control de anticoagulación y monitoreo de hemorragias. Conclusión: se entiende que la atención de Enfermería impacta directamente en la mejora de la condición clínica de los pacientes que utilizan este tipo de soporte hemodinámico, siendo esencial para su recuperación completa. Se debe proporcionar capacitaciones específicas para que los enfermeros tengan suficientes habilidades y competencias para ayudar al paciente de manera segura y efectiva.(AU)

Mechanical Ventilation and Extracorporeal Membrane Oxygena tion in Acute Respiratory Insufficiency

Mechanical ventilation is life-saving for patients with acute respiratory insufficiency. In a German prevalence study, 13.6% of patients in intensive care units received mechanical ventilation for more than 12 hours; 20% of these patients received mechanical ventilation as treatment for acute respiratory distress syndrome (ARDS). The new S3 guideline is the first to contain recommendations for the entire process of treatment in these groups of patients (indications, ventilation modes/parameters, accompanying measures, treatments for refractory impairment of gas exchange, weaning, and follow-up care). This guideline was developed according to the GRADE methods. Pertinent publications were identified by a systematic search of the literature, the quality of the evidence was evaluated, a risk/benefit assessment was conducted, and recommendations were issued by interdisciplinary consensus. Mechanical ventilation is recommended as primary treatment for patients with severe ARDS. In other patient groups, non-invasive ventilation can lower mortality. If mechanical ventilation is needed, ventilation modes allowing spontaneous breathing seem beneficial (quality of evidence [QoE]: very low). Protective ventilation (high positive end-expiratory pressure, low tidal volume, limited peak pressure) improve the survival of ARDS patients (QoE: high). If a severe impairment of gas exchange is present, prone positioning lessens mortality (QoE: high). Veno-venous extracorporeal membrane oxygenation (vvECMO) has not unequivocally been shown to improve survival. Early mobilization and weaning protocols can shorten the duration of ventilation (QoE: moderate). Recommendations for patients undergoing mechanical ventilation include lung-protective ventilation, early spontaneous breathing and mobilization, weaning protocols, and, for those with severe impairment of gas exchange, prone positioning. It is further recommended that patients with ARDS and refractory impairment of gas exchange should be transferred to an ARDS/ECMO center, where extracorporeal methods should be applied only after application of all other therapeutic options.

Oral Care Protocols With Specialty Training Lead to Safe Oral Care Practices and Reduce Iatrogenic Bleeding in Extracorporeal Membrane Oxygenation Patients.

INTRODUCTION: Oral care, using either a mouth rinse, gel, toothbrush, or combination of them, together with aspiration of secretions, may reduce the risk of ventilator-acquired pneumonia in intubated patents. Oral care procedure in patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) may cause bleeding due to the systemic anticoagulation required. PURPOSE: The aim of this study was to investigate the rate of bleeding episodes during oral care in patients supported by VV-ECMO. METHODS: A retrospective observational study was performed. All patients admitted to an Italian ECMO center during 2014 were included in the study. RESULTS: Data from 14 patients were analyzed. The median intensive care unit length of stay was 39.0 days (interquartile range, 27.3-83.3 days), and median days on VV-ECMO was 19.5 (10.3-46.0). There were 440 ECMO days, with 1320 oral care maneuvers. In 7 patients, bleeding episodes occurred: 2 with orotracheal intubation and 5 initially managed with orotracheal intubation, thereafter via Translaryngeal tracheostomy tube (according to Fantoni's technique). In 61 oral care procedures (4.6%), bleeding was detected during or after the maneuver, whereas the total numbers of days with at least 1 bleeding episode were 35 (8%).The presence or absence of bleeding during ECMO days was statistically significant for international normalized ratio (1.01 [0.95-1.11] vs 1.13 [1.03-1.25], P < .0001), platelets (163 000 [93 500-229 000] vs 61 000 [91 00-100 000], P < .0001), and mouth care score (6 [5-7] vs 8 [7-9], P < .001). CONCLUSION: Oral care can cause bleeding in patients on VV-ECMO. Implementation of protocols for daily oral care in patients on ECMO may reduce risks. As recommended by the literature, this category of patients should be treated in selected centers distinguished by a regular volume of ECMO activity and the presence of dedicated ECMO specialist nurses.

