Cue Audio

Vessel Cannulation

Dilatation

Cannulation

4501

12 july 14

Cannula Positioning

Preparing Circuit

Connection with underwater seal

Establishing ECMO

E-CPR: Making it happen

Jason McClure

The Alfred ICU

ECMO ECMO CPR

Issues with ECPRTime critical & stressful

Infrequent

Highly technical

Large Number of Staff

24/7

CPR to ED (Autopulse)HypothermiaECPREmergencyReperfusion

Developing A Protocol

Our MethodIdentify Problems in Realtime

Collaboration

Refine & Test the process

Develop a finished model of care

Protocol V40

Areas developed

Equipment Roles Tasks

Airway DoctorAirway Nurse

Chest Compressions!

!(Autopulse)

Defibrillation!!

(Autopulse)

Drugs

!Equipment to bring!• E-CPR trolley!• (CHEER trial only – bring 4L of cold saline)!!Role!• Handover Team Leader role!• Allocate roles (with Team Leader)!• Cannulation!!!!!!!!!!!!!!

C2

Cannulator 1

Trolley

C1

Team Leader

U/S

Procedure!1. Open Cannulator 1 Box contents!2. Open Defries pack !3. Scrub!4. Sterilise groin & drape!5. Apply ultrasound sleeve!6. Cannulation!

• Right access, Left return!

!Equipment to bring!• U/S machine!!Role!• Assist Cannulator 1!!!! !!!!!!!!!!

C1

Cannulator 2

Trolley

C2

Team Leader

U/S

Procedure!1. Open Cannulator 2 Box contents

(open Blue Box inside first)!2. Pour Betadine into green bowl!3. Pour 1L saline and 10,000 unit heparin

into blue bowl!4. Open 15F arterial, 19F Multi-stage

venous cannulae!5. Scrub!

!Role!• Confirm guidewire placement!!!

C1

Sonographer

Trolley

U/S

Team Leader

C2

Procedure!1. Prepare ultrasound machine !2. Assist in applying ultrasound sleeve!3. Confirm guidewire position!

• IVC for access!• Aorta for return

CHEER trial only: !• bolus 40mL/kg ice-saline iv

!Equipment to bring!• ECMO console!!Role!• Prepare ECMO circuit!

• No heater, no albumin for E-CPR !!

C2

Console Person

Trolley

C1

Team Leader

ECMO Console

Console!Person

U/SProcedure!Prepare primed circuit!1. Turn console on!2. RPM to 0!3. Unscrew yellow cap from oxygenator !4. Unclamp blue & red tubes!5. Run 2000 RPM for 2min (ensure flow in

priming bag)!6. Reapply yellow cap!7. Clamp circuit (both blue & red tubes

close to de-airing bag)!8. RPM to 0, ECMO safety clamp on!9. Apply white U/S cream!10.Zero flow on console!11. Connect oxygen to O2 cylinder

(not blender) at 3L/min!12.Await for transfer to bedside!13.Ask C1 or C2 to check no air in circuit

!Role!• Documentation and timing!!

C1

Scribe

Trolley

Team Leader

C2

U/S

Scribe

Procedure!• Time cycle!• Important times to document !

1. CPR start!2. Decision for ECPR!3. Equipment arrival!4. Skin preparation!5. On support

#Resuswanker

The CHEER Trial

In patients with refractory cardiac arrest,

does the CHEER protocol improve survival with good neurologic

recovery?

54% SURVIVAL

36% SURVIVAL

54% SURVIVAL

CHEER Trial - 54% Survival26 Patients (11 OHCA 15 IHCA)

24 Patients established on ECMO (92%)

Median Time 20 mins (IQR 15-30)

Median Duration 2 days (IQR 1- 5)

13/24 Patients Successfully weaned from ECMO (54%)

14 Patients discharged home with full recovery (54% survival)