In December of 2018, an interdisciplinary team at UTMC came together to ensure effective, safe patient care. A patient was admitted to the intensive care unit (ICU) for post procedure care and observation. The patient was in a critical situation that required treatment outside of our facility's scope of service. The team collaborated on the next steps for this patient in order to ensure safe care and eventually transition to another facility. Each team member had a valuable role in the care of this patient and the family stated they were thankful to the team for their hard work.
RN Leader and Primary Nurse
Day 1 started out as a normal day. My assignment was a patient who had undergone an elective Video-Assisted Thoracoscopic Surgery (VATS) from a few days prior. Typically, these patients have a routine stay in the ICU pending any complications and are transferred to acute care within a couple of days. Nonetheless, this patient underwent a total right pneumonectomy due to a more discoverable finding during the surgery and was forced to create a "stump" for the left-over lung after the pneumonectomy. However, the patient had sadly taken a turn, which would soon need acute critical medical intervention. The patient had been extubated one or two days prior and was progressively improving. This would not last long. After suffering an acute exacerbation with dyspnea, the patient was re-intubated that night.
During my assessment, the patient was adequately sedated with some vasopressor support. Throughout the shift the patient's oxygenation requirements were increasing, as well as the increased need for blood pressure support. This patient was experiencing post pneumonectomy pulmonary edema. As we found some common ground with the ventilator adjustments, vasopressors, sedation medications, and bagging the patient for the last 50 or so minutes, the team collaborated with Cardiothoracic Surgery (CTS), Critical Care Medicine (CCM), and Respiratory Therapy (RT) for managing the patient the most beneficial way.
A problem RT and I faced was that of PEEP pressures. The patient's good lung was not inflating properly, but to fix this you run the risk of forcing air into the space of the previous pneumectomy site. Throughout the day, we would be trying to develop strategies for this. After speaking with the physicians, we discussed the following options:
1. We increase the PEEP pressures on the vent to help improve the inflation of the patient's remaining lung.
2. Have RT increase the tidal volume on the vent to improve oxygen.
3. Paralyze the patient for respiratory compromise and totally take over his drive to oxygenate allowing better oxygenation.
4. Attempt to start Flo-Lan or Nitrus to promote alveolar recruitment.
5. Continue with lung protective strategies of "good lung down" positioning and allow the lung to heal.
6. Contact someone at an outside hospital and ask for them to accept this patient as a candidate for Extracorporeal Membrane Oxygenation (ECMO).
The remainder of the shift, the family and I discussed the treatments, strategies, and changing the plan of care. We spent several hours on what we were attempting and trying to benefit from our newly developed plan. At the end of the shift, the physician notified me to say that Vanderbilt Medical Center was unable to take the patient for ECMO.
Day 2, the patient had a peaceful night being chemically paralyzed to improve ventilatory support and he was 85% or higher. We were still applying the strategies to help maintain his O2 level. After a family update with plan of care, treatments, and transfer plans we were all set on still maintaining the goals for recovery and were headstrong for those goals. However, things would quickly start to deteriorate, and I spoke with the physician about any progress on seeking an ECMO. He said he'd gotten in touch with the University of Kentucky (UK) and they would need to travel by ground to get here in 4 hours if the family would like to pursue this treatment. Together with the help of physicians, nurses and RT, the physician and I spoke with the family about transitioning to ECMO, the processes with cannulation and the fact that he would need to be transported to Kentucky (KY). After informed topics were discussed, the family decided to pursue this treatment plan. The nurse Team Leader (TL) worked to get supplies together such as blood on standby and labs needed for transport. Case Management was contacted and responded immediately to prepare all paperwork and forms for transfer. With the help of CCM, we placed the Central Venous Line (CVL) and a new A-line for the ECMO requirements.
As night shift began, we changed the ICU room into an operating room. The KY team arrived at 1930 and we quickly set up a scrub table, sterility bay, and overhead lighting. With the primary physician running point, and another physician assisting with cannulation, the team had come together to provide the best outcome for this patient who had minutes to live with an O2 reading trending at 69%. The physicians, with the help of the TL, now turned first assistant, another nurse and I were able to run point on drip management, vital signs, and aiding in the patient management. The process of cannulation went as smooth as it could have. When the words, "cannulation achieved" and "ready for initiation" were announced, we took a deep breath in the angst of hoping this therapy would work as we so desperately had reached for. With that same effortless cannulation, the blood circulated through the ECMO machine and we were there. In seconds, the dark maroon blood became enriched with oxygen. As labs improved, the vasopressors improved and constant titration of meds every 15-30 minutes, we had made an impact together on this patient and his family.
Because of our steadfastness, attentiveness, and critical thinking skills, this patient had made it for this therapy. With the help of all the doctors, RTs, and RNs, and with the family at our side, the patient was bettered for it. The patient did make it to KY in stable condition on ECMO. The ECMO was even able to be weaned and discontinued.
Unfortunately, he did not ultimately survive.
Comments from Physicians:
"This patient's care in the unit was a demonstration of teamwork, dedication, attention to detail, and especially compassion for both him and his family. The nursing staff was particularly effective in managing his many critical care needs during that period. It eventually became clear that his lung dysfunction would not be survivable with conventional ventilatory support. ECMO appeared to offer his only real hope at this point. Since ECMO is not currently available at the medical center here we called other institutions to see if the transfer would be possible. Physicians at UK graciously agreed to accept him and even sent a team to transport him to KY. The unit staff worked tirelessly over that day while awaiting the UK team to facilitate his transfer. Pulmonary Physicians worked to adjust his ventilatory support and medical regimen as he rapidly deteriorated. When the KY team arrived, we were able to cannulate and get him on ECMO support just in time. He was on the verge of cardiac arrest, on high dose pressors when the oxygenated blood from the ECMO circuit began to flow. This was a very labor intense time and we had excellent support from our nursing staff who worked above and beyond the normal requirements of their shift to see this through. The care of this patient really shows the cooperative and collegial atmosphere we have here at UTMC. I am very grateful to be working with such a wonderful group of people."
"There are many things that make great institutions but above all, it is the quality and dedication of the team members and their willingness to work as a team, that makes a difference and clearly UTMC is well endowed in this capacity. It is a pleasure to be part of UTMC and work with outstanding nurses and support staff daily. This was just another day exemplifying how lucky we are to have such great people on staff."