Marek Dąbrowski

The role of simulation to support donation after circulatory death with extracorporeal membrane oxygenation (DCD-ECMO)

Maintaining the viability of organs from donors after circulatory death (DCD) for transplantation is a complicated procedure, from a time perspective in the absence of appropriate organizational capabilities, that makes such transplantation cases difficult and not yet widespread in Poland. We present the procedural preparation for Poland’s first case of organ (kidney) transplantation from a DCD donor in which perfusion was supported by extracorporeal membrane oxygenation (ECMO). Because this organizational model is complex and expensive, we used advanced high-fidelity medical simulation to prepare for the real-life implementation. The real time scenario included all crucial steps: prehospital identification, cardiopulmonary resuscitation (CPR), advanced life support (ALS); perfusion therapy (CPR-ECMO or DCD-ECMO); inclusion and exclusion criteria matching, suitability for automated chest compression; DCD confirmation and donor authorization, ECMO organs recovery; kidney harvesting. The success of our first simulated DCD-ECMO procedure in Poland is reassuring. Soon after this simulation, Maastricht category II DCD procedures were performed, involving real patients and resulting in two successful double kidney transplantations. During debriefing, it was found that the previous simulation-based training provided the experience to build a successful procedural chain, to eliminate errors at the stage of identification, notification, transportation, donor qualifications and ECMO organ perfusion to create DCD-ECMO algorithm architecture.

Customization of a patient simulator for ECMO training

Background: Poland is setting up its first regional ECMO program and relies heavily on the use of simulation in testing processes and training clinicians.1 As ECMO is a complex and expensive procedure, we developed an advanced ECMO simulator for high-fidelity medical simulation training.2–6 It can be used to modify any type of full-body patient simulator and allows for the creation of an unlimited number of scenarios. Methods: The system is equipped with an electronic core control unit (CCU) (Figure 1), a set of synthetic valves, pressure sensors, and hydraulic pumps. The major functions of the CCU are to stabilize the hydraulic system (flow of simulated blood, differential pressures in the arterial and venous lines), providing instant information about the system to the user via a display. Electric valves and sensors provide ‘on-the-fly’ information to the CCU about the actual systems status and it can be made to respond to specific instructions imitating the physiological circulatory system and simulating several scenarios (i.e. bleeding, low pressure, occlusion, reaction to proper and incorrect pharmacological treatment). It can be connected to an ECMO machine to act like the human body during ECMO run. Silicone tubes (modified polyethylene) that can be realistically cannulated using ultrasound imaging represent the artificial vessels. The CCU is made of electronic components that can be integrated to customize any mannequin as shown in Figure 1. The hardware includes both digital and analogue components that are controlled by a software run on a computer connected to the CCU via a serial port (RS232) (Figure 2). The software allows for the visualization of measurements obtained from the sensors and the control of the pumps and valves via electronic controllers. The controllers affect the ECMO circuit simulated blood flow, and hence the readings from the ECMO machine sensors, to recreate various clinical scenarios.Figure 1. The modified patient simulator with circulatory loop prepared for VA ECMO cannulation and CCU (core control unit) for high-fidelity simulations. Figure 2. The ECMO simulator architecture. Results: Every component used can be easily replaced. The total cost of the simulator modification, excluding the cost of the computer or future mobile device, is approximately 200 USD, and the consumable parts cost about 20 USD. It has been used to help simulate successfully a range of scenarios.1 Although the system is currently tethered, the next prototype will include a wireless controller so that the system can be controlled from a mobile application. Conclusions: This advanced simulator allows for unlimited possibilities with regard to creating clinical scenarios. Our ambition is to become a reference ECMO training center in Poland so that our high-fidelity ECMO simulator can be used to its full potential and for the benefit of more clinicians and their patients around Poland.

Using simulation to create a unique regional ECMO program for the Greater Poland region

