Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) flows are titrated to achieve adequate perfusion while attempting to ideally maintain arterial pulse pressure (PP). We assessed risk in patients with low PP defined as <10 mmHg within the first 2 days of support. Methods Demographics, haemodynamics, echocardiographic and radiological findings were recorded retrospectively in cases conducted between 2014 and 2016. Outcomes were hospital mortality, requirement for renal replacement therapy (RRT) and severe pulmonary oedema (PO). Results Of 101 patients, 66.3% were male, mean age was 56 (range 18–71 years), mean duration of support was 6.3 days ± 4.1 days, 37.6% died prior to hospital discharge, 39.6% needed RRT and 11.9% had severe PO. Areas under the receiver operating curves of PP at 48 h for hospital mortality, RRT and severe PO were (respectively): 0.69 (95% CI 0.58–0.80, p = .001), 0.64 (95% CI 0.50–0.77, p = .044), 0.69 (95% CI 0.55–0.82, p = .009). The odds ratio for mortality, RRT, severe PO for those with low PP were (respectively) 2.8 (95% CI 1.01–7.5, p = .04), 3.1 (95% CI 1.11–8.40, p = .026), 7.6 (95% CI 2.06–27.89, p = .001). Central venous pressure, mean arterial pressure were not predictive. Conclusion PP during the first 2 days of support is predictive of clinically important outcomes in patients supported with VA-ECMO.

Background: There is limited literature exploring the relationship between simulation training and extracorporeal cardiopulmonary resuscitation (ECPR) outcomes. We examined whether there was an association between the implementation of an in situ simulation training program and ECPR utilisation, time to extracorporeal membrane oxygenation (ECMO), and neurologically intact survival. Methods: In this retrospective pre-post study of in-hospital cardiac arrests (IHCA) and out-of-hospital cardiac arrests (OHCA), we analysed data for all patients recorded as receiving ECPR from September 2009 to December 2020 at our institution, relative to the implementation of an in situ ECPR simulation training program and a standardised procedure for high-quality ECPR. The primary outcome was Cerebral Performance Category (CPC) 1 or 2 at hospital discharge. Results: There were 27 patients in the pre-intervention period and 39 patients in the post-intervention period. The median ECPR rate per year was 2 pre-intervention and 7 post-intervention (p = 0.073). There was an association between the implementation of the program and decreased median time from OHCA to ECMO flow, from 87 (IQR 78-95) minutes pre-intervention to 70 (IQR 69-72) minutes post-intervention (p = 0.002). Median time from IHCA to ECMO flow was 40 (IQR 20-75) minutes pre-intervention and 28 (IQR 16-41) minutes post-intervention (p = 0.134). Survival with CPC 1 or 2 was 7/27 (25.9%) pre-intervention and 15/39 (38.5%) post-intervention (p = 0.288). Conclusion: We observed an association between the implementation of an ECPR-specific simulation program and decreased time from OHCA to ECMO flow. There was no association between the implementation of the program and neurologically intact survival at hospital discharge.

Objectives: To describe the incidence and outcomes of radiologically confirmed acute CNS complications in extracorporeal membrane oxygenation patients at an Australian extracorporeal membrane oxygenation referral center and identify associated patient characteristics. Design: Retrospective cohort study. Setting: Single-center tertiary institution. Patients: Four-hundred twelve consecutive adult patients supported with extracorporeal membrane oxygenation from 2009 to 2017. Results: Fifty-five patients (13.3%) had a CNS complication confirmed by CT or MRI, including ischemic stroke (7.0%), intracerebral hemorrhage (3.4%), hypoxic ischemic encephalopathy (3.6%), and spinal cord injury (1.2%). CNS complication rates in the venoarterial, venovenous, and veno-pulmonary artery extracorporeal membrane oxygenation subgroups were 18.0%, 4.6%, and 13.6%, respectively. Neurologic complications were independently associated with the use of venoarterial extracorporeal membrane oxygenation ( p = 0.002) and renal replacement therapy ( p = 0.04). Sixty-five percent of patients with a neurologic complication died during their hospital admission compared with 32% of patients without this complication ( p < 0.001). Venoarterial extracorporeal membrane oxygenation, renal replacement therapy, and days of extracorporeal membrane oxygenation support were also associated with hospital mortality and remained so after adjustment in a multivariable regression model ( p = 0.01, p < 0.001, and p = 0.003, respectively). Conclusions: CNS complications appear to occur more frequently in patients requiring circulatory as opposed to respiratory support on extracorporeal membrane oxygenation and are independently associated with mortality. It remains unclear if these complications are causative of a poor outcome or a marker of severity of the underlying condition. Further research is required to better elucidate modifiable or preventable aspects through better patient selection and change in ongoing care.

