Nursing Strategy for Multidisciplinary Team Comprehensively Treating Three Children with Fulminant Myocarditis

Dongqin HE

Department of pediatric，Taihe Hospital (Hubei University of Medicine), Shiyan 442000, China

Abstract [Objectives] To explore nursing strategy for comprehensive treatment of children with fulminant myocarditis by multidisciplinary team (MDT), and clarify the nursing emphasis and difficulties in the treatment of fulminant myocarditis in children. [Methods] Retrospective analysis was made on three cases of fulminant myocarditis in children treated in Taihe Hospital of Shiyan City from January 2021 to January 2022. The different clinical characteristics and treatment plans were analyzed and compared, and the nursing emphasis and difficulties in comprehensive treatment of fulminant myocarditis in children were discussed. [Results] The minimum age of three children with fulminant myocarditis was 11 days old, and the remaining two children were 9-12 years old. All three children were successfully treated, in which two cases were treated with extracorporeal membrane oxygenation (ECMO) combining with mechanical ventilation (MV), including one case of neonatal explosive myocarditis. One case was treated with temporary cardiac pacing implantation. The psychological counseling and nursing of children with fulminant myocarditis and their guardians were also critical to the successful treatment and good prognosis of the disease. [Conclusions] The condition of fulminant myocarditis in children is dangerous, and it should closely observe the changes of the illness condition. The key to successful treatment is to start a comprehensive treatment plan based on life support as early as possible. The key point of nursing is to closely assist in observing the condition at the early stage, assist in maintaining and operation during advanced life support period, and avoid complications. At the same time, strengthening the psychological care of pediatric patients and guardians and health education after leaving hospital are the key and difficult points of nursing.

Key words Fulminant myocarditis, Extracorporeal membrane oxygenation, Mechanical ventilation, Nursing strategy

1 Introduction

Fulminant myocarditis in children is mainly caused by virus infection, which is a disease characterized by severe edema and dysfunction of myocardial tissue[1-2]. The patient’s condition is dangerous, and the onset is rapid, which often causes Adams-Stokes syndrome, cardiogenic shock, atrioventricular block, and malignant arrhythmia, with very high case fatality rate, and mainly sudden death. Extracorporeal membrane oxygenation (ECMO) is used to treat critical patients with severe heart and lung failure by replacing or partially replacing heart and lung functions with cardiopulmonary bypass, so as to save lives or win expensive time for saving lives[3]. Artificial cardiac pacemaker is a treatment method that uses a pacemaker to release a certain amount of energy and stimulate the heart to replace the heart beat through wires and electrodes. Because of the high risk of fulminant myocarditis, temporary cardiac pacemaker is a simple and effective first aid measure to prepare for a series of rescue activities[4-5].

2 Case data

2.1 Case 1The child, male, 7 days old, and was admitted to hospital for "intermittent fever for 4 d". Temperature was 37.9 ℃; HR was 168 times/min; R was 60 times/min; BP was 57/32 mmHg. His mind was clear, but reaction was slightly poor. Bilateral pupils had equal size and circle (3-4 mm), and were sensitive to light reflection. The skin of the whole body was dark, and the speckles can be seen. The breath was quick, and slight inspiratory three concave sign can be seen. Without oxygen inhalation, blood oxygen saturation fluctuated at 75%. Anterior fontanelle was plump, and angle arch had reverse posture, and resistance of neck was obvious. His limb movement was poor, and muscle tension was high, and peripheral circulation was poor, with obvious abdominal distension. After admission, the intestinal nucleic acid virus test was positive, and he was immediately isolated from a single room. Non invasive ventilator, tracheal intubation, high-frequency oscillatory ventilation, cardiotonic therapy, catheter dilatation, diuresis (continuous pumping adrenaline, dopamine, and diuretic mixture), anti infection (MEBO+VINCO), nutritional myocardium (phosphocreatine+vitamin C), hormone (methylprednisolone), IVC, and albumin were used to improve blood coagulation function. Multiple injections of plasma and platelets was conducted to support circulation. The dyspnea of the child was gradually aggravated, and the markers of myocardial damage were significantly increased. The systolic function of the heart continued to deteriorate, and arrhythmias occurred, and heart failure occurred. After the ECMO MDT team discussed and evaluated, an ECMO special medical team was established. The child received ECMO adjuvant treatment at 22:00 on May 7. After 120 h of rescue treatment, the blood pressure, circulation, cardiac function and blood oxygen saturation of the child were maintained at normal levels. On May 12, the patient was evacuated from ECMO treatment and left the hospital after 23 d of hospitalization.

