Construction of a Reusable, High-Fidelity Model to Enhance ...astec.arizona.edu/sites/astec.arizona.edu/files/pdf_files/ECMO... · Initiation of extracorporeal membrane oxygenation

Professional Growth and Development

103Advances in Neonatal Care • Vol. 14, No. 2 • pp. 103-109

ABSTRACT Initiation of extracorporeal membrane oxygenation (ECMO) is stressful, especially for inexperienced extracorporeal life support providers. The main objective of this study was to create a novel, reusable mannequin for high-fidelity simulation of ECMO initiation. We modified a Laerdal neonatal manne-quin (SimNewB; Stavanger, Norway) so that it could be used to simulate an ECMO initiation. A simu-lation of a neonatal patient suffering from meconium aspiration was performed in the pediatric inten-sive care unit, and participants included new extracorporeal life support specialists in addition to the composition of the clinical ECMO team. A total of 17 individuals participated in the neonatal ECMO initiation simulation. Questionnaire results showed that 88% of participants felt better prepared to assist in an ECMO initiation after the simulation. All participants (100%) agreed that the modified man-nequin and the environment were realistic and that this simulation helps teamwork and communica-tion in future initiations of ECMO. Simulation can be used for the prevention, identification, and reduction of anxiety–related crisis situations that novice providers may infrequently encounter during routine clinical use of mechanical circulatory support. Use of a reusable, high-fidelity mannequin may be beneficial for effective team training of complex pediatric ECMO–related procedures. Key Words: ECMO , extracorporeal membrane oxygenation , life support , neonatal , resuscitation , teamwork

Construction of a Reusable, High-Fidelity Model to Enhance Extracorporeal Membrane Oxygenation Training Through Simulation

Jess L. Thompson , MD, MSc ; Lisa M. Grisham , MS, NNP-BC ; Jeanne Scott , BSN ; Chris Mogan , CCP ; Hannes Prescher , BA ; David Biffar , MS ; John Jarred , BS ; Robyn J. Meyer , MD ; Allan J. Hamilton , MD

DOI: 10.1097/ANC.0000000000000054

Author Affiliations: Section of Congenital Heart Surgery (Dr Thompson and Mr Mogan), Diamond Children’s Medical Center (Mss Grisham and Scott), Arizona Simulation Technology and Education Center (Ms Grisham, Messrs Prescher, Biffar, and Jarred, and Dr Hamilton), and Department of Pediatrics (Dr Meyer), University of Arizona, Tucson.

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are

provided in the HTML and PDF versions of this article on the journal’s Web site ( www.advancesinneonatalcare.org ).

Correspondence: Jess L. Thompson, MD, MSc, Section of Congenital Heart Surgery, University of Arizona, 1501 N Campbell Ave, PO Box 245071, Tucson, AZ 85724 ( [email protected] ).

Copyright © 2014 by The National Association of Neonatal Nurses

Simulation-based learning in healthcare has been found to be a beneficial educational adjunct to clinical scenarios. High-fidelity

simulations improve outcomes in complex, time-

critical situations that require multidisciplinary health teams. 1 Simulation-based training, coupled with a structured curriculum that focuses on knowl-edge, shared decision making, and execution, builds

Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.

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104 Thompson et al


the confidence of the participants as they learn com-plex procedures and processes. 2 , 3 Simulation train-ing can also improve a team’s response to critical situations that may occur infrequently during the routine use of mechanical circulatory support. 4 , 5

The University of Arizona Medical Center has a strong history of education for mechanical circula-tory support. For more than a decade, we have trained new extracorporeal life support (ECLS) spe-cialists and provided continuing education for expe-rienced specialists. Our training program is format-ted according to the guidelines set forth by the Extracorporeal Life Support Organization. 6 Recently, experienced specialists expressed a high level of trepidation the first time they assisted with the cannulation and initiation of extracorporeal membrane oxygenation (ECMO). For this reason, we constructed a novel, reusable mannequin for use during high-fidelity simulations of ECMO initiation. We then performed a simulation scenario of an unstable newborn secondary to meconium aspira-tion. Our objectives for this research were to show feasibility of this reusable model and to reduce anxiety involved in placing an infant on ECMO by allowing new specialists to practice in a safe, simulation-based environment.

