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User Manual - ECMO Simulator

1. Maxima y 0 0529x 0 0645 0 10 y P 0 05 y 0 00 3 T T T T T 0 0 1 0 2 0 3 0 4 0 5 0 6 0 Bloodflow l min By default Vd Vt Dead Space of the oxygenator at a nominal blood and gas flow of 3 0 Ipm is set to 0 08 Pybus et al The nominal values of these parameters can be altered using the Supervisor Application The behaviour of the model is illustrated in the following figure in which the output of the model has been compared in real time with data acquired from a CDI 500 in line blood gas analyser from a patient on cardio pulmonary bypass The predicted arterial PO2 has been compared with the actual arterial PO2 during a manoeuvre where the inspired oxygen concentration to the oxygenator green line was reduced from 100 to 60 and then returned to 100 two minutes later The concordance between the actual and predicted readings is clearly apparent 2010 MSE Australia PL 500 0 350 0 300 0 250 0 200 0 Pa02 mm Hg 150 0 50 0 Actual Predicted 0 0 T T T 00 00 30 00 01 30 00 02 30 00 03 30 Time hh mm ss References Pybus DA Lyon M Hamilton J Henderson M Measuring the efficiency of an artificial lung 1 Carbon dioxide transfer Anaesth Intensive Care 1991 Aug 19 3 421 5 Riley RL and Cournand A 1949 Ideal Alveolar air and the analysis of ventilation perfusion relationships in the lungs J Appl Physiol 1 825 847
2. 100 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 RPM The relationship between this stagnation pressure and RPM is shown in Figure 4 where the black line represents the behaviour of the simulator s centrifugal pump and the red triangles the stagnation pressures of a modern ECMO system Maquet CardioHelp O at the various rpm s Now let s see what happens if we go through the same exercise but with the outlet line unclamped Before we do this we ll perform a baseline blood gas analysis Click lt Investigations gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt window And return to the ECMO system A Click lt Devices gt lt ECMO System in the lt Inspector gt window Now turn the flow control back to zero and set a flow of oxygen of about 8 Ipm Fully release the outlet clamp by sliding the clamp control to the top of the scale and slowly increase the pump rpm to about 2250 This time the response of the system is quite different In the data display area note that the pressure increase is much smaller that blood is flowing through the system at about 3 4 lpm and that the SvO2 is rising On the patient monitor there has been no great change in either CVP or arterial pressure but the saturation has risen and the frequency of ectopy has fallen If you now further increase the rpm you ll see that both flow and pressure begin to fall progressively until eventually at about 4000 rp
3. Tutorials Scope Of Tutorials The system comes with a series of ten pre loaded tutorials which are intended to familiarize the user with the simulation system and to explore the techniques and problems associated with the use of VV and VA ECMO The learning objectives contained in each tutorial are summarized in the following table Objectives Getting Started e To become familiarized with the basic elements of the MSE simulation environment VV ECMO 1 e To understand the design of a basic veno venous ECMO circuit e To become familiarized with the basic controls of a VV ECMO system e To become familiarized with the basic behaviour of a centrifugal pump VV ECMO 2 e To investigate the effect of cannula position on ECMO system performance e To investigate the effect of temperature control on metabolic rate and oxygenation VV ECMO 3 e To examine the impact of return cannula size on ECMO system performance VV ECMO 4 e To understand the impact of obstruction of the inlet or outlet line on ECMO system performance 1 VA ECMO e To understand the design of a simple veno arterial ECMO circuit e To become familiarized with the basic controls of a VA ECMO system e To understand the mechanism of Differential Hypoxia 2 e To explore the cardiovascular effects of VA ECMO in a patient with cardiogenic shock e e To recognise the signs of oxygenator gas supply failure e To recognise the signs of oxygenator fa
4. 2010 MSE Australia PL Applications 19 2 Applications The system comprises two separate computer programs Applications The main Trainee application is contained within the executable file MSEHDTV exe and is designed to be displayed on a computer with a single WUXGA 1920 1200 pixels or HDTV 1920 1080 pixels display This application comprises three modules Patient Monitor Therapeutic Interface and Inspector The second Supervisor application is used to control the behaviour of the simulation system in real time and is intended to be run ona second PC or Netbook which is in communication with the Main Application using the IP4 implementation of the TCP IP protocol The supervisory application can be run within a Local Area Network or over the Internet 2 1 Trainee The Main Trainee Application is contained within the executable file MSEHDTV exe and is designed to be displayed on a computer with a single WUXGA 1920 1200 pixels or HDTV 1920 1080 pixels display This application comprises three modules Patient Monitor Therapeutic Interface and Inspector 2 1 1 Menu Bars The Main Application itself and the Inspector window both have menu bars The items on the menu bar of the main Trainee application vary according to the mode of operation of the system In lt Unsupervised gt mode the main menu items are e lt System gt lt Exit gt e lt View gt lt Patient Monitor gt
5. Before the administration of 10 000 units of heparin the Activated Clotting Time ACT is 130 secs After the administration of heparin the ACT rises rapidly to about 325 2010 MSE Australia PL seconds 10 minutes later the patient is given 100 mg of protamine and virtually complete reversal of the anticoagulant effect of the heparin occurs References Maitre PO Shafer SL A simple pocket calculator approach to predict anesthetic drug concentrations from pharmacokinetic data Anesthesiology 1990 Aug 73 2 332 6 5 5 Cardiovascular Model The cardiovascular model combines a ventricular pump together with a four element Windkessel model Stergiopulos et al The pump is pre and after load sensitive and generates a sinusoidal output The intra vascular pressure calculations are computed every 5 msecs The effect of variation in pre load on the cardiac output of the model in a patient with normal contractility and sympathetic tone is illustrated below These data were generated from the system itself and recorded using the data recording system Effect Of Volume Loading on Cardiac Output CO LPM 5 0 5 10 15 20 25 30 35 CVP mm Hg In addition to exhibiting Frank Starling behaviour the cardiovascular model also incorporates some reflex activity The effect of haemorrhage on blood pressure and pulse rate is shown below Over a 60 second period a 70 kg patient loses 1L of blood As a result the systolic blood
6. Segers PA Heida JF de Vries Maas C Boogaart AJ Eilander S Clinical evaluation of nine hollow fibre membrane oxygenators Perfusion 2001 Mar 16 2 95 106 5 7 Cannula Model The pressure drops across some of the MSE system cannulae are shown below The values are comparable with those found in many modern inflow cannulae O 2010 MSE Australia PL s ECMO Simulation User Manual v5 7 350 4 Pressure Drop Across MSE Cannulae Varying Flow Rates 15F 300 4 250 4 D 18F p 200 E eB O 5 150 y a 21F D 100 4 a 23F 24F 50 4 0 T gt o 1 2 3 5 6 7 Flow lpm During VV ECMO the cannula model takes into account the relative positions of the tips of the drainage and return cannula e If these are positioned too closely re circulation will start to occur and oxygenation will be impaired Return cannula size can be set by the trainee in the range 15 24F using the Cannula Selector Interface 2010 MSE Australia PL MSE Cannula Selector E The effect of changing the size of the return cannula on pre membrane pressure at a flow rate of 4 lpm is shown below 300 250 200 Oo E 2 a 150 E E E 100 w 174 un a 50 0 14 16 18 20 22 24 Cannula Size FG 2010 MSE Australia PL s ECMO Simulation User Manual v5 7 5 8 5 9 Centrifugal Pump Model The centrifugal pump used by the MSE is modelled according
7. e lt View gt lt Inspector gt e lt View gt lt Therapeutic Interface gt e lt View gt lt Camera gt e lt Tools gt lt Load Patient gt e lt Tools gt lt Load Scenario gt In lt Supervised gt mode the main menu items are e lt System gt lt Exit gt e lt View gt lt Patient Monitor gt e lt View gt lt Inspector gt e lt View gt lt Therapeutic Interface gt e lt View gt lt Camera gt e lt Tools gt lt Save Patient gt In lt Maintenance gt mode the main menu items are e lt System gt lt Exit gt e lt System gt lt Scenario Editor gt e lt System gt lt Scenario Data Source gt e lt System gt lt Recorded Variables Editor gt 2010 MSE Australia PL 20 ECMO Simulation User Manual v5 7 e lt System gt lt ECG Editor gt e lt System gt lt Help System gt e lt System gt lt Miscellaneous Settings gt The function of each of the respective main menu items is e lt System gt lt Exit gt To stop the application e lt System gt lt Scenario Editor gt To start the Scenario Editor e lt System gt lt Scenario Data Source gt To allow the user to change the location of the ScenarioData folder e lt System gt lt Recorded Variables Editor gt To allow the user to select the variables which are recorded by the data recorder lt System gt lt ECG Editor gt To start the ECG Editor lt System gt lt Help System gt To open this Help file lt View gt lt Patient Monitor gt To show or
8. e To become familiarized with the basic behaviour of a centrifugal pump We will be simulating the use of a system in a patient with essentially normal cardiovascular function but with severe respiratory failure The patient is a 24 year old man weighing 75 kgs who has been transferred to your Intensive Care Unit for Veno Venous ECMO He had been admitted to the Intensive Care Unit of a large regional hospital 3 days before transfer to your institution At that time he presented a four day history of increasing respiratory distress fever and a productive cough The patient had been sedated intubated and ventilated shortly after admission to the regional ICU Blood and sputum cultures grew a methicillin sensitive staphylococcus aureus Despite treatment with appropriate antibiotics the use of prone ventilation permissive hypercarbia and inhaled nitric oxide he continued to deteriorate Following discussions with the clinicians at the regional hospital he has been transferred to your institution for initiation of veno venous ECMO On arrival in your ICU the patient is being given assisted ventilation via an Ambu bag on 100 oxygen 2010 MSE Australia PL 2 ECMO Simulation User Manual v5 7 Blood gas analysis is reported as Pa02 45 mm Hg PaCOQ2 44 mm Hg pH 7 3 BXS 3 5 Temp 37 0 Sa02 74 The patient has an Acute Lung Injury Score Murray Score of 3 5 but has no other significant co morbidities He has a
9. lt BIS gt display on the physiological monitor You elect to cannulate the patient percutaneously employing the Seldinger technique and using a 21F cannula in the right femoral artery and 24F cannula in the right femoral vein Imagine now that you have e Placed the Seldinger wires in the artery and vein e Given the patient 7500 units of heparin Select lt Heparin gt from the lt Therapeutic Interface gt lt Bolus Drug gt page and lt Give gt 7500 units and e Positioned the cannulae under ultrasonic control The cannulae have been connected to the ECMO system The entire system is heparin coated The system s centrifugal pump is responsible both for generating the negative pressure which is required to facilitate drainage and the positive pressure which is required to pump blood through the artificial lung and back into the patient The pump head and oxygenator are integrated into a single disposable unit which is mounted on the system console Figure 2 2010 MSE Australia PL VA ECMO Active venous drainage from the inferior vena cava is via the 24F venous cannula and return via the 21F arterial cannula A femoral backflow cannula has not been used Figure 2 Before commencing ECMO you may wish to confirm that the patient is effectively anti coagulated Select lt Devices gt lt ACT Monitor gt and click lt Start gt in order to commence the measurement If you do this you ll need to click lt Devices gt lt ECMO