2.2 Case 2Male, 10 years old, with abdominal pain, anorexia and mental retardation for 3 d, vomit for 6 times and was admitted to the hospital. He was diagnosed as fulminant myocarditis. After admission, the child suffered from cardiogenic shock and severe arrhythmia, so he was admitted to PICU and received emergency ECMO catheterization and endotracheal intubation for auxiliary treatment. On the third day of ECMO treatment, the cardiac systolic function continued to improve. After gradually reducing the vasoactive drugs and ECMO related parameters, the heart rate and blood pressure could be maintained, and the monitored ejection fraction rose to 56%. The arrhythmias were obviously improved, and it basically turned to sinus rhythm. After the operation of ECMO for 88 h, the patient’s heart rate and blood pressure gradually recovered, and LVEF gradually recovered as indicated by cardiac ultrasound. The patient stopped the auxiliary treatment of ECMO. His echocardiography was monitored, and his heart function has basically returned to normal. He was transferred to the general ward and discharged from hospital.

2.3 Case 3Female, 9 years old. Fever, abdominal pain for 4 d, fainting twice. On admission, the patient had an acute face, and face and lips were pale. Her breathing was slightly fast, and slight inspiratory triple concave sign can be seen. Emergency ECG examination was conducted after admission: (i) sinus rhythm; (ii) degree III atrioventricular block; (iii) ventricular escape beat with ventricular escape rhythm. The initial diagnosis of fulminant myocarditis was made according to the physical signs of the child. Considering that the child’s life was in danger at any time, vasoactive drugs were immediately pumped into the vein, and she was treated with large doses of hormone, and the myocardium was nourished. The ECG, cardiac function, blood test, arterial blood pressure monitoring and other symptomatic treatments were dynamically rechecked. In view of the possibility of cardiac arrest in child at any time, temporary pacemakers must be implanted urgently after discussion by the expert group. The emergency rescue team was immediately started to implant temporary pacemakers for the child. At the same time, the ECMO team was ready to get on board at any time, and made a foolproof treatment plan. After 5 d of temporary pacemaker operation, the patient’s heart gradually recovered to normal rhythm, with stable temperature, clear mind, good spirit, good appetite, no complaints of fatigue, dizziness, abdominal pain, palpitation, chest pain, vomiting, and abdominal distension. She had normal night soil and urine, good circulation of extremities. CRT was less than 2 sec, and cardiac function was basically normal. After 16 d of treatment, she was cured and discharged.

3 Discussion

3.1 First aid cooperationPICU shall be placed immediately after the pediatric patients were admitted to the hospital to provide a quiet and good treatment environment for critically ill pediatric patients. Vital signs were monitored, and doctors were notified, and it should cooperate with doctors for rescue. ECG monitoring was conducted, and oxygen was taken. Venous channels were established to facilitate rescue and medication.

3.2 Establishing ECMO teamThe core members of children’s MET (emergency medical treatment) team and ECMO (artificial heart and lung replacement therapy) team were started, and emergency human resources were allocated. A special care team for all ECMO professional nurses in the hospital was set up, and a team for each child was established. Taking the pediatric patients as the center, clinical work as the basis, quality management as the focus, multidisciplinary cooperation as the link, one-to-one professional guidance was conducted, and a complete and organized treatment plan was jointly discussed and formulated.

3.3 ECMO treatment nursingThe team members discussed the problems before and during the treatment of ECMO. Through the preparation of articles, ECMO operation, puncture and catheterization, a complete and organized nursing plan was provided. After endotracheal intubation, the patient cooperated with the surgeon to perform left femoral artery, vein incision, catheterization and suture. The whole process required skilled and strict aseptic operation to ensure that there were no bubbles when the pipes were connected, and the connection was firm, and each pipe was properly fixed. It should carefully check the pipes again for bubbles. After the connection was completed, it should adjust the ECMO speed step by step to the treatment speed. During the treatment, the patient’s condition was closely observed, and ACT, blood gas analysis, urine volume and other indicators were dynamically monitored.

3.4 Nursing care of artificial cardiac pacing in childrenIt should comprehensively understand the patient’s condition, pacing threshold, and pacing frequency, closely inspect the electrode connection and whether the position of temporary pacemaker was appropriate, observe and record vital signs. The hip joint shall be braked to avoid flexion and extension of the hip joint, so as to prevent the electrode from slipping out and pacing failure. Passive massage was given to lower limbs to prevent deep vein thrombosis. The skin temperature and color change of lower limbs and dorsalis pedis artery pulsation were observed. It should observe whether there is bleeding and hematoma at the puncture site, change the dressing every day, keep the local skin clean and dry to prevent infection.