Background: “ECMO for Greater Poland” is a program being developed to serve the 3.5 million inhabitants of the Greater Poland region (Wielkopolska) based on an approach already implemented in the USA1 or Qatar.2,3Method: The program is complex and takes full advantage of the ECMO perfusion therapy opportunities to save the life of patients in the Greater Poland region. The main implementation areas are: – treatment of patients with hypothermia;4 – treatment of reversible severe respiratory failure;5 – treatment of acute intoxication resulting in cardiorespiratory failure6 or other critical conditions resulting in heart failure; – in the absence of response to treatment and eventual death, and with donor authorization, there is possible organ transplantation from a non-heart beating donor (NHBD) to another patient.7 This led to the development of a program for donation after circulatory death (DCD). Study: The program will help to put in place a Medical Rescue System including ECMO (Figure 1). It requires training in specialized resuscitation, perfusion, and transplantation teams in the implementation of this “ECMO rescue chain”. The main strength of the program is the widespread use of extracorporeal perfusion. All program arms in the use of ECMO should be implemented in parallel to maximize its positive impact.Figure 1. Organizational model of “ECMO for Greater Poland” – “ECMO rescue chain” scheme divided into three stages: prehospital, hospital/perfusion, and transplantation. As this organizational model is complex and expensive, we used high-fidelity medical simulation to prepare for the real-life implementation of our ECMO program. During 4 months, we performed scenarios including: – “ECMO for DCD” which includes: prehospital identification, CPR ALS (cardiopulmonary resuscitation advanced life support), perfusion therapy (CPR-ECMO or DCD-ECMO), inclusion and exclusion criteria matching, mechanical chest compression, transport, DCD confirmation, and donor authorization, the veno-arterial (VA) cannulation of a mannequins artificial vessels, and starting on-scene organ perfusion.7 – “ECMO for INTOXICATION” which includes: hospital identification (Department of Toxicology), poisoning treatment, CPR ALS, mechanical chest compression, VA cannulation, for the implementation of ECMO therapy and transport to another hospital (Department of Cardiac Surgery).6 – “ECMO for RRF” (reversible respiratory failure) which includes: hospital identification (Regional Department of Intensive Care) – inclusion and exclusion criteria matching, ECMO team transport (80 km), therapy confirmation, veno-venous cannulation for the implementation of perfusion therapy, and return transport (80 km) with ECMO to another hospital in a provincial city (Clinical Department of Intensive Care), where the veno-venous (VV) ECMO therapy was continued for the next 48 hours.5 The training programs, in a short time, resulted in a team being appropriately trained to successfully undertake the complex procedures. Soon after these simulations, Maastricht category II DCD procedures were performed involving real patients and resulting in two double successful kidney transplantations, for the first time in Poland. One month later, we treated two hypothermia patients and, for the first time in the region, also treated on ECMO an adult patient with reversible respiratory failure. Conclusions: The “ECMO for Greater Poland” program will allow the use of perfusion therapy for the inhabitants of Wielkopolska in a comprehensive manner, covering all critical disease states, by what appears to be a unique regional program in Poland. The full-scale, high-fidelity simulation enabled standardized training and testing of new, commonly, and rarely used procedures, and facilitated clinicians’ skills development.

Which position should we take during newborn resuscitation? A prospective, randomised, multicentre simulation trial

BACKGROUND Early bystander cardiopulmonary resuscitation (CPR) for cardiac arrest is crucial in the chain of survival. Cardiac arrest in infants is rare, but CPR is also performed in severe bradycardia. European Resuscitation Council and American Heart Association guidelines recommend continuing CPR until the heart muscle is sufficiently oxygenated and regains sufficient contractility and function. The most common and recommended CPR techniques that can be applied in newborns are the two-finger technique and two-thumb technique. AIM We sought to assess the quality of CPR performed in newborns with the two-finger technique depending on the posi-tion of the rescuer during resuscitation. METHODS This was a prospective, randomised, crossover, simulated study. It involved 93 nurses who were required to perform a two-minute CPR using the two-finger technique in three scenarios: (A) with the newborn lying on the floor; (B) on a table; and (C) with the newborn on the rescuers forearm. The Newborn Tory® S2210 manikin was used to simulate a neonatal patient in cardiac arrest. The following parameters were measured: chest compression (CC) depth, CC rate, no-flow time, percentage of full release, ventilation rate, and ventilation volume, as well as the number of effective compressions and effective ventilations. RESULTS Statistical analysis showed significant differences in CC rates between scenarios A and B (p < 0.001) and between scenarios B and C (p = 0.002). Significant differences were also observed between the median CC depth. The median per-centage of no-flow-fraction was the highest for scenario A (55%), followed by scenario B (48%), and scenario C (46%). There were significant differences between the values of no-flow-fraction between scenarios A and B (p < 0.001), and between scenarios A and C (p < 0.001). The percentage of chest full releases for scenarios A, B, and C amounted to 94%, 1%, and 92%, respectively. Significant differences in the number of effective CCs between scenarios A and B (p < 0.001) as well as B and C (p < 0.001) were revealed. The median ventilation rate was highest for scenario B (13 × min-1), and lowest for scenario A (9 × min-1). The highest tidal volume was obtained in scenario A (27 mL), and the lowest in scenario C (26 mL). The most effective CPR was performed when resuscitation was carried out on the rescuers forearm. CONCLUSIONS The quality of CCs in newborns depends on the location of the patient and the rescuer. The optimal form of resuscitation of newborns is resuscitation on the rescuers forearm.