10. System gt to return to the ECMO interface You can periodically return to the ACT Monitor to check on the progress of the estimation Additional information regarding the ECMO system can be found by clicking on the lt Resources gt menu of the lt Inspector gt window and selecting the resource which you want to view These resources include lectures on ECMO images of various systems relevant websites and various descriptions and protocols relating to the technique To visualize the ECMO interface itself wa Click on the lt Devices gt lt ECMO System gt menu item of the lt Inspector gt Bu window lt Q Select the lt VA ECMO gt option at the bottom right of the interface 2010 MSE Australia PL 122 ECMO Simulation User Manual v5 7 Notes Investigations Devices Resources Help The key components of the system interface are shown above To the left of the interface are three controls which control respectively the inspired oxygen concentration of gas flowing through the oxygenator the gas flow rate lpm to the oxygenator and the temperature setting control Co for the heater cooler The heater cooler can be used to vary the patient s temperature and metabolic rate Between these three controls and the CardioHelp data display area is the electronic clamp which controls flow through the outlet Arterial side of the pump When the slider is at the bottom the clamp is fully closed when at the top
11. all of this return and oxygenate and remove carbon dioxide from it there would be no need for the patient s native lung to make any contribution at all to gas exchange and the native lung could be completely rested in order to allow healing to occur Ideally we need to drain blood separately from the Superior Vena Cava SVC and IVC blood using separate cannulae and we ll explore the effect of using dual drainage cannulae in a future tutorial However for the moment we ll stay with a single drainage cannula and explore the effect of advancing the cannula up the IVC To do this e Click the lt Adjust Cannula gt button e Slide the blue slider at the left hand side of the CXR to position 8 This will advance the drainage cannula to the optimal position e Click lt Devices gt lt ECMO System in the lt Inspector gt window You should see that there has been a small increase in ECMO flow from 3 4 to 4 0 lpm 2010 MSE Australia PL Tutorials 105 Apart from positioning the drainage cannula there are two other techniques which we can use to increase venous return through the system In particular elevation of the CVP by transfusion or posture adjustment and the use of dual cannulae should be considered when confronted with this problem So at this stage in the exercise we ve done two things in an attempt to improve oxygenation 1 We ve advanced the cannula further up the IVC and 2 We ve cooled the
12. between these modes using the control at the bottom right hand side of the ECMO system interface The features of each of these devices are outlined in the lt Devices gt section of this manual Clicking on the lt Resources gt menu item allows the trainee to examine the resources which are available for the current scenario The resources may include e Static Images eg Photographs in jpg bmp or pdf format e Video Files eg Training Videos Lectures in wmv or avi format e Text Documents eg Scientific Papers in pdf format or e Web Sites in url format e Powerpoint files in ppt or pptx format Clicking on the lt Help gt lt Help Manual gt menu item allows the trainee to access this document Clicking the lt Help gt lt About gt menu item displays Version and License information relating to the installation 2 1 4 Therapeutic Interface 2 1 4 1 Overview The lt Therapeutic Interface gt is used for the administration of bolus infusion drugs and or fluids The main window for bolus drugs is shown below Bolus Drug Infusion Drug Fluids History Select Bolus Drug Adrenalin 100 mcg ml Atropine 600 mcg ml CaCl2 100 mg ml Fentanyl 50 mcg ml Heparin 1000 units ml Isoprenalin 100 mcg ml KCI 1 mMol ml Ketamine 10 mg ml Lignocaine 10 mg ml Mivacurium 2 mg ml Metaraminol 500 mcg ml Metoprolol 1 mg ml Midazolam 1 mg ml Noradrenalin 100 mcg ml Pancuronium 2
13. fully open The data display area displays the current values of e Flow through the system in lpm e Pre membrane circuit pressure measured between the pump head and the oxygenator e Venous oxygen saturation e Pump speed in rpm e Haematocrit and e Blood Temperature 2010 MSE Australia PL Tutorials 123 To the right of the display area are four controls e The main power switch enables the flow control knob which is situated just beneath it e The flow control is used to adjust the speed of the centrifugal pump in the range 0 5000 rpm e The lt Adjust Cannula gt button allows you to move the drainage cannula e in or out and to select the size of your return Arterial cannula e Finally the lt Mode gt button is used to set the system up for either VV or VA ECMO Note that the flow control is not enabled until the ECMO system is turned lt On gt The first exercise we ll be undertaking is initiation of VA ECMO First we ll perform a baseline blood gas analysis lt Investigations gt lt Arterial Blood Gas Analysis gt and then return to the ECMO system lt Devices gt lt ECMO System gt Click the lt Adjust Cannula gt button and advance the drainage cannula as far as it will go using the slide control on the left hand side of the window then re open the ECMO interface by clicking lt Devices gt lt ECMO System gt Click the main power button at the top right of the interface Turn on 4 LPM o
14. the window s title bar and drag it while holding down the left mouse button The position of the window will be retained when you next start the application Refer to the section entitled Inspector in the user manual for a complete description of the functionality of this window Patient Monitor The lt Patient Monitor gt is based on a modern physiological monitor and is used to display the patient s current vital signs The patient who has been selected for this scenario is essentially normal Click the lt Display gt button in the lt Patient Monitor gt window Clicking the lt Display gt button on the Patient Monitor allows you to select the parameters which you want to view Check lt ECGs lt Direct Arterial Pressure gt and lt Central Venous Pressure gt inthe lt Display gt window Click the lt Display gt button in the lt Patient Monitor gt window The lt Display gt window will now close and the ECG Direct Arterial Pressure and Central Venous Pressure waveforms will be displayed in the lt Patient Monitor gt window The parameters which can be displayed include e ECG e NIBP e Direct Arterial Pressure e Central Venous Pressure e SaQ2 e Sa02 waveform e BIS e Temperature 2010 MSE Australia PL so ECMO Simulation User Manual v5 7 e Capnographic Waveform and e Inspired and Expired Gas values If you want to reposition the lt Patient Monitor gt place the mouse
15. 11 o Unsupervised Simulation Mode e Supervised Simulation Mode e Maintenance Mode Choose lt Unsupervised Simulation Mode gt the default selection and click the lt Start gt button The system s three primary windows will appear At the left hand side of the screen is the lt Inspector gt window to the right hand side is the lt Patient Monitor gt and below this is the lt Therapeutic Interface gt Inspector Window The lt Inspector gt window is used to display textual or audio visual information relating to the scenario and to allow the user to manipulate the virtual devices which can be used in the treatment of the patient Click the lt Notes gt menu item to view the notes which describe the patient in the current scenario Click the lt Prev gt and lt Next gt menu items of this window to navigate the current document The lt Investigations gt menu item lists the investigations which are currently available for the patient Oxygenator Blood Gas Analysis is only available if an ECMO system is in use The lt Devices gt menu item is used to visualise any of the 6 devices which are available to the user These devices are a e Ventilator e VV ECMO System e VA ECMO System e ACT Monitor e Nerve Stimulator e Defibrillator and e Stethoscope Click on lt Devices gt lt Nerve Stimulator gt to display the nerve stimulator and then click on the lt TOF gt button to see the patient s current Tra
16. 115 20 100 o 2 Fi02 PEEP cm H20 Tam Turn the ventilator on by clicking the power switch at the top right hand side e of the device Set the tidal volume Vt to 500 mls the rate to 12 bpm the N FiO2 to 100 and the PEEP to 5 cms H20 Note that the ventilator s controls are not enabled until the ventilator is turned lt on gt The ventilator is based on a simple anaesthesia system which is in Intermittent Mandatory Ventilation IMV mode At this time the pressure flow and volume signals appear somewhat chaotic because the patient is also breathing spontaneously If any of the signal traces appear discontinuous adjust the gain of the appropriate signal channel using the green arrows at the right hand side of the display Also note that the peak airway pressure is very high 35 cms H20 because the patient has a very low static lung compliance lt 20 mls cm H20 Stop the patient fighting the ventilator by controlling his ventilation To do this CAN Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt S24 window SQ Drag the green slider until it says 8 mgs and click the lt Give gt button If you wish to monitor the onset of muscle paralysis by monitoring his Train of Four CAN Click the lt Devices gt lt Nerve Stimulator gt menu item in the lt Inspector gt yA window A COANN a l lt Q Click the lt TOF gt button on the nerv
17. 3 Maintenance Mode Select lt Unsupervised Simulation Mode gt the default selection and click the lt Start gt button The system s three primary windows will appear At the left hand side of the screen is the lt Inspector gt window to the right hand side is the lt Patient Monitor gt and below this is the lt Therapeutic Interface gt Inspector Window The lt Inspector gt window is used to display textual or audio visual information relating to the scenario and to allow the user to manipulate the virtual devices which can be used in the treatment of the patient Click the lt Notes gt menu item in the lt Inspector gt window The notes are normally used to outline the clinical history and findings of the patient in the current scenario If more than one page is available use the lt Next gt and lt Prev gt menu options of this window to navigate to other pages within the notes In this instance we have used the lt Notes gt to describe the conduct of the tutorial rather than to present the clinical picture of the patient 2010 MSE Australia PL ECMO Simulation User Manual v5 7 Sy lt Q Click the lt Investigations gt menu item in the lt Inspector gt window The lt Investigations gt menu item lists the investigations which are currently available for the patient Oxygenator Blood Gas Analysis is only available if an ECMO system is in use Click the lt Investigations gt lt Arteri
18. 65 1 473 7 Glass PS Bloom M Kearse L Rosow C Sebel P Manberg P Bi spectral analysis measures sedation and memory effects of propofol midazolam isoflurane and alfentanil in healthy volunteers Anesthesiology 1997 Apr 86 4 836 47 Green HD 1944 Circulation Physical Principles Medical Physics 1 208 232 Hardman JG Wills JS Aitkenhead AR Factors determining the onset and course of hypoxemia during apnea an investigation using physiological modelling Anesth Analg 2000 Mar 90 3 619 24 Hardman JG Wills JS Aitkenhead AR Investigating hypoxemia during apnea validation of a set of physiological models Anesth Analg 2000 Mar 90 3 614 8 Kelman GR 1966 Digital computer subroutine for the conversion of oxygen tension into saturation J Appl Physiol 1966 Jul 21 4 1375 6 Kelman GR 1967 Digital computer procedure for the conversion of PCO2 into blood 2010 MSE Australia PL 158 ECMO Simulation User Manual v5 7 CO2 content Resp Physiol 3 111 115 Kirklin JW and Barratt Boyes BG Cardiac Surgery New York Churchill Livingstone 1993 61 127 Lewis RP Rittogers SE Froester WF Boudoulas H A critical review of the systolic time intervals Circulation 1977 Aug 56 2 146 58 Maitre PO Shafer SL A simple pocket calculator approach to predict anesthetic drug concentrations from pharmacokinetic data Anesthesiology 1990 Aug 73 2 332 6 McSharry PE Clifford GD Tarassenko L Smith LA A
