Post cardiac arrest

PART 1

Introduction

Systematic post–cardiac arrest treatment following return of spontaneous circulation (ROSC) is becoming more widely recognized as a way to enhance the chances of patient survival with a decent quality of life (Topjian et al, 2019). This is based on the findings of randomized controlled clinical studies as well as a description of the post-cardiac arrest condition. healthcare dissertation help can be crucial in exploring this topic further. Early mortality from hemodynamic instability, as well as morbidity and death from multi-organ failure and brain damage, can be reduced significantly with post–cardiac arrest treatment.

Pro-activity in responding to change

Since cardiac arrest affects several organ systems, developing system-wide approaches for proactive treatment of these patients will be beneficial to successful post–cardiac arrest care. Restoration of blood pressure and gas exchange, for example, does not guarantee survival or functional recovery (Johson et al., 2018). Significant cardiovascular failure can occur, necessitating intravascular volume expansion, vasoactive and inotropic medications, and invasive devices to maintain blood flow and breathing. Survival and neurological outcomes are affected by therapeutic hypothermia and treatment of the underlying cause of cardiac arrest.

In this case scenario, the patient’s condition deteriorated after episodes of severe chest pains and a rise in K. She was then admitted in the ICU after the administration of insulin. To prevent the patient’s condition from worsening, I administered mechanical ventilation to minimise injury to the lungs. Instead of single treatments, protocolized hemodynamic optimization and multidisciplinary early goal-directed therapy protocols have been adopted as part of a bundle of care to increase survival. According to the findings, proactive titration of post–cardiac arrest hemodynamics to guarantee organ perfusion and oxygenation may enhance outcomes (Ameloot et al., 2019). There are several precise alternatives for achieving these objectives, and it is difficult to discern between the benefits of protocols and the importance of any one component of treatment.

PART 2

Evaluation of care that influences patient’s outcomes

Continuous renal replacement therapy (CRRT)

Continuous Renal Replacement Therapy (CRRT) is a nonstop dialysis treatment for individuals with renal (kidney) failure that lasts 24 hours. The IV is used to take blood from the body and send it to the CRRT machine. Blood is pushed through a filter that cleans it before returning it to the body (Richardson and Whatman, 2015). When the kidneys can no longer filter enough waste and water from the blood, CRRT is required. In this instance, your child may require CRRT until his or her kidneys begin to function normally again. CRRT functions similarly to the kidneys in removing toxic waste and fluid. This helps maintain the proper balance of chemicals and electrolytes in your child's blood, such as potassium and salt.

Description

The patient in this case was a 65 year old man who had been suffering from diabetes. The sugar in the body had accumulated and damaged millions of tinny filtering units found the kidney. This incapacitated the normal kidney functions leading to kidney failure. The patient had been battling his diabetic condition for five years now. He exhibited symptoms such as fluid retention, fatigue, headache, nausea and would occasionally vomit. The patient’s urine was tested and high levels of proteins were found in the urine. This condition takes time before symptoms could manifest. Blood pressure was checked regularly during his time at the admission ward. The patient was complaining of chest pains and had some swelling in his legs ankles and feet. The patient was moved to the ICU unit after he collapsed and had trouble breathing. A temporary haemodialysis was done to prevent further injury to the kidney filters which were to only sustain the patient until he came out of the coma. Two days later the patient awoke and a CRRT was performed to purify the patient’s blood. This was done by passing the patient’s blood through special filters that remove fluids and uremic toxins. After 24 hours of administration, the patient’s vitals returned to normal and could breathe on his own without using a ventilator.

Evaluation

At first, the patient I used a replacement fluid, a sterile fluid that is used to flush toxins out of the body as well as restore electrolytes, other blood components, and volume lost during the filtering process. I administered this to the patient during his initial treatment stages, however this intervention treatment method did not work. As the patient continued to experience side affects which later deteriorated his condition. However, with the use of the filtration instrument, the patient’s state was improved after toxins were extracted from his blood. A patient's blood travels through a specific filter that eliminates fluid and uremic toxins before restoring clean blood to the body during this therapy (Zhang et al., 2020). Patients with unstable blood pressure and heart rates, known as hemodynamically unstable, might benefit from the gradual and continuous nature of the procedure, which is generally conducted over a 24-hour period.

