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8/14/2019 Rapid Deployment for E-CPR
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RAPID DEPLOYMENTfor
E-CPR
Organizing the Chaos
Ruth Ferroni, BSN, RN
E-CPR
ECMO: ExtraCorporeal Membrane Oxygenation
Rapid deployment infers a swift, timelymaneuver.At CNMC, we define Rapid Deployment as aprocess using ECMO therapy to rescue apatient who is in cardiopulmonary arrest and
unresponsive to conventional resuscitativemeasures.Desired time: 30 minutes from CPR event toachieving full ECMO support
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E-CPR
Advantages:
Offers quick, life saving rescue therapy forpatients in cardiopulmonary failure
Disadvantages:
Requires highly trained healthcare
personnel from many resources within thehospital
QUESTIONS TO ASKOURSELVES
Who is doing what?
How long does it take
to safely prepare and cannulate
a patient for ECMO support?
How quick do we need to be?
How do we accomplish this?
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PLAYERS
HEADLINERS.
PATIENT
IntensivistSurgeons/ surgical teamICU nurses and respiratory therapistsECMO circuit primers
SUPPORTING CAST
Unit ancillary staffBlood bankPharmacy
PLAYERSIs anyone leading?
Is anyone listening?
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Roles
ESTABLISH ROLES with DUTIES:
Physician Team Leader
Cannulating Surgeon
Charge Nurse
Bedside Nurse
Medication Nurse
Respiratory Therapists
Circuit PrimersAncillary Staff
Rapid Deployment ECMO kit on RD cart
One bag for Pt. One for Circuit
One Topical Kit including:
Gelfoam, Surgicel
Thrombin 20,000u
Bacitracin Oint.
Chest irrigation kit in MED fridge:
Antibiotics for irrigant; mix & add to
500 ml warmed saline (in Warmer)
Place patient label on medication charge
sheet from cart. meds used on sheet.Take to MAIN pharmacy for kit replacement.
Return unused medications from ECMO to
credit bin with patient label
RestockECMOmedson cart/in frid e
Medications and Saline
Bovie Pad
Shoulder roll
Med line
A.line access
Pacer attached and outside field
Extra suction gauge and cannister
Med RN to prepare and give priorto
cannulation of vessels: with MD re: time and doseHeparin 50 units/kg
Paralytic (with sedative)
Patient Prep
Hats and masks for all
Sterile gown, gloves for set-up person
Open blue custom pack on table
Prep kit, gown aside for surgeon
Place surgeons gloves near gown
Remove basin and unwrap on mayo stand
Remove bovie pen, yankauer and sx tubing
from basin; place on sterile field
Stack gowns and drapes in order
Make room for instruments
Ask someone to remove lid from instrument
case (maintain inside sterility)
Pull trays from instrument case
Add sutures, tourniquet pack and scalpel
Cover with sterile drape if waiting for surgery
Cannulation Set-Up
Communicate with MD and UCA
#2222, weight, room location
CLEAR the room
Move equipment in
Rapid Deployment activated
Charge Nurse/RN Role
Work with team leader to fulfill multipl e roles
Secure airway issues; hand off to RT
Assess IV access. Establish as necessary
Insure adequacy of CPR technique
Complete ECMO orders
Assist surgeon until OR staff arrives
MD assistant to CODE Leader
Recommend cannula size/ site to surgeon
Ensure paralytic/sedation given BEFORE
vessel cannulation
Order heparin dose; usually 50 units/kg
Communicate with surgeon: Give heparin just
before vessel cannulated
Assess circuit readiness with primer;
determine if time to prime with blood
Review pump ABG and ACT if circuit blood
primed
Cefazolin 25mg/kg as soon as practical
Complete Rapid Deployment Orders
Cannulation Procedure and Meds
2 units RBC < 15 kg
4 units RBC > 15 kg
Sign emergency release form for
uncrossmatched blood if emergency
Order Blood
Ensure adequate CPR
Call for Rapid Deployment
Order staff to prep opening of Chest
Ensure closed-loop communication with
Charge RN, UCA and recorder
Initiate Resuscitation
MD Rapid Deployment Team Leader Role
Remain in room to assist as needed
During cannulation
Clear area of unnecessary equipment behind
bedspaceStabilize ETT/vent tubing prior to draping of
patient. Place stent around ETT
Organize suction source and ambu bag for
sterile procedure
Ensure equipment is easily accessible
Ambu bag outside of sterile field
Prep for cannulation
Ensure adequate CPR
Stabilize airway with MD
Ensure closed-loop communication with
Charge RN and MD Teamleader
During initial resuscitation
Bedside RT Rapid Deployment Role
ROLEBADGES
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EXPANDED ROLE
If the field is prepared, time is reducedPrepping the sterile field and instrument tray:
ICU RNs first to arrive however, unfamiliar with sterile, surgical techniqueand set-up
OR staff not always available to respond to emergency procedures
Surgeons MUST have help to quickly and safely cannulate the patient
PRACTICAL Barriers to
Efficient ProcessesRoom and equipment set-up MUST be STANDARDIZED including location
of equipment once the procedure has begun
Im a nice,
big roomwith a
view!
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CICU
CICU
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STREAMLINE the ECMO CART
Rotate cart check task through all RN staff
EQUIPMENT
BOVIEHEAD LAMP
Where do I get this stuff?
What is it for?
How do I work it?Where does it belong?
Solutions
Sterile Set up Education for ICU nursesSimplify the instrument traySimplify the ECMO supply cartInclude the surgeons!
Develop roles with responsibilities badgesDO or DELEGATE
Medication location
Daily preparednessRoom configurationPatient preparednessECMO supply cart reviewMock rapid deployment scenarios
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Solutions
MEMORIZE THE CONSTANTS!Patient prep
Room configuration
Equipment position
Supplies
Personnel position
Close the loop communication
And, KEEP your COOL
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References
Fiser RT, Morris MC. Extracorporeal Cardiopulmonary Resuscitation in
Refractory Pediatric Cardiac Arrest . Pediatric Clinics of North America. 2008.55:4
Huang, et al. Extracorporeal membrane oxygenation rescue for
cardiopulmonary resuscitation in pediatric patients. Critical Care Medicine.2008. 36:5
Van Meurs K, Lally KP, Peek G, Zwischenberger J (Eds.). ECMO Extracorporeal
Cardiopulmonary Support in Critical Care 3rd Edition. 2005.