Introduction: It is difficult to evaluate learning effectively in a complex simulated educational environment. Objectives: The aim was to evaluate the perceived learning of participants in a 1-day extracorporeal membrane oxygenation (ECMO) management workshop. Methods: The approach to learning in the workshop was didactic presentation, then practical demonstration and hands-on practice. All attendees then participate in a series of simulated scenarios and de-briefing. Participants are administered an anonymous pre-assessment questionnaire at commencement. They identify their staff category and how they would rate their current level of proficiency from beginner through to expert. They rate from 1 = worst possible/most negative to 9 = best possible/most positive their perception of their current level of knowledge regarding veno-arterial (VA) /veno-venous (VV) ECMO, confidence with ECMO patients, confidence with ECMO emergencies and skill with ECMO circuit issues. At conclusion participants rate themselves on the same elements. Results: Four hundred and sixteen participants attended a workshop between 2010 - 2018. The pre/post assessment has been tested for 18 workshops with 251 participants: nurses, doctors, perfusionists and physiotherapist. The mean improvement (with p<0.001) on the scale of 1 to 9 was: knowledge VV-ECMO +2.9(SD±1.4); VA-ECMO +2.9(SD±1.4); confidence caring for ECMO patients +3.0(SD±1.6); confidence dealing with ECMO emergencies +3.6(SD±1.6); and skill in managing circuit issues +3.6(SD±1.6). All 127 participants agreed they could incorporate learning into clinical practice. Conclusion: An easily administered pre/post evaluation for participants in a simulation based ECMO workshop provides an indication of learning that occurs from beginning to end of a 1-day multi-modal education session. Participants perceived an increased knowledge base, improved confidence and skill development.

Introduction: Mortality from refractory cardiac arrest is greater than 90%. Survival may be significantly improved with Extracorporeal Membrane Oxygenation Cardio Pulmonary Resuscitation (ECPR).

Rationale: Current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown. Objectives: To report current practices regarding mechanical ventilation in patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes. Methods: This was an international, multicenter, prospective cohort study of patients undergoing ECMO for ARDS during a 1-year period in 23 international ICUs. Measurements and Main Results: We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU, and 6-month outcome data for 350 patients (mean +/- SD pre-ECMO Pa-O2/FIO2 71 +/- 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. V-T (6.4 +/- 2.0 vs. 3.7 +/- 2.0 ml/kg), plateau pressure (32 +/- 7 vs. 24 +/- 7 cm H2O), driving pressure (20 +/- 7 vs. 14 +/- 4 cm H2O), respiratory rate (26 +/- 8 vs. 14 = 6 breaths/min), and mechanical power (26.1 +/- 12.7 vs. 6.6 +/- 4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal-replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher VT and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes. Conclusions: Ultraprotective lung ventilation on ECMO was largely adopted across medium- to high-case volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context.

Introduction: ICU sound and light levels may impact patient sleep, delirium and outcomes.

