rapid deployment for e-cpr

8/14/2019 Rapid Deployment for E-CPR

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RAPID DEPLOYMENTfor

E-CPR

Organizing the Chaos

Ruth Ferroni, BSN, RN

E-CPR

ECMO: ExtraCorporeal Membrane Oxygenation

Rapid deployment infers a swift, timelymaneuver.At CNMC, we define Rapid Deployment as aprocess using ECMO therapy to rescue apatient who is in cardiopulmonary arrest and

unresponsive to conventional resuscitativemeasures.Desired time: 30 minutes from CPR event toachieving full ECMO support


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E-CPR

Advantages:

Offers quick, life saving rescue therapy forpatients in cardiopulmonary failure

Disadvantages:

Requires highly trained healthcare

personnel from many resources within thehospital

QUESTIONS TO ASKOURSELVES

Who is doing what?

How long does it take

to safely prepare and cannulate

a patient for ECMO support?

How quick do we need to be?

How do we accomplish this?


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PLAYERS

HEADLINERS.

PATIENT

IntensivistSurgeons/ surgical teamICU nurses and respiratory therapistsECMO circuit primers

SUPPORTING CAST

Unit ancillary staffBlood bankPharmacy

PLAYERSIs anyone leading?

Is anyone listening?


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Roles

ESTABLISH ROLES with DUTIES:

Physician Team Leader

Cannulating Surgeon

Charge Nurse

Bedside Nurse

Medication Nurse

Respiratory Therapists

Circuit PrimersAncillary Staff

Rapid Deployment ECMO kit on RD cart

One bag for Pt. One for Circuit

One Topical Kit including:

Gelfoam, Surgicel

Thrombin 20,000u

Bacitracin Oint.

Chest irrigation kit in MED fridge:

Antibiotics for irrigant; mix & add to

500 ml warmed saline (in Warmer)

Place patient label on medication charge

sheet from cart. meds used on sheet.Take to MAIN pharmacy for kit replacement.

Return unused medications from ECMO to

credit bin with patient label

RestockECMOmedson cart/in frid e

Medications and Saline

Bovie Pad

Shoulder roll

Med line

A.line access

Pacer attached and outside field

Extra suction gauge and cannister

Med RN to prepare and give priorto

cannulation of vessels: with MD re: time and doseHeparin 50 units/kg

Paralytic (with sedative)

Patient Prep

Hats and masks for all

Sterile gown, gloves for set-up person

Open blue custom pack on table

Prep kit, gown aside for surgeon

Place surgeons gloves near gown

Remove basin and unwrap on mayo stand

Remove bovie pen, yankauer and sx tubing

from basin; place on sterile field

Stack gowns and drapes in order

Make room for instruments

Ask someone to remove lid from instrument

case (maintain inside sterility)

Pull trays from instrument case

Add sutures, tourniquet pack and scalpel

Cover with sterile drape if waiting for surgery

Cannulation Set-Up

Communicate with MD and UCA

#2222, weight, room location

CLEAR the room

Move equipment in

Rapid Deployment activated

Charge Nurse/RN Role

Work with team leader to fulfill multipl e roles

Secure airway issues; hand off to RT

Assess IV access. Establish as necessary

Insure adequacy of CPR technique

Complete ECMO orders

Assist surgeon until OR staff arrives

MD assistant to CODE Leader

Recommend cannula size/ site to surgeon

Ensure paralytic/sedation given BEFORE

vessel cannulation

Order heparin dose; usually 50 units/kg

Communicate with surgeon: Give heparin just

before vessel cannulated

Assess circuit readiness with primer;

determine if time to prime with blood

Review pump ABG and ACT if circuit blood

primed

Cefazolin 25mg/kg as soon as practical

Complete Rapid Deployment Orders

Cannulation Procedure and Meds

2 units RBC < 15 kg

4 units RBC > 15 kg

Sign emergency release form for

uncrossmatched blood if emergency

Order Blood

Ensure adequate CPR

Call for Rapid Deployment

Order staff to prep opening of Chest

Ensure closed-loop communication with

Charge RN, UCA and recorder

Initiate Resuscitation

MD Rapid Deployment Team Leader Role

Remain in room to assist as needed

During cannulation

Clear area of unnecessary equipment behind

bedspaceStabilize ETT/vent tubing prior to draping of

patient. Place stent around ETT

Organize suction source and ambu bag for

sterile procedure

Ensure equipment is easily accessible

Ambu bag outside of sterile field

Prep for cannulation

Ensure adequate CPR

Stabilize airway with MD

Ensure closed-loop communication with

Charge RN and MD Teamleader

During initial resuscitation

Bedside RT Rapid Deployment Role

ROLEBADGES


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EXPANDED ROLE

If the field is prepared, time is reducedPrepping the sterile field and instrument tray:

ICU RNs first to arrive however, unfamiliar with sterile, surgical techniqueand set-up

OR staff not always available to respond to emergency procedures

Surgeons MUST have help to quickly and safely cannulate the patient

PRACTICAL Barriers to

Efficient ProcessesRoom and equipment set-up MUST be STANDARDIZED including location

of equipment once the procedure has begun

Im a nice,

big roomwith a

view!


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CICU

CICU


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STREAMLINE the ECMO CART

Rotate cart check task through all RN staff

EQUIPMENT

BOVIEHEAD LAMP

Where do I get this stuff?

What is it for?

How do I work it?Where does it belong?

Solutions

Sterile Set up Education for ICU nursesSimplify the instrument traySimplify the ECMO supply cartInclude the surgeons!

Develop roles with responsibilities badgesDO or DELEGATE

Medication location

Daily preparednessRoom configurationPatient preparednessECMO supply cart reviewMock rapid deployment scenarios


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Solutions

MEMORIZE THE CONSTANTS!Patient prep

Room configuration

Equipment position

Supplies

Personnel position

Close the loop communication

And, KEEP your COOL


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References

Fiser RT, Morris MC. Extracorporeal Cardiopulmonary Resuscitation in

Refractory Pediatric Cardiac Arrest . Pediatric Clinics of North America. 2008.55:4

Huang, et al. Extracorporeal membrane oxygenation rescue for

cardiopulmonary resuscitation in pediatric patients. Critical Care Medicine.2008. 36:5

Van Meurs K, Lally KP, Peek G, Zwischenberger J (Eds.). ECMO Extracorporeal

Cardiopulmonary Support in Critical Care 3rd Edition. 2005.

rapid deployment for e-cpr

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