Rapid Deployment For E-cpr

RAPID DEPLOYMENT for E-CPR “Organizing the Chaos” Ruth Ferroni, BSN, RN

E-CPR ECMO: ExtraCorporeal Membrane Oxygenation Rapid deployment infers a swift, timely maneuver. At CNMC, we define Rapid Deployment as a process using ECMO therapy to rescue a patient who is in cardiopulmonary arrest and unresponsive to conventional resuscitative measures. Desired time: 30 minutes from CPR event to achieving full ECMO support

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E-CPR Advantages: Offers quick, life saving rescue therapy for patients in cardiopulmonary failure Disadvantages: Requires highly trained healthcare personnel from many resources within the hospital

QUESTIONS TO ASK OURSELVES 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 Intensivist Surgeons/ surgical team ICU nurses and respiratory therapists ECMO circuit primers SUPPORTING CAST… Unit ancillary staff Blood bank Pharmacy

PLAYERS Is 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 Primers Ancillary Staff

Charge Nurse/RN Role Rapid Deployment activated ♥Communicate with MD and UCA ♥#2222, weight, room location ♥CLEAR the room ♥Move equipment in Cannulation Set-Up ♥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 surgeon’s 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 Patient Prep ♥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 prior to cannulation of vessels: √ with MD re: time and dose Heparin 50 units/kg Paralytic (with sedative) Medications and Saline ♥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 ♥Restock ECMO meds on cart/in fridge

ROLE BADGES MD Rapid Deployment Team Leader Role Initiate Resuscitation ♥Ensure adequate CPR ♥Call for Rapid Deployment ♥Order staff to prep opening of Chest ♥Ensure closed-loop communication with Charge RN, UCA and recorder Order Blood ♥2 units RBC < 15 kg ♥4 units RBC > 15 kg ♥Sign emergency release form for uncrossmatched blood if emergency Cannulation Procedure and Meds ♥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 MD assistant to CODE Leader

Bedside RT Rapid Deployment Role During initial resuscitation ♥Ensure adequate CPR ♥Stabilize airway with MD ♥Ensure closed-loop communication with Charge RN and MD Teamleader Prep for cannulation ♥Clear area of unnecessary equipment behind bedspace ♥Stabilize 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 During cannulation ♥Remain in room to assist as needed

♥Work with team leader to fulfill multiple 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

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EXPANDED ROLE

If the field is prepared, time is reduced Prepping the sterile field and instrument tray: ICU RNs first to arrive however, unfamiliar with sterile, surgical technique and 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 Processes Room and equipment set-up MUST be STANDARDIZED including location of equipment once the procedure has begun

I’m a nice, big room with a view!

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CICU

CICU

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EQUIPMENT Where do I get this stuff? What is it for? How do I work it? Where does it belong?

HEAD LAMP

STREAMLINE the ECMO CART Rotate “cart check” task through all RN staff

BOVIE

Solutions Sterile Set up Education for ICU nurses Simplify the instrument tray Simplify the ECMO supply cart Include the surgeons!

Develop roles with responsibilities badges DO or DELEGATE

Medication location Daily preparedness Room configuration Patient preparedness ECMO supply cart review Mock 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.

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