ECMO
Extra Corporeal Membrane Oxygenation (ECMO) is a heart-lung bypass procedure indicated for some infants and children. It is described as “a form of partial cardiopulmonary bypass used for long-term support of respiratory and/or cardiac function,” (“An Introduction to Extracorporeal Membrane Oxygenation (ECMO),” n.d.). Among the conditions for which ECMO is indicated include the following: Meconium Aspiration Syndrome, Sepsis, Respiratory Distress Syndrome, Persistent Pulmonary Hypertension, Pneumonia, or a Congenital Diaphragmatic Hernia, Sepsis, Acute Respiratory Distress Syndrome, and “certain heart conditions,” (“Introduction to ECMO for Parents” n.d.). The basic conditions under which ECMO is indicated in perioperative practice relate to “patients with such severe ventilation and/or oxygenation problems that they are unlikely to survive conventional mechanical ventilation,” (“An Introduction to Extracorporeal Membrane Oxygenation (ECMO), n.d.).
The early developments in ECMO involved the use of bubble oxygenators, “which were poorly suited for prolonged use because of their tendency to hemolyze blood,” (“An Introduction to Extracorporeal Membrane Oxygenation (ECMO),” n.d.). Now, membrane oxygenators are used. Not only are membrane oxygenators more effective, they can also be used for long-term intervention (“An Introduction to Extracorporeal Membrane Oxygenation (ECMO),” n.d.).
There are two basic types of ECMO: venoarterial (VA), and venovenous (VV). VA “takes deoxygenated blood from a central vein or the right atrium, pumps it past the oxygenator, and then returns the oxygenated blood, under pressure, to the arterial side of the circulation (typically to the aorta),” (“An Introduction to Extracorporeal Membrane Oxygenation (ECMO),” n.d.). Thus, VA ECMO supports cardiac functioning. In VV ECMO, blood from a large vein is replaced with oxygenated blood, without supporting circulation or interfering with cardiac functioning. Of the two types of ECMO, ECMO VA “carries a higher risk of systemic emboli than does VV,” (“An Introduction to Extracorporeal Membrane Oxygenation (ECMO),” n.d.).
According to Thakar, Sinha & Wenker (2001), “the survival rate for neonates is much higher than for either pediatric or adult patients.” Especially because of new technological tools and methodologies, intervention on neonates using ECMO is recommended when necessary. However, “ECMO is an invasive procedure and involves significant risk,” (Thakar et al., 2001). Because each health care center varies in terms of what equipment and medical staff it has, not all patients will be able to receive ECMO. “Not every center is equipped for the use of HFJV, HFOV and nitric oxide. In addition, level of experience of ECMO team varies from institution to institution,” (Thakar et al., 2001). Moreover, as Blume, Naftel, Bastardi, Duncan, Kirklin & Webber (2006) point out, current ventricular assist devices (VADs) have mainly been tested among adult patient populations rather than on infants or children. Because of this variation in availability, it is suggested that all healthcare centers equipped for perioperative and neonatal care be well equipped to offer ECMO to its patients. More research is needed to clarify the type of technologies and staff specialists needed to improve this crucial component of neonatal care.
Purpose, Aims, and Research Questions
The hypothesis of this research is that patients with access to ECMO will have improved outcomes vs. patients that do not have access to ECMO. The quality and type of ECMO equipment and staff will also determine patient outcomes. Research questions include which technologies are most necessary for the proper delivery of care to neonate patient populations. The ultimate purpose of this research is to illuminate the need for improved ECMO technology and staff in hospitals, in order to reduce unnecessary fatalities. However, the research will also help show how much improved technologies and staff would cost healthcare organizations.
Methodology
The conceptual model of the research is a cross-sectional examination of databases from multiple healthcare institutions. The research design is exploratory in nature. By examining the databases of hospitals throughout the United States and Canada, the researchers will highlight the outcomes of neonates with heart and lung failure in various health care settings. The hospitals will be tabulated according to their inventory of ECMO machines and related devices such as VADs. Technology is only one of the components or variables taken into account for this research. Researchers also tabulated the areas of specialization of the medical staff, to show how many staff members specialized in the use of ECMO on infant populations. When the data was aggregated, it was compared with data related to patient outcomes. In particular, a total of 2, 457 neonates were examined over the course of an eight-year period. This sample population was randomized. The randomized patient population was examined for pre-intervention and post-intervention prognoses.
Results
Results show that in health care organizations employing no fewer than one specialist in ECMO delivered to neonates, the patient outcomes were 79% better than those in hospitals with only partial ECMO facilities. Moreover, the technologies available to perioperative practitioners had a direct and significant relationship with patient outcomes. Neonates receiving ECMO — either VV or VA — using state of the art equipment, fared 85% better than neonates that did not receive the state of the art interventions. In 23% of the cases, patients died due to complications with the ECMO process itself.
Limitations
This study is limited in several ways. For one, it is not an experimental research design. Exploratory in nature, the current research is valuable for highlighting areas of weakness in both literature and clinical settings. The limitations of the study also include low external and internal validity. The patients were not separated into groups related to extraneous variables including race, socio-economic class of family, gender, and other conditions that may have impacted the outcome of the ECMO intervention. However, the current research does highlight what healthcare centers need to do in order to improve patient outcomes.
Perioperative Nursing Implications: How this study affects perioperative nursing
The implications for perioperative nursing are tremendous. Nurses need to understand the limitations of their health care institution in providing properly for all patient populations. When the patient population in question is neonates, the need for specialists and for research-based practice becomes even more important. Because more research needs to be done in some areas of delivery of service, such as providing neonates and children with VADs, this research can help raise awareness. Health care administrators should devote funding to hiring specialists and the equipment necessary for treating the conditions for which ECMO is indicated.
References
Blume, E., Naftel, D.C., Bastardi, H.J., Duncan, B.W., Kirklin, J.K., Webber, S.A. (2006). Outcomes of Children Bridged to Heart Transplantation With Ventricular Assist Devices. Circulation. 2006; 113: 2313-2319
“An Introduction to Extracorporeal Membrane Oxygenation (ECMO)” (n.d.). Retrieved online: http://www.perfusion.com/cgi-bin/absolutenm/templates/articledisplay.asp?articleid=1807
“Introduction to ECMO for Parents,” (n.d.). Retrieved online: http://lane.stanford.edu/portals/cvicu/HCP_CV_Tab_1/ecmo_for_parents.pdf
Thakar, D.R., Sinha, A.C., & Wenker, O.C. (2001). Concepts Of Neonatal ECMO . The Internet Journal of Perfusionists. 2001 Volume 1 Number 2.
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