key: cord-0866793-ic3aacev
authors: Tu, Zhongyu; Xia, Qingbin; Xu, Ming; Lu, Yibin
title: Nursing of critically ill COVID-19 patients treated with extracorporeal membrane oxygenation
date: 2020-07-14
journal: J Emerg Nurs
DOI: 10.1016/j.jen.2020.07.006
sha: 818bf98ed01269b92a3c27b1c6e6e6be1df060b9
doc_id: 866793
cord_uid: ic3aacev

OBJECTIVE: This study attempted to explore nursing methods as well as extracorporeal membrane oxygenation (ECMO) therapy in the treatment of critically ill COVID-19 patients. It can be used for reference by nursing colleagues to improve the treatment success rate of critically ill patients with COVID-19 treated with ECMO and reduce the mortality rate. METHODS: The clinical data of three critically ill COVID-19 patients who underwent ECMO therapy and their nursing measures were retrospectively analyzed. RESULTS: Two patients were successfully removed from ECMO while one patient died. CONCLUSION: Severe COVID-19 is a highly contagious disease with a high case fatality rate. Strict prevention, timely observation, effective management of complications and smooth running of ECMO are key ways in successfully treating critically ill COVID-19 patients.

4-6 ml/kg, PEEP≥10 cmH2O), however, their oxygenation indexes remained under 80 mmHg for 28 over 6 hours. ECMO was used after confirming that the patients had no contraindications to the 29 therapy. 30 31 Extracorporeal membrane oxygenation (ECMO) is an effective technique that provides cardiac 32 and respiratory support. This form of treatment can provide temporary cardiac and respiratory 33 support for critically ill patients by oxygenating the patients' blood and allowing the lungs to rest, 34 giving time to treat the primary disease and repair the lungs. According to The Extracorporeal Life 35 Support Organization (ELSO) in January 2015, the survival rate of patients with viral pneumonia 36 on ECMO was 65% [5] . 

The abnormal laboratory indexes of patients with COVID-19 are shown in Table 1 . 82 According to previous investigations, differences in lymphocyte, lactic dehydrogenase, D-dimer 85 and NT-proBNP were found to be statistically significant between ordinary COVID-19 patients 86 and critically ill ones. In the present study, even among the critically ill group, the patient that died 87 had indexes more off the normal range compared to patients that survived among these on ECMO. People are susceptible to 2019-nCoV. It is currently known to spread mainly through close contact 92 between individuals and via small droplets [6] . The blood, bodily fluids and secreta of patients with 93 COVID-19 are highly infectious. The body and skin of clinical staff are exposed to potential 94 splashes of secreta, blood, bodily fluids or contaminants, especially in high-speed airflow 95 generated from the ventilator and ECMO, putting them at high risk. Clinical staff should take 96 strict precautions against air, droplets and contact that may cause infection. According to 97

Institutes (First Version) released by to the National Health Commission [7] , clinical staff should 99 wear 12 personal protective equipment including fission type work clothes, disposable medical respiratory protective devices or positive-pressure hoods, disposable fluid-resistant shoe covers, 102 rubber boots, isolation gown, disposable surgical masks and two latex gloves in front of a mirror 103 strictly following the wearing and doffing sequence on the wall in order to ensure that everyone 104 wears the protective equipment correctly. Following duty, the protective equipment should be 105 removed from top to bottom and from outside to inside. Hand hygiene should be strictly practiced 106 each time an equipment is removed. Finally, the staff should take a bath, put on clean clothes, 107 leave the isolation area and return to the resting room. It is important to ensure the safety of 108 clinical staff. During the course of treatment, no clinical staff were infected. 

Once the clinical staff donned their personal protective equipment (PPE), their field of view was 113 limited, and it was not easy for them to move freely. Wearing two gloves makes it difficult to feel 114 certain objects, and there is a minimum number of clinical staff allowed in the isolation wards at a 115 specific time. Therefore, it is important to prepare fully the staff and articles of PPE prior to the 116 initiation of ECMO. The articles on the ECMO initiation list were prepared in one time, and every 117 staff present played a role. In the ECMO team, one associate senior doctor decided the treatment 118 scheme of the patients, and two attending doctors helped the associate senior doctor in cannulation 119 and disease management. Moreover, one professional nurse of the intensive care unit took care of 120 the patients, while one professional nurse of ECMO prepared the ECMO device and circuits. 121

Additionally, one radiologist performed X-rays of the patients' chests. ECMO is typically initiated 122 by an associate senior doctor in the ICU. 123