19. Australia PL s discretion MSE Australia PL may provide limited support through email or discussion forums at the download web site The evaluation copy of the Software contains a feature that will automatically disable the Software at the end of Trial Period MSE Australia PL will have no liability to you if this feature disables the Software 2 2 License After Trial Period This Software is licensed not sold During the Trial Period you have the option of paying a license fee in order to use the Software after the expiration of the Trial Period Upon your payment of the license fee MSE Australia PL provides you with a permanent registration number License key hardware protection device Dongle and grants you a limited non exclusive non transferable license to a use the Software ona Named User basis meaning specific individuals are authorized to access the Software and the total number of named users may not exceed 2010 MSE Australia PL 162 ECMO Simulation User Manual v5 7 the total number licensed by You b copy the Software in machine readable form solely for archival and backup purposes 2 3 The Named User of the Software may install and use the Software on any number of computers including operating systems and Virtual Machine Environments that are connected to each other in a network there has to be a TCP IP connection between these computers 3 LICENSE RESTRICTIONS 3 1 You shall undertake any
20. Blood Gas Analysis gt and e Repeat the lt Oxygenator Blood Gas Analysis gt Note that the Arterial and Oxygenator PO2 has fallen precipitously to about 45 mm Hg and that the PCO2 has risen by about 10 mm Hg to 47 How can we interpret these results We suspect that the oxygenator is becoming partially occluded by the deposition of fibrin and or thrombus As a result the pre membrane pressure is rising and the delivered flow falling If we were to measure the pressure drop across the oxygenator we would see that it had increased The gas transfer function of the oxygenator is also failing The supervisor has failed about 50 of the membrane As a result the PO2 is falling and the PCO2 rising These results are typical of one of the more common forms of oxygenator failure and can be summarized as e Elevation of the pre membrane pressure e Reduction of the blood flow rate in association with e Hypoxia and e Hypercarbia In real life how can we think about oxygenator failure One method is to classify it according to the mechanism of failure of the oxygenator Using this approach we can identify three categories e Failure of gas transfer function e Failure of structural integrity and e Failure of heat transfer function In the example given above the oxygenator failure is manifest as both a failure of gas transfer function and as a failure of structural integrity the membrane resistance has 2010 MSE
21. MSE Australia PL Applications 31 The lt Set as Ectopic gt button sets the selected ECG rhythm as the ectopic cardiac rhythm Checking the lt Diathermy gt box simulates diathermy interference on the ECG which continues until the control is unchecked Checking the lt ECG Lead Off gt box simulates disconnection of an ECG lead which continues until the control is unchecked 2 2 3 Lung Page The lt Lung gt page of the supervisory application is used to make adjustments to the respiratory state of the patient EF MSE Supervisor Scenarios CVS ECG Lung Misc ECMO 0 00 0 00 0 0 0 0 0 0 0 0 QsQt Vdvt Comp Raw FRC vt FIO2 The values set on this page are all nominal ie they represent the value of the parameter before any intervention or therapy has occurred The lt QsQt gt slider is used to set the nominal Shunt Fraction of the patient In healthy patients Shunt Fraction typically ranges between 0 03 and 0 10 whereas a patient in severe respiratory failure may have a shunt fraction of gt 0 5 The lt VdVt gt slider is used to set the nominal Physiological Dead Space of the patient In healthy patients Dead Space is typically 0 3 whereas a patient in severe respiratory failure may have a dead space of gt 0 6 2010 MSE Australia PL 32 ECMO Simulation User Manual v5 7 2 2 4 The lt Comp gt slider is used to set the nominal Total Lung Compliance of the patient The
22. Turn the ventilator on by clicking the power switch at the top right hand side ARO lt Q of the device and then choose the settings which you think are appropriate by dragging on the control knobs Note that the ventilator s controls are not enabled until the ventilator is turned lt on gt For the purpose of this tutorial ensure that the Inspired Oxygen concentration is set to 21 In order to assess the patient s gas exchange r AN we Y OMY wed DA Click the lt Display gt button in the lt Patient Monitor gt window O X Check lt Capnography gt and lt Gases gt in the lt Display gt window SQ Click the lt Display gt button in the lt Patient Monitor gt window And perform a baseline blood gas analysis g TA Click lt Investigations gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt lt Q window Ne To paralyse the patient and control his ventilation CAN Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt Sk window 2010 MSE Australia PL 120 ECMO Simulation User Manual v5 7 Click the lt Devices gt lt Nerve Stimulator gt menu item in the lt Inspector gt window Click the lt TOF gt button on the nerve stimulator itself Sedation may be administered by selecting the appropriate bolus or infusion drugs using the lt Therapeutic Interface gt and monitoring the depth of sedation by turning on the
23. a flu like illness some weeks before and had been complaining of increasing shortness of breath and lethargy ever since His family practitioner had prescribed two courses of broad spectrum antibiotics and some bronchodilator therapy Initial Examination The endotracheal tube appears to be correctly positioned and breath sounds are symmetrical The patient is hypotensive tachycardic and has an irregular pulse He is afebrile His ventilation is being assisted using 100 oxygen and an AmbuO bag Pulse oximetry indicates a saturation of 80 Previous Medical History The family tells you that the patient has previously been in good health that he takes no regular medications and that he has no drug allergies He has no relevant previous medical history Subsequent Management The patient is transferred to the Intensive Care Unit further investigations are performed a tentative diagnosis of viral myocarditis is made and the decision is taken to support the patient with VA ECMO The results of some of these investigations Echo ECG CXR and ABG can be seen by clicking lt Investigations gt on the main menu 2010 MSE Australia PL 132 ECMO Simulation User Manual v5 7 We ll assume that you have already worked your way through VA ECMO tutorials 1 and 2 so quite quickly we ll Set up our monitoring e Click the lt Display gt button in the lt Patient Monitor gt window e Check lt ECGs lt Direct Arterial Pressur
24. a pyrexial patient 38 8C on stable VV ECMO and over a period of ten minutes cooled him by 5 0C Note how the arterial saturation rises from 91 to gt 99 This concludes the exercise In future tutorials we ll examine the effect of using dual drainage cannulae and changing the size of the return cannula on the efficacy of ECMO References Kirklin JW and Barratt Boyes BG Cardiac Surgery New York Churchill Livingstone 1993 61 127 VV ECMO 3 Some of the manoeuvres undertaken in this tutorial generate extreme circuit pressures and are only intended to demonstrate the performance characteristics of the system They should not be employed under clinical conditions In this simulation we ll continue to explore the characteristics of a Veno Venous Extra Corporeal Membrane Oxygenation VV ECMO system The learning objectives of the session are to investigate e The impact of return cannula size on ECMO system performance We will be simulating the use of a system in a patient with essentially normal 2010 MSE Australia PL 40 39 38 37 36 35 34 33 Temperature 108 ECMO Simulation User Manual v5 7 cardiovascular function but with severe respiratory failure The patient is a 24 year old man weighing 75 kgs who has been transferred to your Intensive Care Unit for Veno Venous ECMO He had been admitted to the Intensive Care Unit of a large regional hospital 3 days before transfer to
25. by any media player which is capable of interpreting an MMS video data stream There is significant latency in the streamed output in this version of the program 5 seconds This will be addressed in future versions To connect to the URL enter an address in the form mms lt IP address gt 10500 The IP Address of the server is shown at the top right hand side of the lt Monitor gt window Thus a valid URL might be mms 192 168 0 249 10500 You will almost certainly have to adjust your firewall in order to permit access to port 10500 There are two small lights at the top left hand side of the window The first indicates whether or not recording is occurring red green the second whether or not streaming Compatible Equipment Computers You will need a high end system if you want to make full HD recordings using this program The system has been developed on a computer which is based on dual six core I7 processors clocked at 3 33 Ghz When recording at 2 Mbits sec CPU utilisation on this machine is about 10 Devices The following devices are known to be compatible with the system and can be recommended Web Cameras Logitech QuickCam Pro 9000 2010 MSE Australia PL Camera 53 Logitech Logitech HD Pro Webcam C910 The video quality and performance of the C910 is quite astounding for such a cheap device IP Cameras Axis PTZ 213 2010 MSE Australia PL s ECMO
26. control at the left 2010 MSE Australia PL Devices 43 Clicking the lt Select Return Cannula gt button opens up the Cannula Selector window Return Cannula Selector Interface MSE Cannula Selector Select the cannula size that you want and then click lt Save gt to close the window Click lt Devices gt lt ECMO System gt to return to the ECMO system itself 3 4 Defibrillator PHYSIO CONTROL MSE LIFEPAK CBE D 2 Selected Charge pa 3 300 4 The defibrillator is loosely modelled on the Lifepak series of defibrillators It must be connected to the patient monitor by selecting ECG as a viewable parameter on the patient monitor Then to use it 1 Turn it on 2010 MSE Australia PL a ECMO Simulation User Manual v5 7 3 5 2 Select the energy required for defibrillation by clicking on the lt Energy gt button 3 Charge the capacitor by clicking the lt Charge gt button 4 When the charge is available defibrillate using the lt Defibrillate gt button The defibrillator delivers a monophasic current and depending on the energy selected and arrhythmia present the shock may or may not be successful Muse VENTILATOR CON 400 600 i a T a l A T Ventilator 200 800 0 1 000 0 20 Vt mls Rate BPM 10 60 40 i Veo 5 115 20 400 o 20 Fi02 PEEP cm H20 The ventilator is loosely based ona simple anaesthesia ventilator which automatically pro
27. dynamical model for generating synthetic electrocardiogram signals IEEE Trans Biomed Eng 2003 Mar 50 3 289 94 Murray F W On the computation of saturation vapor pressure J Appl Meteorol 6 203 204 1967 Nunn JF Applied Respiratory Physiology 4th edition Pappenheimer JR Comroe JH and Cournand A et al Standardization of the definitions and symbols in respiratory physiology Fedn Proc 9 602 Pybus DA Kerr JH A simple system for administering intermittent mandatory ventilation IMV with the Oxford ventilator Br J Anaesth 1978 Mar 50 3 271 4 Pybus DA Lyon M Hamilton J Henderson M Measuring the efficiency of an artificial lung 1 Carbon dioxide transfer Anaesth Intensive Care 1991 Aug 19 3 421 5 Riley RL and Cournand A 1949 Ideal Alveolar air and the analysis of ventilation perfusion relationships in the lungs J Appl Physiol 1 825 847 Riley RL Lilienthal JL Proemmel DD Franke RE On the determination of the physiologically effective pressures of oxygen and carbon dioxide in the alveolar air Am J Physiol 1946 147 191 Riley RL and Cournand A 1949 Ideal alveolar air and the analysis of ventilation perfusion relationships in the lungs J Appl Physiol 1 825 847 Segers PA Heida JF de Vries Maas C Boogaart AJ Eilander S Clinical evaluation of nine hollow fibre membrane oxygenators Perfusion 2001 Mar 16 2 95 106 Severinghaus JW Simple accurate equations for human bloo
28. e lt Investigations gt lt Venous Blood Gas Analysis gt To generate a current venous blood gas analysis report 2010 MSE Australia PL Applications 21 e lt Investigations gt lt Oxygenator Blood Gas Analysis gt To generate a current oxygenator blood gas analysis report e lt Devices gt lt Ventilator gt To show the Ventilator e lt Devices gt lt ECMO System gt To show the ECMO System e lt Devices gt lt ACT Monitor gt To show the ACT Monitor e lt Devices gt lt Nerve Stimulator gt To show the Nerve Stimulator e lt Devices gt lt Defibrillator gt To show the Defibrillator e lt Devices gt lt Stethoscope gt To show the Stethoscope e lt Resources gt e lt Help gt lt Help Manual gt To open this Help file e lt Help gt lt Help About gt To display version information about the application If investigations in the form of documents static images audio files or video files have been added to the scenario using the scenario editor these investigations will appear as lt Investigations gt below the lt Oxygenator Blood Gas Analysis gt item Similarly if resources in the form of documents static images audio files video files or web addresses have been added to the scenario using the scenario editor these resources will appear as items in the lt Resources gt drop down list When viewing the lt Notes gt lt Resources gt and lt Help File gt the size of the viewing window can be enlarged