Nursing Challenges in Interactions With Patients Receiving Mechanical Circulatory and Respiratory Support.

BACKGROUND: Mechanical circulatory and respiratory support (MCRS) systems provide short- to long-term life support for patients with severe cardiac or respiratory failure. Whereas the challenges of patients with these lifesaving systems are well understood, the challenges faced by nurses of patients receiving MCRS remain relatively unidentified. OBJECTIVES: In this study, we investigated the challenges and experiences of MCRS nurses, with the aim of informing the design of future interventions. DESIGN: A qualitative approach was taken to develop an in-depth understanding of the emotional issues nurses experience in their daily interactions with patients. PARTICIPANTS AND SETTING: Nine MCRS nurses ranging in clinical experience were recruited from Australian hospitals. METHODS: Participants were divided into 3 focus groups, with design prompts being used in the focus groups to facilitate discussion. Data from these focus groups were analyzed through a thematic analysis protocol. RESULTS: The nurses' accounts were clustered around 2 themes, including (1) patient connection and (2) compassion vitality and fatigue. Each theme elicits a conflicting compromise that MCRS nurses face daily. CONCLUSION: The challenges of nurses who support patients with MCRS are complex, multifaceted, emotionally stimulating, and exhausting. We therefore contributes a set of design criteria to support such nurses, setting a direction for future research.

Cuidados de enfermagem especializados ao doente com insuficiência cardíaca aguda sob suporte circulatório mecânico / Specialized nursing care for patients with acute heart failure on mechanical circulatory support

A IC é uma epidemia crescente do século XXI e uma síndrome clínica complexa que resulta de problemas cardíacos estruturais ou funcionais de etiologia variada. O Suporte Circulatório Mecânico é uma terapêutica não farmacológica recomendada para um conjunto de doentes altamente selecionados. A prática avançada em enfermagem requer que os enfermeiros possuam conhecimentos científicos atualizados na sua área de especialização, integrando-os com o conhecimento empírico derivado da prática diária de cuidados centrados no doente. Tal pressupõe que os enfermeiros detenham competência profissional, conhecimento e habilidade de tomar decisões e priorizar os cuidados. O presente relatório de estágio tem como objetivo demonstrar o desenvolvimento das competências essenciais à obtenção do grau de mestre em enfermagem na área de especialização à pessoa em situação crítica (PSC). O estágio realizado em três contextos distintos ao longo do 3º semestre permitiu implementar o projeto por mim desenhado previamente, com o intuito de desenvolver competências de enfermagem especializadas à PSC, nomeadamente ao doente com insuficiência cardíaca (IC) sob suporte circulatório mecânico (SCM). A descrição e análise crítico-reflexiva do percurso de desenvolvimento de competências foi norteada pela Teoria do Cuidar Tecnológico (Locsin, 2005, 2017), pelo Cuidado Centrado no Doente (McCormack & McCance, 2006), à luz do The Strong Model of Advanced Nursing Practice (Ackerman, Norsen, Martin, Wiedrich, & Kitzman, 1996) e do modelo de Julgamento Clínico (Tanner, 2006). A componente de investigação e translação do conhecimento, a par e passo com a reflexão na ação decorrente do percurso de desenvolvimento de competências permitiu identificar implicações para a prática, nomeadamente, a necessidade de criar instrumentos que avaliem a eficácia e efetividade das intervenções de enfermagem na predição e melhoria dos outcomes destes doentes. Os cuidados de enfermagem especializados ao doente com IC sob SCM são complexos, requerem capacidade de trabalho em equipa e de relação com o outro e dependem de conhecimentos científicos sólidos baseados na melhor evidência disponível, da experiência de vida dos intervenientes e das características do contexto e do meio ambiente onde nos encontramos inseridos.

