Qatar Medical Journal - 1 - Extracorporeal Life Support Organisation of the South and West Asia Chapter 2017 Conference Proceedings, February 2017

Transport of extracorporeal membrane oxygenation (ECMO) patients in India, where there are very few ECMO centres, is a real challenge due to the huge area and large population of the country, and the diversities of resources between urban and rural areas. Road and air transportation are well established but another common mode of transport not fully developed is the train. Road transportation is used in almost 98% of our ECMO transfers. It is cheaper but its limitations are traffic congestions, road conditions, and travel times. The maximum distance covered is up to 250 miles,¹ which represents almost 5–6 h of travel time. Air transportation is a good option for long distances but is costly.² The average cost of air transportation (fixed wing) in India is around US $1600–2500 per hour, and the average run time is 4–6 h. Helicopter is not a preferred aeromedical transportation modality in India. Train transport services could be ideal in India as many superfast trains are covering the length and breadth of the country but the coaches are currently not suitable.

As an alternative option we developed the concept of a mobile ECMO unit, keeping in mind safety and cost effectiveness. It involves taking the ECMO team to the referring hospitals rather than transferring the patient. It is a viable practice as cardiac surgical skills are available in tertiary hospitals. Patients can be cannulated locally and managed by an expert visiting ECMO team in association with the referring team. Advantages:

•  Safer – no patient transfer •  Cheaper – no aeromedical patient retrieval •  Creates more awareness and utilization of ECMO services in different parts of India •  Opportunity to train and develop regional centres.

Drawbacks:

•  Staff need to get adjusted to different environments, cultures, and languages •  Coordinating teamwork with an entire new team

Retrospective case series of patients managed by our mobile ECMO team from August 2010 to August 2016 shows that we have had 45 patients transported during or before ECMO, without loss of life or major clinical or technical issues during the transport phase. Of the 45 patients, 39 had intrahospital transport for investigation like CT scan and for therapeutic procedures in the operating theatre. Of the 39 patients, 35 (90%) were transported on ECMO, while 4 were transported with conventional ventilation before initiating ECMO. Six patients had interhospital road transport while on VV ECMO with an average distance of 130 km (Ranging of 9–250 km). Of the 6 interhospital transport patients, 4 survived (67%) and were discharged alive from the hospital, and the other two patients died after 5 and 7 days on ECMO. The team has provided mobile ECMO services to 121 patients in different tertiary care hospitals and covered so far eight states of India, roughly 20 cities, and more than 50 tertiary care hospitals. The average survival remained around 45%. The average ECMO expense per patient was US $7340 (Range: US $4500–$23,000).

A dedicated mobile team allows safe road transportation of patients with severe ARDS;³ however, in India, where healthcare is self-sponsored, mobilizing the ECMO team and equipment to put a patient on ECMO in the referring hospital is more cost effective and safer. Our ultimate objective is to develop affordable transport services to reduce healthcare costs. Inclusion of ECMO as part of the curriculum for critical care consultants and cardiac surgeons is essential for improving awareness and getting hands on experience in initiating and streamlining the process of ECMO teaching and training. A definitive roadmap for developing Indian critical care services is crucial.

This study reports India's first international extracorporeal membrane oxygenation (ECMO) transfer as a joint operation between Hamad Medical Corporation (HMC) (Doha, Qatar), International Critical Care Air Transfer Team (ICATT), and Apollo Hospital (Chennai, India).

Severe respiratory failure (SRF) patients can be transferred safely, and there may be a survival advantage in transferring such patients to regional centers of expertise.¹ Patients can also be transported between facilities while on ECMO.² In the case reported below, ECMO was initiated as a bridge for lung transplant,³ which is currently not a procedure available in Qatar. ECMO support as a bridge for these patients could provide acceptable 1-year survival.⁴ It is also important to note that newer ECMO pumps are small and compact, and can safely be used to transfer patients by air.⁵

The first contact between the HMC and ICATT teams was made a month prior to the transfer of an ECMO patient due for the lung transplant. The patient was a middle-aged male with a very complicated and stormy ICU course, known to have interstitial lung disease (ILD) and ECMO-dependent referred for lung transplant.

The patient issues were:

[1]  Advanced ILD [2]  ECMO-dependent [3]  Resolving septic shock [4]  Frequent sepsis with multiple organisms, bacterial and fungal [5]  Hemothorax [6]  Pneumomediastinum [7]  Deep vein thrombosis [8]  Low body mass index (BMI) of 19 kg/m² [9]  Pulmonary embolism [10]  Bilateral brain microhemorrhages

The challenges were:

[11]  Air logistic [12]  Cost [13]  Long-distance ECMO transfer (Qatar to India) [14]  Complicated patient factor [15]  Poor understanding of ECMO among airport authorities [16]  Pump exchange on arrival

There were initial discussions for the ECMO team from India to aeromedically retrieve the patient from Doha, but considering the cost factor, it was more economically viable for the ECMO team from Doha to perform the transfer and return by the same carrier. An appropriate aircraft was chosen to fit all the equipment and the mobile ECMO team. Preparation of an appropriately staffed and equipped intensive care unit (ICU) ambulance (“Mobile ECMO unit”) along with patient stabilization was performed before the transfer to the airport. A bed in the receiving ICU in India was arranged. A mobile communication application was used from the onset of the transfer to communicate among all the relevant team members, referring hospital, receiving hospital, and the aviation team. It included the intensivists, transplant surgeons, ECMO specialists, perfusionists, logistical lead, and the transplant co-coordinator. The patient was mobilized from the medical ICU in Doha to the mobile ECMO unit, while in India the airport and receiving hospital team re-visited the entire operation from the landing to the airport exit of the ambulance to the hospital. Passport details of the patient and team from Doha were obtained and the immigration officer at Chennai airport, India, was appraised about the criticality and the complexity of the operation. A fully loaded ECMO capable ambulance was mobilized with the full team and stationed at the airport, pre-empting and preparing for a possible pump exchange in the event of any possible complication. Nine hours after leaving the hospital, the team from Doha safely landed with the stable patient. Following multiple negotiations, permission for the tarmac transfer of the patient from the air ambulance to the land ambulance was obtained. The patient arrived safely in at Apollo Hospital, Chennai, India, nearly 6 h after leaving the HMC's MICU.

Background: Transport of patients on ECMO has been demonstrated to be safe, if undertaken by well-trained teams.^1–3 Incorporating an Ambulance Service Critical Care Paramedic (CCP) into the team provides a seamless team dynamic during retrieval improving safety.⁴ The CCP helps to co-ordinate logistics, monitors patient and team safety and provides an additional resource for advanced life support during ECMO patient transport. In addition, they provide a link to decision-making and execution of patient movement systems and help access any additional resources within the Ambulance Service. Seamless team dynamics: The success of each retrieval depends as much on team dynamics as on the technical skills of the individual specialties represented in the team.⁵ In recognition of the central role of the Ambulance Service in ECMO transport, CCPs were included in the working group, training and development process for ECMO at Hamad Medical Corporation in Doha, Qatar. Based on their experience, they led the design of the retrieval service Mobile Intensive Care Vehicle and High-Acuity Patient Transport Trolley, helping to develop a platform and system that provides redundancy and limits the requirement for the ECMO team to carry additional backup equipment. In addition, they are part of activities like developing and participating in ECMO transport multidisciplinary simulations. Patient and team safety: Multitasking is a potential source of medical error.⁴ To allow each member of the team to focus on their specific tasks, the CCP takes a patient and team safety role, oversees the various aspects of the process, and ensures the timing of each process and completion of all tasks before movement. Each step in the patient preparation and movement is confirmed as per the safety checklist to ensure nothing is overlooked, and the risk of accidental snagging of lines, trip hazards and subsequent dislodgment of invasive lines or ET tubes is assessed at each step and thus minimised. Logistics: Successful cannulation by the ECMO team requires them to be self-sufficient and independent of the referral hospital for supplies. Prior to the ECMO team activation, the CCP is responsible to ensure that all equipment boxes, required for cannulation and patient care, are loaded into the transport vehicles, and the subsequent delivery of these boxes to the appropriate venue at the referral hospital. The CCP, being familiar with ambulance service equipment (oxygen, power sources, and electronic equipment placement within the ambulance), is there to ensure appropriate connection, trip hazard and snag risk reduction, and troubleshooting on route. ALS and clinical support: Critical Care or Intensive Care Paramedics have received additional training in Critical Care Transport and Aeromedical Medicine. CCPs within the Ambulance Service are able to provide advanced airway interventions (rapid sequence induction intubation), use multimodal mechanical ventilation and provide advanced cardiovascular life support – including infusion devices, inotropes, external pacing and mechanical chest compression devices. The CCP also plays a support role for the ECMO nurse specialist in preparing the patient for transfer to theatre (infusions, monitoring and ventilation), and becomes lead for the safe movement of the patient from the unit to the theatre, and later to the ambulance.