29. fibre oxygenator e A physiological monitor e A ventilator e A defibrillator e A data recording system e An armamentarium of drugs and fluids which can be used to treat the virtual patient e A scenario database which can be used to provide a large variety of relevant clinical data to the trainee The system can be used to simulate both veno venous VV and veno arterial VA ECMO In VV mode the system can be used to illustrate the effect of e Variation in blood flow through the oxygenator e Variation in gas flow through the oxygenator e Heating or cooling of the patient e Changing the position of the drainage cannula e Insertion of a second drainage cannula e Changing the size of the return cannula e Changes in central venous pressure on venous drainage In VA mode the system can be used to illustrate the effects of all of the above together with e The impact of VA ECMO on systemic blood flow e Differential hypoxaemia e Back flow through the system The simulation can be remotely controlled by a supervisor using a separate application 2010 MSE Australia PL e ECMO Simulation User Manual v5 7 1 2 which runs on a second PC Netbook or PDA Using this application the supervisor is able to reproduce a wide variety of ECMO or patient crises including e Oxygenator failure e Inlet obstruction e Outlet obstruction e Fresh gas disconnection e Massive blood loss e Changes in lun
30. he has no drug allergies He has no relevant previous medical history 2010 MSE Australia PL Tutorials 139 Subsequent Management The patient is transferred to the Intensive Care Unit further investigations are performed a tentative diagnosis of viral myocarditis is made and the decision is taken to support the patient with VA ECMO The results of some of these investigations Echo ECG CXR and ABG can be seen by clicking lt Investigations gt on the main menu We ll assume that you have already worked your way through the previous VA ECMO tutorials so quite quickly we ll Set up our monitoring e Click the lt Display gt button in the lt Patient Monitor gt window e Check lt ECG gt lt Direct Arterial Pressure gt lt Central Venous Pressure gt and lt SaO2 gt and e Click the lt Display gt button again to close this window and display the physiological signals Ventilate the patient e Click the lt Devices gt lt Ventilator gt menu item in the lt Inspector gt window e Click the power switch at the top right hand side of the device and then set the tidal volume Vt to 500 mls the rate to 12 bpm the FiO2 to 100 and the PEEP to 5 cms H20 Paralyse the patient e Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt window e Drag the green slider until it says 8 mgs and click the lt Give gt button And perform a baseline blood gas analysis e Click lt
31. hide the patient monitor lt View gt lt Inspector gt To show or hide the inspector window lt View gt lt Therapeutic Interface gt To show or hide the therapeutic interface lt View gt lt Camera gt To show or hide the Camera lt Tools gt lt Load Patient gt To load the patient with a new set of physiological data from a pat file e lt Tools gt lt Load Scenario gt To load an entire scenario e lt Tools gt lt Save Patient gt to save the current physiological data in a pat file The items on the menu bar of the Inspector window vary according to the scenario which has been loaded The consistently available menu items are lt Notes gt lt Investigations gt lt Arterial Blood Gas Analysis gt lt Investigations gt lt Venous Blood Gas Analysis gt lt Investigations gt lt Oxygenator Blood Gas Analysis gt lt Devices gt lt Ventilator gt lt Devices gt lt ECMO System gt lt Devices gt lt ACT Monitor gt lt Devices gt lt Nerve Stimulator gt lt Devices gt lt Defibrillator gt lt Devices gt lt Stethoscope gt lt Resources gt lt Help gt lt Help Manual gt lt Help gt lt Help About gt The function of each of the respective Inspector window menu items is e lt Notes gt To display the notes describing the current patient or the conduct of a tutorial if one has been loaded e lt Investigations gt lt Arterial Blood Gas Analysis gt To generate a current arterial blood gas analysis report
32. of the Supervisor Application How as Supervisor can make the patient hypotensive Either slowly reduce the SVR or slowly reduce the Cl on the lt CVS ECG gt page of the Supervisor Application Is there a drug database editor No At the present time it is not possible to add new drugs to the system Can Irun the system using a dual display Yes the system has been tested on conventional dual display second monitor systems as well as remote dual display systems such as Maxivista How as Supervisor can change the patient pat file which is associated with a scenario e Start the Main Application in lt Maintenance Mode gt e Click lt System gt lt Scenario Editor gt e Navigate to the ScenarioData folder by clicking the appropriate lt gt signs in the lt Folder Navigator gt folder tree e Click on the database file MSEScenario mdb e Right Mouse Button click this file to load it into the lt Database Editor gt window e Click on the folder of the Scenario whose patient file you wish to change e Click lt Edit gt in the pane which appears e Select the Pat file which you want to use from the lt Folder Navigator gt window This file name should be transferred into the File Name field of the editor pane e Click the lt Save gt button e Click lt Save Exit gt e Click lt System gt lt Exit gt Do the alarms work on the physiological monitor No Not yet 2010 MSE Aust
33. pre membrane pressure will rise to about 250 mm Hg as a result Thus we can see that the resistance of the 15F cannula is much higher than that of the 21F cannula and the ECMO pump has to work much harder to achieve a flow rate of 4 0 lpm Now let s examine the effect of increasing return cannula size To do this e Click lt Adjust Cannula gt e Click lt Cannula gt e Select lt 24F gt e Click lt Save gt e Switch back to the ECMO system Devices gt lt ECMO System Note that the blood flow has now increased to 4 4 lpm and the pre membrane pressure has fallen to 140 mm Hg Return the flow to 4 0 lpm by decreasing the rom to 2500 and note that the pre membrane pressure falls further to 115 mm Hg Figure 2 2010 MSE Australia PL Tutorials 1 1 1 300 250 200 O E 2 oa 150 D I E E 100 3 uN w o k a 50 0 i 14 16 18 20 22 24 Cannula Size FG The pre membrane pressure measurements for the complete range of cannulae at a flow rate of 4 0 Ipm are summarized in Figure 2 Note how the pre membrane pressure increases quite markedly once the return cannula size is reduced below 21F Although there are no absolute rules for determining the maximum pressure which can be accepted within the ECMO circuit it is believed that ceteris paribus higher pre membrane pressures are more harmful than lower pressures There are several reasons for this belief 1 The use of s
34. rather than passive The presence of a venous reservoir in a surgical CPB circuit allows the perfusionist to control LV preload relatively independently of main pump flow by adjusting the volume 2010 MSE Australia PL 130 ECMO Simulation User Manual v5 7 of blood in the reservoir In contrast during VA ECMO the perfusionist can only adjust LV preload by changing the main pump flow rate As a result tight control of systemic blood pressure is more difficult to achieve during VA ECMO than during surgical CPB In this simulation note how the mean arterial pressure MAP has risen from 65 mm Hg before bypass to 105 mm Hg This higher mean pressure reflects the fact that the patient s total systemic flow LV output ECMO output is now higher than before ECMO and that the patient s Systemic Vascular Resistance SVR is little changed As a result mean arterial pressure is considerably higher Under normal circumstances if we were on surgical CPB we would respond to this scenario by temporarily reducing the arterial pump flow at the same time as minimizing left ventricular LV preload by ensuring that drainage into the venous reservoir was unimpeded However during VA ECMO if we reduce blood flow rate we will divert more flow through the pulmonary circulation increase LV preload and the left ventricle will begin to eject again In practice we can only adjust SVR by the use of vaso dilator or constrictor ther
35. slider is used to set the bicarbonate set point for the patient 2 2 5 ECMO Page The lt ECMO gt page of the supervisory application is used to make adjustments to the ECMO system 2010 MSE Australia PL s ECMO Simulation User Manual v5 7 EF MSE Supervisor Scenarios CVS ECG Lung Misc ECMO 1 0 1 0 200 0 0 0 0 0 0 QsQt Vdvt Mem Res VL Res The lt QsQt gt slider is used to set the shunt fraction of the oxygenator at a nominal blood flow of 3 0 lom According to Segers et al the best performing oxygenators in 2001 had shunt fractions of 0 08 at this flow rate If you wish to simulate complete gas transfer failure push the lt QsQt gt slider to 1 0 Simulate partial failure by placing it around 0 5 The system automatically varies shunt fraction according to blood flow rate The lt VdVt gt slider is used to set the Dead Space of the oxygenator at a nominal blood and gas flow of 3 0 Ipm Some work by Pybus et al suggest that a value of 0 08 0 10 is representative If you wish to simulate complete disconnection of the gas supply push the lt VdVt gt slider to 1 0 The system automatically varies dead space according to blood and gas flow rate The lt Mem Res gt slider is used to set the Membrane Resistance of the oxygenator The scale represents the pressure drop across the oxygenator in mm Hg L min Typically the value of this parameter is inthe range 10 30 mm Hg L M
36. starting it at 20 ml hr e Slide green slider to lt 20 gt and click lt Set gt After five minutes e Perform an Arterial Blood Gas Analysis e Perform an Oxygenator Blood Gas Analysis and e Return to the lt ECMO System gt As there is no ventricular ejection there is little difference between the arterial and oxygenator samples In both cases the PO2 should be about 425 mm Hg and the PCO2 about 40 mm Hg Now ask the Supervisor to disconnect the gas supply to the oxygenator and e Re start the timer After five minutes note that e There is evidence of increased sympathetic tone e Ventricular ejection may be just apparent e There is frequent ventricular ectopy and e The mixed venous saturation has fallen quite markedly Now repeat the lt Arterial gt and lt Oxygenator Blood Gas Analysis gt Note that the e Patient is profoundly hypoxic e Pa02 is very low and that e PCOZ2 is markedly elevated Hypercarbia e Oxygenator pre membrane pressure is unchanged e Oxygenator blood flow is unchanged These are the hallmarks of disconnection of the gas supply to an oxygenator In real life how should we respond to suspected disconnection of the gas supply to an oxygenator Our response can be divided into four separate stages e Checking the integrity of the oxygen supply chain e Performing a Bobbin Drop test e Performing an exhaust gas analysis e Performing an lt Oxygenator Blood Gas Analysi
37. the negative pressure which is required to facilitate drainage and the positive pressure which is required to pump blood through the artificial lung and back into the patient The pump head and oxygenator are integrated into a single disposable unit which is mounted on the system console Figure 1 Figure 1 2010 MSE Australia PL 128 ECMO Simulation User Manual v5 7 VA ECMO Active venous drainage from the right atrium is via the 24F venous cannula and return via the 21F arterial cannula A femoral backflow cannula has not been used Additional information regarding the ECMO system can be found by clicking on the lt Resources gt menu of the lt Inspector gt window and selecting the resource which you want to view These resources include lectures on ECMO images of various systems relevant websites and various descriptions and protocols relating to the technique To visualize the ECMO interface itself e Click on lt Devices gt lt ECMO System gt menu item of the lt Inspector gt window The key features of the ECMO system have been outlined in the tutorials entitled VA ECMO Tutorial 1 and VV ECMO Tutorial 1 Refer to these examples for an explanation of the use of the system Before commencing VA ECMO you may wish to confirm that the patient is effectively anti coagulated lt Devices gt lt ACT Monitor gt lt Start gt If you do this you ll need to click lt Devices gt lt ECMO System gt t
