Tomasz Klosiewicz

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.

High-fidelity simulation — the first DCD-ECMO procedure in Poland

Mateusz Puslecki, Marcin Ligowski, Marek Dabrowski, Maciej Sip, Sebastian Stefaniak, Tomasz Klosiewicz, Lukasz Gasiorowski, Marek Karczewski, Tomasz Malkiewicz, Malgorzata Ladzinska, Marcin Zielinski, Aleksander Pawlak, Agata Dabrowska, Piotr Ziemak, Bartlomiej Perek, Marcin Misterski, Slawomir Katarzynski, Piotr Buczkowski, Wojciech Telec, Ilona Kiel-Puslecka, Michal Kiel, Michael Czekajlo, Marek Jemielity Poznan University of Medical Sciences, Department of Cardiac Surgery and Transplantology, Clinical Hospital SKPP, Poznan, Poland Poznan University of Medical Sciences, Department of Rescue and Disaster Medicine, Poznan, Poland Polish Society of Medical Simulation, Poland Poznan University of Medical Sciences, Center for Medical Simulation, Poznan, Poland Poznan University of Medical Sciences, Department of Intensive Care and Pain Treatment, Poznan, Poland Poznan University of Medical Sciences, Department of Transplantology, General, Vascular and Plastic Surgery, Poznan, Poland Poznan University of Medical Sciences, Department of Anesthesiology and Intensive Care, Clinical Hospital H. Święcickiego, Poznan, Poland Voivodeship Emergency Medical Services, Poznan, Poland Poznan University of Medical Sciences, Department of Palliative Medicine, Poznan, Poland ZF RTW, Częstochowa, Poland Hunter Holmes McGuire VA Medical Center, Department of Surgery, Richmond, United States of America Lublin Medical University, Lublin, Poland

Emergency medical system response time does not affect incidence of return of spontaneous circulation after prehospital resuscitation in one million central European agglomeration residents

BACKGROUND The survival of out-of-hospital sudden cardiac arrest (OHSCA) in Europe still remains low. The State Medical Rescue System is composed of several elements. The efficacy of each of these elements may have an influence on the victims survival. Until now, the incidence of return of spontaneous circulation (ROSC) and its correlation with rescue services time in the city of Poznan has not been determined. AIM The main purpose of this study was to assess incidents of OHSCA and prehospital frequency of ROSC after OHSCA in Poznan city and district. We also wanted to analyse whether ROSC depends on Emergency Medical System (EMS) reaction time. METHODS Retrospective analysis based on medical documentation conducted in 2015 in Poznan EMS. RESULTS Return of spontaneous circulation was achieved in 68.88% of cases. It was most frequent when OHSCA occurred in public places (p = 0.000, contingency factor = 0.233) and victims were younger (p = 0.042, contingency factor = 0.129). 63.17% of patients were male, but sex did not affect the incidence of ROSC. The median time of system response was 8.53 min, while time from ambulance departure to arrival was 5.42 min. We did not find any statistically significant difference between the number of deaths and those parameters (p = 0.723, p = 0.891). However, longer team response time correlated with the highest mortality (p = 0.042, contingency factor = 0.126). In the group where ROSC was achieved the median time of EMS response was 8.18 min, while among the group of deceased the median was 8.63 min. CONCLUSIONS The incidence of OHSCA in our region is similar to other Polish and European cities. EMS response time does not affect the frequency of ROSC. ROSC was achieved more often if OHSCA occurred in public and the victim was younger.

The role of extracorporeal membrane oxygenation in patients after irreversible cardiac arrest as potential organ donors

The number of people waiting for a kidney or liver transplant is growing systematically. Due to the latest advances in transplantation, persons after irreversible cardiac arrest and confirmation of death have become potential organ donors. It is estimated that they may increase the number of donations by more than 40%. However, without good organization and communication between pre-hospital care providers, emergency departments, intensive care units and transplantation units, it is almost impossible to save the organs of potential donors in good condition. Various systems, including extracorporeal membrane oxygenation (ECMO), supporting perfusion of organs for transplantation play a key role. In 2016 the “ECMO for Greater Poland” program was established. Although its main goal is to improve the survival rate of patients suffering from life-threatening cardiopulmonary conditions, one of its branches aims to increase the donation rate in patients with irreversible cardiac arrest. In this review, the role of ECMO in the latter group as the potential organ donors is presented.