Extracorporeal membrane oxygenation (ECMO) is a highly complex, resource-intensive intervention. The use of veno-venous ECMO for the management of patients with acute, reversible lung failure has increased significantly over the past 10 years.¹ Advances in ECMO technology have resulted in the development of simpler, safer circuits, which are associated with fewer complications. Concomitantly with the clinical and technological changes in ECMO, the role of the ECMO specialist has evolved to manage patient–circuit interaction and the clinical needs of the patient, and to ensure safety of the ECMO circuit through continuous surveillance, assessment and troubleshooting, as well as preventing and managing circuit emergencies.

The Extracorporeal Life Support Organization (ELSO) defines the specialist as “the technical specialist trained to manage the ECMO system and clinical needs of the patient on ECMO under direction and supervision of an ECMO trained physician”.² Internationally, specialists come from a range of professional backgrounds including perfusion, nursing, physiotherapy and medicine. Each ECMO center, depending on the local needs and the availability of resources, in terms of both manpower and finances, has developed its own local specialist role, training program and staffing arrangements. A recent international survey confirmed that despite variation in funding and practice, the staffing arrangement implemented by most centers responding to the survey was the ECMO specialist nurse providing 24/7 ECMO care supported by perfusionist backup for the technical aspects of circuit management.³ Most centers responding to the survey reported a “two carers” approach to nurse staffing with the ECMO specialist nurse working collaboratively with the bedside nurse to ensure the safe co-ordination and management of a critically ill patient with a wide range of complex needs, including multi-organ system support and complex haematological, fluid and sedation management. In addition to meeting the complex needs of the patient, the ECMO specialist nurse is responsible for ensuring the safe management of the ECMO circuit, which includes the titration of blood flow and sweep gas flow to achieve oxygen and carbon dioxide targets, titrations of blood flows and sweep gas flows to facilitate exercise and the management of emergency situations should they arise. Understanding the management of both patient and circuit and the potential patient–circuit interaction is an essential component of the ECMO specialist nurse role. While other professionals have the educational background and technical skills to function in the role of the ECMO specialist, the advantage of the ECMO specialist with a nursing background is their ability to provide 24-hour care managing all aspects of patients' needs, including administration of medication, and to have the technical skills and knowledge to safely manage the ECMO circuit with perfusion backup for the more complicated aspects of circuit management.

As part of the National Health Strategy in the State of Qatar to improve the healthcare sector, the Critical Care Service in Hamad General Hospital (HGH) sets up an extracorporeal membrane oxygenation (ECMO) service within the Medical Intensive Care Unit (MICU) to enhance the care provided to critically ill patients. The new service demands a new technology and specific staff training in order to maintain high standards and safe care. Therefore, our initial investment was in training the team following ELSO guidelines and the purchase of ECMO equipment, especially for the adult population in our case.

In the State of Qatar, the first use of ECMO treatment as respiratory support was in May 2014. Our experience supports other research that this technique requires expert knowledge and skills to deliver best and safe practice.¹ We believe that this can be developed through regular practice and interaction at the bedside with patients and the ECMO technical equipment. Moreover, planning a robust ECMO education programme for the team is central to improving the quality of care and safety that we provide to these vulnerable patients. As part of our preparation process, in November 2013, six ICU nurses attended the ECMO specialist training course in London (UK). Since then, continuing educational programme has been established to train all the whole MICU nursing team focused on ECMO patient care. Several in-house training workshops and external re-training programmes were provided to nurses to develop their theoretical knowledge and technical skills with other members of the clinical team. In addition, we have performed simulation training that focused on multidisciplinary team, emphasising that teamwork is important and necessary for the care of such patients.

The ECMO specialised nurse who takes care of these patients is educated to provide specialised assessment, appropriate monitoring, and clinical reasoning interventions. In addition to manipulating the ECMO machine, understanding ventilation requirements and the patient's medical treatment is crucial to help the ECMO nurses detect the signs of deterioration early and intervene immediately. Therefore, naturally, the role of the ECMO nurse has expanded and tends to be developed with theoretical and technological developments.² The primary roles being close monitoring of alterations in blood flow and observation and maintenance of the circuit, and also an ability to assess the risks and assist with patient care.

We also compared the role of the ECMO specialist nurse versus the role of the perfusionist. We believe in the importance of both roles; however, we argue that when the ECMO nurse works alongside the ICU bedside nurse, the bedside care becomes more effective. Both nurses and perfusionists are able to understand the patient's overall condition and needs during the ECMO run, and have better interpretation regarding observed changes.³ The partnership promotes the continuity of patient care and allows better communication and support of the family as an aspect of care. This also increases the opportunity of bedside training and education and allows developing other nurses under supervision.

Overall, with proper planning, education, and structuring of ECMO care, we were able to obtain outcomes that are similar to those reported internationally. We aim to further improve patient outcome, especially regarding post-ICU discharge as part of holistic nursing care.

Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a highly specialized procedure relying on advanced technology, and specific attention is required to ensure safe operation. Who should or can accomplish this procedure is roughly defined by the ELSO guidelines.¹ Before starting an ECMO program, proper assessment of resource adequacy is crucial, and developing the structure for the program is mandatory. Recommendations can be found on the Extracorporeal Life Support Organization (ELSO) website.² Formal training of the whole team is desired, not to say highly recommended, to be able to provide the best patient care possible.

In the UAE, the need for an ECMO program was identified and formalized in 2009. Two batches of nurses were consequently sent to a high-volume ECMO center in Europe to acquire both theoretical knowledge and practical training in the waterlab to master the required technical skills. Observation of clinical shifts and daily routine for ECMO as well as sharing protocols and policies provided for a safe startup in the UAE. When volume increased and the need for more trained nursing specialists was identified, we developed a three-day specific training course: first day for general introduction, second day for veno-arterial (VA) ECMO, and third day dedicated to veno-venous (VV) ECMO. The course is backed by competency assessment during supervised bedside shifts.

Maintenance of task skills for our ECMO team is achieved during monthly waterlab sessions (de-airing, pump failure, etc.) when not only manual practice is done, but also case presentations and reviews are discussed, team debriefing is done, and lectures are delivered to ensure up-to-date knowledge and understanding. The importance of simulation for ECMO has been described,³ and we made it a focus of our specialist ECMO training. Our concept of training has since then spread over the Middle East area and South Africa.