38. use by unsupervised trainees In this mode a variety of previously recorded scenarios and or tutorials can be undertaken but no intervention by a supervisor is possible The trainee is able to load different patients pre recorded physiological states and to experiment with the use of various drugs and therapeutic techniques lt Supervised Simulation Mode gt is used when active interventions by a simulation supervisor are required during the course of a simulation session Events such as oxygenator failure catastrophic haemorrhage or the occurrence of a malignant cardiac arrhythmia can only be initiated when the supervisor is connected to the Main Application in lt Supervised Simulation Mode gt The supervisor controls the flow of events using the supervisory application lt Maintenance Mode gt is used to access the Scenario ECG and Recorded Variable editors and to allow the system administrator to move the location of the lt ScenarioData gt folder 1 5 1 Maintenance Mode lt Maintenance Mode gt is used to access the Scenario ECG and Recorded Variable editors and to allow the system administrator to move the location of the lt ScenarioData gt folder The menu options which are available in this mode are e lt System gt lt Exit gt e lt System gt lt Scenario Editor gt e lt System gt lt Scenario Data Source gt e lt System gt lt Recorded Variables Editor gt e lt System gt lt ECG Editor gt e lt System gt
39. your possession 1 DEFINITIONS a Software means the executable code of MSE ECMO Simulator additional tools libraries source files header files data files any updates or error corrections provided by MSE Australia PL any user manuals guides printed materials on line or electronic documentation b License Key means a serial number issued to you by MSE Australia PL to activate and use the Software c Named User is an individual authorized by you to use the Software through the assignment of a single user ID regardless of whether or not the individual is using the Software at any given time A non human operated device is counted as a User in addition to all individuals authorized to use the Software if such device can access the Software d Maintenance Plan is a time limited right to technical support and Software updates and upgrades Technical support only covers issues or questions resulting directly out of the operation of the Software MSE Australia PL will not provide you with generic consultation assistance or advice under any other circumstances 2 LICENSE GRANTS 2 1 Trial Period License You may download and use the Software for free for thirty 30 days after installation Trial Period During the Trial Period MSE Australia PL grants You a limited non exclusive non transferable non renewable license to copy and use the Software for evaluation purposes only and not for any commercial use At MSE
40. 3 Click on the lt View gt menu item of the main window The three primary windows will be listed as menu items Checking or unchecking any of these items will turn on or off their visibility Click on the lt Tools gt menu item of the main window Two menu items lt Load Scenario gt and lt Load Patient gt and will now appear Selecting a new scenario from the list of available scenarios will load a new patient together with a completely new set of clinical notes investigations and resources In contrast selecting a new patient from the list of available patients will load a patient with a different patho physiological state but the notes investigations and resources will remain unchanged Finally to close the system down Click on the lt System gt lt Exit gt menu item of the main window VV ECMO 1 Some of the manoeuvres undertaken in this tutorial generate extreme circuit pressures and are only intended to demonstrate the performance characteristics of the system They should not be employed under clinical conditions In this simulation we ll explore the fundamental characteristics of a modern centrifugal pump which can be used in either a veno venous VV or veno arterial VA Extra Corporeal Membrane Oxygenation ECMO system The learning objectives of the session are e To understand the design of a basic veno venous ECMO circuit e To become familiarized with the basic controls of an ECMO system
41. 4 0 0 169 254 255 255 e Permits recording of a restricted dataset of system variables The Network version of the software e Has none of these restrictions but e Requires a hardware key Dongle to function 1 7 Configuring Dual Displays If the system is run on a dual monitor system the second monitor should be configured as a 1024 768 device and the lt Patient gt lt Monitor gt window then dragged onto this second display The monitor will now completely fill the window 2010 MSE Australia PL ECMO Simulation User Manual v5 7 2 ma oe jaa ie If used in an operating theatre in order to enhance realism this second display can now be positioned on the anaesthesia machine as the patient monitor If a remote dual display system such as Maxivista is used the connection to the second monitor can be made over the LAN rather than via a DVI connection 2010 MSE Australia PL Introduction Dual display adjustments are made through the Windows control panel lt Start gt lt Control Panel gt lt Display gt lt Settings gt Display Properties Themes Desktop Screen Saver Appearance Settings Drag the monitor icons to match the physical arangement of your monitors Display 2 Default Monitor on Maxi_Vista_DriverA Screen resolution Color quality Highest 32 bit C Use this device as the primary monitor Y Extend my Windows desktop onto this monitor
42. Australia PL 12 ECMO Simulation User Manual v5 7 increased Fibrin or thrombus deposition is one of the most common causes of this type of oxygenator failure in ECMO systems which use non porous polymethylpentene hollow fibre membrane systems Figure 2 Figure 2 In contrast the older micro porous polypropylene hollow fibre systems were prone to plasma leakage which occurred much earlier in the life cycle of the device An example of this is shown in figure 2 Figure 2 2010 MSE Australia PL Tutorials 143 In this case plasma leakage was associated with a significant degree of gas transfer failure which necessitated an urgent oxygenator change out This concludes VA ECMO Tutorial 4 Supervisor s note e Increase Oxygenator lt Qs Qt gt to 0 5 e lt Vd Vt gt to 0 5 and e lt Membrane Resistance gt to 50 mm Hg L Min over the course of a few minutes 2010 MSE Australia PL MSE System 1 8 MSE System 8 1 Overview The Modular Simulation Environment MSE is a high fidelity immersive patient simulation system which can be based on more or less any intubation or resuscitation manikin At the heart of the system is the Smart Lung a pneumatically powered computer controlled lung which is connected to the trachea of the manikin Figure 8 1 Figure 8 1 Trainee Manikin Ventilator Y Smart Lung Bag Mask The Smart Lung is in turn
43. CP IP 169 254 xxx yyy 2010 MSE Australia PL 10 10 1 References 157 References References The seminal work on medical simulation which provided the inspiration for this work is that of Dickinson Dickinson CJ 1977 A Computer Model of Human Respiration MTP Press Limited ISBN 0852001738 Some other important sources of data or descriptions of computational and or mathematical techniques can be found in the work of Christoforides C Hedley Whyte J Effect of temperature and hemoglobin concentration on solubility of O2 in blood J Appl Physiol 1969 Nov 27 5 592 6 Christoforides C Hedley Whyte J Supersaturation of blood with O2 J Appl Physiol 1969 Feb 26 2 239 40 Christoforides C Laasberg LH Hedley Whyte J Effect of temperature on solubility of O2 in human plasma J Appl Physiol 1969 Jan 26 1 56 60 Dantzker DR Lynch JP Weg JG Depression of cardiac output is a mechanism of shunt reduction in the therapy of acute respiratory failure Chest 1980 May 77 5 636 42 Dash RK Bassingthwaighte JB Ann Biomed Eng 2004 Dec 32 12 1676 93 Blood HbO2 and HoCO2 dissociation curves at varied O2 CO2 pH 2 3 DPG and temperature levels Dickinson CJ A digital computer model to teach and study gas transport and exchange between lungs blood and tissues MacPuf J Physiol Lond 1972 Jul 224 1 7P 9P Douglas AR Jones NL Reed JW Calculation of whole blood CO2 content J Appl Physiol 1988 Jul
44. ECMO Simulation User Manual v5 7 2010 MSE Australia PL ECMO Simulation System A Component of the Modular Simulation Environment by MSE Australia PL All rights reserved No parts of this work may be reproduced in any form or by any means graphic electronic or mechanical including photocopying recording taping or information storage and retrieval systems without the written permission of the publisher Products that are referred to in this document may be either trademarks and or registered trademarks of the respective owners The publisher and the author make no claim to these trademarks While every precaution has been taken in the preparation of this document the publisher and the author assume no responsibility for errors or omissions or for damages resulting from the use of information contained in this document or from the use of programs and source code that may accompany it In no event shall the publisher and the author be liable for anyloss of profit or any other commercial damage caused or alleged to have been caused directly or indirectly by this document Under no circumstances must this computer application be used to guide the management of any living patient Printed November 2010 in Sydney Australia SE Contents 3 Table of Contents Foreword 0 Part Introduction 7 Y COVE VIEW NA A a eatvesttens 7 2 System REqUIFEMeNtS oiiiiii ct ccctec ct ce ccea i Lar aein KENA st ecevecsusecvecat Jes
45. Equation pdf ECMO_DAP wmy Ninomiya Perfusion Simulator pdf CHAY jpg WA ECMO Parameters pdf Scenarios Changing the data source The ScenarioData folder which by default is in the executable directory can be moved to another location on the network If this is done the system must be made aware of the new location To do this e Start the application in lt Maintenance Mode gt e Click lt System gt lt Scenario Data Source gt e Navigate to the folder s location in the browsing dialog e Highlight the folder e Click lt OK gt e Click lt System gt lt Exit gt e Restart the application in lt Supervised gt or lt Unsupervised gt mode O 2010 MSE Australia PL Scenarios 81 Browse For Folder Desktop u a My Documents amp My Computer 4 se Local Disk C se Local Disk D E 2 DVD RW Drive E E Ea TB Drive F 3 00bc114b3168fc9ce7 5 827e587d9c64e452862894 Applicensing 3 Browser Downloads O Correspondence Documents and Settings Gnostice Lectures 2 MSE Eval 20 Distractions Help File E E PDFView4Net232 Pellegrino El A Quickstart O RECYCLER E 3 Simulation Projects E E E Oo E E E El 6 7 Scenarios Database Structure The scenario database is contained within a Microsoft Access database named MSEScenario mdb and can be found in the ScenarioData folder in the executable directory The basis structure of a sc
46. FOrMats inc 5 cece os ceceeceeeadeconnes aae maiaa abrea aeaa eaa pipaa eoni tii 74 Scenarios Creating RESOUICES ccceeeseceeneeseeeeeeeeeeeeeeeseeeeeeeseeeeeeeseeeeeeseeeaeeeseeeeneeseesseeeas 75 Scenarios Database Eqitor ccccsecceeeeee eee eee cece ee eeee ee eeee seca ee aa l eaaa a Paaran ionan da Eaa ania 76 Scenarios Required Files cccccccceeeeeeeeeeeeeeeeeeeeeeeeeeeseeeeeeeseeeneeeseeeeneeseeeeeenseeeeeenseeeseeens 79 Scenarios Changing the data SOUICE cececeeneeeeeeeeeeeeeeeneeseeeeeeeseeeeneeseeeeneeseeeeeeneeeeaeeess 80 Scenarios Database Structure cccceeeseceeeeeseeeeeeeeeeeeeeeseeeeeeeseeeeeeeseeeeeeeseeeeeeeseeeeeeeseesaeents 81 Scenarios ECG Editotissccc n ae cece ea aa ea A ii er aana aaaea 82 Tutorials 86 Scope Of Tutorial Seo a a aA Naa iia 86 Getting Stared oair aar EAEAN ai 86 VV ECMO di nai 91 VV ECMO so aa a aaa a N aas aAa a aaa aE ae aa aS aAA EE T aaea aeaa 100 VV ECMO Boca cece decveseves cceuddctoseuatercccueccuonsuvehecteudccuccdsssrsccsuetetoocuassecesudectccdsnseecceteccozed 107 VV ECMO Mita id ino de 112 VA ECMO Desi dida 117 VA ECMO Di ici 125 VA ECMO S e a r a aAA a A ar cia 131 VA ECMO Minnie id a cti 138 MSE System 145 AUTO oi E a se ctavecctossecch secede cet secuasectedsccerecudstoctsbdcaecccoassuanetencesee 145 Trouble Shooting 148 A leva tect A E codeus Gece Ueevabuceeks cduavevent cides E T 148 Trouble SHOOtIING iii id 150 Installing a new
