Dengue Fever: A Communicable Disease

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Extracorporeal Membrane Oxygenation

 

EXTRACORPOREAL MEMBRANE OXYGENATION TREATMENT

Extracorporeal Membrane Oxygenation Treatment and Outcomes within Varying Age Groups

Michelle R. Boswell

Southwest Baptist University

Abstract

Extracorporeal membrane oxygenation is a complex heart and lung machine that creates a man-made circulatory system to keep patients alive. There are many different medical diagnoses that can be treated with ECMO. ECMO can be used in premature neonates, pediatric patients, and adults up to sixty years of age. This paper will discuss the success rate of ECMO within varying age groups. Literature was used to come to these conclusions. The most success has been shown in pediatric patients. Adult patients have a lower success rate and therefore ECMO is a last resort treatment for them. ECMO has great risks associated with it. Many patients who are put on ECMO would otherwise have a very high chance of mortality. Some long term effects have been associated with ECMO treatment and the disease processes that the patients were being treated for. One study in Oslo, Norway showed that pediatric patients have the highest rate of survival after ECMO treatment (Wagner, Risnes, Abdelnoor, Karlsen, & Svennevig, 2008).  The outcome of the study was as follows: 50% of the neonatal patients in the study were discharged from the hospital, 71% of pediatric patients, and 40% of the adult patients.

Extracorporeal Membrane Oxygenation Treatment and Outcomes within Varying Age Groups

                                Extracorporeal membrane oxygenation (ECMO) is a method used to treat cardiac or respiratory failure when other methods are unsuccessful.  ECMO has been used for many years in intensive care units with neonatal and pediatric patients, but it has just recently started to be used more with adult patients (Gay, Ankney, Cochran, & Highland, 2005).   There are two different types of ECMO circuits, veno-venous and veno-arterial.  In both types, venous blood is drained through a large cannula into the ECMO machine itself and then returned to the patient (Gay, et al., 2008). In veno-venous it is returned to a vein and in veno-arterial ECMO, it is returned to the patient through an artery. Veno-venous is more often used with the adult patient (Gay, et al., 2008). Veno-venous ECMO is also called pulmonary ECMO because it assists the lungs with oxygenation. Veno-arterial ECMO is also called cardiac ECMO and used with cardiac patients since it pumps back to the body through an artery, it is also assisting the cardiac system (Wagner, et al., 2008). The 2008 study that Wagner and his colleagues performed showed that the length of time a patient is on ECMO can vary, and has not been shown to correlate with mortality rate.

Disease Process

                There are several different reasons a patient would be treated with ECMO. Some of the diagnoses for neonatal patients on ECMO include: persistent pulmonary hypertension of the neonate, meconium aspiration syndrome, sepsis or sepsis with pneumonia, congenital diaphragmatic hernia, congenital heart disease, and respiratory distress syndrome (Hamutcu, Nield, Garg, Keens, & Platzker, 2004).  Some diagnoses of the adult patient on ECMO are the same as the neonate. They may also include:  post lung transplantation, acute respiratory distress syndrome post-trauma, post cardiotomy failure, or post myocardial infarction (Wagner et al., 2008).  ECMO can also be used to keep a patient alive while trying to stabilize them during a code situation (Gonski, 2004). When ECMO is used, it reduces the amount of high oxygen concentrations as well as high peak inspiratory pressures that are associated with ventilator use (Gay, et al., 2005). This gives the lungs time to heal, because the ECMO machine is doing the work of the lungs by oxygenating the blood while reducing carbon dioxide levels in the blood.

Use of ECMO

                Some criterion has been established to decide when ECMO should be used to treat an adult patient. Gay, et al. found that these criteria include age, different ratios of pulmonary performance, and what quality of life patients are expected to have after the treatment (2005). Patients who have irreversible neurological damage, chronic systemic disease, or who are immunocompromised are not considered for ECMO (Gay, et al., 2005). Their quality of life is not expected to be high if they do survive, and their life expectancy is already severely decreased before treatment.