In 2010, following the H1N1 swine flu pandemic,¹ five severe respiratory centers were commissioned in England. These were established to provide veno-venous ECMO (extracorporeal membrane oxygenation) for patients with refractory respiratory failure. Moreover, it was a condition set out by the commissioning body that each center would carry out a minimum of 20 cases per year to remain certified. The reality of the situation has proved somewhat different. At Guy's and St Thomas’ NHS foundation Trust (GSTT), the annual number of cases has steadily increased. In 2015, the Trust carried out almost 100 veno-venous ECMO cases.² These recent developments in available therapies for patients with refractory respiratory failure or cardiac failure meant that intensive care staff have been exposed to equipment with which they have been hitherto unfamiliar. Clinical perfusion scientists, previously “shackled” to the heart lung machine, have found themselves thrust into clinical, supportive, and educational roles, teaching both nurses and medical staff the ins and outs of the ECMO equipment and being an integral part of the multidisciplinary team retrieving patients from tertiary centers.

This increase in workload has necessitated an increase in staffing requirements across all specialties and an ever evolving training program. All ECMO specialist nurses are required to undergo a comprehensive training program.³ This serves to familiarize them with the equipment used, give them a good understanding of the nuances of the ECMO circuit, and train them to an accepted level of competency in ECMO emergencies. All water laboratory training is carried out by perfusion ECMO trainers. The competencies practiced have evolved to include emergency procedures that staff have encountered over the years since the service began. Since 2009, at Guy's and St Thomas’ NHS Foundation Trust, we have developed a robust and comprehensive training program to ensure that we have a large cohort of well-trained, confident, and competent intensive care staff who are able to handle any ECMO emergencies in a safe and timely manner.

ECMO specialist training involves water drills approximately 3 days a week prior to “signing off” and then mandatory updates every 3 months.³ ECMO consultants and medical fellows also undergo the same training and have yearly updates.

This presentation explains how the role of the clinical perfusionist at GSTT has evolved outside the operating theater environment in training, supportive, and clinical roles.

It also explains the role of the perfusionist in the retrieval process as well as outlining the training program and the three-day bi-annual high-fidelity simulation course developed by the multidisciplinary team in the Trust.

Intensive care unit-acquired weakness is a common sequela of critical illness and is associated with deficits in physical strength, functional performance, and associated health-related quality of life.^1–3 Early rehabilitation in the intensive care unit (ICU) is recognised as safe and feasible.^4,5 Maintaining and restoring musculoskeletal strength and function is recognised as an essential element of therapy in critical care.³

Active rehabilitation of patients with femoral access veno-venous extracorporeal membrane oxygenation (VV ECMO) has been deemed a high-risk procedure and to the authors' knowledge is not a routine practice. There is limited published literature describing the rehabilitation of those requiring VV ECMO in critical care.^6–8 The aim of this study was to explore the active rehabilitation of those requiring VV ECMO.

A retrospective review of the medical records of patients admitted to the Intensive Care Unit at Saint Thomas’ Hospital requiring VV ECMO was undertaken. Owing to the nature of this observational retrospective study, it was exempt from ethical approval. Data were collected for the period from 1 September 2012 to 31 January 2015. Details of rehabilitation sessions were recorded daily on the electronic patient record by physiotherapists. Data on the frequency and type of active rehabilitation, time on VV ECMO, and patient characteristics, including diagnosis, were collected. Active rehabilitation was defined as any of the following interventions: active range of movement, bed mobility, sitting on the edge of the bed, step transfers, mobilisation, and leg cycle ergometer use.

During the study period, 56 patients (30 male) who required VV ECMO were identified. Of them, 55 were cannulated bi-femorally and 1 required femoral and jugular cannulation. The mean (SD) patient age was 44.2 (14.3) years and the diagnoses requiring VV ECMO were: bacterial pneumonia (n = 19), viral pneumonia (n = 20), interstitial lung disease (n = 5), aspiration (n = 2), asthma (n = 4), tuberculosis (n = 2), cancer (n = 1), and non-pulmonary ARDS (n = 3). The mean (SD) duration of VV ECMO was 32 (37.6) days.

Twenty-six patients (46%) participated in active rehabilitation. A total of 808 active rehabilitation sessions were carried out. The active rehabilitation interventions provided were: sitting on the edge of the bed (n = 683); step transfer to chair (n = 112); and cycle ergometer use (n = 13). Rehabilitation sessions generally involved two physiotherapists, one bedside nurse, and one ECMO clinical nurse specialist. Thirty patients (54%) did not participate in active rehabilitation. The reasons recorded for this were either a deterioration in the patient's condition or the indication that the patient did not meet the criteria for active rehabilitation, e.g. Richmond Agitation and Sedation Score <  − 2 or >+2; neurologically inappropriate; or unable to follow commands. No rehabilitation sessions had to be terminated due to adverse events.

This small retrospective cohort study showed that active rehabilitation is feasible in patients receiving VV ECMO, the majority (98%) of whom were cannulated bi-femorally. However, not all patients are suitable for active rehabilitation. Previous local evaluation data have shown that care for those requiring VV ECMO is resource intensive, requiring increased numbers of staff and time compared with those requiring conventional mechanical ventilation. Sufficient resource is essential to ensure a safe, structured, and co-ordinated approach, which enables active rehabilitation for those requiring VV ECMO. Further research is required, investigating the physiological response to exercise in this patient cohort, to inform future practice.

The last couple of decades has brought a lot of changes in thoughts and technology in the domain of simulation-based healthcare education, ranging from emergency preparedness using screen-based technology to the practice of precise surgical procedures with computerised simulators with haptic and performance feedback.¹ There is a perpetually evolving educational and technological simulation continuum available to educators and clinicians promoting the practical and cognitive aspects of healthcare delivery. It is becoming an increasingly competitive market area from an industry perspective as more and more governments invest on technology to support educational initiatives and programmes in order to increase patient safety and standards of care.² Although industry strives to develop more advanced and realistic simulators, it is increasingly argued that it is not necessarily linked to better learning outcomes.³ For an effective use of simulation as an educational approach, a key aspect is to focus on selecting the approach that best addresses the intended learning objectives.⁴

Extracorporeal membrane oxygenation (ECMO) is a bridge therapy that can be separated into several phases from a training perspective such as patient selection, cannulation type (veno-venous (VV)/venous-arterial (VA)/VVA) and process (ultrasound guided cannulation, fluoroscopy cannula placement, securing the cannula, etc.), ECMO patient management and issues, and ECMO circuit issues.⁵ Overall, it is a complex system that all ECMO team members need to grasp at least theoretically in order to be able to support one another at any stage when a problem occurs. The safest way to become familiar with ECMO is to use simulation; however, at present, there is no single simulation platform that allows us to seemingly practise the succession of phases without transiting from one type of simulator to another type, and this is what we are trying to address. At best, and generally only for demonstration purposes (appropriate in that case), we are “simulating the simulation” as a form of deception.⁴ We currently pretend the ultrasound or fluoroscopy procedure by playing a video making observers believe that it is a live view or we ask them to imagine a colour change in the oxygenated blood, which might be a more significant gap.

Several teams have developed their own simulation solution⁶ to bridge a gap in the market or save on the purchase of prohibitive technologically advanced simulators that still have limitations. The simulations for ECMO training often either start post cannulation, whereby a team of learners has to fix a machine or patient issue during the ECMO run, or they concentrate on very technical skills such as cannulation insertion and water drills to practise circuit change. Both aspects are critical but still leave room for missed educational opportunities involving the whole team. Collaboration, generally without commercial ambition, between clinicians, educators, and engineers is now pushing the boundaries of ECMO simulation, making it a more affordable and common practice, but ultimately industrial support is generally required to “mass-produce” and distribute the solutions as we need them: functional, effective, and affordable, so the use of simulation for ECMO training can become a common practice and clinical teams are better prepared to initiate ECMO and deal with emergency situations. We hope to introduce ELSO very soon with a collaboratively developed simulator that meets all key training requirements.

