Wojciech Telec

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

The bipolar ablation of refractory typical atrial flutter with CARTO 3 Confidense system

The typical atrial flutter is a reentrant arrhythmia with critical isthmus between tricuspid valve and inferior vena cava. The main target of ablation is to create a bidirectional block in the cavotricuspid isthmus. There are several anatomical variants which can create the obstacle to achieve successful ablation, namely the long isthmus, its shape (straight, convex, or pouch like), prominent Eustachian ridge or overdeveloped Chiari’s network. The bipolar ablation can result in higher transmurality than unipolar ablation, however there are only a few published cases and there are no dedicated systems. We report on the 59 year old female with incessant atrial flutter with rapid ventricular response who developed cardiomyopathy. She previously underwent three unsuccessful RF ablations in two different EP centers. Long applications up to 50 W with the use of 8 mm and irrigated tip electrodes were only transiently successful. At this stage the patient was qualified for RF bipolar ablation. As it is off-labelled use of standard RF generator and ablation electrodes the procedure obtained an individual permission from Local Ethics Committee and patient provided a written informed consent before procedure. Ablation was performed under general anaesthesia as previous ablations were painful. The 10 pole electrodes were positioned in the coronary sinus and the lateral part of right atrium. The high density map has been created using THERMOCOOLR SMARTTOUCH Catheter connected to CARTO 3 system with Confidense module (Biosense-Webster, Inc.). The entrainment pacing and propagation map confirmed cavotricuspid isthmus involvement in the flutter. The isthmus was meticulously visualized and measured. The slow conduction through the middle part was identified (Figure 1A). Initially, standard 180 s linear application (40 W) was delivered without success. Thereafter the THERMOCOOLR SMARTTOUCH Catheter was positioned on the middle part of the isthmus. The 7F 4 mm Celsius electrode (Biosense-Webster, Inc.) was introduced to the right atrium and connected to the LabSystem Pro (Boston Scientific) and Stockert generator in order to record the most distal atrial potential of the isthmus and impedance. This was to avoid going to deeply into IVC and performing ablation in the vein. After checking the position of electrodes on fluoroscopy in two projections, Celsius electrode was connected with indifferent electrode receptacle of the RF generator using a custom-made connector (Figure 1B). 40 W application was started resulting in flutter interruption in 10 s with bidirectional block. The application was continued for 90 s slowly dragging the active electrode to reach the other side of the isthmus precisely monitoring the impedance which decreased from 147 to 141 X. After 30 min after ablation there was bidirectional block with line of double potentials. The patient was discharged and followed for 3 months without recurrence of atrial flutter.

Bipolar irrigated radiofrequency ablation of resistant ventricular tachycardia with a septal intramural origin: the initial experience and a description of the method

Bipolar radiofrequency (RF) ablation is effective in treatment of ventricular tachycardia originating from thick interventricular septum. The RF generator and CARTO system can be used to precisely and safely perform ablation. Standard ablation catheter can be used with indifferent ablation electrode connected to the electrode receptacle in RF generator with custom‐made cable.

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.

Stent loss in the radial artery - surgical vs. interventional approach - report of two cases

Stent loss during coronary angioplasty is a complication that can be managed in various manners; however, transradial access limits the options available. We describe two coronary interventions complicated by stent dislodgement, initially managed by pulling the stent back to the radial artery. Both stents were unwillingly lost on different levels in radial arteries. The first case was managed with a direct radial artery cut-down because distal location made it a quick and straightforward procedure. In the second case a partially deployed stent was lost in the proximal part of the radial artery. It was rewired, deployed, and post-dilated with a larger balloon. This enabled continuation of the procedure using the same access. Both cases were asymptomatic during 24 months of follow-up. It is crucial to avoid leaving artificial bodies in arteries supplying vital organs because stent-related thrombosis or stenosis may seriously compromise blood flow. Removing the stent via the introducer sheath should be considered the optimal treatment. Unfortunately it is common that a partially expanded stent will not pass through the sheath. The superficial location of the distal radial artery segment facilitates surgical cut-down with local anaesthesia. When dislodgement occurs in deeper segments of the radial artery, the benefits from cut-down seem to be less because the procedure might take more time and be more difficult – as in the presented case in which we decided to rewire and fully expand the stent in situ. Retrieval of the stent at all costs might have led to further complications; hence stent deployment may be a good alternative to retrieval in such cases.