47. Haemoglobin of 12 gm dL and you estimate his shunt fraction Qs Qt to be about 65 The results of some ancillary investigations Echo CXR and ECG are also available Click the lt Investigations gt lt TG SAX gt in the lt Inspector gt window We ll start the tutorial by connecting the patient to our monitoring system and putting him on a ventilator Click the lt Display gt button in the lt Patient Monitor gt window Clicking the lt Display gt button on the Patient Monitor allows you to select the parameters which you want to view Check lt ECGs lt Direct Arterial Pressure gt lt Central Venous Pressure gt and lt Sa02 gt in the lt Display gt window Click the lt Display gt button in the lt Patient Monitor gt window The lt Display gt window will now close and the ECG Direct Arterial Pressure Central Venous Pressure and SaQ2 signals will be displayed in the lt Patient Monitor gt window As you can see the patient is profoundly hypoxic SaO2 70 and is having frequent ventricular ectopic beats To ventilate the patient Click the lt Devices gt lt Ventilator gt menu item in the lt Inspector gt window The ventilator should now appear in the lt Inspector gt window Figure 1 Figure 1 2010 MSE Australia PL Tutorials 93 l Muse VENTILATOR ces 400 600 0 E 5 15 200 800 r i y 0 1 000 o 20 Vt mis Rate BPM 10 60 40 1180 5
48. Image Display BMP Image Display URL Web Site Address WAV Audio File PPT PowerPoint PPTX PowerPoint Note that DOC or DOCX files cannot be incorporated into the database If you wish to author a document in this format you must convert it to PDF format before inclusion Conversion can most easily be performed using the Microsoft Save As PDF plugin which is freely available on the Microsoft Site The full version of Microsoft Office PowerPoint is required if you wish to show PowerPoint files in the Inspector Windowr The system will not work with the Viewer version of this program Depending on the version of PowerPoint which you are using you may also need to modify the Windows registry to permit successful display A registry modification script which will make all the necessary alterations has been included in the installation package Refer to the section entitled Displaying PowerPoint Files further information on this topic 2010 MSE Australia PL 6 3 Scenarios Scenarios Creating Resources The creation of scenarios involves two distinct steps e First all the resources to be used in the scenario must be created and placed in the application s ScenarioData folder e Second links to the collection of resources which constitute the scenario must then be added as a new record within the scenario database In this section we will only describe the first stage A complete description of the second st
49. Investigations gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt window You elect to cannulate the patient percutaneously via the right femoral artery and vein using the Seldinger technique and ultrasonic guidance Imagine now that you have e Placed the Seldinger wires in the artery and vein e Given the patient 7500 units of heparin lt Therapeutic Interface gt lt Bolus Drug gt lt Heparin gt lt Give gt 7500 units and e Positioned the cannulae under ultrasonic control The cannulae have been connected to the ECMO system The entire system is heparin coated The system s centrifugal pump is responsible both for generating the negative pressure which is required to facilitate drainage and the positive pressure which is required to pump blood through the artificial lung and back into the patient The pump head and oxygenator are integrated into a single disposable unit which is mounted on the system console Figure 1 Figure 1 2010 MSE Australia PL 10 ECMO Simulation User Manual v5 7 VA ECMO We re now nearly ready to commence VA ECMO To complete our preparations we need to e Click lt Devices gt lt ECMO System gt and select the lt VA ECMO gt option at the bottom right of the interface e Click the lt Adjust Cannula gt button and advance the drainage cannula as far as it will go using the slide control on the left hand side of the window e Re open the ECMO interface by clicking lt D
50. Kaspersky Internet Security 2009 an MSE ECMO Simulator Getting Started e MSE ECMO pE MSE Supervisor Uninstall ECMO Simulator P MSE User Manual e lt Getting Started gt describes how to use the system for the first time e lt MSE ECMO runs the Main Trainee Application e lt MSE Supervisor gt runs the Supervisor Application e lt Uninstall ECMO Simulator gt completely removes the software from the computer e lt MSE User Manual gt gives you access to this manual in paf format The Full version can be installed without the protection Dongle in place but the Main Application will not run until it has been plugged in The Dongle can be plugged into any of the computer s USB ports and does not require the installation of any drivers The Full version of the system can be installed on any number of computers If you are intending to run the Supervisor Application on your Local Area Network LAN the firewall security settings must be set to permit incoming and outgoing TCP IP streams on the relevant connections of both computers Getting Started Run the application by clicking on the lt MSE ECMOs short cut on the lt Start gt menu or the MSEHDTV exe file in the installation directory The first time you run the application it will take about 30 seconds to load You will be given the opportunity to start the application in one of three modes 2010 MSE Australia PL Introduction
51. Lung Injury Score Murray Score of 3 5 but has no other significant co morbidities He has a Haemoglobin of 12 gm dL and you estimate his shunt fraction Qs Qt to be about 65 The results of some ancillary investigations Echo CXR and ECG are also available We ll start the tutorial by connecting the patient to our monitoring system and putting him ona ventilator To do this e Click the lt Display gt button in the lt Patient Monitor gt window e Check lt ECGs lt Direct Arterial Pressure gt lt Central Venous Pressure gt and lt SaO2 and e Click the lt Display gt button again to close this window and display the physiological signals As you can see the patient is profoundly hypoxic SaO2 70 and is having frequent ventricular ectopic beats To ventilate the patient e Click the lt Devices gt lt Ventilator gt menu item in the lt Inspector gt window The ventilator should now appear in the lt Inspector gt window Turn the ventilator on by e Clicking the power switch at the top right hand side of the device and then e Set the tidal volume Vt to 500 mls the rate to 10 bpm the FiO2 to 100 and the PEEP to 5 cms H20 Note that the ventilator s controls are not enabled until the ventilator is turned lt On gt The ventilator is based on a simple anaesthesia system which is in Intermittent Mandatory Ventilation IMV mode Because the patient is still breathing spontaneously the flow p
52. Old Phone Ringtone wav O Distractor On The tabbed pages of the application include e Scenarios e CVS ECG e Lung e Misc and e ECMO Refer to the individual items in this manual for a description of the functions of each page Refer to the Troubleshooting section of this manual if you are having difficulty in connecting to the Main Application 2010 MSE Australia PL Applications 29 2 2 1 Scenarios Page The lt Scenarios gt page of the supervisory application is used to load any of the available scenarios into the Main Application and to provide access to the various distractions which can be initiated during a simulation session Es MSE Supervisor Scenarios CVS ECG Lung Misc ECMO Getting Started Annoying Alarm2 wav VV ECMO Tutorial 1 Car Alarm wav VA ECMO Tutorial 1 Fire Alarm wav Mobile Ringtone wav Old Phone Ringtone wav O Distractor On To load a scenario e Click on the desired scenario in the left hand window e Click on the lt Load gt button which has now appeared To provide a distraction e Click on the desired distraction in the right hand window e Check the lt Distractor On gt box The distraction will be continued until the lt Distractor On gt box is unchecked If you wish to add a new distraction to the system place a suitably annoying audio file in wav format inthe lt Distractions gt sub fold
53. Simulation User Manual v5 7 Axis 243SA Television systems Toshiba 47WL66 Panasonic TH 50PZ80 Other Equipment Axis P8221 Audio Encoder This device permits encoding and streaming of any microphone signal at very low latency Axis 243SA Video Encoder This device permits encoding and streaming of any PAL or NTSC video signal at very low latency D Link Dir 655 router The following URL s have been successfully tested on Axis equipment Axis PTZ 213 http XXX XXX XxXX xxx axiS cgi mjpg video cgi axXrtpu xxx xXxx Xxx Xxx mpeg4 media amp Axis 243SA http xXxx Xxx xXxx xxx axis cgi mjpg video cgi Axis P8221 axrtsp xxx xxx Xxx xxx axis media media amp 2010 MSE Australia PL s ECMO Simulation User Manual v5 7 Models Cardio Respiratory Model The cardio respiratory model is based on the work of Dickinson and comprises five functional units These units are the 1 Native Heart 2 Native Lung 3 Arterial Blood Pool 4 Peripheral Tissue Pool 5 Venous Blood Pool Qs Qt Venous Pool Tissue Pool Arterial Pool The model describes the passage of blood from the tissue pool through the venous pool and the native lung to the arterial pool in an iterative fashion During a single iteration cycle the blood is passed from one pool to the next in an amount which corresponds to the volume which has flowed during the iterative period This incoming blood is then mixed perfectly with the
54. Total Lung Compliance of a normal adult is around 100 ml cm H20 Many disease states including Adult Respiratory Distress Syndrome ARDS pulmonary oedema pulmonary fibrosis and pneumonia result in a decreased Total Lung Compliance The lt Raw gt slider is used to set the nominal Airway Resistance of the patient The normal value for an adult is around 0 5 1 5 cm H20 L sec The lt FRC gt slider is used to set the nominal Functional Residual Capacity of the patient The normal value for an adult is around 2 0 2 5L The lt Rate gt slider is used to set the nominal Respiratory Rate of the patient The lt Vt gt slider is used to set the nominal Tidal Volume in litres of the patient The lt FiO2 gt slider is used to set the initial inspired oxygen of the patient Misc Page The lt Misc gt page of the supervisory application is used to make adjustments to various Miscellaneous parameters of the patient HE MSE Supervisor Scenarios CVS ECG Lung 100 400 0 20 20 BMR CO2 SP Temp The values set on this page are all nominal ie they represent the value of the parameter before any intervention or therapy has occurred 2010 MSE Australia PL Applications 33 The lt BIS gt slider is used to set the nominal BIS score of the patient A fully conscious person has a score of 98 100 Glass et al According to Glass et al typical values for BIS are BIS range Hypnotic State 70 100 Awak
55. VC is via a right internal jugular cannula and arterialised return to the right atrium via a 21F left internal jugular cannula Figure 1 Figure 1 In this exercise we re only interested in the effect of changing the size of the return cannula so we ll make sure that the venous drainage is absolutely optimal To do this e Switch to the ECMO system Devices gt lt ECMO Systems e Click lt Adjust Cannula gt e Click lt Dual Cannulation gt Advance the SVC drainage cannula 2010 MSE Australia PL tio ECMO Simulation User Manual v5 7 e Slide the top left hand slider down to lt 2 gt and Advance the IVC drainage cannula e Slide the bottom left hand slider up to lt 8 gt e Switch back to the ECMO system Devices gt lt ECMO System e Turn on the lt Main Power gt e Seta gas flow of lt 6 gt lpm e Fully open the arterial clamp e Increase the blood flow to lt 4 0 gt lpm Note the pre membrane pressure 130 mm Hg and the rom 2375 We re now going to reduce the return cannula size from 21F to 15F To do this e Click lt Adjust Cannula gt e Click lt Cannula gt e Select lt 15F gt e Click lt Save gt e Switch back to the ECMO system Devices gt lt ECMO System Note that the blood flow has now fallen from 4 0 lpm to 2 9 lpm and the pre membrane pressure has risen to 150 mm Hg To return the flow to 4 0 lpm you will need to increase the rpm to 3100 and the
