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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)
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