3.5 Specialized nursing

3.5.1Vital sign monitoring. It should ensure to absolutely stay in bed, and the head of the bed shall be raised, and it should keep the ward quiet. It should avoid stimulation, and operation should be conducted intensively. It should closely monitor the changes of vital signs and temperature of patients, continuously monitor invasive arterial blood pressure, and observe the temperature, heart rate, heart rhythm, respiration, blood pressure, and blood oxygen saturation of pediatric patients every hour. The dosage of drugs for newborns is one tenth of that for adults. The pump speed of multi-channel rehydration drugs should be adjusted at any time, making it difficult to record the amount of drugs in and out. Therefore, special injection pumps, special measuring tools and special record sheets should be used to record the incoming and outgoing volume every hour. It should observe the circulation of extremities at any time, closely observe whether there was hemolysis, and pay attention to the change of urine color.

3.5.2Airway management. Protective ventilation strategy. Low-pressure and low-flow ventilation shall be set, and appropriate humidification shall be conducted to prevent the formation of sputum scab. Closed sputum suction pipe shall be used to suck sputum at shallow level to avoid excessive negative pressure. Once the airway mucosa was damaged, the wound will continue to bleed. It should keep respiratory tract unobstructed, regularly monitor arterial partial pressure of oxygen, closely observe respiratory rate, rhythm change, blood oxygen saturation, the effect and complications of oxygen therapy.

3.5.3Skin care. When the patient was completely calm, he had severe edema. The ECMO tube was placed at a shallow position, and the risk of changing the position was high, and skin care was difficult. The management of pressure ulcers was strictly implemented, and prevention was the main task. The risk of pressure ulcers and skin integrity should be correctly evaluated. Comfortable position should be selected, and regular turning should be conducted. It could select appropriate pressure ulcer pads and water pillows, to buffer and reduce pressure. It should apply hydrocolloid dressing on the bone protuberance and massage the skin regularly to protect the integrity of the skin. It should gently observe the skin condition at the place where the tube is placed. When changing the dressing, it could be teared at 0 angle. The bed unit should keep clean and tidy, to prevent the pipeline from pressing under the body, avoid moisture. It should strictly perform bedside shift handover to avoid the existence of potential hazards.

3.5.4Medication nursing. Children have small dosage and various drugs. The plasma, vasoactive drugs, sedatives and analgesics, and intravenous nutrient heparin cannot be interrupted. It was necessary to strictly and promptly administer the drugs correctly, pay attention to the pump speed and whether there were incompatibilities, reasonably arrange the types of drugs, do a good job in the diversion of each channel, prepare special drugs in advance, and properly dilute them. The adverse drug reactions were observed closely and recorded correctly. After using vasoactive drugs, it should closely observe the changes of blood pressure and heart rate to prevent extravasation. After using diuretics, it should monitor the changes of urine volume, blood pressure, heart rate, respiration,etc.

3.5.5Prevention of infection. The pediatric patients were isolated in a single room and were nursed by a special person on a special shift. Disinfection and isolation measures were strengthened. The closed management of arterial and venous pipelines was conducted to prevent catheter related bloodstream infection. It should restrict personnel access and avoid cross infection. Hand hygiene should be strictly implemented, and the compliance of hand hygiene of medical personnel was improved, and it should do a good job of protective isolation. It should strictly perform aseptic operation, disinfection of environment and articles, implement basic nursing, and ensure nutrition supply.

3.5.6Mental nursing. During hospitalization, it could learn their favorite through the love manual and the special psychological nursing activities for pediatric patients. The customized special humanistic care could be tailored, and it could comfort the pediatric patients by shaking hands, hugging, touching and other related actions, so that the pediatric patients could feel safe, alleviate the corresponding fear and anxiety of the pediatric patients and their families for sudden diseases during hospitalization. Moreover, it could encourage the pediatric patients to face the disease bravely and actively cooperate with the treatment. It should tell the family members more about the knowledge of explosive myocarditis, so as to reduce the bad mood of the family members and pediatric patients. The extended family services should be carried out. During the epidemic, it could guide the pediatric patients to take regular re examinations through WeChat group and video follow-up to eliminate psychological pressure during hospitalization.

4 Conclusions

Explosive myocarditis is characterized by rapid onset, rapid progress and high mortality. Heart failure could be caused by fulminant myocarditis in children. With the close cooperation of MDT team doctors and nurses, fine nursing measures for intervention, and multidisciplinary cooperation, all efforts were made to save pediatric patients’ lives[6-11]. It can effectively improve the risk of progressive aggravation of children’s disease, and reduce the occurrence of complications. Clinical effect was obvious, and the course of disease was shortened, and satisfaction and social reputation were improved.