Transfer and retrieval of extracorporeal membrane oxygenation (ECMO) patients is an aspect of a severe respiratory failure (SRF) service, which has generally low volume and high risk thus necessitating attention to particular safety measures. One of the key aspects in preventing patient safety issues and minimising risks of harm during the transportation of an ECMO patient is to develop a well-prepared multiprofessional team. This is the key area where simulation can play a very important role in various stages of a patient care pathway. There is much more to ECMO patient transfer and retrieval than one may suspect as it involves a referral, a lot of planning regarding activation, tasking, transporting, and disposing of the patient at the receiving facility,¹ all of which should be done collaboratively and maintaining open and high communication standards to prevent mishaps.

Simulation is used not only to develop important ECMO-related clinical or teamwork skills, but also to identify potential safety threats.² There are several modalities of simulation that can be used to prepare the clinical team and test processes put in place.³ The modality needs to be selected according to the specific learning objectives expected to be addressed. The full-scale high-fidelity approach is usually the most complex to orchestrate as it would most likely involve the team members, a scenario, a patient simulator or simulated patient (Actor), real clinical equipment, and the patient care setting (ambulance and potentially the referring and/or receiving facility). For this type of simulation to be beneficial to more people than the immediate participants, it requires the scenario to be audio/video recorded with live broadcast into an observation room, where other learners could follow the event and then be engaged in the debriefing with the participants. This does not constitute the ideal starting point of developing an ECMO transport simulation programme but is certainly an objective to achieve to really prepare a team on all aspects of “Mobile ECMO”.

Our recommendation is to start more simply and gradually increase the level of realism and complexity, so that teething issues can be identified and fixed in a more manageable manner. Process testing, new staff orientation, emergency procedures, and understanding of roles and responsibilities are elements that should initially be addressed in a low-fidelity simulation context such as Visually Enhanced Mental Simulation.⁴ It is also important to realise that a scenario, of low or high fidelity, can simply be a snapshot of the Mobile ECMO process, as it helps focus on key pre-identified learning objectives. The starting point might be to simulate how a referral is evaluated via remote patient assessment and how the team is activated. A different phase might involve starting at the point of transferring the newly cannulated patient from the operating table onto the ambulance stretcher and moving through the hospital and loading onto the vehicle (Fig. 1). A whole scenario could take place inside the ambulance during the journey with the ECMO patient. As in real life, the possibilities offered by simulation are endless but need to serve a real educational purpose.

Simulation training is increasingly being used to provide clinical care providers with experience and competence in high-risk procedures that occur infrequently. Implementation of standardized extracorporeal life support (ECLS) simulation training improves multidisciplinary team processes and increases efficiency of establishing ECLS. The initiation of ECLS is a highly complex process that requires technical proficiency of the surgeon and frequently depends on advanced crisis-management skills. Human performance simulation systems can be designed to simulate complex surgical procedures and used to teach and assess technical skills and refine team management protocols. Furthermore, high-fidelity simulators may enhance technical competency and improve patient safety.

The use of ECLS cannulation simulation has been shown to improve proficiency of surgical cannulation.¹ However, advanced surgical skills simulators are generally expensive and require extensive setup time.² The use of commercially available simulation systems that cost >$500 USD per use represents a significant financial burden for many centers that are establishing an ECLS program.

Affordable ( < $10 USD per use), silicone-based ECLS cannulation simulators can be created using commercial available materials. Custom ECLS cannulation simulators may be designed to fulfill specific educational and quality improvement requirements in unique hospital settings. High-fidelity simulation models may be used to accurately recreate anatomic structures. When integrated into a comprehensive ECLS simulation program, cannulation simulators create a more realistic learning environment that more accurately represents clinical scenarios encountered in the clinical management of ECLS patients, including cannula malpositioning events, bleeding, air entrainment, and hypovolemia. In addition, ECLS cannulation simulators can be used to teach and reinforce proper techniques in a standardized manner.

Commercially available, silicone-based materials may be combined to reproduce layers of skin, subcutaneous tissue, blood vessels, and boney. Percutaneous models utilize similar materials but require additional processing to render ECLS cannulation models ultrasound compatible. Cannulation simulators may be integrated with low-cost compliance chambers and tubing to reproduce circulatory physiology after initiating ECLS. Although each cannulation simulator may be used only once, the raw materials for custom-made simulators cost less than $10 USD each. This low cost for production allows centers to use them frequently and incorporate them into existing skills-based ECLS training programs.

Percutaneous cannulation simulators that are designed to reproduce the cervical cannulation with dual-lumen veno-venous ECLS cannulae are being developed by our team. These novel simulators will enable users to perform ultrasound-guided percutaneous reproduce cannulation using standard dual-lumen cannulae and echocardiography. This system will facilitate communication between proceduralists and echocardiographers.

Background: Extracorporeal membrane oxygenation (ECMO) is a high-complexity life-saving procedure riddled with mechanical complications that can place the patient in a critical state where fast and coordinated actions are required to avoid mortality. Thus, patients on ECMO are supervised round the clock by highly trained nurses and perfusionists. Currently, ECMO training programs include patient emergency simulations performed with different levels of success. Some training facilities use mannequins that have computer-controlled physiological parameters such as heart rate and oxygen saturation. The circuit parameters such as pressure are manually adjusted per scenario; air and artificial blood are manually injected to indicate problems such as air embolism, and hypovolemia.¹ Despite being realistic, using an actual ECMO circuit for simulation training purposes has disadvantages such as the use of expensive disposable equipment (oxygenation membrane), lack of oxygenation color differentials, and manual circuit adjustments and injections. Methods: This paper describes the design of a modular ECMO simulator centered on the use of thermochromic ink and instructor/clinician interface. The goal is to re-create the ECMO circuit and its functionalities using affordable, reusable, and extensible mechanisms that do not require the presence of a real ECMO machine. Results: Oxygenation is visually simulated by heating and cooling thermochromic ink, allowing it to switch between dark and light red. A replica of an ECMO machine's console interface allows manual adjustment of parameters wirelessly through a tablet instructor application. Furthermore, the visual and audio cues of mechanical complications such as access line shattering can be easily implemented using mechanical vibrators. See proposed simulator design in Figure 1. Conclusions: Advantages of the proposed system include the removal of the cost barrier and inconvenience of current ECMO simulators, while adding modularity and customizability to simulate a multitude of emergency scenarios, thus increasing the accessibility, fidelity, and versatility of ECMO patient management training.

Background: In medical simulation and training, blood is used to exhibit its different behaviors in context. In some cases, blood color differential is an imperative visual effect to ensure high-fidelity training and practical understanding. High simulation realism is usually achieved by using animal or artificial blood (which mimics some biological features of blood), which has high cost, requires disposable equipment such as oxygenators, and entails contamination or infection risks. Methods: A novel method for blood simulation is introduced. Using the thermal properties of thermochromic ink, its color can be altered by adjustment of temperature.¹ The unique red color of blood can be mimicked to a high fidelity using a custom hue of thermochromic ink. Then, by adjusting its temperature, realistic dark and bright red can be employed to simulate the low and high oxygen concentrations of blood, respectively. Although thermochromic ink currently does not imitate other blood properties such as viscosity and clotting, it has superior merits when color change simulation is a paramount priority. The major advantages of the proposed solution are reusability and cost. Thermochromic ink can be used for multiple simulations without any noticeable change in quality. It also costs significantly less than using actual or artificial blood. Results: Testing results of the proposed solution in extracorporeal membrane oxygenation (ECMO) simulation has proven its efficacy as a practical solution for medical simulations (see Figure 1). To prevent membrane occlusion because of the thermochromic ink, the latter needs to be pierced. In addition to ECMO simulation, other medical applications are being considered. Conclusions: The use of thermochromic ink in medical training provides reproducible color change simulation features of blood while maintaining significantly lower equipment costs and contamination risks as all circuit components can be reused.