METHODS

Our training program for new ECLS specialists follows the ECLS organization guidelines. 6 Before the ECMO initiation simulation, we provided 24 hours of classroom didactic coursework and 8 hours of struc-tured, hands-on time with an ECMO circuit (ie, water-drill). On the final day of the course, the stu-dents were asked to participate in a simulation of can-nulation and initiation of ECMO, along with evacua-

tion of air from the circuit. This was a quality improvement project to enhance the current ECMO training and, therefore, exempt from the institutional review board approval. The clinical scenario was introduced prior to initiation of the simulation exer-cise. The trainees received a written synopsis of the baby’s history, from birth through the time of the deci-sion to cannulate for ECMO because of the infant’s diagnosis of persistent pulmonary hypertension sec-ondary to meconium aspiration syndrome ( Table 1 ). This scenario was adapted from the Extracorporeal Life Support Organization Specialists Training Manual. 7 The Arizona Simulation Technology and Education Center ( http://www.astec.arizona.edu ) staff conducted an orientation at the bedside in the pediatric intensive care unit (PICU) by describing the simulation and familiarizing the participants with the physical components of the high-fidelity manne-quin. Participants were instructed to use all of the real equipment for the cannulation. Each candidate specialist was assigned a role ( Table 2 ), and the responsibilities of each role were discussed prior to the simulation.

A high-fidelity mannequin model was constructed to simulate veno-arterial cannulation of an unstable neonatal patient because of meconium aspiration. The specific objectives of the simulation scenario were as follows: (1) demonstrate the role of the ECLS specialist during cannulation; (2) practice effective and coordinated teamwork during cannula-tion and initiation of ECMO; (3) describe parame-ters that indicate adequate oxygen delivery and hemodynamic support in venoarterial ECMO; (4) review frequently encountered complications associ-ated with ECMO support; and (5) describe common technical causes of acute desaturation during ECMO. Specific questions that addressed the

TABLE 1. Newborn Extracorporeal Membrane Oxygenation (ECMO) Case Scenario a Baby J is a 41-week gestational age, 3.5-kg infant born by normal spontaneous vaginal delivery. The infant

required resuscitation at birth and had meconium aspiration syndrome. The infant was taken to the special care nursery but developed respiratory distress over the next hour. He was transferred to the neonatal intensive care unit, intubated and placed on a mechanical ventilator. Surfactant was adminis-tered but the infant sustained a right-side pneumothorax. A pigtail catheter was placed and the pneu-mothorax was resolved. The infant continued to be in distress, and the repeat CXR showed bilateral patchy infi ltrates. A trial of nitric oxide failed to show improvement in oxygenation. The baby continued to decompensate and was transferred to the ECMO center. The baby is receiving Fentanyl 1 mcg/kg/h, Versed 0.1 mg/kg/h, Nimbex 0.2 mg/kg/min, Epinephrine 0.1 mcg/kg/min, and Dopamine 15 mcg/kg/min. The infant’s best pO 2 was 42 mmHg, and the lactic acid level continued to rise. A cardiac ECHO showed suprasystemic pulmonary artery pressures, right to left shunting at the ductal level and at the foramen ovale, with poor biventricular function. A head ultrasound was negative for hemorrhage. A coagulation panel was WNL. The decision was made to place the infant on VA ECMO.

Abbreviations: CXR, chest x-ray; VA, veno-arterial; WNL, within normal limits. a This case scenario was given to the students before the simulation, which provides the background of the patient.


Advances in Neonatal Care • Vol. 14, No. 2

Neonatal Simulation Model for ECMO Initiation 105


learning objectives of the simulation were posed by the instructor throughout the training exercise and again reviewed during the debriefing to ensure that everyone received the information ( Table 3 ). Time in the debriefing was also allotted to allow for ques-tions, review of our institutional algorithms, and for participants to provide feedback on the experience.

The simulation was performed with the neonatal SimNewB mannequin (Laerdal, Stavanger, Norway) that had been modified by Arizona Simulation Technology & Education Center. This mannequin was chosen because it has umbilical vessels that can be cannulated, providing a more realistic neonatal simulation experience. Simulated neck vessels were constructed from a piece of latex tubing. Latex tubing with 8-mm external diameter and 6-mm internal diameter was chosen for its projected ease of cannula-tion and ability to sustain adequate flows. Each end of the tubing was attached to an intravenous saline bag by removing the ends of the administration and injection ports, pulling the tubing onto the port, and securing the tubing with a zip-tie. Simulated blood (Pocket Nurse, Ambridge, Pennsylvania) was added to the intravenous bag. The pediatric ECMO circuit consisted of the Jostra Rota Flow centrifugal pump (Maquet, Rastatt, Germany) and the Quadrox iD oxygenator (Maquet, Rastatt, Germany) Bioline- coated .25 inch tubing. We used a Cincinnati Sub-Zero ECMO-heater (CSZ Medical, Cincinnati, Ohio) to regulate blood temperature. Using this novel ECMO model, a variety of flow rates can be achieved depending on the choice of cannulas ( Table 4 ).