CRRT, like any other medical procedure, comes with its own set of hazards. The start of CRRT necessitates the insertion of a large-bore central venous catheter, which may need to be kept in place for an extended period of time (Bourbonnais et al., 2020). Vascular or visceral damage leading in bleeding, pneumothorax, hemothorax, and the development of an arterio-venous fistula are all well-known consequences of catheter placement. Long-term catheter usage has been linked to venous thrombosis and stenosis. Due to cytokine activation, blood contact to the extracorporeal circuit may cause acute allergic or delayed immunologic responses. Circuit clotting is the most prevalent problem during CRRT, and the most common cause of circuit clotting is poor catheter performance, which causes flow restriction and pressure alarms, interrupting blood flow (Richardson and Whatman, 2015). If a blood flow of 200 to 300 mL/min cannot be maintained, prompt catheter replacement may be required. A high filtration fraction can cause hemoconcentration inside the hemofilter, which can lead to filter clotting. Bleeding and heparin-induced thrombocytopenia are two possible side effects of heparin anticoagulation. Citrate anticoagulation can lead to citrate toxicity, overt hypocalcemia from insufficient calcium replacement, and metabolic acidosis.

Supporting literature

Most CRRT is currently done utilizing pump-driven venovenous extracorporeal circuits, despite its origins as an arteriovenous treatment. The pump-driven venovenous circuit delivers greater and more constant blood flows and removes the risks associated with extended arterial cannulation with a large-bore catheter, despite the added complexity of pressure monitors and air detectors (BING-Rui et al., 2020). CRRT has been delivered via a variety of methods. The therapy is known as slow continuous ultrafiltration when it is used only for volume control. CRRT provides both solute clearance and volume removal when delivered as continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), or continuous venovenous hemodiafiltration (CVVHDF), with the differences between these modalities relating to the mechanisms for solute clearance (Richardson and Whatman, 2015).

A hydrostatic gradient creates a high rate of ultrafiltration across the semi-permeable hemofilter membrane in CVVH, and solute transfer proceeds by convection. Solutes are entrained in the bulk flow of water across the membrane, a process known as "solvent drag." To achieve sufficient solute clearance, high ultrafiltration rates are required, and ultrafiltrate volume in excess of what is required to achieve desired net fluid removal is replaced with balanced IV crystalloid solutions. These replacement solutions can be injected either before or after the hemofilter in the extracorporeal circuit (Bing-Rui et al., 2020). The danger of sludging and fibre blockage is enhanced because the high ultrafiltration rate hemoconcentrates the blood as it passes through the hemofilter fibres.

Prefilter infusion of replacement fluid dilutes the blood before it enters the hemofilter, reducing hemoconcentration. Prefilter administration of replacement fluid, on the other hand, dilutes the blood's solute concentration, lowering effective solute clearance at a constant ultrafiltration rate (Baldwin and Mottes, 2021). There are no such consequences with post filter infusion. Volume overload, severe metabolic acidosis and electrolyte abnormalities, and overt uremic symptoms are among the indications for CRRT, which include volume overload, severe metabolic acidosis and electrolyte disturbances, and overt uremic symptoms.

Even though these indicators are well-established, they are open to interpretation and should only be regarded as semi-objective. In addition, RRT is often started in the absence of these requirements in patients who have chronic or worsening the acute kidney injury (AKI). The major benefit of CRRT is that it may be used in patients who are hemodynamically unstable, even if they are in shock (Liu and Jiang, 2019). It may be simply set up and operated by normal ICU staff, obviating the requirement for highly trained dialysis nurses and technicians. When compared to normal intermittent hemodialysis membranes, CRRT membranes are generally more permeable.

The majority of high-flux hemodialysis membranes can remove molecules up to 1,000 Da. The clearance of molecules as big as 20,000–40,000 Da is possible using CRRT membranes. When compared to conventional intermittent hemodialysis, the main drawback of CRRT is its reduced clearance rate. The method has become the gold standard for extracorporeal xenobiotic removal due to its significant comparative advantage over hemodialysis (Ruiz et al., 2020). While a reduced clearance rate may be sufficient for days of support in an intensive care unit for a patient with acute kidney damage, a patient with acute poisoning and cellular toxicity typically requires more fast and immediate effective therapy.