Background: Transport of critically ill patients especially on extracorporeal membrane oxygenation (ECMO) is a real challenge. In India, more than 98% of cases requiring transfer are transported by road and less than 2% of cases are transported by air due to costs involved. As an institutional policy, and considering the safety and cost effectiveness, we have decided to develop mobile teams who can go to the patients, cannulate them, and stay during the course of the ECMO run. The mobile team program was established in 2010 when there were less than 10 ECMO centers in the country.¹Methods: First, the ECMO intensivist talks to the referring physician to confirm the need for ECMO, and then the coordinator settles financial issues and organizes the team, equipment, and travel arrangements. The team composed of the nursing staff, perfusionist, and intensivist² leaves within 2 hours of receiving the confirmation. Results: Retrospective analysis of patients managed on ECMO by our mobile ECMO team from August 2010 to August 2016 shows that we received 170 referrals. Of these, 132 calls were confirmed, but we initiated ECMO in 121 patients only (Table 1). We visited the eight Indian states, roughly 20 cities, and more than 50 tertiary care hospitals.³ Only four patients were in secondary care centers and were transferred to nearby tertiary care units after initiation of ECMO and stabilization. The average time from call confirmation to initiation of ECMO was 8 hours, with a minimum of 4 hours and a maximum of 14 hours, mainly depending on the availability of a transport modality.

There was not much of mortality difference when ECMO is done in an ECMO center or when it is done by an expert mobile ECMO team out of the hospital.

Problems encountered included:

1. □ Forgetting part of the equipment or disposables in four cases, resulting in a 4-hour delay to ECMO initiation;
2. □ Getting adjusted to a different environment, different culture, and language;
3. □ Coordinating team work with an entire new team at the referring facility.

Background: The mission of the King Faisal Specialist Hospital and Research Center (KFSH&RC), Riyadh, Saudi Arabia, is to provide safe and effective care to patients. KFSH&RC is a 985-bed hospital that started its ECMO program in 2004. Based on the ELSO guidelines, KFSH&RC invested in establishing a successful ECMO program by upgrading the logistic, team composition, quality, and educational structure in the organization.¹Methods: The following key components were utilized including institutional commitment, to build a strong program block by block relying on the support of the following team structure: physician champion, multidisciplinary leadership, nursing-led ECMO program, ECMO coordinator, ECMO specialist, and organized training² that includes low- to high-fidelity simulations.³Results: The KFSH&RC ECMO nursing-led program caters for a diverse patient population and provides support in the following areas: bridge-to-transplant program such as heart and lung; adult and pediatric patients, including acute lung injury/acute respiratory distress syndrome (ARDS); and cardiac surgeries and congenital anomalies. In addition, KFSH&RC is establishing a referral and transport system to acknowledge our center as supporter to the surrounding organizations to refer patients.

In 2014, KFSH&RC provided 30 ECMO supports, of which 26 were for cardiac support. A total of 39 ECMO supports were provided in 2015, of which six were post-lung transplant and three related to acute lung injury.

A total of 66 patients were treated with veno-arterial ECMO with a survival to decannulation of 56.6 and 46.15% in 2014 and 2015, respectively.

With recent advancement, KSH&RC has initiated the extracorporeal cardiopulmonary resuscitation (ECPR) life support program and activation of code ECMO services under the facility with unified code pager and team. Conclusion: The results highlight that a developed nursing-led ECMO program can improve patient outcomes and provide safe transport services.¹ Further study is required to determine whether ECMO patient outcomes will continue to improve with less complications and good survival rate.

Background: Although there have been many developments related to specific strategies for treating patients after poisoning exposure, the mainstay of therapy remains symptomatic and supportive care. Objectives: To highlight different techniques of ECMO, indications, contraindications, and some case reports of its use in patients with poisoning. Methods: PubMed and the Cochrane database were searched using the terms “extracorporeal membrane oxygenation”, “ECMO”, and “poison”. Results: Two types of ECMO are used: veno-venous ECMO (VV-ECMO) and veno-arterial ECMO (VA-ECMO). Indications: As the clinical impact of intoxication is often temporary, ECMO can be used as a “bridge to recovery”. Contraindications: Absolute contraindications are uncontrolled coagulopathy and severe intracranial bleeding, which precludes the use of anticoagulation therapy. Relative contraindications to ECMO include advanced age, severe irreversible brain injury, untreatable metastatic cancer, and severe organ dysfunction.

In different case reports, ECMO has been successfully used in treating cases of aluminum phosphide poisoning,^1,2 hydrocarbon aspiration,³ and calcium channel blocker toxicity.^4,5

Patients with aluminum phosphide poisoning treated with ECMO recovered very well and were safely discharged from hospital.²

There is evidence that pulmonary parenchymal tissue can recover from hydrocarbon pneumonitis, but the degree of injury and recovery is variable. In the Extracorporeal Life Support Organization Registry, 19 children with hydrocarbon pneumonitis were treated with extracorporeal membrane oxygenation during 1985 to 1994 and 68% survived compared with the 52% overall survival of 883 pediatric cases who had a diagnosis of a respiratory condition.³

For calcium channel blocker toxicity, ECMO was an efficient and relatively safe last resort therapy in critically ill poisoned patients (i.e. cardiac arrest and refractory shock) who did not respond to conventional therapies.⁴Conclusions: Recently, ECMO equipment has improved considerably, rendering it more biocompatible, and it has been used more frequently as an assist device for patients needing oxygenation as well as circulatory support. ECMO is considered a bridge for patients who are severely poisoned with acute respiratory distress syndrome (ARDS) or refractory circulatory shock.

Background: Streptococcal toxic shock syndrome (STSS) is a life-threatening illness associated with invasive or non-invasive group A streptococcal (GAS) infection with rapid progression and a high mortality rate.¹ There are limited data on the use of extracorporeal membrane oxygenation (ECMO) in toxic shock syndrome (TSS) with few case reports in adults with TSS-induced cardiac dysfunction^2,3 and a pediatric series of severe group A streptococcal infections from Australia.¹ The mode of ECMO was veno-arterial (VA) in all these case reports due to significant myocardial failure. According to our knowledge, we present the first reported case of STSS in a child managed with veno-venous (VV) ECMO. Methods: Clinical presentation, investigations, management, and outcome of the child was followed from the health records. The study was exempt from ethical approval. Detailed search of the published medical articles did not reveal similar publication. Results: A 13-month-old, previously healthy child presented in a state of shock 3 days after sustaining a burn wound to the dorsum of the left hand. Blood and wound cultures were positive for Streptococcus pyogenes, and there were signs of multiorgan failure, satisfying the Center for Disease Control (CDC) criteria for STSS. Acute respiratory distress syndrome (ARDS) developed on day 2 of presentation, accompanied by hemodynamic instability requiring support with multiple inotropes with a modified inotropic score of 117.5. Echocardiography revealed a structurally normal heart with ejection fraction of 40%. Hemodynamics were found to be associated with blood oxygen saturation. Blood pressure increased on increasing SpO2 with no change in the inotropic support. VV ECMO was initiated when the oxygenation index reached 68 in spite of being on inotropes. Inotropic support was weaned and stopped after 12 h. The child remained on ECMO for 7 days before being successfully decannulated. Conclusions: As the underlying cause of STSS is frequently treatable, ECMO may be considered early in the management of these cases when conservative measures fail. Presence of inotropic support should not be considered as a contraindication for VV ECMO in pediatric STSS.^4,5