Before securing the jugular vessels to the manne-quin, the internal circuitry was protected from fluid

by placing DuoDERM (Convatec, Skillman, New Jersey) across the seams of the neck, shoulders, and back. For additional reinforcement, Tegaderm (3M, St. Paul, Minnesota) was then applied over the DuoDERM. The tubing of the jugular vessels was fixed in anatomic position by covering it with

TABLE 2. Extracorporeal Life Support (ECLS) Specialist Roles a ECMO circuit specialist

Point of care testing

Recorder

Bedside nurse

Runner

Observer(s)

Surgeon’s assistant b

Abbreviation: ECMO, extracorporeal membrane oxygenation.

a These roles were assigned to the ECLS specialist students to perform during the simulation.

b Not a typical role of the ECLS specialist, but sometimes is necessary for completion of wet-to-wet connection for the circuit to the cannula.

TABLE 3. Questions That Address Extracorporeal Membrane Oxygenation (ECMO) Simulation Learning Objectives a 1. With pump fl ows set at nearly 115 mL/kg/min,

why didn’t the patient’s arterial oxygenation increase further?

2. What is the normal cardiac output of a 3.5-kg infant?

3. Why did the arterial waveform dampen when the infant was placed on ECMO?

4. What changes do I need to make to the ventilator after going on ECMO?

5. What changes do I need to make to my drips after going on VA ECMO?

6. Why not start on full fl ow and sweep?

7. Should the patient have been cannulated for VV support instead of VA support?

8. Is 20 min an appropriate amount of time to ramp up the pump fl ow to 400 mL/min?

9. If this had been VV ECMO, what are specifi c concerns associated with the use of a double lumen cannula?

10. What are signs of signifi cant recirculation?

11. What can be done to minimize recirculation?

12. Could the pump occlusion be set inappropri-ately?

13. How can the pump occlusion be verifi ed after support has been started?

14. What steps are required to make the prime suitable for going on ECMO?

15. What options exist if the electrolyte values are too high or too much CO 2 is present on the blood gas?

Abbreviation: ECMO, extracorporeal membrane oxygenation; VA, veno-arterial; VV, veno-venous.

a The above questions were asked during the simulation and/or debriefi ng to ensure the learning objectives were addressed.



106 Thompson et al


Tegaderm in the neck and DuoDERM along the right side of the mannequin ( Figure 1 ).

Final preparations of the mannequin included the construction of a sheet of skin to place over the neck and chest wall of the mannequin and, thereby, to cover the jugular vessel tubing. The silicone skin was made with Dragon SkinFX-Pro (Smooth-on, Easton, Pennsylvania), to which Silc Pig (Smooth-on, Easton, Pennsylvania) flesh tone pigment was added. The sili-cone mixture was poured into a metal tray (1/8th-inch thickness) and took 45 minutes to cure. Once solid, we used a template to cut out the skin (see Supplemental Digital Content 1, http://links.lww.com/ANC/A2 , which provides a template for the simulated skin tis-sue). A small amount of Graftobian make-up loose powder (skin-tone light, Graftobian Makeup Company, Madison, Wisconsin) was then applied, and the skin was laced up in the back. The umbilical catheters were brought out through the Dragon Skin umbilical open-ing and secured in place. The mannequin was intubated and monitoring leads were applied ( Figure 2 ). Total material costs are approximately $25 for 1 ECMO model, and each model can be made in approximately 1 hour. However, bulk start-up costs for supplies can

TABLE 4. Extracorporeal Membrane Oxygenation (ECMO) Flow Rates a

Arterial Cannula (Fr) Venous Cannula (Fr)Flow at 3000 RPM,

L/minFlow at 4000 RPM,

L/min

8 8 1 1.3

10 8 1 1.3

12 8 1 1.3

14 8 1 1.3

8 10 1 1.3

10 10 1.1 1.5

12 10 1.3 1.8

14 10 1.3 1.9

8 12 1 1.3

10 12 1.3 1.9

12 12 1.7 2.5

14 12 1.8 2.7

8 14 1 1.3

10 14 1.4 2.2

12 14 1.8 2.6

14 14 2.2 3.1

Abbreviation: ECMO, extracorporeal membrane oxygenation, RPM, revolutions per minute. a This table demonstrates the different fl ow rates achieved with our model using different arterial and venous cannula sizes. Some fl ow rates and cannula sizes reported would not be appropriate for use in a neonatal simulation. They are reported here should others want to use these data to create scenarios with adult sized cannulas and fl ow rates.