Heart Failure (HF) is a major and growing Public Health issue worldwide. Mechanical circulatory support (MCS) is a non-pharmacologic therapeutic recommended to highly selected patients. Advanced Nursing Practice requires nurses to have actualized scientific knowledge in their specialty area, integrating it with the empirical knowledge derived from daily practice of patient centered care (PCC). It presupposes that nurses have professional competence, knowledge and ability to make decisions and prioritize care. The aim of this report is to describe the competencies development path to obtain a master's degree in critical care nursing. An internship in three different contexts during the 3rd semester allowed me to implement the project I designed previously, with the aim of developing specialized nursing competence in critical care nursing, focusing on patients with heart failure (HF) under mechanical circulatory support (MCS). Critical-reflective description and analysis of the competency development pathway was guided by the Technological Care Theory (Locsin, 2005, 2017), Patient-centered Care (McCormack & McCance, 2006), in The Strong Model of Advanced Nursing Practice (Ackerman, Norsen, Martin, Wiedrich, & Kitzman, 1996) and the Clinical Judgement Model (Tanner, 2006). Translational knowledge and research, along with the reflection on action about the development of competences pathway allowed me to identify implications for future practice, namely, the need to create tools to evaluate the efficacy and effectiveness of nursing interventions to improve and predict better patient-related outcomes. HF patient-centered care under MCS is complex, requires teamwork and relational skills, and it depends on the best available evidence-based scientific knowledge, on stakeholders' life experience and on context and environment specificity in which we find ourselves.

Impacto en un programa de trasplante renal de un protocolo de donación tras muerte cardiaca controlada con soporte de ECMO / Impact of a donor protocol on a renal transplant program after controlled cardiac death with ECMO support

Objetivo: Analizar el impacto de un protocolo de donación tras muerte cardiaca controlada con soporte de sistema de oxigenación de membrana extracorpórea (PMCC-ECMO) en el programa de trasplante renal de nuestro centro. Material y Método: Estudio retrospectivo, observacional, descriptivo en una cohorte de injertos renales (IR) procedentes de un PMCC-ECMO. Se evalúan los IR procedentes de 8 pacientes con enfermedad irreversible (EI) en los que se aplica limitación del esfuerzo terapéutico y se consideran como potenciales donantes durante el último semestre del 2014 y el primer trimestre de 2015. Se excluyeron los IR enviados fuera de la comunidad. Se evaluaron indicadores del proceso de donación (IPD) y resultados clínicos de los injertos (RCI). Resultados: IPD: 100% hombres, edad media 60 años, tiempo medio agónico 9,37 minutos; causa EI 62,5% de origen pulmonar, 37,5% de origen neurológico. Se obtuvieron 13 riñones, 3 hígados y 2 pulmones: 2 IR fuera de la comunidad. Los IR provenientes del PMCC-ECMO supusieron un 20% de los IR del 2014 en nuestro centro. RCI: De los 11 IR trasplantados en nuestro centro, sólo 1 no fue viable por trombosis de las venas renales, y otro IR se retrasó la función renal por causas inmunológicas. Valores medios función IR al mes: creatinina sérica 1,88 mg/dl, aclaramiento creatinina 56,82 mL/min, urea 0,798 g/L. Conclusiónes: El PMCC-ECMO ha tenido un alto impacto en el programa de trasplante renal, tanto por incrementar la tasa de donación, como por la alta tasa de viabilidad de los injertos (AU)

Aim: To analyze the impact of a donor protocol after controlled cardiac death with support of extracorporeal membrane oxygenation (PMCC-ECMO) in the renal transplant program of our center. Material and method: Retrospective, observational, descriptive study in a cohort of renal grafts (RG) from PMCC-ECMO. RGs from 8 patients with irreversible disease (IE) in which therapeutic effort limitation is applied are evaluated and considered as potential donors during the last six months of 2014 and the first quarter of 2015. IRs sent out of the community were excluded. Indicators of the donation process (IDP) and clinical results of the grafts (CRG) were evaluated. Results: IDP: 100% men, mean age 60 years, mean agonizing time 9.37 minutes; cause of IE: 62.5% of pulmonary origin, 37.5% of neurological origin. We obtained 13 kidneys, 3 livers and 2 lungs: 2 RG outside the community. RGs from the PMCC-ECMO accounted for 20% of the total in 2014 at our center. CRG: Of the 11 RGs transplanted in our center, only 1 was not viable due to thrombosis of the renal veins, and another RG presented delayed renal function due to immunological causes. Mean values of RG function per month: serum creatinine 1.88 mg / dl, creatinine clearance 56.82 mL / min, urea 0.788 g / L. Conclusions: PMCC-ECMO has had a high impact on the renal transplant program, both for increasing the donation rate and for the high viability rate of the grafts (AU)