                What is the mortality rate with the use of ECMO? One study done in 2008 in Oslo, Norway tried to predict the outcomes of patients treated with ECMO (e.g. Wagner, et al.). They included various factors like age, gender, and other types of treatment that had been utilized prior to ECMO treatment. The outcome of the study was as follows: 50% of the neonatal patients in the study were discharged from the hospital, 71% of pediatric patients, and 40% of the adult patients (Wagner et al., 2008). The point of this study was that it is hard to predict the outcome of the patient placed on ECMO. For obvious reasons, adults have a lower success rate than other groups of patients. Adults just have a larger volume of blood to be taken out and re-circulated. Also, adults have hearts that have worked longer than neonatal or pediatric patients’ hearts. There were two factors found to correlate with mortality rate in this study, however. All three patients in the study who had intra-aortic balloon pumps prior to ECMO did not survive (Wagner, et al., 2008). These patients probably had less healthy valves than most of the other patients in the study. Also, in comparing patients who lived versus those who did not survive, serum creatinine levels were much lower in the surviving patients (Wagner, et al., 2008).  The report was conclusive in proving that age is a factor in ECMO treatment. For adult patients, ECMO is a last resort of treatment modality.

Complications

ECMO is not without risks. There can be complications that lead to mortality. Patients must take an anticoagulant during therapy and have their hemoglobin, hematocrit, and clotting time levels monitored (Gay, et al., 2005). Heparin therapy can lead to thrombocytopenia, as well as disseminated intravascular coagulation (Gay, et al., 2005). Also, the cannulas used for treatment are so large, that if one were to come out accidentally, it would be easy for a patient to hemorrhage.  Pulses distal to the insertion site of the cannula must be monitored for proficient circulation (Gay, et al., 2005). Patients on ECMO are also at risk for renal failure, so their intake and output must be monitored very carefully. If the patient’s kidneys do start to fail, a special filter attachment can be put on the ECMO machine to do dialysis as well (Gay, et al., 2005).

Research Studies

                One study done in 2004 in Los Angeles shows the sequelae, or long term effects of ECMO treatment (Hamutcu, et al.). Fifty children between the ages of ten and twelve were studied for pulmonary deficits related to their ECMO treatment as a neonate (Hamutcu, et al., 2004).  This group of children was compared to a control group of twenty-seven healthy children of the same ages. Different exercise regimens were performed by each group of children and their pulmonary functioning was measured. The children who had had ECMO treatment showed lung hyperinflation and airway obstruction at rest, decreased aerobic fitness, and lower arterial oxygen saturation (Hamutcu, et al., 2004).  Having a pulmonary issue severe enough to be treated with ECMO as a neonate, it is no surprise that these children are experiencing long term pulmonary effects. The question is, was it the ECMO treatment that caused these sequelae, or the disease for which the patient had to be placed on ECMO treatment? Whichever it may be, these children are living, and that is the most significant factor.

                ECMO is a treatment modality for which modern medicine is to thank. Neonatal patients to adult patients have benefitted from ECMO treatment. Pediatric patients have shown the highest success rate. It has been a treatment to rely on when other things, such as oscillating ventilators and nitric oxide are unsuccessful (Gonski, 2004).  Long term effects have been discovered after use of ECMO. The risks of ECMO can be fatal, but not having it as a treatment option could also be fatal for many patients as well. Although it is not the answer for every patient, it has saved numerous lives.

References

Gay, S., Ankney, N., Cochran, J., & Highland, K. (2005, July). Critical care challenges in the                    adult ECMO patient. Dimensions of Critical Care Nursing, 24(4), 157-164. Retrieved    July 13, 2009, from CINAHL Plus with Full Text database.

Gonski, Anna. (2004). A cutting edge technology grows up. Dream: The magazine of possibilities,   Children’s Hospital Boston. Retrieved July18, 2009 from http://www.childrenshospital.org/dream/DreamWin04/ecmo.html.

Hamutcu, R., Nield, T., Garg, M., Keens, T., & Platzker, A. (2004, November). Long-term pulmonary         sequelae in children who were treated with extracorporeal membrane oxygenation for neonatal   respiratory failure. Pediatrics, 114(5 Part 1), 1292-1296. Retrieved July 13, 2009, from CINAHL    Plus with Full Text database.

Wagner, K., Risnes, I., Abdelnoor, M., Karlsen, H., & Svennevig, J. (2008, March). Is it possible to             predict outcome in pulmonary ECMO? Analysis of pre-operative risk factors. Perfusion, 23(2),       95-99. Retrieved July 13, 2009, from CINAHL Plus with Full Text database.

3

What is the future of nursing informatics? There are so many possibilities, I don’t know where to begin.