FIGURE 1.

Preparation of the Neonatal SimNewB man-nequin. Note the tubing that extends up to the neck, simulating the carotid and jugular ves-sels. The tubing then traverses down the body of the mannequin to attach to the reservoir. The simulated skin is reflected backward and is positioned into place over the tubing before initiating the simulation.





amount to $200, which provides sufficient materials to create 6 to 8 models.

RESULTS

A total of 17 individuals participated in the neonatal ECMO simulation. Participants included 7 ECLS students, 3 experienced ECLS specialists, a pediatric intensivist attending, a congenital heart surgeon, a respiratory therapist, a perfusionist, a perfusion stu-dent, a nurse practitioner, and an operating room scrub nurse. This was the first time anyone at our facility had used this high-fidelity neonatal ECMO simulation mannequin, and it was the first exposure to simulation for several of the participants.

The simulation was conducted in a patient room in the PICU; at the time of this simulation, all ECMO for our hospital was centralized on this unit. For maximal efficiency, the timeline of the simula-tion was determined prior to initiation of the simulation (see Supplemental Digital Content 2, http://links.lww.com/ANC/A3 , which shows the simulation timeline). Ample time was given to intro-duce the scenario, respond to questions, initiate ECMO, practice evacuation of air from the circuit, and debrief after the scenario had been concluded. The cannulation itself occurred through the neck vessels ( Figure 3 ). Once the ECMO circuit was deaired, the cannulae were connected and ECMO was initiated. The remainder of the simulation was then carried out. See a video of the making of the ECMO model as well as highlights of the simulation (see Supplemental Digital Content 3, http://links.lww.com/ANC/A4 , which shows the making of the model and highlights progression of the simulation).

Postcourse evaluations (see Appendix A, Supplemental Digital Content 4, http://links.lww.com/ANC/A5 , which is the postcourse questionnaire) demonstrated that 15 of the 17 participants (88%) felt the high-fidel-ity simulation would better prepare them to assist in future ECMO initiations. This included both the ECLS specialist students and the experienced specialists. In addition, all the participants felt that the simulated sce-nario “provided a sense of realism” and that the “debriefing was valuable.” Subjectively, the experi-enced specialists remarked that participation in a simi-lar simulation during their initial training would have reduced their anxiety during their first real ECMO initiation. Importantly, both new and experienced spe-cialists indicated that the simulation increased their awareness of the steps to initiate ECMO and their will-ingness and confidence to alert the team leader to a potential problem.

DISCUSSION

In the appropriate clinical context, ECMO may be the final option when advanced cardiac life support has been maximized and is generally performed under emergent conditions. Recently, experienced ECLS specialists at our institution expressed that they felt a high level of trepidation the first time they assisted with the cannulation and initiation of ECMO. For this reason, we developed a reusable, high-fidelity model that could be used to simulate the physical process of carotid artery and jugular vein cannulation as part of the initiation process for placing a patient on ECMO.

Previous ECMO models have been developed by modifying commercially available high-fidelity mannequins with tubing and fluid reservoirs. 8-11 In

FIGURE 2.

Mannequin fully prepared for scenario, just before cannulation. Note the circumoral cyanosis.

FIGURE 3.

Cannulation of the simulated internal jugular vein and carotid artery using purse-string suturing method.



108 Thompson et al


point out potential errors to the team leader in future ECMO procedures. Finally, it enabled par-ticipants to verify that all of the appropriate ECMO equipment and supplies were present. Having a reusable model gives us the ability to refine the sce-nario and involve additional new specialists in the future at a very little incremental cost.

Our project had 1 main limitation. This was a proof of concept that our newly developed manne-quin would work for the intended purpose. Therefore, this study lacked a validated precourse and post-course questionnaire to ensure quality and improve-ment. Having established the feasibility of conducting the training using this novel mannequin and having received positive feedback from our trainees during the debriefing, we then develop formal assessment tools and use them with subsequent simulations.

The development of an inexpensive reusable, high-fidelity model allows us to produce a reliable method to continually evaluate improvements in our teaching and training techniques. Using this model during the training of ECLS specialists was anecdot-ally found to instill confidence and encourage team-work. Further studies are needed to confirm whether the perceived increase in comfort and preparedness translates to improved skill in a clinical setting. We hope that our efficiency with ECMO initiation improves as simulation participants become more comfortable with their own roles and are able to anticipate the needs of other team members. ECMO initiation under the best of circumstances is stressful for everyone involved. A realistic simulation should help students experience stress in a controlled, super-vised environment, without risk to an actual patient.