Alternative actions

In the care of the critically sick patient with kidney failure, a variety of renal support methods can be utilized. CRRT, conventional intermittent hemodialysis (IHD), and prolonged intermittent renal replacement treatments (PIRRTs), which are a hybrid of CRRT and IHD, are some of these options (ZHANG ET AL., 2020). All of them employ comparable extracorporeal blood circuits and differ largely in terms of therapy time and, as a result, net ultrafiltration and solute clearance speed. Furthermore, dialysis relies mostly on diffusive solute clearance, whereas convection is used to remove solutes during hemofiltration.

Supporting literature

The intermittent therapies provide more gradual fluid removal and solute clearance over longer treatment times (ideally, 24 hours per day but often interrupted due to system clotting or diagnostic or therapeutic procedures); the continuous therapies provide more gradual fluid removal and solute clearance over longer treatment times (ideally, 24 hours per day but often interrupted due to system clotting or diagnostic or therapeutic procedures) (Vangala et al., 2021). PIRRT is usually administered with apparatus identical to that used for IHD, but with lower blood and dialysate flow rates.

CRRT and PIRRT are the most widely utilized treatments in hemodynamically unstable patients, however there is a lot of heterogeneity in practice. Some facilities employ CRRT (or PIRRT) independently of hemodynamic state in all ICU patients with renal failure, whilst others use IHD, albeit with prescription modifications, even in vasopressor-dependent patients (Zhang et al., 2020). Although the benefit of a slow, continuous renal support modality in hemodynamically unstable patients may appear self-evident, randomized trials comparing CRRT to either IHD9 or PIRRT have failed to reveal differences in mortality or kidney function recovery.

To deliver IHD in hemodynamically unstable patients, the conventional prescription may need to be modified, such as extending the treatment period to allow for more progressive ultrafiltration, using greater dialysate salt concentrations, and lowering the dialysate temperatures (Bourbonnais et al., 2020). Although the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for AKI supports CRRT for hemodynamically unstable patients, the evidence for this recommendation is weak. However, observational evidence suggests that CRRT is more successful than IHD in achieving net negative fluid balance.

The use of traditional intermittent hemodialysis in patients with acute renal damage is a staple of supportive treatment . Despite more than six decades of renal replacement treatment, a number of basic concerns about the best management of IHD remain unresolved (Vangala et al., 2021). There is an ongoing debate over whether one RRT method is better than another in terms of clinical outcomes in ICU patients with AKI. Despite growing consensus that CRRT should be utilized in hemodynamically unstable patients, the benefits of CRRT over IHD in terms of survival remain unclear due to a lack of data from well powered randomized controlled studies (RCTs). Furthermore, in hemodynamically stable patients, CRRT did not outperform intermittent renal replacement therapy (IRRT) (Gardner, 2019). Although individuals undergoing continuous low-efficiency dialysis appear to have a lower death rate than those receiving CRRT, this advantage is primarily based on observational studies and is skewed by patient selection.

What I learnt from taking care of this patient

From this cases scenario, I was able to understand that many factors play a role in determining which form of treatment is appropriate for AKI. While some individuals may recover completely, AKI can exacerbate pre-existing chronic kidney disease (CKD), induce CKD to develop, or result in permanent kidney function loss or end-stage renal disease in others. In this scenario, survival may need chronic dialysis or a transplant. Chronic kidney disease necessitates a lifetime commitment to continuing therapy, which can be hemodialysis (HD) three days a week for four hours a day in a dialysis facility or peritoneal dialysis (PD) conducted at the patient's home while they sleep.

I also learnt that CRRT is the most recommended form of dialysis therapy compared to other forms like IHD and PIRRT. The recovery process is faster when compared to other forms. I was able to deduce that CRRT is a more complex therapy than conventional dialysis, it is only accessible at facilities with the necessary competence. It necessitates specific medical expertise as well as nursing training. Special anticoagulants are required to make the therapy last for 24 hours.