An innovative panel to assess endothelial integrity of pedicled and skeletonized internal thoracic artery used as aortocoronary bypass graft: a randomized comparative histologic and immunohistochemical study

Background Optimal preservation of endothelial integrity of the vessels used as aortocoronary grafts is a crucial determinant of long-term clinical success of coronary artery bypass grafting (CABG). The purpose of this study was to evaluate an impact of two common techniques to harvest left internal thoracic artery (LITA) on endothelial integrity. Methods One hundred twenty consecutive patients (84 males and 36 females) with a mean age of 64.9±8.8 years undergoing CABG were randomized to receive pedicled (group P; n=60) or skeletonized (group S; n=60) LITA grafts. During surgery LITA was harvested by the same experienced cardiac surgeon. The most peripheral surplus segments of LITA were obtained and then analysed histologically under light microscope. Additionally, endothelial expression of CD31, CD34, CD133 and nitric oxide synthase (eNOS) were evaluated by means of immunohistochemistry. Results In both groups, no cases of major arterial wall damage such as disruption, dissection, thrombosis or subadventitial hematoma were noted on LITA cross sections. Immunohistochemical assessment of protein expression revealed no differences in endothelial expression of CD133, CD34 antigens (markers of regeneration potential) and eNOS (indicating preserved functional integrity) between studied groups. Contrary to them, endothelial immunoreactivity of CD31, a marker of the morphological integrity of the endothelium, was revealed to be stronger in group P. Conclusions The skeletonized method of LITA harvesting may be associated with worse preservation of morphological integrity of endothelium but without compromising functional integrity and potential for tissue regeneration.

Development of regional extracorporeal life support system: The importance of innovative simulation training

Background: Despite advances in mechanical ventilation, severe acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality rates ranging from 30% to 60%. Extracorporeal Membrane Oxygenation (ECMO) can be used as a “bridge to recovery”. ECMO is a complex network that provides oxygenation and ventilation and allows the lungs to rest and recover from respiratory failure, while minimizing iatrogenic ventilator‐induced lung injury. In the critical care settings, ECMO is shown to improve survival rates and outcomes in patients with severe ARDS. The primary objective was to present an innovative approach for using high‐fidelity medical simulation before setting ECMO program for reversible respiratory failure (RRF) in Polands first unique regional program “ECMO for Greater Poland”, covering a total population of 3.5 million inhabitants in the Greater Poland region (Wielkopolska). Aim and methods: Because this organizational model is complex and expensive, we use advanced high‐fidelity medical simulation to prepare for the real‐life implementation. The algorithm was proposed for respiratory treatment by veno‐venous (VV) Extracorporeal Membrane Oxygenation (ECMO). The scenario includes all critical stages: hospital identification (Regional Department of Intensive Care) ‐ inclusion and exclusion criteria matching using an authorship protocol; ECMO team transport; therapy confirmation; veno‐venous cannulation of mannequins artificial vessels and implementation of perfusion therapy and transport with ECMO to another hospital in a provincial city (Clinical Department of Intensive Care), where the VV ECMO therapy was performed in the next 48 h, as training platform. Results: The total time, by definition, means the time from the first contact with the mannequin to the cannulation of artificial vessels and starting VV perfusion on ECMO, did not exceed 3 h – including 75 min of transport (the total time of simulation with first call from provincial hospital to admission to the Clinical Intensive Care department was 5 h). The next 48 h for perfusion simulation “in situ” generated a specific learning platform for intensive care personnel. Shortly after this simulation, we performed, the first in the region: ECMO used for RRF treatment. The transport was successful and exceeded 120 km. During first year of Program duration we performed 6 successful ECMO transports (5 adult and 1 paediatric) with 60% of adult patient survival of ECMO therapies. Three patients in good condition were discharged to home. Two years old patient was successfully disconnected from ECMO and in stabile condition is treated in Paediatric Department. Conclusions: We discovered the important role of medical simulation, not only as an examination for testing the medical professionals skills, but also as a mechanism for creating non‐existent procedures. During debriefing, it was found that the previous simulation‐based training allowed to build a successful procedural chain, to eliminate errors at the stage of identification, notification, transportation and providing ECMO perfusion therapy.