Chain of survival used for a victim of sudden cardiac arrest in a public place

The complete chain of survival is highly recomended management of sudden cardiac arrest. Although it is well known, in Poland not always works properly, because of poor availability to AED devices. We present the history of 56 years old man, who suddenly suffered from sudden cardiac arrest in public place. Thanks to rapid reaction of his family and medical staff this men recived high quality resuscitation including AED and spontaneous circulation returnem before paramedics arrived. On admission to emergency department the patient was awake, without neuroligic deficites. Miocardial infarction was diagnosed as the cause of cardiac arrest.

THE FUNCTIONING OF THE MARITIME MEDICAL RESCUE TEAM: THE EXAMPLE OF SLUPSK EMERGENCY MEDICAL SERVICE WATER AMBULANCE

As people walk different paths they require qualified help either when they are in the mountains, by the sea or a lake. Although medical rescue procedures are the same for all patients, the specific environment of coastal area forces rescue services to use different modes of transportation for paramedics and equipment. The aim of this paper is to show the exceptional nature of the work of the Maritime Medical Rescue Team as part of the National Medical Rescue System. Members of this unit are not only qualified paramedics but also specialists in the field of navigation and rescue operations at sea.

Emergency intubation in prehospital care

Endotracheal intubation in emergency situations is a challenge even for the most experienced medical professionals [1,2]. Due to the fact that every prehospital patient should be treated as a patient with full stomach, there is a real risk of vomiting or regurgitation and aspiration of stomach content to respiratory tract, followed by aspiration pneumonia. In addition, intubation in prehospital conditions is associated with the pressure of time, as the patient in most cases has a life-threatening hypoxaemia.Moreover, intubation is repeatedly performed under unfavorable conditions such as poor lighting or inconvenient positions of the rescuer. In cases of suspected cervical spine injury, it is necessary to stabilize the victims head and spine with cervical collar which also reduces the effectiveness of endotracheal intubation [3]. Of course, there are many alternative devices for airway management in both trauma and non-trauma patients.Many studies have compared endotracheal intubation with Laryngeal Mask Airways [4], iGEL [5], Combitube or EasyTube [6]. However, it should be noticed that although these methods can be used by professionals who do not have the authority or ability to perform endotracheal intubation, such as firefighters or water rescuers, these methods will never replace endotracheal intubation. Properly placed endotracheal tube fully isolates the airway from the outside environment. That allows to provide continuous chest compressions during resuscitation, even when positive airway pressure is applied. In the case of supraglottic airway devices, increased pressure in the esophagus, or ventilation with large respiratory volumes, as well as movement of the patients body may cause leakage which in

Chest compressions in infants

Cardiopulmonary resuscitation on infants and children is associated with extreme emotions and stress among members of resuscitation team. Formost healthcare professionals in the pre-hospital care system, infant sudden cardiac arrest is a rare incident. Detailed knowledge of the guidelines and regular training is essential to ensure a high quality of resuscitation. Only proper chest compressions are able to provide adequate high coronary perfusion pressure and consequently maintain oxygenation of the cardiomyocytes and provide them with an energy reserve [1]. It is easy to make a mistake even in such simple operations as chest compressions while working under stress conditions [2]. Professionalmedical teams have equipment formechanical chest compression. It has been estimated that the use of these devices in children also significantly improves chest compression quality parameters such as rate, depth, correct recoil. It also allows to minimize unnecessary interruptions [1]. The key to improve survival is resuscitation provided by bystanders, and services such as fire brigade or water rescue. In addition, before ambulance arrival, a medical dispatcher instructs witnesses on how to perform resuscitation. First people at the scene are often parents of the injured infant who are unable to carry out complicated procedures. The first-aid rescue techniquesmust therefore be simple and at the same time highly effective so that even those without appropriate medical training could provide high quality chest compressions. In the present day, first aid training is widely available to the public. Also a large part of citizens declare their willingness to provide first aid in cases of sudden cardiac arrest [3]. Nonetheless, the outcome of pediatric out-of-hospital sudden cardiac arrest remains unsatisfactory. That is why it is important to look for new techniques that would make it even easier to provide good resuscitation.