Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study.

BACKGROUND: A multidisciplinary group of stakeholders were used to identify: (1) the core competencies of a training program required to perform in-hospital ECPR initiation (2) additional competencies required to perform pre-hospital ECPR initiation and; (3) the optimal training method and maintenance protocol for delivering an ECPR program. METHODS: A modified Delphi process was undertaken utilising two web based survey rounds and one virtual meeting. Experts rated the importance of different aspects of ECPR training, competency and governance on a 9-point Likert scale. A diverse, representative group was targeted. Consensus was achieved when greater than 70% respondents rated a domain as critical (> or = 7 on the 9 point Likert scale). RESULTS: 35 international ECPR experts from 9 countries formed the expert panel, with a median number of 14 years of ECMO practice (interquartile range 11-38). Participant response rates were 97% (survey round one), 63% (virtual meeting) and 100% (survey round two). After the second round of the survey, 47 consensus statements were formed outlining a core set of competencies required for ECPR provision. We identified key elements required to safely train and perform ECPR including skill pre-requisites, surrogate skill identification, the importance of competency-based assessment over volume of practice and competency requirements for successful ECPR practice and skill maintenance. CONCLUSIONS: We present a series of core competencies, training requirements and ongoing governance protocols to guide safe ECPR implementation. These findings can be used to develop training syllabus and guide minimum standards for competency as the growth of ECPR practitioners continues.

Human factors in ECLS - A keystone for safety and quality - A narrative review for ECLS providers.

INTRODUCTION: Although the technology used for extracorporeal life support (ECLS) has improved greatly in recent years, the application of these devices to the patient is quite complex and requires extensive training of team members both individually and together. Human factors is an area that addresses the activities, contexts, environments, and tools which interact with human behavior in determining overall system performance. HYPOTHESIS: Analyses of the cognitive behavior of ECLS teams and individual members of these teams with respect to the occurrence of human errors may identify additional opportunities to enhance safety in delivery of ECLS. RESULTS: The aim of this article is to support health-care practitioners who perform ECLS, or who are starting an ECLS program, by establishing standards for the safe and efficient use of ECLS with a focus on human factor issues. Other key concepts include the importance of ECLS team leadership and management, as well as controlling the environment and the system to optimize patient care. CONCLUSION: Expertise from other industries is extrapolated to improve patient safety through the application of simulation training to reduce error propagation and improve outcomes.

Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization.

DISCLAIMER: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available.

Extracorporeal Membrane Oxygenation in the Emergency Department.

Extracorporeal membrane oxygenation (ECMO) is a mechanical way to provide oxygenation, ventilation, and perfusion to patients with severe cardiopulmonary failure. Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of ECMO during cardiac arrest. ECPR requires an organized approach to resuscitation, cannula insertion, and pump initiation. Selecting the right patients for ECPR is an important aspect of successful programs. A solid understanding of the components of the ECMO circuit is critical to troubleshooting problems. Current evidence suggests a substantial benefit of ECPR compared with traditional CPR for refractory cardiac arrest but is limited by lack of randomized trials to date.

Emergency Physician-Initiated Resuscitative Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has several applications as a resuscitative intervention, including extracorporeal cardiopulmonary resuscitation (ECPR). ECPR is rarely initiated in the emergency department (ED) by emergency physicians outside regional academic institutions. OBJECTIVES: To evaluate whether ECPR improves clinical outcomes after cardiac arrest when initiated by emergency physicians (EPs) in a nonacademic hospital. METHODS AND MATERIALS: We performed a retrospective analysis of prospectively identified consecutive EP-initiated ECMO subjects from a single community hospital over a 7-year period. Logistic regression and propensity models tested the association between ECPR and survival to hospital discharge compared with concurrent ECPR-eligible control subjects. RESULTS: Over 7 years (2010-2017), EPs initiated ECMO on 58 subjects; 44 (76%) were venoarterial cases (43 ECPR) initiated in the ED. Of those, 11 (25%) survived to discharge (n = 9 with cerebral performance category score 1) and most were still alive after 5 years (66%). Adjusting for known covariates, ECPR subjects were more likely than concurrent controls to survive to discharge (odds ratio 8.4; 95% confidence interval 1.2-60.4). Propensity analysis revealed a favorable trend toward survival to discharge after ECPR (odds ratio 2.0; 95% confidence interval 0.51-7.8). CONCLUSIONS: Emergency physicians initiated ECMO with promising clinical outcomes. Prospective trials are needed to define the efficacy, safety, and cost-effectiveness of EP-initiated ECMO.

Extracorporeal life support in the emergency department: A narrative review for the emergency physician.

