Authors (including presenting author) :
AU SY(1), Fong KM(1), Leung PWR(1), Ng WYG(1), So SO(1), Leung KHA(1)
Affiliation :
(1) Intensive Care Unit, Queen Elizabeth Hospital
Introduction :
Veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) is a form of mechanical circulatory support for cardiogenic shock. Its demand has been rapidly growing in HA, especially with the initiation of 24-7 primary PCI service. QEH ICU provided near 40 VA-ECMO support annually. When VA-ECMO support can be terminated, arteriotomy wounds of the patients of are traditionally closed by open repair in the operation theaters. Lots of manpower including ECMO specialists, vascular surgeons, anesthetists etc. are involved and timeslots in operating theaters are scarce. Transport of the critically-ill is risky.
Objectives :
Successful VA-ECMO decannulation using percutaneous device called ProGlide was described by JW Hwang et al. Our group had adopted and modified this approach and the detailed ultrasound guided technique had been published. However, two major elements determine the success of such service: 1. Preparation and collaboration among colleagues, especially in times of failure or complications and 2. Technique of applying the closure devices in large bore arterial wounds. Simulation was the best training modality for this new service.
Methodology :
Crew resource management was a must during the preparation phase and trouble shootings on complications. Potential problems including unstable hemodynamics, failed hemostasis necessitating arrangement of emergency open repair were simulated in the scenarios. For the technical part, a self-designed part-task model using latex tubing with elasticity and thickness similar to the real arterial vessels was used to practice ProGlide application. A roller pump and pressure was generated to simulate the arterial pulsatile wound bleeding. The “skin” above the “vessel” was ultrasound penetrable to allow ultrasound guided technique. The most valuable thing of this simulation was that the participants could took out the “vessel” and directly observe the performance of their arteriotomy closure during the debriefing session, and such feedback could never be possible in real patients. Evaluation was performed and the results were analyzed.
Result & Outcome :
Three sessions of identical internal training were organized to 41 colleagues in 2019. They evaluated that a more thorough understanding of the new service and that patient safety was enhanced with the training and they scored 8.74/10 on both questions. They scored 8.64/10 that the simulation environment provided them the best learning environment and scored 8.71/10 that they would recommend this course to other colleagues. This service model and training method were introduced to the HA central ECMO training workgroup and 2 pilot classes would be conducted in early 2020, aiming to introduce such technique to ICU/CCU in other clusters. With practice and training, bedside VA-ECMO decannulation not only saves resources but is safe and effective.
