Extracorporeal life support is a promising treatment for pediatric patients in cardiac arrest who are unresponsive to traditional cardiopulmonary resuscitation (CPR), according to an article in the February issue of Critical Care Nurse (CCN).
The article, "Extracorporeal Membrane Oxygenation (ECMO) for Pediatric Cardiac Patients," examines the use of extracorporeal cardiopulmonary resuscitation (ECPR) and addresses ethical principles related to its use and the continued advancement of end-of-life care.
"More than 50,000 patients have survived because of ECPR, and this revolutionary treatment offers hope where there was none before," said author Jennie Ryan, MS, CPNP-AC. "However, the appropriate use of this therapy and delineated guidelines for initiating and withdrawing it have yet to be defined."
Ryan is a nurse practitioner in the intensive care unit at Nemours Cardiac Center, A.I. DuPont Hospital for Children, Wilmington, Delaware. She is also a per diem faculty member at the Helene Fuld Pavilion Simulation Lab at the University of Pennsylvania School of Nursing, Philadelphia.
During veno-arterial ECMO, 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.
ECPR is considered the initiation of ECMO, following cardiac arrest unresponsive to conventional CPR. Transition from ECPR to standard ECMO care occurs once the patient is placed on the extracorporeal circuit. Survival rates for ECPR patients are higher than those for traditional cardiopulmonary resuscitation, although neurological outcomes require further investigation.
Highly skilled nurses are needed to manage daily care of patients supported by ECMO, with frequent lab and physical assessments, neurological checks and daily ultrasound imaging. Centers providing this treatment must offer educational programs to train nurses in rapid deployment of the ECMO circuit to ensure a smooth transition from CPR to artificial circulation.
"ECPR is a technologically advanced and complex treatment that requires extensive knowledge from every member of the healthcare team," Ryan said. "But the technical aspects of caring for these critically ill patients must not supersede a holistic approach to care, with appropriate support of the patient and the patient's family." Nurses must strive to ensure that time is allocated for family support. The bedside nurse is often a primary point of contact for patients' families and should be aware of resources available to family members, including palliative care teams, social workers and chaplain services.
Many ethical concerns arise with ECPR. 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 often left to the patient's caregivers.
Materials provided by American Association of Critical-Care Nurses (AACN). Note: Content may be edited for style and length.
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