(1) Assessment of disease condition: Cardio-pulmonary function and vessels were assessed by the 125 associate senior doctor in the ICU who confirmed the mode of ECMO therapy and created an needed for ECMO therapy were prepared. Specifically, ECMO nurses prepared all items following 130 a list of instructions and prepared the bedside ultrasonic apparatus. The bilateral skin preparation 131 range for femoral venous puncture was taken from the navel to the knees, while that for internal 132 jugular vein puncture was from the lower lip to the point-point level of both nipples. (4) The 133

catheter was connected, and the power supply, gas supply and the water tank were checked to 134 ensure that the electric and gas circuits were correctly connected. (CPOT) of 0 points so as to prevent restlessness caused by pain that may lead to blood spatter and 142 transmission of aerosols. (7) Cannulation: With the help of the other two physicians, the patient 143 adopted the supine position without a pillow, which was followed by routine sterilization and 144 draping. The femoral and jugular veins were cannulated through the skin, and the cannula was 145 then fixed. After the initial successful establishment of vascular access, the patients were given 146 3000U heparin intravenously while the nurse monitored the vital signs of the patient as well as the 147 equipment. (8) Following cannulation, the venous cannula was connected correctly, the ECMO 148 device was started, the flow was adjusted, and the cannula and various catheters were fixed to 149 avoid traction, bending or falling off in order to ensure the machine runs normally. In addition, 50 150 mL 250U/mL heparin saline was prepared, and the intravenous dose was adjusted according to the 151 bedside ACT results, which was kept within 180-200 seconds. (9) All waste was placed in a 152 yellow double-ply bag, sealed in a gooseneck type and labelled with "novel coronavirus", which 7 155 156

(1) During the initial stage of ECMO, the oxygen debt was paid back as soon as possible at high 158 flow, and the speed was controlled at 50-70 mL/kg.min. The flow may be lowered according to the 159 patient's cardio-pulmonary function following improvement of oxyhemoglobin saturation and 160 once hemodynamics were stable. (2) Changes in hemodynamics were monitored closely: 161 Temperature, heart rate, blood pressure, oxyhemoglobin saturation, central venous pressure and 162

invasive arterial blood pressure were monitored. The temperature of the water tank was adjusted in 163 accordance with the patient's temperature, and the pump speed and flow were adjusted according 164 to blood gas assay. (3) Blood gas assay, electrolytes, blood routine, bleeding and coagulation 165 indexes as well as the functions of the heart, liver, and kidneys were monitored. The flow and 166 speed were checked to determine whether they matched, in which the alarm would be triggered. 167

The presence of thrombus in circuits and membrane lung was also checked. the initial stage, after which coagulation was monitored every 4 hours. The dose of heparin was (6) Arterial blood gas analysis was carried out every 4-8 hours and ECMO gas and blood flow 173

were adjusted according to the partial pressure of carbon dioxide and oxyhemoglobin saturation. 174

The partial pressure of carbon dioxide was maintained at 40mmHg, while that of oxyhemoglobin 175 was 95%. (7) Chest radiography was performed every 1-2 days in order to observe changes in 176 pulmonary imaging. (8) Ventilator parameters: Low tidal volume <4 mL/kg weight, low pressure 177 (target flat pressure<25 cm H2O, PEEP<15 cm H2O) lung protective ventilation strategy and 178

Pressure-Synchronized Intermittent Mandatory Ventilation (PSIMV) mode were adopted. (9) 179

Blood lactic acid: Blood lactic acid was controlled under 3mmol/L, and patients were attempted to 180 be kept at a negative fluid balance, reduced pulmonary exudate and improved level of oxygenation. 181

(10) Ventilator-associated pneumonia and catheter-associated bloodstream infection were 182

prevented and controlled. The patient was turned over in order to prevent pressure ulcers. (11) 183

Nurse shift system was adhered to strictly: Due to the infectiousness of such diseases, clinical staff 184 wore protection products when entering the isolation area and could not drink water or go to the 185 toilet. As frequent shifts may increase the risk of adverse events, they shifted every 4 hours, 

(1) Bleeding: Bleeding is the most common and severe complication of ECMO. According to 192 ELSO, the incidence of bleeding is 22.2% when ECMO is used in respiratory support [5] . During 100%, observing PaO2, if PaO2 increasing rapidly as FiO2 increases, the patient's lung function 232 was proved to be good. Afterward, the doctor assessed the patients' lung function and upregulated 233 the ventilator to an acceptable condition. If the transcutaneous oxygen saturation reached 95% for 234 12 h or above while the oxygenation index in the blood gas assay was >200mmHg, then ECMO 235 support can be withdrawn. Weaning process: ECMO was powered off, and the internal cannula of 236 right femoral vein and right internal jugular vein was clamped and removed. The spot was pressed 237 for one hour, which was followed by pressure dressing for 24 hours. The extracorporeal 238 circulation pipelines were removed, and the device was powered off, checked, maintained and 239 recorded according to the user guide. bypass technique able to replace the lungs and heart, has been applied in an increasing number of 245 critically ill patients suffering from respiratory failure and/or circulation failure in the past ten 246 years [8, 9] . When VVECMO was applied for ARDS, it was found to perform extracorporeal gas 247 exchange and allow the lungs to fully rest, giving time for the recovery of pulmonary function so 248 patients may recover [7] . 249

In the present study, the three critically ill COVID-19 patients had "white lung", and their lungs 251 had lost the function of gas exchange. Hypoxia was not relieved even when the ventilator was 

Xinyang Emergency Scientific Research Project for the Prevention and Control of 2019-nCoV