Part 3- critical reflection

Learning outcome

The study of CRRT was advantageous and enabled as it enables one to acquire a lot including, Continuous fluid status control, hemodynamic stability, acid–base control, ability to provide protein-rich nutrition while maintaining uremic control, electrolyte balance control, including phosphate and calcium balance, prevention of intra-cerebral water swings, low infection risk, and high biocompatibility. For patients with cerebral edema, significant hemodynamic instability, ongoing metabolic acidosis, and substantial fluid removal requirements, CRRT should be explored (Gardner, 2019). Through use of the anti-coagulant, a person can lean more on how blood enters the extracorporeal circuit, the coagulation cascade is activated, causing the filter and circuit to clot. Anti-coagulants are used to prevent clotting and ensure that the circuit has a long enough operating life (about 24 hours). Anti-coagulant needs may be affected by the timing of RRT (intermittent or continuous), the use of convection or diffusion, membrane selection, treatment dosage, blood flow, co-morbidities, hematocrit, and pre-dilution.

Supporting literature

In the United Kingdom, around 8000 individuals begin renal replacement treatment each year. Around 60 000 individuals are now on dialysis or have had a kidney transplant (Gardner, 2019). Transplant is the most frequent method of renal replacement therapy (about 54% of patients), followed by hemodialysis (40%), and finally peritoneal dialysis (6% ) (Ruiz et al., 2020). In 2016, about 3000 fresh transplants were performed; this number has progressively grown in previous years. Some people will receive a kidney from a living donor, but others who must join the kidney donation waiting list should plan on waiting 2.5 to 3 years (Zhang et al., 2020).

The use of anti-coagulant-coated dialysis membranes, such as heparin-bound hemophan or heparin-binding to surface-treated AN69 membranes, as well as full covalent coating of the entire extracorporeal system with LMWH, may allow effective IHD without or with decreased systemic anti-coagulation. If blood flow is sustained at around 200 ml/min and vascular access is reliable, enough filter life can be achieved (Vangala et al., 2021). Responding to frequent filter clotting by simply increasing anticoagulation without addressing technical issues like insufficient access or catheter kinking puts the patient at risk of bleeding. Due to a paucity of randomized controlled trials comparing different RRT procedures, there is a lot of debate on whether form of RRT is "better" in the ICU (Gardner, 2019). Hemodynamic side effects, ability to control fluid status, biocompatibility, risk of infection, uremic control, avoidance of cerebral edema, ability to allow full nutritional support, ability to control acidosis, absence of specific side effects, and cost are some of the criteria that can be used to evaluate RRT techniques. Various considerations, such as availability, knowledge, resources, and cost, are currently influencing the choice of RRT modality.

Anticoagulation is used to keep the extracorporeal circuit open while reducing the risk of patient problems. Anticoagulation is a delicate balancing act between clotting and haemorrhages. General methods such as saline flushes and online pre-dilution, as well as anticoagulants such as unfractionated and low molecular weight heparin, heparin coated membranes, and localized citrate anticoagulation, are all used to prevent clotting (RCA) (Richardson and Whatman, 2015). In continuous renal replacement operations, heparins are the most often utilized anticoagulants. They are readily available and easily monitored, although they do have certain drawbacks. Haemorrhage, heparin resistance, and heparin-induced thrombocytopenia are among the dangers (HIT) (Rui et al., 2020). Monitoring the activated partial thromboplastin time (APTT), which is an excellent predictor of the risk of filter coagulation and patient bleeding, is used to determine the safety and efficacy of heparin treatment.

In most ICU patients, regional citrate anticoagulation has been demonstrated to be safe and effective for CRRT anticoagulation. Citrate's capacity to inhibit coagulation in the extracorporeal circuit by binding and chelating free ionized calcium, a key co-factor in both the intrinsic and extrinsic coagulation cascades, is the basis for this theory. The citrate–calcium complex is formed when one molecule of citrate binds two calcium anions (Baldwin and Mottes, 2021). Due to its low molecular weight, roughly 60% of this complex is lost in the CRRT effluent, depending on the individual CRRT modality and other parameters such as flow rates and membrane surface area. Some complexes, on the other hand, are transported to the systemic circulation via the venous blood line and processed in the liver, where one citrate molecule is converted into three bicarbonate molecules and calcium is released into the bloodstream (Liu and Jang, 2019). Because the calcium produced does not entirely replace the calcium lost in the effluent, calcium is given through a separate central blood line to keep systemic (blood) ionized calcium in the usual range (1.1–1.3 mmol/L). Circuit and patient ionized calcium levels are monitored regularly at first, but once stable dosages have been established, they are monitored every 6–8 hours.