Ethical Considerations for Care of the Child Undergoing Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a complex, highly technical surgical procedure that can offer hope for children born with congenital heart defects. The procedure may only briefly prolong a life, has limited potential for decreasing mortality, and may lead to serious complications, however. Perioperative nurses play an important role in caring for the child who requires ECMO. They are involved in assessing the child, implementing the plan of care, and facilitating communication between the child's family members and the health care team. Thus, perioperative nurses have a responsibility to consider the broad range of ethical issues associated with the procedure. By examining the ethical concepts of beneficence, nonmaleficence, autonomy, justice, and moral distress, the perioperative nurse can better understand the dilemmas that can affect the care and outcome of the critically ill child who requires ECMO.

The Utility of Nurse-Managed Extracorporeal Life Support in an Adult Cardiac Intensive Care Unit.

BACKGROUND: The use of extracorporeal life support (ECLS) worldwide has increased exponentially since 2009. The patient requiring ECLS demands an investment of hospital resources, including personnel. Educating bedside nurses to manage ECLS circuits broadens the availability of trained providers. METHODS: Experienced cardiothoracic intensive care unit (CTICU) nurses underwent training to manage ECLS circuits, including volume assessment, treatment of arterial blood gas values, the physiology of ECLS, and recognition of common emergencies. In addition to lectures and a written examination, simulation using water circuits and an ICU model allowed assessment of skills and understanding of concepts. Performance assessments were completed regularly at the bedside, and skills revalidation occurred every 6 months. A sequential cohort of 40 patients was tracked over 1 year. RESULTS: Despite doubling the census of ECLS patients in 1 year, management by specially trained CTICU nurses has positively affected patient care and outcomes. At a single institution, 40 patients had a median of 6 days (interquartile range, 2 to 226 days) of support in 2014, leading to 767 patient-days of support. Survival to hospital discharge increased to 45% in 2014. Most survivors were weaned from support. Neurologic injury was the most common cause of death, followed by failure to qualify for advanced therapies. CONCLUSIONS: With on-going education and assessment, including crisis training, physiology, and cannulation strategies, CTICU nurses can safely operate ECLS circuits and can increase the availability of appropriately trained providers to accommodate the exponential increase in ECLS occurrences without negatively affecting outcomes and generally at a lower cost.

An international survey: the role of specialist nurses in adult respiratory extracorporeal membrane oxygenation.

BACKGROUND: The last decade has seen an increase in the number of centres able to provide venovenous extracorporeal membrane oxygenation (VV-ECMO) internationally across different health care systems. To support this growth, a variety of staffing arrangements have been adopted depending on local need and availability of resources, both in terms of manpower and finances to safely meet the complex needs of the patient and circuit management. AIM: The aim of the survey was to describe current staffing arrangements of care provision for adult patients on VV-ECMO, with a focus on understanding the professional roles and responsibilities of staff managing the circuit in order to inform further discussion around different approaches to staffing. METHODS: We conducted a cross-sectional international survey using an electronic questionnaire emailed to 177 worldwide ECMO centres treating adult patients with acute respiratory failure. The survey questions were generated through an internal and external iterative process and assessed for clarity, content and face validity. RESULTS: The response rate was 82%. Respondents managed extracorporeal oxygenation for adult respiratory alone (75%) or in combination with adult cardiac (67%), paediatric respiratory (62%) and paediatric cardiac (58%). The specialist nurse to patient ratio was 1:1 in 59% of centres, with 24-h/day presence in 74%. Overall, the specialist nurse provided the 24-h/day management of the circuit, including interventions. Perfusionists were responsible for the technical aspects of circuit management. CONCLUSIONS: A specialist nurse with perfusion backup is the staffing arrangement implemented by most centres and likely reflects the most efficient use of the professional competences available. RELEVANCE TO CLINICAL PRACTICE: Staffing for adult respiratory extracorporeal support has important implications for the planning of workforce, training and education, quality of service and the number of ECMO beds available.