Background: Survival following extracorporeal membrane oxygenation (ECMO) has steadily improved over the past decade owing to better knowledge and training.^1,2 The objective of our study is to identify the predictors and trend of in-hospital morbidity and mortality during our initial experience. Methods: After obtaining an DSREC (Dubai Scientific Research Ethics Committee) review and exemption, we collected the clinical data of patients from May 2013 to November 2016 and analyzed for baseline characteristics, indication, type, undergoing cardiopulmonary resuscitation (CPR) or not, duration of ECMO treatment, morbidity, and mortality. Results: A total of 24 adults received ECMO (18 M/6 F), of which 22 were supported with veno-arterial (VA) ECMO and the remaining were converted from VA to veno-venous (VV) ECMO during the course of their treatment. There were 8 (6 M/2 F) survivors (30%) with two bridged for left ventricular assist device (LVAD) and one for heart transplant. The mortality pattern as shown in Figure 1 shows a consistent improvement of more than 50% from mid-2015. Weaning was overall successful in 30% of surgical and 38% of medical patients. CPR was necessary in 12 patients, none from the survivor group. The minimum to maximum duration of ECMO was 53–483 hours in the survivors versus 2–528 hours in the non-survivors, of which 8 (50%) survived less than 24 hours on ECMO. The most frequent complications were bleeding from catheterization or surgical site (58.3%), renal failure (29.1%), GI bleeding (20.8%), and leg ischemia (12.5%). Two patients had raised bilirubin and one altered response to medication, resulting in hypertension and bleeding.³ The percentage among survivors to non-survivors with reference to bleeding was 38% vs. 69%, leg ischemia 0% vs.18%, renal failure 12.5% vs. 37.5%, and GI bleeding 12.5% vs. 31.2%.Figure 1.  Mortality rate of ECMO patients at Dubai Hospital from 2013 to 2016.

Conclusions: In spite of a steep learning curve, a remarkable improvement in the reduction of mortality was achieved during the latter half of the term possibly due to better understanding, education, and training. The survival during this interval compared well with the previous results and Extracorporeal Life Support Organization (ELSO) reports.^4,5 The percentage of complications and the number of patients requiring CPR were less in the survivors' group, indicating that early referral and prevention of ECMO complications are equally important. These two elements could be the key to our success in the management of these patients.

Introduction: Bleeding is the most frequent complication in patients receiving veno-arterial or veno-venous extracorporeal membrane oxygenation (ECMO).^1,2 Recombinant activated factor VII (rFVIIa) has been used in these patients with conflicting results. We describe our experience in pediatric patients on ECMO who received rFVIIa for refractory bleeding in whom conventional management was not successful. This conventional management to stop the bleeding included adjustment of anticoagulation medications, substitution of clotting factors and platelets, and exclusion of surgical cause of bleeding.^3–6Methods: We reviewed the medical records of all the patients who underwent ECMO in our PICU from January 1999 to July 2014 and received rFVIIa for refractory bleeding. Clinical characteristics, demographics, type of congenital heart disease, surgical correction, bleeding, thrombotic complications, mortality, and rFVIIa dose were documented. Being based on retrospective hospital data, this study is exempt from IRB approval. Results: A total of 123 patients underwent ECMO in our unit since 1999, and five of them received rFVIIa for persistent refractory bleeding during veno-arterial ECMO. All of them had corrective cardiac surgery for congenital defects before installation of ECMO. Bleeding dramatically decreased in four patients (Figure 1), without a major thrombotic event. In one patient, bleeding remained significant and he developed left pulmonary artery thrombosis confirmed by cardiac catheterization, and this patient died. Four patients survived at 48-h after withdrawal from ECMO.Figure 1.  Rate of bleeding in the 3 h prior to the dose of rFVIIa and the 3 h after the dose of rFVIIa.

Conclusions: rFVIIa use for refractory bleeding in patients on ECMO was efficacious in four out of five patients in stopping bleeding without major thrombotic events. While the use of rFVIIa seems effective, indications for its use, modalities of administration, and precautions to be taken need to be better defined.

Background: ECMO has been successfully used to support patients with trauma-induced respiratory failure. Here, we present the successful application of ECMO in a patient with life-threatening polytrauma following a road traffic accident complicated by severe acute respiratory failure.¹Methods: This is a retrospective case report, and approval for presentation has been obtained from the department and can be submitted upon request.

The patient was 20 years old and found at the roadside after being hit by a vehicle. The patient was rushed into the ED by an ambulance, where the trachea was intubated due to the low Glasgow Coma Score. A trauma CT scan revealed severe head injury with possible diffuse axonal injury. The scan also confirmed fractures of the mandible, left transfers process of L3,4,5 and first sacral vertebrae, pelvis and comminuted fracture of the right tibia and fibula. The patient was admitted to the Trauma Intensive Care Unit (TICU). A subsequent head CT scan showed multiple hemorrhagic contusions and cerebral edema. The patient underwent ventriculostomy and intracranial pressure (ICP) monitoring insertion, and was treated by neuroprotective interventions including sedation, paralysis, hypothermia, and hyperosmolar therapy. Unfortunately, the patient developed ventilator-associated pneumonia (VAP), which resulted in severe ARDS. Despite appropriate antibiotics, lung-protective ventilation, rescue inhaled nitric oxide, and high-frequency oscillatory ventilation (HFOV), the patient continued to have severe respiratory failure. The patient was evaluated for rescue ECMO despite severe neurological injury.² Veno-venous ECMO was initiated using percutaneous femoral–jugular configuration with a 25 French access cannula in the inferior vena cava and a 21 French return cannula in the right internal jugular vein.³ Throughout the ECMO run, no systemic anticoagulation was used, except the initial 5,000 units heparin administered during cannulation.⁴ Percutaneous tracheostomy was placed and the patient was weaned off ECMO over the next week. ECMO decannulation was performed on day 7 and decannulation of tracheostomy on day 18 of ICU admission with good neurological outcome, and transferred for rehabilitation. Conclusion: ECMO may be an acceptable therapy for patients with profound respiratory failure secondary to trauma and intracranial pathology, contraindicating the use of systemic anticoagulation.^1,5 Neurological prognosis is difficult to predict in patients with intracranial pathology and multiple organ dysfunction.^2,6 Axonal injury based on imaging studies may not predict neurological recovery in individual patients, and salvage therapies, including ECMO, should not be denied in these patients.^6,7

Background: Intensive care patients are at high risk of increased mortality and morbidity and longer hospital stay secondary to prolonged immobility.¹Methods: Early mobilization and therapeutic exercises reduce delirium and days on mechanical ventilation, shorten ICU and hospital stay, improve physical function, and reduce healthcare costs.^2,3

Mobilization and exercise can be safely implemented for patients receiving mechanical ventilation and continuous hemofiltration.^4–6

The incidence of physical deconditioning and other ICU-acquired morbidities are very high among patients with severe respiratory failure. Protocol-directed progressive early mobilizations of these groups of patients are safe and feasible even if they are on ECMO.^7,8

Our ECMO patients are evaluated daily to assess hemodynamic and respiratory stability, and suitability for mobilization and exercise program. Assessment includes cardiovascular parameters, ECMO circuit, APTT and arterial blood gas results and targets, sedation level, muscle relaxation use, medical and nursing plan for the day, recent chest X-ray, and ECMO settings and recent changes. Figure 1 illustrates the continuum of early mobility protocol in the Hamad General Hospital Medical Intensive Care Unit (ICU). The mobilization level and exercises determined are based on these assessments. Adequate patient preparation is essential before initiating any exercises or mobilization.

Patient safety is a primary goal and to achieve this, the multidisciplinary ECMO team pays due attention to intravenous lines, ECMO cannulas, and monitoring devices in place. Maintenance of adequate oxygenation and hemodynamic stability has to be assured throughout mobilization and rehabilitation therapy.