Background: Reported rates of limb ischaemia on peripheral veno-arterial extracorporeal membrane oxygenation (pVA ECMO) vary from 1-52%. Objectives: Primary: To explore (i) the feasibility for appropriately trained intensive care unit staff to measure Doppler derived flow velocities of the lower limbs for patients on pVA ECMO; and (ii) whether these measurements are clinically useful. Secondary: explore the relationship between ECMO pump flow, backflow cannulae (BFC) properties, mean arterial blood pressure (MAP), and pulse pressure on flow velocities. Method: Inclusion criteria: age> 18 years, on pVA ECMO >24 hours. Exclusion criteria: any guardianship limitations and patients without a BFC. Serial patients receiving pVA-ECMO over a 10 month period had Doppler derived flow velocities of the lower limbs sampled. Simultaneously, other pertinent parameters were recorded. 80% inclusion was considered clinically feasible. Study personnel were asked for feedback regarding the ease and usefulness of studies. Results: 15 of 17 patients were included: 88% inclusion. Mean peak systolic velocity (PSV) in the cannulated limb was 31 +/- 29 cm/s in the dorsalis pedis (DP) and 27 +/- 18 cm/s posterior tibial (PT). Similar flows were recorded in the non-cannulated limbs (DP 34 +/- 29 cm/s, PT 44 +/- 36 cm/s; P > 0.05). PSV was positively correlated with pulse pressure in cannulated and non-cannulated limbs respectively (r = 0.63, P < 0.05; r = 0.67 and P < 0.05). There was no significant correlation between PSV and MAP. ECMO pump flow and BFC were negatively correlated with PSV (r = -0.51, P < 0.05; r = -0.43, P < 0.05). Conclusion: It is generally feasible for ICU staff to measure flow velocities of the lower limbs for patients on pVA ECMO. It remains unclear how clinically useful these measurements are. Doppler derived flow velocities of arteries of the lower limbs of patients on pVA ECMO appear different to non-ECMO patients. PSV in the lower limbs of patients on pVA ECMO seems to be more related to pulse pressure than to other haemodynamic parameters. (C) 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Introduction: Intrinsic cardiac output is not accurately assessed with thermo-dilution or pulse contour analysis in veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Pulse pressure (PP) is thought to be a surrogate marker for intrinsic cardiac output. We compare invasive haemodynamic parameters with echocardiography (EC) findings.

Introduction: Ventilation settings, parameters and outcomes may appear different for alternative categories of patients who receive veno-venous (VV) extracorporeal membrane oxygenation (ECMO).

Introduction: It may occasionally be difficult to clearly differentiate superventricular arrhythmias for some patients. Where atrial epicardial wires are present performing an atrial electrocardiogram (AECG) may be useful.

Unable to meet one-on-one, annual ALS re-accreditation for ICU nursing ALS team leaders (ALS T/L), one single ICU trialled regular simulated ALS scenarios as a way of maintaining ALS proficiency.

A single centre ICU investigated an alternative model of ALS re-accreditation for ICU nurses. The focus changed from one-on-one assessments, to a multidisciplinary, team-based simulation model. Nursing ALS team leaders (ALS T/Ls) were deemed re-accredited by performing the role of ALS T/L to pre-determined standards, in high fidelity simulations.

Patients receiving peripheral veno-arterial (pVA) ECMO may experience lower limb ischemic complications. Near infrared spectroscopy (NIRS) [regional Oximetry (rSO2)], may be used as a monitoring adjunct of distal limb perfusion. The aim of this pilot study was to compare rSO2 measurements of patients who experienced a significant ischemic lower limb event, an intervention to relieve ischemia, then the resultant rSO2. Secondary goals were to provide an initial evaluation of the usefulness, causes and outcomes of regional oximetry. Regional oximetry probes were placed midcalf bilaterally of pVA ECMO pts from 2015 to July 2016. RSO2 measurements were recorded on the affected and non-affected limbs. 58 patients were placed on VA ECMO during this period; 49 on pVA. 7 (14%) patients experienced significant lower limb ischaemia. One patient died soon after initiation of pVA ECMO and was not included as no intervention occurred. 4 patients received fasciotomy and 2 were changed to central ECMO. Two patients received a back flow cannula which is standard practice at this centre. Two patients survived, one with an amputation. For one, the outcome remains unknown. Causes for limb ischemia included: pre-ECMO hypo-perfused states, vasopressor requirements, known effects of ECMO cannulation (eg requisite back flow cannulae), and actual/attempted insertion of non-ECMO devices eg IABP. The mean rSO2 prior to an intervention for an ischaemic limb event was 27.9±29.7% and post intervention was 71.1±11.3%. The mean difference was 43.3±26.6 (P

