Out-of-Hospital Cardiac Arrest
Patients with out-of-hospital cardiac arrest, refractory to standard Advanced Cardiac Life Support (ACLS) treatment, without exclusion criteria, may be considered for ECPR in the Emergency & Trauma Centre by the attending intensivist.
In-hospital Cardiac Arrest
At a Code Blue in the ICU, cardiac catheter laboratory or wards, the ICU SR will activate the ECPR team. For eligible patients, cannulation may be performed in situ if adequate space and patient exposure can be achieved, otherwise the patient will need to be transported with CPR ongoing (LUCAS) to the ICU for cannulation.
Staff notification and mobilisation
Emergency & Trauma Centre (Out-of-Hospital Cardiac Arrest)
For out-of-hospital cardiac arrest patients, the ambulance service will provide a warning prior to the arrival of a patient with refractory cardiac arrest to the Emergency & Trauma Centre including to the Admitting Officer.
ICU notification is via the ICU (external) Senior Registrar on for wards (62622). The external ICU-SR will then have the responsibility of immediately contacting the ICU Consultant on for Ward referrals (Ward Consultant or Night Consultant) who will notify the ECMO consultant, backfill consultant and ICU nursing staff and assign roles.
The Emergency & Trauma Centre nursing staff prepare a Trauma Bay (preferred) for the reception of the patient.
The ICU Consultant on for referrals (Ward Consultant or Night Consultant) should be notified by the ICU (external) Senior Registrar on for wards (62622) attending the Code Blue (Cardiac Arrest) calls in the hospital, so preparations can occur for readiness to cannulate after 3 cycles of CPR if the patient is eligible for mechanical support. Immediate activation to send for the ECPR trolley also allows early use of the LUCAS during the arrest, freeing up staff to assist in cannulation.
A fully stocked ECPR trolley is provided in ICU (1st and 3rd floor). Knowledge of the location of all equipment is a credentialing requirement. Equipment in the ECPR trolley should only be accessed for the management of urgent ECMO cannulation.
The trolley including required ECPR equipment is checked daily and signed off.
Standard ECPR equipment consists of 3 components
- ECMO Equipment trolley with cannulae (see image below):
- Venous access cannula sizes 19Fr and 21Fr multistage
- Arterial return cannula sizes 15Fr and 17Fr
- Large cannulation trolley with LUCAS-2 plugged in and charging, shaver plugged in and charging
- Primed ECMO circuit – PLS circuit preferred
Principle of the ECMO trolley
The trolley is based on a few key principles that we discovered as useful in training and practical delivery of ECPR to reduce the time to support.
- The order from top to bottom is in line with the workflow
- One single operator (Cannulator 3) can provided equipment effectively without time delays
- Items required are found in the front compartment of each drawer with further stock at the back
- The trolley can be reset (moving items to the front compartment of each drawer) within minutes to be ready for another cannulation
- ECPR equipment is checked meticulously every day
A list of the stocked equipment on the ECPR trolley can be found here.
Note: the role card lanyards are currently replaced with role stickers during the COVID-19 pandemic. The role descriptions, however, can be found on the side of the trolley.
Role allocation is a crucial sequence at the start. It is challenging when preparation time is limited. The role cards are inside the ECMO Equipment trolley door. Each role must be allocated prior to, or at commencement of ECPR. The team leader will allocate the ALS cards and Cannulator 1 or an ICU staff member will allocate the ECPR cards.
Set up and workflow
The set up in the room is crucial and adherence to the displayed set up on the team leader role card is highly recommended.
The basic workflow aims to minimise needle to skin time even when there is no prior notification or time to set up.