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simulation-based teamwork training improves early trauma care . J Surg Educ. 2011 ; 68 ( 6 ): 472-477 .

2. Burkhart HM , Riley JB , Hendrickson SE , et al. The successful applica-tion of simulation-based training in thoracic surgery residency . J Thorac Cardiovasc Surg. 2010 ; 139 ( 3 ): 707-712 .

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these models, tubing is typically connected via ports to an ECMO circuit to practice priming of the cir-cuit, adjustments of flow rates, and emergency ECMO scenarios. However, none of these models allow for physical cannulation of the vessels; they do not include an artificial tissue skin specifically designed to allow a surgeon to make an incision to gain vascular access as part of the simulated cannu-lation procedure. In addition, none of these models provide a realistic bleeding response. Recently, 1 study developed a trainer independent of our own, who met these criteria. 12 These novel features, incor-porated into both their trainer and our own model, increase functional fidelity by allowing the surgeon to practice specific procedures such as cutdown, ligature, cannulation, and advanced suturing techniques.

While featuring these same novel components, our ECMO model has several additional benefits. First, it is very inexpensive. The materials required to make 1 ECMO model cost approximately $25. Second, it is easy to assemble; it can be made in approximately 1 hour. In addition, we tested our model in a multidisciplinary simulation. This per-mitted the participating surgeon to practice the tech-nical skills involved in the cannulation of neonatal vessels, while also addressing important teamwork skills involved in the actual initiation of ECMO. We used an interprofessional approach to include all team members (attending, residents, nurses, respira-tory therapists, and perfusionists) who are involved during the actual initiation of ECMO. Consequently, our trainer was used in a setting that is more similar to the setting in which actual ECMO cannulation occurs. Performing this as an in situ training allowed more accurate progression of the ECMO initiation as compared to water drills that are the current stan-dard in ECMO training.

We feel that it is important to replicate the com-plex environment of a real ECMO initiation with as much fidelity as possible. Medical professionals who adopt interprofessional teamwork building exercises similar to those employed by the airline industry have found significant improvement in their knowl-edge of teamwork and shared decision making. 13 Furthermore, these teamwork building exercises have been shown to decrease the number and severity of adverse events and improve patient outcomes. 14-18 Using the simulation in the actual clinical setting and using ECLS personnel and real equipment carried several potential benefits for trainees. First, the enhanced realism potentially allowed trainees to suspend disbelief while encour-aging effective communication and helping trainees explore their respective roles in the procedure. Second, it may have instilled confidence in the trainees because they reported being more willing to





14. Neily J , Mills PD , Young-Xu Y , et al. Association between implementa-tion of a medical team training program and surgical mortality . JAMA. 2010 ; 304 ( 15 ): 1693-1700 .

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18. Smith CC , Huang GC , Newman LR , et al. Simulation training and its effect of long-term resident performance in central venous catheter-ization . Simul Healthc . 2010 ; 5 : 146-151 .

improve human performance. Part II: assessment of technical and behavioral skills . Simul Health . 2006 ; 1 ( 4 ): 228-232 .

10. Nimmo GR , Wylie G , Scarth J , et al. Critical events simulation for neonatal and paediatric extracorporeal membrane oxygenation . J Intensive Care Soc . 2008 ; 9 ( 1 ): 20-22 .

11. Kilcommons MM , Costales KG , Tyree MM , Tyree K , Tanaka LY . ECMO simulation without busting the budget . Poster presented at: IMSH , February 2, 2012 , San Diego, CA.

12. Allan CK , Pigula F , Bacha EA , et al. An extracorporeal membrane oxygenation cannulation curriculum featuring a novel integrated skills trainer leads to improved performance among pediatric cardiac surgery trainees . Simul Healthc. 2013 ; 8 ( 4 ): 221-228 .

13. Suva D , Haller G , Lubbeke A , Hoffmeyer P . Differential impact of a crew resource management program according to professional spe-cialty . Am J Med Qual. 2012 ; 27 ( 4 ): 313-320 .


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Construction of a Reusable, High-Fidelity Model to Enhance ...astec.arizona.edu/sites/astec.arizona.edu/files/pdf_files/ECMO... · Initiation of extracorporeal membrane oxygenation