So, I have an ICU and hemodialysis background, I've been a nurse for a long time. And as he said, I'm presently working at the University of Michigan, and we have about 450 nurses in the CRT program. And so I help to research with implementation of some of these extracorporeal therapies. And this is all from a nursing perspective. So it would be a lot less intense. I have no disclosures. So we're going to discuss extracorporeal therapies available and the nursing considerations, kind of the connection things with those, and some common nursing obstacles to implementation of these therapies. So back in COVID, these three were given the EUAs. And from a nursing perspective, an EUA is an emergency use authorization that the FDA grants to both medical devices that are already approved, but in an unapproved manner, or actually an alternative manner. And then it also gives some of the unapproved devices some emergency use for trials. But these still have to be tested before they're put out. But the Cytosorb was granted an EUA in 20, in 4, 10, 20. And we did not use this at University of Michigan. The Seraph was granted as well EUA. It's already discussed this a little bit. But it has absorption of inflammatory mediators, bacteria, viruses, and toxins. And then the Exiris. That's a Baxter product. It had also gotten the EUA. It's designed to remove inflammatory mediators and just removes the cytokines. The Torimixin PMX and the SCD were ones that are not on the market yet. They did not receive an EUA. They did not go for that. And we have been using those in studies as well. So when you're talking about the phases of sepsis, there's the phase or the continuum. A pathogen starts in a host and it infects the host. And then it produces endotoxins. Those endotoxins circulate. And then the monocytes that are part of the leukocytes are stimulated. And that causes a storm of inflammation. And then once you have that, you have a cytokine storm, which can cause multisystem organ failure. So each of these cartridges can be introduced in different areas or different phases of the continuum. The Seraph would be with the pathogens. The Torimixin B would be more effective in the endotoxins produced. The Selective Cytophoretic Device or SCD comes in play with the monocytes. And then the Exiris by Baxter is the cytokine storm. So some of the considerations for use I will go over. And I'm going to introduce these in the way that they fit into that continuum. So the Seraph is most effective when started early in COVID or sepsis. It removes pathogens only. It does not remove anti-infectives. It's made to be used commercially with the available bloodlines and lures. It's inserted pre-filter. And it can be used with IHD in this picture or with CRT sets. However it is not for use in HIT-positive patients. So it's pretty easy to prime the Seraph. But it is outside of the regular filter that you use. The cartridge has to be held in place right now. It needs to be about an inch below the deaeration chamber. And right now they do not have a clip or anything to hang that. So you have to use like a tourniquet or tape or something and tape it on. Hopefully in the future they will have some kind of clamp to be used because that can be a little bit tenuous. And then it is single use and it has to be changed out every 24 hours. But it could be used less than that if the blood flow rate is higher. The Toramixin B, we have not used this much in our university. We have been involved in the study. But because of some of the requirements to be part of the study, we have not used it a whole lot. But when we have used it, we've used it with the SAMI and the IHD. And hopefully we will be using that a little bit more in the future. Then we have the SCD. We have had more use with this. This is able to be used on HIT-positive patients. It's added on post-filter to the CRT cartridge. It requires use of citrate as anticoagulation and calcium chloride replacement then. It requires the circuit iCal to be 0.25 and less than 0.4. Typically though, it does decrease pressor requirements in 12-24 hours. It targets hyperactive neutrophils and monocytes to not just stop the cytokine storm but potentially reverse that damage. This is the only one that's able to be used for HIT-positive patients. All of the other ones, if you have a HIT-positive patient, they all have some kind of heparin induced in their cartridge. This does have a clip to hold it on. So if any of you would end up going ahead and having this SCD, from a nursing perspective, when you're priming it, it's a little bit difficult to prime and get it right. So there is like a little bit of a learning curve with that. However, when you do put it in a clip, it's better to have the bottom of it kind of slanted backwards, like posterior, and the top of it pointed towards you. And the reason for that is, when you prime it, there's like a little air bubble that likes to trap in the one part. So if you have it towards the back, the air bubble goes to the back and it doesn't interfere with anything and you don't get clotting. That's something you won't hear any doctors talk about. The Exiris. The Exiris has an EUA for COVID patients, but it's still in studies for sepsis. It combines three functionalities, endotoxin removal, cytokine removal, and fluid uremic toxin removal. So it can be used as you would any other CRT filter. It comes as a CRT set and doesn't require any extra tubing or priming. It's only available though for use with a PrismaFlex or Prismax. It uses an enhanced AN69 membrane and it is not to be used for HIPP-positive patients as well. It is definitely the easiest to prime because it primes just like any of the other Baxter filters. So roadblocks. Let's face it, there are lots of roadblocks anytime you're getting ready to do any kind of studies. So during COVID, EUAs were much easier to obtain because more extracorporeal therapies were trialed, but it's now more difficult to get those approvals from the FDA. So that's kind of stunting it a little bit. Nursing staffing shortages have made the extracorporeal therapies and studies much more difficult to implement because of required training time and the perceived increase to workload. Some of the studies require timed labs, daily therapies, and these all can discourage the buy-in of staff. Because most of the nurses are already feeling a little bit overworked and understaffed. There can be disagreements. I mean, this is one that you wouldn't think would be a problem, but the nuts and bolts of things are there can be many disagreements within an institution as to who has to run this thing and whose responsibility is it? So is it the ICU? Is it the hemodialysis nurse? Who needs to train? Who needs to learn to implement it? And who's going to check on it, right? Some therapies require heparin and those patients are HIPP-positive, and again the SED was the only one that was okayed for that. Priming and connectivity of some of the cartridges to the CROT sets can be challenging at times. It gets much easier as you do it, but there's a learning curve. And again, so it's going to take some time to learn some of that. Priming and connectivity of some cartridges to the CROT, I'm sorry, depending on the type of CROT machine you have and your institution's anticoagulation protocol, some therapies may be more difficult to initiate. In our institution we use solely citrate as our anticoagulation, but a lot of places use only heparin. And so in either of those, it can be a little bit of a learning curve to do it differently. So let's face it, nurses are burnt out from COVID and most hospitals are short-staffed. So the idea of one more task can be very daunting and even angering sometimes. But don't let a failed attempt skew your perspective. Each product works differently. It's important to remember that, because one of the things that I face when I go to the ICUs and I say, hey, we're going to try this, and they're like, oh, I've tried these before and they never worked, you know. Well, each one works differently. And so when you implement them at a different time, you may have a different outcome. So eventually there may not be effective antibiotics to combat these things. So we have to keep in mind, as these superbugs are coming, that we may not have anything else left to combat these. So we're going to need something else to fight sepsis. And we have to keep just an open mind with that. And then look to the future where the possibility of several adjunct therapies. It may be that 5, 10 years down the line, we may see the use of the Seraph in one part and maybe the STD in another portion or whatever. It depends on, because you can simultaneously use these and you can catch the sepsis as it goes down the continuum. So that's a possibility. And it may decrease the mortality of our septic patients. What would a good nursing talk be without Florence? Just as Florence, I'm sure, was burnout after the Crimean War, right? We are all burnout from COVID. But I just want to encourage everyone to keep an open mind and remember that in the future, we may not have any other options. And so we kind of have to just, you know, stay in there and fight and do our best. And the extracorporeal therapies may be a way that we can help fight. Thank you.

extracorporeal therapies

sepsis

COVID-19

nursing considerations

patient outcomes