Daily nursing care on patients undergoing venous-venous extracorporeal membrane oxygenation: a challenging procedure!

Daily nursing in critical care patients may alter vital parameters, especially in the most critically ill patients. The aim of our study was to evaluate feasibility and safety of daily nursing on patients undergoing venous-venous extracorporeal membrane oxygenation (vv-ECMO) for severe respiratory failure. Daily nursing was performed following defined phases (sponge bath, elevation with scooping stretcher, change position of endotracheal tube, dressing replacement). We recorded physiological and ECMO parameters before and during daily nursing in 5 patients for several days (total: 25 daily nursing) and adverse events: desaturation, hypertension, reduction of mixed venous oxygen saturation, arterial oxygen saturation or ECMO blood flow and elevation in minute ventilation. Sedative drug dosage and additional bolus were recorded. Daily nursing was performed in 92 % of cases (23/25), with a minimum of two adverse events per daily nursing. Hypertension and tachycardia were mostly recorded at the beginning, while desaturation, reduction in mixed venous oxygen saturation and blood flow were recorded during elevation with scooping stretcher. Increase in minute ventilation was frequent in spontaneous breathing patients. Additional bolus of sedation was required before and/or during nursing. Daily nursing significantly alters physiologic parameters; thus, it should be performed only when physicians are readily available to treat adverse events.

Severe hypoxemia: which strategy to choose.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is characterized by a noncardiogenic pulmonary edema with bilateral chest X-ray opacities and reduction in lung compliance, and the hallmark of the syndrome is hypoxemia refractory to oxygen therapy. Severe hypoxemia (PaO2/FiO2 < 100 mmHg), which defines severe ARDS, can be found in 20-30 % of the patients and is associated with the highest mortality rate. Although the standard supportive treatment remains mechanical ventilation (noninvasive and invasive), possible adjuvant therapies can be considered. We performed an up-to-date clinical review of the possible available strategies for ARDS patients with severe hypoxemia. MAIN RESULTS: In summary, in moderate-to-severe ARDS or in the presence of other organ failure, noninvasive ventilatory support presents a high risk of failure: in those cases the risk/benefit of delayed mechanical ventilation should be evaluated carefully. Tailoring mechanical ventilation to the individual patient is fundamental to reduce the risk of ventilation-induced lung injury (VILI): it is mandatory to apply a low tidal volume, while the optimal level of positive end-expiratory pressure should be selected after a stratification of the severity of the disease, also taking into account lung recruitability; monitoring transpulmonary pressure or airway driving pressure can help to avoid lung overstress. Targeting oxygenation of 88-92 % and tolerating a moderate level of hypercapnia are a safe choice. Neuromuscular blocking agents (NMBAs) are useful to maintain patient-ventilation synchrony in the first hours; prone positioning improves oxygenation in most cases and promotes a more homogeneous distribution of ventilation, reducing the risk of VILI; both treatments, also in combination, are associated with an improvement in outcome if applied in the acute phase in the most severe cases. The use of extracorporeal membrane oxygenation (ECMO) in severe ARDS is increasing worldwide, but because of a lack of randomized trials is still considered a rescue therapy. CONCLUSION: Severe ARDS patients should receive a holistic framework of respiratory and hemodynamic support aimed to ensure adequate gas exchange while minimizing the risk of VILI, by promoting lung recruitment and setting protective mechanical ventilation. In the most severe cases, NMBAs, prone positioning, and ECMO should be considered.