The team must ensure that adequate ECMO tubing slack is available to allow safe movement of the patient without undue strain on the circuit, and a dedicated team member, typically a perfusionist or ECMO nurse, will be in charge of monitoring the circuit. ECMO sweep gas and blood flow rates as well as supplemental oxygen may all be increased. Hemodynamic or respiratory instability should be assessed immediately and the session can be stopped without delay. Conclusions: Goal-directed slow progressive early mobilization of ECMO patients is feasible and safe when undertaken by a multidisciplinary team. As evidence supports the implementation of rehabilitation in the ICU, particular attention should be made to incorporate mobility and exercises in the daily routine of ECMO patients.⁷

Background: Awake extracorporeal membrane oxygenation (ECMO) in conscious, extubated patients has been used successfully in adults and children, primarily as a bridge to lung or heart–lung transplantation and recovery from refractory cardiogenic shock.^1,2 However, this strategy has been reported only as an exceptional measure in neonatal patients. We present a case of neonatal respiratory failure where an infant was extubated while on ECMO and managed without invasive ventilation. Methods: The clinical details, laboratory investigations, management, and outcome of the patient were reviewed from the electronic health record. This single-patient case report was exempt from the IRB at our institution. The photograph was used with parental consent. Results: The patient was a 2950 g product of an uncomplicated term pregnancy, whose postnatal course was complicated by neonatal acute respiratory failure, pulmonary hypertension, and bilateral pneumothoraces. The infant was managed on veno-arterial (VA) ECMO. Despite the presence of thoracostomy tubes and rest ventilator settings while on VA ECMO, pneumothoraces persisted. On ECMO day 2, the patient was electively extubated to a humidified high-flow nasal cannula. At 96 h after extubation, there was complete resolution of bilateral pneumothoraces. The infant achieved adequate lung recruitment with only spontaneous respiration and underwent decannulation on ECMO day 6. He was electively intubated for decannulation and extubated 12 h later. At 5 days post-decannulation, the infant was weaned off respiratory support and discharged home 4 weeks after decannulation after weaning from sedation and establishing successful oral feedings. Conclusions: Awake neonatal ECMO appears to be safe and effective and may offer significant advantages over traditional management in certain clinical scenarios, particularly in cases of persistent air leak. To our knowledge, there have been no published studies comparing awake ECMO with traditional (ventilated) ECMO in neonatal patients, although we have successfully managed five patients in our neonatal intensive care unit using this strategy for various clinical indications. Extubation offers the advantages of mitigating ventilator-associated pneumonia (VAP) risk and tracheal trauma, facilitating resolution of air leak, de-escalating sedation, and promoting family bonding. Prospective comparison trials are warranted.

Background: Extracorporeal membrane oxygenation (ECMO) has evolved as a treatment option for patients having rev ersible severe respiratory failure who are deter iorating on conventional ventilation.^1,2 We describe our experience with a patient who received ECMO for refractory hypoxemic respiratory failure due to community-acquired pneumonia associated with systemic lupus erythematosus (SLE). Methods: This is a retrospective case report for which approval for presentation has been obtained from the administration of the department and can be submitted upon request. Our patient was an 18-year-old female with a long history of SLE with nephritis who was recently started on immunosuppression, admitted with azotemia, fluid overload, and respiratory failure, and initially improved with fluid removal.³ Her respiratory status later worsened with saturations in the low 80s despite 100% FiO2 and a positive end-expiratory pressure (PEEP) of 14 cm H2O. She had a trial of prone positioning together with PEEP optimization, but her condition continued to deteriorate.⁴ The patient was evaluated for rescue ECMO therapy as a life-saving measure.⁵ Both femoral veins were cannulated, and when ECMO started, there was immediate improvement in oxygenation. The ventilator was soon switched to the pressure control setting (PEEP 10 cm H2O/inspiratory pressure 10 cm H2O/rate 10 cycles/min) with 40% FiO2. The patient's hospital stay was complicated by lupus-induced thrombocytopenia, resulting in our decision to run heparin-free ECMO. She was decannulated after 25 days of ECMO without receiving any systemic anticoagulation. Results: The patient improved and was decannulated, extubated, and discharged from hospital, with no residual lung comorbidity. Conclusions: ECMO without any systemic anticoagulation is an acceptable therapy when there is profound respiratory failure secondary to infection in an immunosuppressed patient.⁵ Most of the literature reviews have already shown the good application of ECMO in SLE-induced diffuse alveolar hemorrhage.⁶ Our case report presents a promising application of rescue ECMO therapy in a lupus-induced immunosuppressed patient with pneumonia, acute respiratory distress syndrome,⁷ and thrombocytopenia.

Background: One of the Millennium Development Goals is to reduce childhood mortality by two-thirds by 2015 (www.un.org/millenniumgoals). This study was conducted to identify the clinical profile and pattern of disease, and to find out the commonest cause of mortality and morbidity of neonatal ICU patients in a Nepali teaching hospital. Methods: A retrospective study was conducted at a grade IIIA NICU in the Neonatal Intensive Care Unit of a tertiary care teaching hospital in the eastern part of Nepal to identify the clinical profile, pattern of disease, and outcome of patients. The data of all neonates were analyzed retrospectively from January 2012 to December 2012. IRB approval was exempted. Results: A total of 361 neonates were admitted in NICU during the study period, 65.6% were male and 34.4% were female. Of these neonates, 86 (23.8%) were admitted with a diagnosis of prematurity and 73 (20.2%) were admitted with a diagnosis of birth asphyxia. One of the commonest causes for birth asphyxia is the meconium aspiration syndrome. Among the neonates with birth asphyxia, 40 (54.8%) were in hypoxic ischemic encephalopathy (HIE) III, 20 (27.4%) in HIE II, and 13 (17.8%) in HIE I. The common causes for admission in NICU were sepsis (n = 118, 32.6%), prematurity (n = 86, 23.8%), and birth asphyxia (n = 73, 20.2%). The overall mortality was 20.2%. Among the ventilated cases, the mortality was 36.1%. In the non-ventilated cases, it was 13.25%. If two-thirds of the cases requiring ventilation would have survived thanks to a different treatment approach, we could have reduced our overall mortality to 15.7%. Conclusions: The neonatal phase is a very vulnerable period with a high risk of mortality and morbidity, most of which are preventable with good obstetric and subsequent neonatal care^1–2. Most of the NICU patients under mechanical ventilation may need advanced ventilation to reduce mortality further. There is a need for timely referral to a tertiary care hospital from peripheral and non-tertiary set-ups to prevent and control neonatal mortality and morbidity. The mortality rate can be reduced by giving advanced care such as extracorporeal membrane oxygenation (ECMO) to patients who fail to improve from conventional mechanical ventilation.³

The utilization of extracorporeal membrane oxygenation (ECMO) to support patients with respiratory and/or cardiac failure continues to increase annually, with growth primarily in the adult population.¹ The life-saving therapy requires a multidisciplinary team to deliver the highly technical treatment with clinical competency in three areas: cognitive knowledge, technical skills, and behavioral skills. The use of traditional methods of education in which knowledge is transmitted through lectures and reading materials results in limited retention and ability to apply learned information in the clinical setting.² Adult education theory promotes alternative methods of learning, which organizes abstract information through association with previous experiences and leads to mastery of knowledge through functional application.³ The educational tool which supports this approach to learning is simulation.