56. a iii 46 Part IV Camera 50 1 System Require mentt ccccceccceeeseeeeeeeeeeeeeeeeeeeeeeeseeeeeeeseeeeeenseeeeeeeseeeeeeeseeeeeeeseeeaeeeseeeseeess 50 2 Camera OVErvieW ciai a ae aa A E Raia E 50 3 Compatible EqQuipMment ccecececeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeaeeeeeaeeeeeeeseeeseeeseeeseeeseaeseeeseeneeeesees 52 Part V Models 56 O 2010 MSE Australia PL ECMO Simulation User Manual v5 7 CO AN OO FPF WO DD o Part VI 0 JO 0 BO N Part VII OO JO 0d RA ON a k o Part VIII 1 Part IX N O Oo FP WD Cardio Respiratory Model ccccceeeeceeeeeeeeeeeeeeeeeeeeeeeeeeeeseeeaeeeseeeaeeesaeeaeeeseeeaeeeseeeeeeeseenseees 56 Qs Qt and Cardiac OUtpUt ccccconnnnnnnncnncnnnnnononnnnnnnonnnnnnn narnia 58 Blood Gas CalGul ations ois os di becetesendee cet aaa ea Eanan aaae aaraa 59 Pharmacokinetic Modell 22 ces cceeeeeeeeeeeeee cece ee eeee ee eeeeeeeeeseeeeeceaeseeeeeeeaaseaeeeeeaeeeeseseeeeeeees 59 Cardiovascular Model 2 cceeeeceeeeeeeeeeeeeeeeeee ee eeee seca neeeeeeeeeaeseeeaeseaeeeeeaeseeeeeseeeeeeeeeseeeeeeees 61 Oxygenator Model APA Penn A 62 Cannula Models viii is 65 Centrifugal Pump Model coo ocoonooiicocancocii ii a 68 ThRCrMal Modelo a 68 AAA atte vesddefaceccecedeczdeiactcectatavadsfaeteceatdaatdesieacecedss 70 Scenarios 73 Scenarios OVE VIC We e a a a a aaa aaa Aa aaa AEE aaa E aA Aare aAa aa aae AA Aaa Erna Eea Peai iaaea raidai 73 Scenarios File
57. age can be found in the section entitled Scenarios Database Editor Creating an initial patho physiological state The initial patho physiological state must be created by the supervisor by adjusting the patient s parameters using the MSE Supervisor application while connected to the Main Application MSEHDTVxxxx exe Thus for example if the supervisor wishes to generate a hypovolaemic patient the steps required are e Start the Main Application in lt Supervised Mode gt e Click the Display button on the patient monitor and select ECG Direct Arterial Pressure and Central Venous Pressure e Click the Display button again to display these parameters e Start the MSE Supervisor application e Connect the Supervisor Application to the Main Application e Click on the Getting Started scenario in the left hand window of the lt Scenarios gt page e Click on the lt Load gt button to load this normal patient into the Main Application e Click on the lt CVS ECG gt page tab and slide the lt Loss gt control up to 1000 mls min e Observe the patient monitor When an appropriate degree of hypotension and tachycardia has developed return the lt Loss gt control on the Supervisor Application back to zero In the Main Application e Save the patient s current patho physiological state under an appropriate name eg Hypovolaemia using the lt Tools gt lt Save Patient gt menu option of the main envi
58. aintenance gt mode e Select the lt Recorded Variables Editor gt e Select the recorded variables e Select the lt Frequency of Recording gt e Click lt Save amp Exit gt e Restart the system in either lt Supervised gt or lt Unsupervised gt mode The Recordable Variables Editor is modal which is to say that it must be closed with the lt Save 8 Exit gt button or lt Cancel amp Exit gt button before any other activities can be undertaken MSE Recordable Yariables Editor Ml Pa02 Pt E Paco Pt E pHa Pt Sa02 Pt E Hct E BXS E PyO2 Pt E PyCO 2 Pt Ml pHy Pt E SvO2 Pt E Pa02 Oxy E PaCO2 Oxy E pHa Oxy E Sa02 Oxy 2010 MSE Australia PL E FiO2 Oxy E FGF Oxy E Q Oxy E Temp E FiO2 Pt E RR lv PR E Sys BP Md Mean BP E Dias BP E CO M Min Vent E TOA E ACT E BIS Minute 5 Minutes ECMO Simulation User Manual v5 7 If you are using the lt Personal gt version of the application only three variables can be recorded at any one time If you select more than this number only the first three selected variables will be recorded Whichever licensed version is used the data recorder also records all bolus infusion and fluid therapy The selected variables are retained between runnings of the application 2010 MSE Australia PL so ECMO Simulation User Manual v5 7 4 4 1 4 2 Camera System Requirements This compon
59. al Blood Gas Analysis gt menu item in the lt Investigations gt list The lt Arterial Blood Gas Analysis gt menu item displays the patient s current blood gases and stores them as a blood gas report in the installation directory of the application Click the lt Devices gt menu item in the lt Inspector gt window The lt Devices gt menu item is used to visualise any of the 6 devices which are available to the user These devices are a e Ventilator e VV or VA ECMO System e ACT Monitor e Nerve Stimulator e Defibrillator and e Stethoscope Click the lt Devices gt lt Nerve Stimulator gt menu item in the lt Inspector gt window Clicking on the lt TOF gt button stimulates the ulnar nerve with a supramaximal 0 5Hz Train of Four and produces contraction of Adductor Pollicis unless a muscle relaxant has been administered Click the lt Resources gt menu item in the lt Inspector gt window The lt Resources gt menu item lists the resources which are available for the current scenario These resources can include documents videos still images or websites 2010 MSE Australia PL Tutorials 89 Click the lt Resources gt lt ELSO Homepage gt menu item in the lt Inspector gt window The lt Help Manual gt opens a navigable version of the system s user manual If you want to reposition the lt Inspector gt window place the mouse at the top right hand corner of
60. amp by moving the slide control upwards Observe that flow increases to about 1 lpm Now e Increase the flow further by slowly rotating the flow control Note how the patient s pulse pressure becomes progressively smaller until it eventually disappears altogether at a flow of about 4 0 lpm What s happening here Well as we steadily increase ECMO flow so we progressively deprive the left ventricle of more and more of its inflow preload until the point is reached where it has none at all and ejection ceases At this point the patient is on full cardio pulmonary bypass CPB there is no flow through the pulmonary circulation or the left side of the heart and the aortic valve remains closed throughout the cardiac cycle The Rule of Thumb which describes the relationship between ECMO flow rate and LV preload can be summarized as LV Preload is proportional to 1 ECMO Flow Or in plain language Left ventricular preload decreases with increasing ECMO flow rate This Rule of Thumb can be contrasted with the relationship between ECMO flow rate and LV afterload where LV Afterload is proportional to ECMO Flow Or in plain language Left ventricular afterload increases with increasing ECMO flow The situation of the patient on full VA ECMO differs from the patient on full Surgical bypass in two important respect s e The circuit does not include a venous drainage reservoir and e Venous drainage is active
61. apeutic Interface The lt Therapeutic Interface gt window is used to administer drugs and or fluids to the patient The interface has four tabbed pages e Bolus Drug Infusion Drug e Fluids and e History To explore the effect of giving adrenalin to a normal patient click on the lt Bolus Drug gt tab and select lt Adrenalin 100mcg ml gt by clicking on it A new window will appear Slide the green slider until a dose of 50 micrograms is indicated and click the lt Give gt button Observe the effect of the drug on heart rate blood pressure and ectopic activity over the ensuing minutes Click on the lt History gt tab to review details of your therapeutic interventions If you want to reposition the lt Therapeutic Interface gt place the mouse at the top right hand corner of the window and drag it while holding down the left mouse button The position of the window will be retained when you next start the application Refer to the section entitled Therapeutic Interface for a complete description of the functionality of this window Throughout this document the terms Click and Select are used to refer to a left mouse button click 2010 MSE Australia PL Introduction 13 1 5 Modes of Operation The application can be used in one of three modes Unsupervised Simulation Mode e Supervised Simulation Mode e Maintenance Mode lt Unsupervised Simulation Mode gt the default selection is intended for
62. apy and we can only adjust circulating blood volume by fluid administration or diuretic therapy After a few minutes perform a blood gas analysis e lt Investigations gt lt Arterial Blood Gas Analysis gt And note that the PaO2 is now 500 mm Hg and that the PaCOZ2 is within the normal range These results are typical for a normally functioning VA ECMO system when 100 oxygen is administered under full bypass conditions It is debatable whether or not a patient should be maintained on full bypass if clinically satisfactory conditions can be obtained by using only partial support Full bypass abolishes pulmonary arterial flow and entails the risks of left heart distension pulmonary or left heart thrombosis and coronary ischaemia due to increased left ventricular wall stress In contrast partial bypass maintains pulmonary flow and reduces the risks of left heart distension and thrombosis but creates the possibility of differential hypoxia and the requirement for some form of ongoing ventilation Finally we ll examine the effect of the administration of a powerful vasodilator Sodium Nitroprusside SNP on the behaviour of the EMO system Commence an infusion of SNP by e Selecting lt Therapeutic Interface gt lt Infusion Drug gt lt SNP 100mcg ml gt And starting it at 20 ml hr e Slide green slider to lt 20 gt and click lt Set gt After about 5 minutes note that the e Mean arterial pressure has fallen to 65 70 m
63. at the top right hand corner of the monitor and drag it while holding down the left mouse button The position of the window will be retained when you next start the application Refer to the section entitled Patient Monitor in the user manual for a complete description of the functionality of this window Therapeutic Interface The lt Therapeutic Interface gt window is used to administer drugs and or fluids to the patient The interface has four tabbed pages e Bolus Drug Infusion Drug e Fluids and e History To explore the effect of giving adrenalin to a normal patient lt Q Click the lt Bolus Drug gt tab in the lt Therapeutic Interface gt window lt Q Click the lt Give gt button Observe the effect of the drug on heart rate blood pressure and ectopic activity over the ensuing minutes Click on the lt History gt tab in the lt Therapeutic Interface gt window Clicking on the lt History gt tab allows you to review details of all of your therapeutic interventions If you want to reposition the lt Therapeutic Interface gt place the mouse at the top right hand corner of the window and drag it while holding down the left mouse button The position of the window will be retained when you next start the application Refer to the section entitled Therapeutic Interface in the user manual for a complete description of the functionality of this window 2010 MSE Australia PL Tutorials 91 7
64. atient on ECMO is shown in the figure below In this case a patient on stable VV ECMO at a flow rate of 5 0 lpm is cooled by 5 C from 38 8 to 33 8 No other changes to the management of the patient or the ECMO system were made The effect on PaO and SaO is shown 2010 MSE Australia PL ECMO Simulation User Manual v5 7 40 39 F 38 3 N Q Lar 09 2 5 2 3 B a 36 2 N O o a 35 34 50 33 0 500 1 000 1 500 2 000 2 500 3 000 3 500 4 000 Time Seconds References Kirklin JW and Barratt Boyes BG Cardiac Surgery New York Churchill Livingstone 1993 61 127 5 10 ECG Model The ECG model is based on the work of McSharry et al and is available on the Physionet website as ECGSYN According to these authors ECGSYN generates a synthesized ECG signal with user settable mean heart rate number of beats sampling frequency waveform morphology P Q R S and T timing amplitude and duration standard deviation of the RR interval and LF HF ratio a measure of the relative contributions of the low and high frequency components of the RR time series to total heart rate variability Using a model based on three coupled ordinary differential equations ECGSYN reproduces many of the features of the human ECG including beat to beat variation in morphology and timing respiratory sinus arrhythmia QT dependence on heart rate and R peak amplitude modulation The output of ECGSYN may be employed
65. ble notes you may do so by scanning the hand written documents and saving them in pdf format These Clinical notes will be displayed when the lt Clinical Notes gt menu option of the Inspector window is clicked Investigations The patient s investigations should also be placed in the scenario data folder These can be in the form of e Documents eg Laboratory Results in paf format e Static images eg Chest x Rays in jpg or bmp format e Audio files eg Heart Sounds in wav format e Video files eg Echo loops in either wmv or avi format There are several good sites on the WWW which can be used as a source of X Rays ECG s Scans etc The investigations will be displayed when the lt Investigations gt menu option of the Inspector window is clicked Resources Similarly appropriate resources should also be placed in the scenario data folder As with the patient s investigations these can be in the form of e Documents eg Scientific References in pdf format e Static images eg ECMO Circuit Diagrams in jpg or bmp format e Audio files eg Lectures in wav format e Video files eg Instructional videos in either wmv or avi format In addition the URL s of relevant websites can also be included as resources The resources will be displayed when the lt Resources gt menu option of the Inspector window is clicked Scenarios Database Editor The scenario database ed