First I will start out with nursing schools integrating informatics. I think that online classes are wonderful, but the ones I have taken before this class don’t involve much interaction between students. I think it would be a wonderful opportunity for learning if SBU would integrate Elluminate or another web-based classroom environment into the online programs. It would be a big step, but I think the difference in learning would be amazing. All students would need to have a speaker setup on their computers. Maybe the ones who didn’t could just type in their input.

I think another big way nursing schools could integrate informatics into the curriculum would be to have all students get an e-reader and download all text needed for classes. We spend so much money on books, and e-readers are getting cheaper and cheaper each year. Think of the back pain it would save us all! To have NIC, NOC, NANDA, and all the medical surgical and pediatric texts on an e-reader would be so amazing I can hardly imagine what it would be like!

As far as nursing informatics and its’ integration into health care, we must all have an open mind. Every day, there are advancements made in robotic surgery, new ways to do patient teaching, and new ways to access information that we use to give the best care possible. There will always be something new on the horizon. We as nurses cannot become complacent. We must never be satisfied. We are on the front lines, and therefore know what we need to give the best care better than anyone out there. Correlating with IT can help implement tools that will actually be useful to us. Willingness to learn is the first step in achieving better ways to care for our patients. We must work with technology and not against it, so it can be to our advantage in the care we give.

2 : Webliography on HPV

Human Papilloma Virus and Vaccination

Human papilloma virus (HPV) is a very common infection. There are over one hundred types. Many of these types cause warts that people may get on their hands or feet. There are about forty different types of genital HPV. Some types can cause cervical cancer, some types can cause genital warts, and other types can clear up on their own without ever being detected. The genital types of HPV are so common that “about half of all men and more than 3 out of 4 women have HPV at some point in their lives” (plannedparenthood.org).

The types of HPV that can cause cancer are known as the “high risk” types of HPV. Other genital types of HPV are known as “low risk” types. The most common cancer caused by HPV is cervical cancer. It can also cause cancer of the vagina, vulva, anus, penis, and throat. It is spread by skin-to-skin contact as well as sexual contact. Many types of HPV clear up without the person ever knowing they have had it. HPV is mainly found in young women and is less common in women over the age of thirty (American Cancer Society).

There are currently two vaccines that can be given to females aged 9-26, Gardasil and Cervarix. Gardasil can also be given to males aged 9-26 (cdc.gov/hpv/vaccine). The vaccines are highly effective against the two strains of HPV that cause over 70% of cervical cancers. They also protect against low risk types of HPV that cause 90% of genital warts cases (Association of Women’s Health, Obstetric, and Neonatal Nurses).

Many people, including health care professionals, are unaware of many facts about HPV and the vaccines. The following websites are reliable and valid resources to answer your questions about HPV. It is important for anyone involved in health care, who has children, or who is sexually active to be aware of the prevalence and causation of this disease process. In order to make informed decisions about your own health care, you must be informed of the risks and benefits of these vaccines. Every person must be their own advocate when it comes to their health.

Planned Parenthood

http://www.plannedparenthood.org/health-topics/stds-hiv-safer-sex/hpv-4272.htm

This website offers information about many health topics, including sexual health, pregnancy, relationships, sexuality, and birth control. Planned Parenthood advocates for “real” sex education in schools, and performs over 3.3 tests and treatments for sexually transmitted infections annually. They advocate that everyone should have access to proper health care. This site is easily laid out and can be navigated by many age groups.

Centers for Disease Control

http://www.cdc.gov/hpv/WhatIsHPV.html

This website is sponsored by the American government. This website has information on hundreds of topics, ranging from H1N1 to marriage data. It is written for any person seeking information. There are statistics about different diseases as well. Their slogan is “Your Online Source for Credible Health Information”.

National Cancer Institute

http://www.cancer.gov/cancertopics/types/cervical/

This website is also sponsored by the American government. There are hundreds of different cancer types listed here. The site discusses treatments, clinical trials, prevention, screening and testing, research, and statistics of cervical cancer. This site offers a toll free hotline for cancer information and support. It offers Western medicine treatment information as well as holistic approaches to healing.

American Social Health Association

http://www.ashastd.org/hpv/hpv_overview.cfm

The ASHA is a non-profit organization that has been around since 1914.  The site offers information about all different types of sexually transmitted infections (STI’s). There is information for the general public as well as health care providers. The ASHA website contains information about testing, support groups, a hotline to call with needs, and emotional issues involved with STI’s.

