Yurasek Gregory K, Fortkiewicz Justine, Duelley Christina, Arold Leah, Pleau Cara, Park Ashley, Greenberg Isabella, Payne Asha S, Mass Paige, Bost James E, Herrera Guillermo, Diddle John Wesley, Peer Murfad, Yerebakan Can
From the Children's National Hospital (G.K.Y., J.F., C.D., L.A., C.P., I.G., A.S.P., P.M., J.E.B., G.H., J.W.D., M.P., C.Y.), Washington, DC; and George Washington University (A.P.), Washington, DC.
Simul Healthc. 2023 Oct 1;18(5):285-292. doi: 10.1097/SIH.0000000000000693. Epub 2022 Nov 2.
Since 2013, the cardiac intensive care unit (CICU) at Children's National has conducted annual extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) simulations that focus on team dynamics, room setup, and high-quality CPR. In 2019 and 2020, the simulations were expanded to include the surgical and extracorporeal membrane oxygenation (ECMO) teams in an effort to better understand and improve this process.
During a 4-week period in 2019, 7 peripheral ECPR simulations were conducted, and through a 3-week period in 2020, 7 central ECPR simulations were conducted. Participants in each session included: 8 to 10 CICU nurses, 1 CICU attending, 1 to 2 ICU or cardiology fellows, 1 cardiovascular surgery fellow or attending, and 1 ECMO specialist. For each session, the scenario continued until the simulated patient was on full cardiopulmonary bypass. An ECMO trainer was used for peripheral simulations and a 3-dimensionally-printed heart was used for central cannulations. An ECMO checklist was used to objectively determine when the patient and room were fully prepared for surgical intervention, and simulated cannulation times were recorded for both groups. A retrospective chart review was conducted to compare actual cannulation times before and after the intervention period, and video was used to review the events and assist in dividing them into medical versus surgical phases. Control charts were used to trend the total ECPR times before and after the intervention period, and mean and P values were calculated for both ECPR times and for all other categorical data.
Mean peripheral ECPR times decreased significantly from 71.7 to 45.1 minutes ( P = 0.036) after the intervention period, and this was reflected by a centerline shift. Although we could not describe a similar decrease in central ECPR times because there were only 6 postintervention events, the times for each of these events were shorter than the historical mean of 37.8 minutes. There was a trend in improved survival, which did not meet significance both among patients undergoing peripheral ECPR (15.4% ± 10% to 43.8% ± 12.4%, P = 0.10) and central ECPR (36.4% ± 8.4% to 50% ± 25%, P = 0.60). The percentage of time dedicated to the medical phases of the actual versus simulated procedures was very consistent among both peripheral (33.0% vs. 31.9%) and central (39.6% vs. 39.8%) cannulations.
We observed a significant decrease in peripheral cannulation times at our institution after conducting interprofessional ECPR simulations taken to the establishment of full cardiopulmonary bypass. The use of an ECMO trainer and a 3-dimensionally-printed heart allowed for both the medical and surgical phases of the procedure to be studied in detail, providing opportunities to streamline and improve this complex process. Larger multisite studies will be needed in the future to assess the effect of efforts like these on patient survival.
自2013年以来，儿童国家医疗中心的心脏重症监护病房（CICU）每年都会进行体外膜肺氧合心肺复苏（ECPR）模拟，重点关注团队协作、房间设置和高质量心肺复苏。在2019年和2020年，模拟范围扩大到包括外科团队和体外膜肺氧合（ECMO）团队，以更好地理解和改进这一过程。
在2019年的4周时间内，进行了7次外周ECPR模拟，在2020年的3周时间内，进行了7次中心ECPR模拟。每次模拟的参与者包括：8至10名CICU护士、1名CICU主治医师、1至2名重症监护室或心脏病学住院医师、1名心血管外科住院医师或主治医师，以及1名ECMO专家。每次模拟场景持续到模拟患者完全处于体外循环状态。外周模拟使用了ECMO训练器，中心插管模拟使用了3D打印心脏。使用ECMO检查表客观确定患者和房间何时为手术干预做好充分准备，并记录两组的模拟插管时间。进行回顾性病历审查以比较干预期前后的实际插管时间，并使用视频回顾事件并协助将其分为医疗阶段和手术阶段。使用控制图对外科干预期前后的总ECPR时间进行趋势分析，并计算ECPR时间和所有其他分类数据的平均值和P值。
干预期后，外周ECPR平均时间从71.7分钟显著降至45.1分钟（P = 0.036），这通过中心线偏移得以体现。尽管由于干预后仅有6个事件，我们无法描述中心ECPR时间有类似下降，但这些事件中的每一次时间均短于37.8分钟的历史平均值。生存情况有改善趋势，在外周ECPR患者（15.4% ± 10%至43.8% ± 12.4%，P = 0.10）和中心ECPR患者（36.4% ± 8.4%至50% ± 25%，P = 0.60）中均未达到显著水平。实际与模拟操作的医疗阶段所占用时间的百分比在外周插管（33.0%对31.9%）和中心插管（39.6%对39.8%）中非常一致。
在进行跨专业ECPR模拟直至建立完全体外循环后，我们观察到本机构外周插管时间显著减少。使用ECMO训练器和3D打印心脏能够详细研究该操作的医疗和手术阶段，为简化和改进这一复杂过程提供了机会。未来需要更大规模的多中心研究来评估此类努力对患者生存的影响。