AED use in public places: a study of acquisition time

BACKGROUND Sudden cardiac arrest (SCA) is a frequent cause of death in the developed world. Early defibrillation, preferably within the first minutes of the incident, significantly increases survival rates. Accessible automated external defibrillators (AED) in public areas have been promoted for many years, and several locations are equipped with these devices. AIM The aim of the study was to assess the real-life availability of AEDs and assess possible sources of delay. METHODS The study took place in the academic towns of Poznan, Lodz, and Warsaw, Poland. The researchers who were not aware of the exact location of the AED in the selected public locations had to deliver AED therapy in simulated SCA scenarios. For the purpose of the trial, we assumed that the SCA takes place at the main entrance to the public areas equipped with an AED. RESULTS From approximately 200 locations that have AEDs, 78 sites were analysed. In most places, the AED was located on the ground floor and the median distance from the site of SCA to the nearest AED point was 15 m (interquartile range [IQR] 7-24; range: 2-163 m). The total time required to deliver the device was 96 s (IQR 52-144 s). The average time for discussion with the person responsible for the AED (security officer, staff, etc.) was 16 s (IQR 0-49). The AED was located in open access cabinets for unrestricted collection in 29 locations; in 10 cases an AED was delivered by the personnel, and in 29 cases AED utilisation required continuous personnel assistance. The mode of accessing the AED device was related to the longer discussion time (p < 0.001); however, this did not cause any significant delay in therapy (p = 0.132). The AED was clearly visible in 34 (43.6%) sites. The visibility of AED did not influence the total time of simulated AED implementation. CONCLUSIONS We conclude that the access to AED is relatively fast in public places. In the majority of assessed locations, it meets the recommended time to early defibrillation of under 3 min from the onset of the cardiac arrest; however, there are several causes for possible delays. The AED signs indicating the location of the device should be larger. AEDs should also be displayed in unrestricted areas for easy access rather than being kept under staff care or in cabinets.

Zastosowanie AED w miejscach publicznych: badanie czasu użycia

BACKGROUND Sudden cardiac arrest (SCA) is a frequent cause of death in the developed world. Early defibrillation, preferably within the first minutes of the incident, significantly increases survival rates. Accessible automated external defibrillators (AED) in public areas have been promoted for many years, and several locations are equipped with these devices. AIM The aim of the study was to assess the real-life availability of AEDs and assess possible sources of delay. METHODS The study took place in the academic towns of Poznan, Lodz, and Warsaw, Poland. The researchers who were not aware of the exact location of the AED in the selected public locations had to deliver AED therapy in simulated SCA scenarios. For the purpose of the trial, we assumed that the SCA takes place at the main entrance to the public areas equipped with an AED. RESULTS From approximately 200 locations that have AEDs, 78 sites were analysed. In most places, the AED was located on the ground floor and the median distance from the site of SCA to the nearest AED point was 15 m (interquartile range [IQR] 7-24; range: 2-163 m). The total time required to deliver the device was 96 s (IQR 52-144 s). The average time for discussion with the person responsible for the AED (security officer, staff, etc.) was 16 s (IQR 0-49). The AED was located in open access cabinets for unrestricted collection in 29 locations; in 10 cases an AED was delivered by the personnel, and in 29 cases AED utilisation required continuous personnel assistance. The mode of accessing the AED device was related to the longer discussion time (p < 0.001); however, this did not cause any significant delay in therapy (p = 0.132). The AED was clearly visible in 34 (43.6%) sites. The visibility of AED did not influence the total time of simulated AED implementation. CONCLUSIONS We conclude that the access to AED is relatively fast in public places. In the majority of assessed locations, it meets the recommended time to early defibrillation of under 3 min from the onset of the cardiac arrest; however, there are several causes for possible delays. The AED signs indicating the location of the device should be larger. AEDs should also be displayed in unrestricted areas for easy access rather than being kept under staff care or in cabinets.