Mayo Clinic

http://mayoclinic.com/health/hpv-infection/DS00906

The Mayo Clinic website offers information about so many health issues. Each issue contains one or more tabs on its home page, depending on the amount of information available. These easy to use tabs include Basics, In Depth, Multimedia, Expert Answers, Expert Blog, and Resources. It is simple to use for any demographic.

American Cancer Society

http://www.cancer.org/docroot/CRI/CRI_2_1x.asp?dt=8

The main page for cervical cancer on the website contains many helpful topics. These topics are explained in a way that is easy to understand. Some pages within the site use pictures to show where different cancers start in the body. This site is one of the easiest to understand for the general public. It discusses things beyond just the facts, like moving on after a person has had cancer, or what if the cancer is found during a pregnancy.

The Association of Women’s Health, Obstetric and Neonatal Nurses

HPV Vaccine for the Prevention of Cervical Cancer Feb-Mar 2010                                                                                                  www.cinahl.com/cji-bin/refsvc?jid=3353&accno=2010551156

This article was found using CINAHL Plus with Full Text. It was co-published by JOGNN at the same time. It focuses on educating health care providers about the importance of screening for and detecting HPV early on. The article also discusses how many people are infected with HPV, as well as how many lives are taken by cervical cancer each year.

College Student Journal

Getting Vaccinated Against HPV: Attitudes, Intentions and Perceived Barriers of Female Undergraduates March 2010

http://eagle.sbuniv.edu:2055/ehost/detail?vid=3&hid=103&sid=3f4bfbe5-6a75-4ff1-b417-e5b4b346a7fe%40sessionmgr104&bdata=JkF1dGhUeXBlPWlwLHVybCxjb29raWUsdWlkJmxvZ2lucGFnZT1jdXN0bG9naW4uYXNwJnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#db=f5h&AN=48646427

This article was found using MasterFILE Premier and discusses a study that was done among college undergraduates. It shows that there are many barriers to receiving the vaccine, including cost, fear of needles, not being sexually active, having to go to the doctor to get it, and not being informed enough about the vaccine. It discusses the many health benefits of people getting vaccinated. This article is very informative but also geared toward the health care provider.

1

I am currently a BSN student at St. John’s College of Nursing. I am taking a class called Health Care Informatics in which I am learning different modes of technological communication as well as how technology is used in the medical field to share information. I felt some trepidation while beginning this course, as I still do. I am not very technologically savvy and have never blogged or Tweeted as a means of communication. But I am trying to throw myself into this course and the technology used with it in order to get all I can out of the content. Hopefully by the end of the course I will be comfortable with these modes of communication or at least understand the various things that can be accomplished by using them. Here’s to getting my words out there!

What exactly is health care informatics? Our text, Nursing Informatics and the Foundation of Knowledge, states that nursing informatics is “…a combination of nursing science, information science, and computer science.” We use technology in healthcare every day. When we have a patient, we take their vital signs using equipment and perform an assessment. We then put these facts into the computer system as data. When we see all the data together, we can use the information formed by it to treat the patient correctly. With the use of an electronic health record, (EHR) many people can access the exact same data from almost anywhere.

Why is health care informatics important? We as healthcare providers use informatics every day. We use the data provided by the patient and use it to figure out how to care for them. Every person involved in a patient’s care inputs data into an interface that allows for a picture to be painted. What is going on with this patient? Are they getting better or worse in terms of their disease process? Radiology, physicians, nurses, laboratory, respiratory therapy, speech therapy, pastoral care…every person who has access to the patient’s chart can put in information that paints the picture. I will use my experience to give an example. Before St. John’s was using an EHR, there was the chart. The physicians would come to the nurse’s station and say, “Where is that patient’s chart?” It was a physical object that only one person could be in possession of at a time. Every person that needed to access it could not at times, because another person had it. So sometimes, things went undocumented and other care givers were left wondering, “Has the doctor been by today?” “Has PT been by to work with them today?” It was not a reliable tool. The system we have now, EPIC, is not a single user interface as the physical chart was, so to speak. Multiple users can access the patient information at one time, and care gets delivered faster. Our text says that, “Information technology per se is not the focus; it is the information it conveys that is central.” I think this quote says it all. Who cares what we use to store patient information? It doesn’t matter, as long as the patient is getting the most reliable and thorough care possible.

McGonigle, D., & Mastrian, K. (2009). Nursing informatics and the foundation of knowledge (pp. 5-95). Sudbury, MA: Jones and Bartlett Publishers

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