Plan de cuidados individualizado durante oxigenación con membrana extracorpórea. Caso clinic / Individualised care plan during extracorporeal membrane oxygenation. A clinical case

Describimos un plan de cuidados individualizado de una mujer diagnosticada de neumonía, intubada y con ventilación mecánica invasiva que ingresa en la Unidad de Cuidados Intensivos para oxigenación por membrana extracorpórea (ECMO). Se realiza valoración enfermera por patrones funcionales de Marjory Gordo, priorizando los diagnósticos enfermeros más relevantes, utilizando un modelo de razonamiento clínico (Análisis de Resultado del Estado Actual) y la taxonomía NANDA. Se describen: ansiedad ante la muerte, deterioro del intercambio de gases, disminución del gasto cardíaco, motilidad gastrointestinal disfuncional, riesgo de síndrome de desuso, riesgo de infección y riesgo de sangrado. Los objetivos principales son: disminuir el miedo de la familia, conseguir un óptimo estado respiratorio y cardiocirculatorio, mantener la función gastrointestinal, evitar las posibles complicaciones de la inmovilidad y disminuir al máximo el riesgo de infección y sangrado. En cuanto a las actividades, se han realizado: apoyo a la familia, correcto manejo de la vía aérea-ventilación mecánica, monitorización cardiorrespiratoria, de la piel y del estado nutricional, control de posibles infecciones y hemorragias (manejo de terapias, catéteres…). Para la evaluación de los resultados se ha utilizado la escala Likert, cumpliéndose todos los indicadores de resultado planteados. No se han encontrado casos que desarrollaran un plan de cuidados individualizado con taxonomía NNN utilizando ECMO veno-venosa. Los planes descritos con otro tipo de ECMO no utilizaron el modelo análisis de resultado del estado actual. Este caso puede apoyar a enfermeras a prestar atención a pacientes sometidos a ECMO veno-venosa, aunque son necesarios más casos para estandarizar los cuidados según la taxonomía NANDA

An individualised care plan is described for a woman diagnosed with pneumonia, intubated, and on invasive mechanical ventilation, who was admitted to the Intensive Care Unit for extracorporeal membrane oxygenation (ECMO). A nursing care plan was designed based on Marjory Gordon functional patterns. The most important nursing diagnoses were prioritised, using a model of clinical reasoning model (Analysis of the current status) and NANDA taxonomy. A description is presented on, death anxiety, impaired gas exchange, decreased cardiac output, dysfunctional gastrointestinal motility, risk for disuse syndrome, infection risk, and bleeding risk. The principal objectives were: to reduce the fear of the family, achieve optimal respiratory and cardiovascular status, to maintain gastrointestinal function, to avoid immobility complications, and to reduce the risk of infection and bleeding. As regards activities performed: we gave family support; correct management of the mechanical ventilation airway, cardio-respiratory monitoring, skin and nutritional status; control of possible infections and bleeding (management of therapies, care of catheters…). A Likert's scale was used to evaluate the results, accomplishing all key performance indicators which were propose at the beginning. Individualised care plans with NNN taxonomy using the veno-venous ECMO have not been described. Other ECMO care plans have not used the same analysis model. This case can help nurses to take care of patients subjected to veno-venous ECMO treatment, although more cases are needed to standardise nursing care using NANDA taxonomy

Extracorporeal membrane oxygenation for pediatric cardiac arrest.

Extracorporeal cardiopulmonary resuscitation (ECPR) remains a promising treatment for pediatric patients in cardiac arrest unresponsive to traditional cardiopulmonary resuscitation. With venoarterial extracorporeal support, blood is drained from the right atrium, oxygenated through the extracorporeal circuit, and transfused back to the body, bypassing the heart and lungs. The use of artificial oxygenation and perfusion thus provides the body a period of hemodynamic stability, while allowing resolution of underlying disease processes. Survival rates for ECPR patients are higher than those for traditional cardiopulmonary resuscitation (CPR), although neurological outcomes require further investigation. The impact of duration of CPR and length of treatment with extracorporeal membrane oxygenation vary in published reports. Furthermore, current guidelines for the initiation and use of ECPR are limited and may lead to confusion about appropriate use of this support. Many ethical concerns arise with this advanced form of life support. More often than not, the dilemma is not whether to withhold ECPR, but rather when to withdraw it. Although clinicians must decide if ECPR is appropriate and when further intervention is futile, the ultimate burden of choice is left to the patient's caregivers. Offering support and guidance to the patient's family as well as the patient is essential.