BACKGROUND: Extracorporeal life support (ECLS) describes the use of blood perfusion devices to provide advanced cardiac or respiratory support. Advances in percutaneous vascular cannula insertion, centrifugal pump technologies, and the miniaturization of extracorporeal devices have simplified ECLS. The intention of this discussion is to review the role of ECLS as a potential rescue method for emergency department (ED) clinicians in critical clinical scenarios and to focus on the prerequisites for managing an ECLS program in an ED setting. DISCUSSION: Possible indications for ECLS cannulation in the ED include ongoing circulatory arrest, shock or refractory hypoxemia and pulmonary embolism with refractory shock. Severe trauma, foreign body obstruction, hypothermia and near drowning are situations in which patients may potentially benefit from ECLS. Early stabilization in the ED can provide a time window for a diagnostic workup and/or urgent procedures, including percutaneous coronary intervention, rewarming or damage control surgery in trauma. The use of ECLS is resource intensive and can be associated with a high risk of complications, especially when performed without previous training. Therefore, ECLS should only be used when the underlying problem is potentially reversible, and the resources are available to address the etiology of organ dysfunction. CONCLUSION: Emergent ECLS has a role in the ED for selected indications in the face of life-threatening conditions. ECLS provides a bridge to recovery, definitive therapy, intervention or surgery. ECLS program requires an appropriately trained staff (physicians, nurses and ECLS specialists), equipment resources and logistical planning.

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).

PURPOSE: To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS: We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS: Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS: Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.

Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs).

INTRODUCTION: The number of patients with left ventricular assist devices (LVADs) is increasing each year. Despite a lack of evidence, many emergency medical systems and hospitals have recommended against performing chest compressions in these patients. This deviation from conventional resuscitation algorithms is secondary to concern that chest compressions could dislodge the LVAD. OBJECTIVE: To assess whether cannula dislodgment occurred in LVAD patients receiving chest compressions. METHODS: We retrospectively analyzed the outcomes of all LVAD patients who received chest compressions for cardiac arrest over a four year period in a large urban hospital. Eight cases were reviewed for both cannula integrity and outcomes. RESULTS: Using autopsy and adequate flow through device as proxy for intact inflow/outflow cannulas, none of the eight patients receiving chest compressions had cannula dislodgment. Four of the 8 patients had return of neurologic function. CONCLUSIONS: In this small retrospective case series, standard chest compressions in patients with LVADs did not cause cannula dislodgment. More research is necessary to determine the utility of chest compressions in the LVAD population.

Emergency department initiation of cardiopulmonary bypass: a case report and review of the literature.

BACKGROUND: Out-of-hospital cardiac arrest carries a dismal prognosis. Percutaneous extracorporeal membrane oxygenation (ECMO) has been used with success for in-hospital arrests, and some literature suggests improvement in long-term survival for out-of-hospital arrests as well. OBJECTIVES: This case highlights the use of ECMO in the emergency department. CASE REPORT: We report a case in which emergency physician-initiated ECMO was used as a bridge to definitive care in an out-of- hospital cardiac arrest in the United States. CONCLUSIONS: ECMO is a novel adjunct for patients in cardiac arrest in whom the usual advanced life support techniques have failed.

Use of ocular ultrasound for the evaluation of retinal detachment.

BACKGROUND: Retinal detachment is an ocular emergency posing diagnostic difficulty for the emergency practitioner. Direct fundoscopy and visual field testing are difficult to perform and do not completely rule out retinal detachment. Ophthalmologists use ocular ultrasound to enhance their clinical acumen in detecting retinal detachments (RD), and bedside ultrasound capability is readily available to many emergency practitioners (EP). STUDY OBJECTIVE: Our study sought to assess whether ocular ultrasound would be a helpful adjunct for the diagnosis of RD for the practicing EP. METHODS: This was a prospective observational study with a convenience sample of patients. As part of a general course on emergency ultrasonography, practitioners received a 30-min training session on ocular ultrasound before beginning the study. Trained practitioners submitted ultrasound scans with interpretation on patients with signs and symptoms consistent with retinal detachment. RESULTS: Thirty-one of the 72 practitioners trained submitted ocular ultrasound reports on patients presenting to the Emergency Department with concerns for retinal detachments. EPs achieved a 97% sensitivity (95% confidence interval [CI] 82-100%) and 92% specificity (95% CI 82-97%) on 92 examinations (29 retinal detachments). Disc edema and vitreous hemorrhage accounted for false positives, and a subacute retinal detachment accounted for the only false negative. CONCLUSION: These data show that trained emergency practitioners can use ocular ultrasound as an adjunct to their clinical assessment for retinal detachment.

Porcine small intestine submucosa does not show antimicrobial properties.

The goal of this study is to examine whether porcine small intestine submucosa (SIS) exhibits antimicrobial properties in a standard in vitro system, without pretreatment with acetic acid or extraction of soluble proteins. Previous animal studies suggest that porcine SIS may have inherent antibiotic properties. Using the guidelines for disk diffusion susceptibility testing by Bauer, 17/64-inch diameter disks made of porcine small intestine submucosa and of gortex were compared with standard antibiotic-impregnated disks against six organisms. The zone of inhibition was measured after 24 hours and minimum bacterial concentrations were determined by serial dilutions of a solution in which porcine small intestine submucosa was allowed to elute for 24 hours. Neither porcine SIS or gortex discs caused inhibition of the growth of any organism. The porcine small intestine submucosa discs showed bacterial growth on top of the discs whereas the gortex did not. Neither the dilutional concentrations of the porcine small intestine submucosa eluent nor the gortex eluent inhibited the growth of any organism. These findings suggest that the porcine small intestine submucosa does not have intrinsic antimicrobial properties. The growth of bacteria on top of the porcine small intestine submucosa suggests that porcine small intestine submucosa itself may provide a favorable environment for the growth of bacteria. More research is necessary to decide what role porcine small intestine submucosa plays in the treatment of infected surgical sites.