Winner: Best Nursing Poster sponsored by

BACKGROUND:Recent advances in the technology of extracorporeal respiratory assist systems have led to a renewed interest in extracorporeal carbon dioxide removal (ECCOR). The Hemolung is a new, low-flow, venovenous, minimally invasive, partial ECCOR device that has recently been introduced to clinical practice to aid in avoiding invasive ventilation or to facilitate lung-protective ventilation.OBJECTIVE:We report our early experience on use, efficacy and safety of the Hemolung in three Australian intensive care units.METHODS:Retrospective review of all patients with acute or acute-on-chronic respiratory failure (due to chronic obstructive pulmonary disease [COPD] with severe hypercapnic respiratory failure when non-invasive ventilation failed; acute respiratory distress syndrome; COPD; or asthma when lung-protective ventilation was not feasible due to hypercapnia) for whom the Hemolung was used.RESULTS:Fifteen patients were treated with ECCOR. In four out of five patients, the aim of avoiding intubation was achieved. In the remaining 10 patients, the strategy of instituting lung-protective ventilation was successful. The median duration for ECCOR was 5 days (interquartile range, 3-7 days). The pH and PCO2 improved significantly within 6 hours of instituting ECCOR, in conjunction with a significant reduction in minute ventilation. The CO2 clearance was 90-100 mL/min. A total of 93% of patients survived to weaning from ECCOR, 73% survived to ICU discharge and 67% survived to hospital discharge.CONCLUSION:Our data shows that ECCOR was safe and effective in this cohort. Further experience is vital to identify the patients who may benefit most from this promising therapy.

Transfusion of blood products is common in the perioperative lung transplant surgical period. Four studies in the area have found variable impact of transfusion on mortality, but mostly an association with adverse outcomes such as duration of mechanical ventilation, intensive care length of stay (ICU LOS), graft dysfunction, requirement for renal replacement therapy and extracorporeal membrane oxygenation (ECMO). In the absence of specific guidelines in this patient group, practices vary widely between centres. From limited available data certain indications for transplantation, presence of pulmonary hypertension and surgery on cardiopulmonary bypass (CPB) appear to predict higher transfusion requirement. Our objective was to describe perioperative transfusion in lung transplant patients. Consecutive adult lung transplant patients in an Australian centre were studied over a 6-year period where surgery on CPB is the norm and in the absence of factor concentrate availability, allogeneic blood products are used. Transfusion data were collected for the intraoperative and first 24 hours of the postoperative period. Of 265 patients, 251 (95%) had bilateral lung transplant; a mean (SD) age of 47(15) years, 131(49%) were male. Common indications for transplant were cystic fibrosis (23%), emphysema (32%) and idiopathic interstitial pneumonitis (24%). Median (IQR) ventilation time, ICU and hospital LOS was 26(17-68) hours, 5(3-11) days and 18 (13-31) days respectively. 217 (82%) patients received packed cells (PC) with a median (IQR) of 4 (1-7) units (U). 104 (39%) and 33(12%) patients required >5 and >10 U respectively. Of 12 bridge to transplant (BTT) ECMO patients, 11 (92%) received >10 U and of 20 patients requiring ECMO for primary graft dysfunction (PGD) 16 (80%) required >5 U. 218 (82%) patients received pooled platelet transfusion -median (IQR) 1(1-2) U. 209 (79%) and 129 (49%) patients received fresh frozen plasma (FFP) and cryoprecipitate with a median (IQR) of 3(2-4) and 0(0-0) U respectively. Rate and volume of transfusion of blood products compare favourably with centres performing surgery off CPB or on ECMO.

Introduction: Monitoring for delirium in ICU using tools such as the CAM-ICU and employing delirium management protocols have been associated with decreased morbidity and mortality.

Introduction: The Medication Error Minimisation Scheme (MEMS) is an ongoing multi-disciplinary quality improvement project within an adult ICU.