Multiple forms of simulation have been used to enhance ECMO education. These include task trainers, virtual patients, standardized patients, human patient simulator, and a combination of these models. High-fidelity ECMO simulation (fidelity on the ECMO circuit versus patient manikin) has been successfully implemented in many clinical centers and reported to have a greater impact on education in the three areas of required competency in ECMO care.^4,5 Using simulation in ECMO training, the technical aspects of routine and emergent care can be rehearsed and mastered. Scenarios can be designed with various objectives and can promote the critical thinking aspects of bedside management of these medically complex patients. Incorporating the lessons learned from the airline industry for effective teamwork in a crisis situation, Crew/Crisis Resource Management (CRM) proficiencies embedded in a scenario, also assists in the development of behavioral skills required for effective communication across multiple disciplines.⁶

The use of ECMO simulation incorporates all elements of adult learning theory and improves the learning experience of the clinical staff. The goal of this improved educational experience is to improve quality and safety in care, and ultimately, improve clinical outcomes.

This is a case presentation of a 16-year-old male patient who arrived in South Africa after a trip to Hong Kong. He had been on a sports tour. Previously, he had been healthy with no past medical history of note. Days prior to leaving Hong Kong, he had contracted a flu-like illness. On arrival at O.R. Tambo International Airport (in South Africa), he was showing signs and symptoms of deterioration in condition, including fever, coughing and confusion. He was tended to by paramedic staff at the airport, who transported him urgently to our emergency department (ED) by ambulance. He was extremely short of breath. At the time of arrival in the ED, he was not intubated. He had a quick sequential organ function assessment (qSOFA) score of 3, with a lactate level >2 mmol/l.

The patient's condition was found to be critical, with marked deterioration in his respiratory and haemodynamic status. Soon after arrival, he required resuscitation in the ED. With no return of spontaneous circulation (ROSC), despite aggressive resuscitation, it was decided to place him on veno-arterial extracorporeal membrane oxygenation (VA ECMO). He was cannulated femoral–femoral with a 23-French venous catheter and a 15-French arterial catheter. Extracorporeal cardiopulmonary resuscitation (ECPR)¹ was performed promptly with successful return of spontaneous circulation. Due to poor saturation and oxygenation on blood gas, veno-venous (VV) ECMO was concomitantly performed. An 18 French Avalon catheter was separately placed in the internal jugular vein. This required a second ECMO machine to be used, as his clinical condition was deemed to be too unstable to create a hybrid circuit (VA-V). The patient had good oxygen saturation levels with a satisfactory blood pressure, and hence, he was transferred to the Intensive Care Unit (ICU).

Appropriate clinical samples were sent (with a request for urgent influenza PCR test to be performed on a tracheal aspiration specimen), and a positive result was found for influenza B. As it was unusual for influenza B to result in such a severe septic shock clinical picture, a bacterial co-infection was suspected. He was started on empiric therapy with broad spectrum antibiotics, including Linezolid, to cover for Staphylococcus aureus infection. Urgent blood Gram stain confirmed Gram-positive cocci, and soon thereafter, a blood culture positive for Staphylococcus aureus was confirmed.

Despite comprehensive treatment, pharmaceutically and mechanically, the patient continued to deteriorate. All parameters did not improve. Discussions were held regarding the central cannulation² and it was decided to commence with the same immediately. The patient was transferred to the theatre for the placement of central ECMO. Despite successfully placing the cannula in the right atrium and aorta, the patient's condition did not improve, and flow³ and haemodynamics were deemed insufficient to maintain brain function. The patient had a cardiac arrest and was not further resuscitated in the theatre.

Profound septic shock was in keeping with Staphylococcus aureus septicaemia and toxic shock syndrome.⁴ This case was an example of combining full medical therapy with mechanical intervention, i.e. ECMO.

Note: Permission to report this case was obtained from the Hospital Administration on the basis that patient confidentiality was maintained. In addition, verbal consent was obtained from the patient's parents to present this case as a learning tool, also on the condition that anonymity is maintained.

Dr Robert Bartlett is the pioneer surgeon credited for moving extracorporeal life support (ECLS) from the operating room to the intensive care unit (ICU), where the therapy has given hope for survival to thousands of neonates, children, and adults with respiratory and/or cardiac failure. Dr Bartlett describes the ECMO timeline as ECMO 1 (1990–2008) and ECMO 2 (2008–present).¹ The first phase of ECMO utilized individual components, designed for other uses, assembled together to provide ECLS at the bedside. Circuit monitoring used equipment engineered for other functions, and hence, the need for clinical personnel to oversee the delivery of this technologically complex therapy was extensive. ECMO 2, the second phase in which we are currently practicing has been revolutionized by low-resistance oxygenators, centrifugal technology, and bicaval catheters that can be placed using the Seldinger technique.² ECMO systems are now integrated, simplified, self-monitoring, and self-regulating, and have allowed for changes in the bedside model of care. A remaining challenge in providing ECLS is the systemic inflammatory response (SIR) induced by blood exposure to the artificial circuitry. The renal, pulmonary, and neurologic dysfunction seen after cardiopulmonary bypass (CPB) has been attributed to the SIR.³ The development of miniaturized extracorporeal circuits (MECC) with reduced tubing length, smaller oxygenators, biocompatible coatings, and fewer components are hypothesized to reduce the blood–foreign surface contact area, and hence, reduce the SIR. A possible breakthrough in the reduction of a SIR may allow transition into the next era of ECMO care.

Published reports have shown laboratory evidence that MECC application in CPB blunts the systemic inflammatory response with decreases in C-reactive protein (CRP), leukocytes, and cytokines (IL-6, IL-8, TNF), SC5b-9 (an inflammation complement complex), and activated neutrophil factors.⁴ In studies evaluating the clinical outcome of patients who have undergone ECLS with MECC, the benefit remains debatable with respect to 30-day mortality, neurocognitive disturbance, cerebrovascular events, renal failure, and myocardial infarction. In the outcome criteria of ventilation period, hospital stay, and ICU stay, MECC showed benefit.⁵ In the meta-analysis report by Harling et al., the authors found other clinical benefits with MECC, which included the reduction in blood production transfusions.⁶

The use of MECC for prolonged ECLS has not been extensively reported in the literature, and may be related to the functional longevity of the oxygenator. A small number of case reports have been published and a conclusion cannot be made from the current level of MECC experience for its use as an alternative equipment option in ECMO. Further research in this area will be necessary before MECC can be clinically adapted for ECMO.

Introduction: At the start of every new extracorporeal membrane oxygenation (ECMO) center, safe and effective use of ECMO therapy requires unique institutional resources and strategies to optimize patient care and outcome. This is a report of the initial experience at the first ECMO center in Lebanon; the course of five patients is described, focusing on the monitoring considerations.^1–4 Lessons learnt help improve patient ECMO care, safety, and outcome. Methods: Two adult cases treated with veno-arterial (VA) ECMO for refractory cardiac failure, and three neonates (two veno-arterial and one veno-venous (VV) ECMO) treated for refractory respiratory failure were retrospectively reviewed with special focus on both medical and mechanical complications. Results: All complications were recognized early and managed successfully. The main complications encountered were: limb ischemia (1 patient), bleeding and clotting requiring circuit change (2 patients), overflow and aortic regurgitation (1 patient), hemolysis (1 patient), acute kidney injury and fluid overload (3 patients), patient–ventilator asynchrony, and technical problems (mainly related to cannula's positioning) (2 patients). In some instances, diagnosis was limited or delayed due to unavailability of monitoring tools, mainly multimodal coagulation studies. All five patients were successfully decannulated. Two patients died following decannulation and three patients were discharged home; one among them needed to go to a rehabilitation center for a few weeks before going back home. Conclusion: Optimal monitoring tools such as cerebral and somatic near infrared spectroscopy, echocardiography, head ultrasound, and multimodal coagulation studies (activated clotting time, aPTT, antiXa, thromboelastogram, and others) would allow for early recognition of complications. This would prevent or at least help anticipate catastrophic events, thus minimizing the impact of life-threatening complications and improving the quality of care and outcome. Furthermore, organizational structure with investment in training and technology is needed to optimize patient care.⁵

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 mannequin's 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.

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 system's 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.