Intra-hospital transport
Staffing.
All intra-hospital transports require the following staff
- Bedside ECMO accredited ICU nurse
- ECMO accredited ICU medical staff
Senior registrars not accredited for ECMO should be accompanied by an additional ECMO accredited staff member (ECLS Co-ordinator or ICU Consultant if possible).
All ECMO lines should be held during patient movements.
ECMO retrieval
Transport of patients requiring ECMO is feasible and safe if undertaken with care and diligence. Critically unwell patients requiring maximal ventilatory or circulatory support often destabilise during transfers. Increased patient stability once established on ECMO support facilitates safe transfer to an ECMO centre for ongoing care.
Staffing
All intra-hospital transports require the following staff
- ICU consultant (ECMO credentialed)
- Additional ECMO accredited staff member (ECLS co-ordinator/additional ECMO CCRN)
- Adult Retrieval Victoria (ARV) physician
- If on-site cannulation is required, at a minimum, 2 ECMO credentialed ICU consultants are required.
The ARV ECMO transport credentialing package must have been completed by all staff members once registered, available online. This covers both road and aviation platforms and is valid for 12 months.
Whilst the transport is a team effort, the Alfred ECMO staff will be responsible for the ECMO console operation and cannula safety, whilst the ARV physician will manage the patient’s monitoring, ventilation, haemodynamic infusion support and sedation. The ARV physician will be supported by an ARV nurse for road transports or an Ambulance Victoria (AV) flight paramedic for aviation platforms (Fixed wing / Helicopter). The ARV team will be experienced in transporting critically unwell patients and will take the lead on the logistics of moving the patient between transport platforms.
Example of ECMO retrieval with a Rotaflow console. The console is firmly strapped onto a bridge across the stretcher and the oxygenator is placed carefully between the patient’s legs while the emergency crank remains within reach (*).
Retrieval equipment & checklist
ECMO Retrieval Checklist printable PDF version
It is the responsibility of the retrieval team’s leading ICU consultant to go through the checklist and ensure completeness of the equipment prior to leaving. As listed (grey) the requirements for Rotaflow and Cardiohelp are quite different.
Key components
- Complete ECMO console including Emergency Drive Unit (“Hand-crank”)
- ECMO Console and corresponding HLS or PLS circuit
- Range of cannulae for anticipated case
- Checked transport bag and adjunct essential equipment
Shown is the retrieval bag with the top (front) pocket on the left, main compartment on the right and the side pockets are also on the right-hand side.
Blue Stash Bag
Defries – ECMO Pack | Need to collect | |
Patient appropriate Cannulae (x4-6) | Need to collect | |
Primed circuit box (PLS) / Unprimed circuit box (HLS) | Need to collect |
Black Boxes – Rotaflow/ PLS circuit only
Console & power cord | Need to collect | Rotaflow Pump head | Pre-packed | ||
Hand crank | Pre-packed | Oxygenator holder | Pre-packed |
Carried Separately – Cardiohelp/ HLS circuit only
Console with 1) power cord 2) flow sensor 3) venous probe 4) pressure/temp cable | Need to collect | |
Hand crank | Need to collect | |
HLS priming guide – www.ecmo.icu – Procedures – Circuit priming | Side pocket of transport bag |
Blue Transport Bag
Front pocket | Medtronic dilator/wire kit if available | Single .025’’ guidewire (IABP exchange only) | Standard .038’’ guidewire x3 | |||
Avalon dilator kit | Amplatz wire | High flow (Y) tubing | ||||
Backflow cannula pack | Extra 3mm backflow connector (male – male) | Arterial line kit | ||||
Main: Lid | Pajunk needles x3 | Scalpel of shame | USB sticks x2 | |||
Main: Left | Sterile ECMO Clamps x6 | Ultrasound sleeve x2 | Sterile scissors x1 | |||
Coon Dilators: F10-22 x2 | Mosquito forceps | |||||
Main: Centre | Haemofiltration spikes x2 | Rotaflow sensor cream | Betadine x2 | |||
O2 tubing (5m, rubber ends) | ||||||
Main: Right | Latex-free gloves 7 ½ (x2) | Tegaderm dressing x8 | Cable ties x8 | |||
Cable gun | Skin prep wipes x8 | Griplocks x8 | ||||
3-way extension taps x5 | Power cord extension | Douglas straps | ||||
⅜ x ¼ & ⅜ x ½ connectors (x2 each) ¼ x ¼ with luer | ⅜ x ⅜ (x3) and ⅜ x ⅜ with luer (x2) | Y connector (⅜ – ⅜ -⅜ ) | ||||
Side pockets | iPhone chargers x2 | Cab Charge x2 | HLS priming guide |
Transport checklist
Any transport in or out of hospital will require basic ECMO checks before leaving.
Retrieval consideration & process
Referral hospital should collect the data required on the critical patient referral form:
https://www.alfredhealth.org.au/contents/resources/referral-forms/ICU-referral-form.pdf
All referrals should be teleconferenced via the ARV switchboard, with the ARV clinical coordinator and Alfred ECMO team able to discuss the case contemporaneously with the referral clinician. Discussion should cover patient management prior to retrieval team arrival, as well as preparation of the patient for emergent ECMO cannulation (e.g. re-siting lines: right radial arterial line (VA), remove femoral CVL if feasible, preparing skin of groins, sourcing equipment) if required.
Considerations for referring hospital
Pre-arrival of the ECMO team
At the referring institution the following items may be prepared in anticipation of supporting the patient with ECMO.
Organisational task
- Shave groin (remove skin hair from both groins with electrical clippers and use large Elastoplast to pick up clipped hair)
- Clearing of the bedspace as able
- CVC / arterial line as discussed with retrieval team
- Copy of available notes and imaging
Equipment – essentials
- Vascular ultrasound machine ± cardiac probe
- Large trolley (for cannulation set up)
- Small size trolley for ECMO pump
- Portable oxygen bottle
- Normal Saline 2000ml + 10,000 units Heparin
- Sterile gloves (if sizes indicated) and gowns x 2
- Face shield with visor x 2
Equipment ideally available
- Sterile gauze (large pack)
- Power cord extension