Personal reflection

From this study, I was able to provide comprehensive nursing care to correct the core bosy systems alteration for critically ill patients. I was able to critically discuss the scope of care units for patients recurring CRRT. In the intensive care unit, I learnt the ethics and legal issues regarding critically ill patients identify their needs and problems as well as those of their families. I was able to recognise the principle of judgement and limitation of practice in critical care units.

In future, I will apply the knowledge acquired during critical to : Examine the requirements of a critically sick patient, determine the best course of action in crucial situations, using the critical thinking process, prioritize activities based on the situation's demands, integrate information from nursing science, medicine, and other sciences and ensure that the critical care unit's available resources and staff are used efficiently and effectively.

To carefully and successfully treat patients in the critical care environment, the critical care nurse requires specialized knowledge and skills. The goal of this case scenario is for the student to gain experience managing patients admitted to critical care units in the health-care industry. Mechanical ventilation, sophisticated haemodynamic monitoring, and the management of patients with life-threatening illnesses are all highlighted. The conditions that need the use of assistive devices such as Ventricular Assisted Devices (VAD) will be investigated.

References

Ameloot, K., De Deyne, C., Eertmans, W., Ferdinande, B., Dupont, M., Palmers, P.J., Petit, T., Nuyens, P., Maeremans, J., Vundelinckx, J. and Vanhaverbeke, M., 2019. Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: the Neuroprotect post-cardiac arrest trial. European heart journal, 40(22), pp.1804-1814.

Baldwin, I. and Mottes, T., 2021, July. Acute kidney injury and continuous renal replacement therapy: A nursing perspective for my shift today in the intensive care unit. In Seminars in Dialysis.

Bassi, E., Tartaglini, D. and Palese, A., 2018. Missed nursing care terminologies, theoretical concepts and measurement instruments: a literature review. Assistenza infermieristica e ricerca: AIR, 37(1), pp.12-24.

Bing-Rui, W.E.I., Savellano, D.F. and Cui-Huan, H.U., 2020. Analysis of status quo and research progress in nursing care for different typed coronavirus disease 2019: A literature review. Journal of Integrative Nursing, 2(4), pp.160-171.

Bourbonnais, F.F., Slivar, S. and Malone-Tucker, S., 2020. Caring for patients on CRRT--Key safety concerns identified by nurses. Canadian Journal of Critical Care Nursing, 31(2).

Gardner, L., 2019. Does Nurse Management Effect Continuous Renal Replacement Downtime?.

Johnson, L., Edward, K.L. and Giandinoto, J.A., 2018. A systematic literature review of accuracy in nursing care plans and using standardised nursing language. Collegian, 25(3), pp.355-361.

Liu, Y. and Jiang, Q., 2019. Nursing Analysis of Patients with Uremia Complicated with Heart Failure Treated with CRRT.

Richardson, A. and Whatmore, J., 2015. Nursing essential principles: continuous renal replacement therapy. Nursing in critical care, 20(1), pp.8-15.

Ruiz, E.F., Ortiz-Soriano, V.M., Talbott, M., Klein, B.A., Bastin, M.L.T., Mayer, K.P., Price, E.B., Dorfman, R., Adams, B.N., Fryman, L. and Neyra, J.A., 2020. Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit. Scientific reports, 10(1), pp.1-10.

Topjian, A.A., De Caen, A., Wainwright, M.S., Abella, B.S., Abend, N.S., Atkins, D.L., Bembea, M.M., Fink, E.L., Guerguerian, A.M., Haskell, S.E. and Kilgannon, J.H., 2019. Pediatric post–cardiac arrest care: a scientific statement from the American Heart Association. Circulation, 140(6), pp.e194-e233.

Vangala, C., Shah, M., Dave, N.N., Attar, L.A., Navaneethan, S.D., Ramanathan, V., Crowley, S. and Winkelmayer, W.C., 2021. The landscape of renal replacement therapy in Veterans Affairs Medical Center intensive care units. Renal Failure, 43(1), pp.1146-1154.

ZHANG, Y., LI, Z., ZHAO, M., LI, Q., LI, Z., SUN, J. and LUO, H., 2020. Nursing care of a patient with postpartum cardiomyopathy treated by ECMO combined with CRRT, IABP and prone position ventilation. Chinese Journal of Practical Nursing, pp.215-219.

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