66. blood in the existing pool and the new contents of oxygen carbon dioxide and metabolic acids are calculated When blood passes through the ideal compartment of a lung pool gas exchange occurs and oxygen and carbon dioxide diffuse across the alveolar capillary membrane according to their pressure gradients These lungs behave as Open Glottis lungs which are exposed to atmospheric air See Hardman At the end of each iteration oxygen is added to the tissue pool in an amount which corresponds to the amount which was acquired during transit through the lungs and carbon dioxide is removed according to the amount which was expired in the ventilating 2010 MSE Australia PL gas Finally oxygen is removed from the tissue pool and carbon dioxide added to the pool according to the metabolic rate The native lung itself is modelled as as a classical Riley three compartment structure The model has been designed to allow for the inclusion of additional the lungs within the circuit In particular an artificial lung can be placed in parallel with the native lung in order to simulate cardio pulmonary bypass or veno arterial ECMO or in series with before the native lung in order to simulate veno venous ECMO Alternatively two native lungs with variable parameters corresponding to the right and left lungs can be placed in parallel with one another in order to simulate the physiology of differential lung ventilation or one lung anaesth
67. ch contains physiological data but does not yet include any Clinical Notes Investigations or Resources To add Clinical Notes e Click on the lt gt sign to the left of the lt Test gt folder e Click on the lt Clinical Notes gt folder itself An lt Add Clinical Notes gt dialog box will appear e Move the cursor to the lt File Name gt field e Click on a paf file in the left hand window eg Getting Started paf This file name should appear in the lt File Name gt field of the lt Add Clinical Notes gt dialog box e Click lt Save gt The clinical notes which are contained in the folder Getting Started pdf should now be visible in the lt Clinical Notes gt folder To add Investigations and Resources go through a similar process to that described for the addition of Clinical Notes Finally click the lt Save amp Exit gt button to commit the changes to the database and then click lt System gt lt Exit gt to shut down lt Maintenance Mode gt Start the Main Application in lt Unsupervised Mode gt and click on lt Tools gt lt Load Scenario gt and confirm that a new scenario named lt Test gt is now available Adding a new investigation to an existing scenario To add a single item for example a pre operative 12 lead ECG to an existing scenario take the following steps e Make an electronic copy of the 12 lead ECG that you wish to include The copy must be in jpg or pdf format and should hav
68. ch is directly connected to the computer 2 Any IP camera which can be accessed over the LAN WAN Select the type you want and lt Test gt the video feed once you have made the appropriate selection Once you have selected a camera you can lt Close gt the selector window and lt Start Recording gt if you wish The video stream is recorded in ASF format and the video files are recorded to the application directory and are named according to the following protocol By default the recorded video file name is in the form MSExxxx asf where ox is an auto incrementing 3 digit sequence If you change the Session Name this name rather than MSE will be used as the file prefix 3 data storage rates are available e lt Small gt corresponds to about 200 Kbits sec e lt Medium gt corresponds to about 1000 Kbits sec e lt Large gt corresponds to about 2000 Kbits sec 2010 MSE Australia PL 52 ECMO Simulation User Manual v5 7 4 3 Whenever possible the system attempts to record at a frame rate of 29 97 fps lt Large gt video files consume disk space at about 1Gb hr Therefore you should periodically clear out recordings you don t want otherwise your disk space will rapidly disappear You can lt Stream gt the video output to somewhere else on your LAN To do this simply click on the lt Start Streaming gt menu item The streamed output is sent to port 10500 on the application computer and can be viewed
69. controlled by the MSE software and unless respiratory depressant drugs or muscle relaxants have been administered exhibits soontaneous respiratory activity The trainee is able to mask ventilate the Smart Lung via the intubation manikin or if the trachea has been intubated attach the patient to any modern anaesthesia ICU ventilator The trainee administers drugs and fluids via the lt Therapeutic Interface gt of the Main Application and observes the patient s responses on the lt Patient Monitor gt Additional information concerning the simulation scenario is provided to the trainee in the lt Inspector gt window The system supervisor controls the simulation using the Supervisor Application running on a second PC Netbook or Mobile phone The simulation can be recorded using a high resolution webcam and the in built data recording system 2010 MSE Australia PL 146 ECMO Simulation User Manual v5 7 A small group of observers are able to watch the simulation on a remote high definition television 2010 MSE Australia PL 1 ECMO Simulation User Manual v5 7 Trouble Shooting FAQ Can Irun it on a MAC One correspondent has told me that it will run in VirtualPC on a Macintosh Can lalter the weight of the patient In this version of the program the weight of the patient is fixed at 75 Kgs although the supervisor is able to vary the patient s nominal oxygen utilisation in the range 1 5 mls
70. d O2 dissociation computations J Appl Physiol 1979 Mar 46 3 599 602 Shappell SD and Lenfant CUM Adaptive genetic and iatrogenic alterations of the oxyhemoglobin dissociation curve 1972 Anesthesiology 37 127 Stergiopulos N Westerhof BE Westerhof N Total arterial inertance as the fourth element of the windkessel model Am J Physiol 1999 Jan 276 1 Pt 2 H81 8 Syroid ND Agutter J Drews FA Westenskow DR et al Development and evaluation of 2010 MSE Australia PL Refere nces 159 a graphical anesthesia drug display Anesthesiology 2002 Mar 96 3 565 75 2010 MSE Australia PL License Agreement 161 11 License Agreement END USER LICENSE AGREEMENT This ECMO simulator is intended only for teaching the users of ECMO systems the principles of this form of therapy Under no circumstances must it be used as a guide to the medical management of any living person This software end user license agreement EULA is a legal agreement between you either an individual or if purchased or acquired by or for an entity an entity and MSE Australia pl It provides a license to use this software and contains warranty information and liability disclaimers By downloading installing or using the software you are indicating your assent to the terms of this license If you do not agree to all of the following terms do not download or install the software discontinue its use immediately and destroy all copies in
71. d started to have frequent 2010 MSE Australia PL 125 ECMO Simulation User Manual v5 7 ventricular ectopy History According to the family the young man had suffered a flu like llness some weeks before and had been complaining of increasing shortness of breath and lethargy ever since His family practitioner had prescribed two courses of broad spectrum antibiotics and some bronchodilator therapy Initial Examination The endotracheal tube appears to be correctly positioned and breath sounds are symmetrical The patient is hypotensive tachycardic and has an irregular pulse He is afebrile His ventilation is being assisted using 100 oxygen and an AmbuO bag Pulse oximetry indicates a saturation of 90 Previous Medical History The family tells you that the patient has previously been in good health that he takes no regular medications and that he has no drug allergies He has no relevant previous medical history Subsequent Management The patient is transferred to the Intensive Care Unit further investigations are performed a tentative diagnosis of viral myocarditis is made and the decision is taken to support the patient with VA ECMO The results of some of these investigations Echo ECG CXR and ABG can be seen by clicking lt Investigations gt on the main menu We ll start the tutorial by connecting the patient to our monitoring system and putting him ona ventilator To do this e Click the lt Di
72. dinger technique and ultrasonic guidance Imagine now that you have e Placed the Seldinger wires e Given the patient 7500 units of heparin Select lt Heparin gt from the lt Therapeutic Interface gt lt Bolus Drug gt page and lt Give gt 7500 units and e Positioned the cannulae under ultrasonic control The cannulae are connected to the ECMO system The entire system is heparin coated Active venous drainage from the inferior vena cava IVC is via a 24F femoral cannula and arterialised return to the right atrium via a 21F Internal Jugular cannula The system s centrifugal pump is responsible both for generating the negative pressure which is required to facilitate drainage and the positive pressure which is required to pump blood through the artificial lung and back into the patient The pump head and oxygenator are integrated into a single disposable unit whichis mounted on the system console Figure 1 2010 MSE Australia PL Tutorials 103 Before commencing ECMO you may wish to confirm that the patient is effectively anti coagulated e Select lt Devices gt lt ACT Monitor gt and e Click lt Start gt in order to commence the measurement The ECMO circuit we ll be using is shown in Figure 1 We re actively draining sucking blood from a point in the inferior vena cava just below the diaphragm pumping it through the oxygenator and returning it via the superior vena cava to the right atrium Additional
73. e Light to moderate sedation 60 70 Light hypnotic state Low probability of recall 40 60 Moderate hypnotic state Unconscious 0 40 Deep hypnotic state The lt BMR gt slider is used to set the nominal Basal Metabolic Rate VO2 at 37C for the patient A typical value for an anaesthetised 70 kg patient undergoing cardiac surgery is inthe range 180 220 ml Min Kirklin and Barratt Boyes The lt CO2 SP gt slider is used to set the carbon dioxide set point for the patient A typical value for an awake patient is 38 42 mm Hg Adjusting it to a higher value will depress the patient s spontaneous respiration whereas lowering it will increase respiratory drive The lt Temp gt slider is used to set the starting temperature of the patient The temperature should not be changed markedly over a short time period as it will produce unexpected blood gas results until re equilibration of the respiratory gases has had time to occur in all body pools The lt K SP gt slider is used to set the potassium set point for the patient A typical value for a patient with normal renal function is 4 0 5 0 The lt Hct gt slider is used to set the starting haematocrit for the patient The typical value fora normal male is 45 The haematocrit should not be changed markedly over a short time period as it will produce unexpected blood gas results until re equilibration of the respiratory gases has had time to occur in all body pools The lt HCO3 gt
74. e environment is available on request 2010 MSE Australia PL Introduction 9 The system is primarily designed for small group learning situations The equipment required for this environment is shown below The communication between the Supervisor and Trainee can be implemented over a wired or wireless LAN or using a direct Ethernet connection The PC display is transmitted to the HDTV using the HDMI ports of the devices Trainee Notebook If a PC rather than a notebook is used by the trainee the system also works well with a hidden PC connected directly to the HDTV as its primary monitor and a Bluetooth wireless keyboard such as the Microsoft Wireless Entertainment 7000 The system can also be run on a conventional dual display second monitor system or a remote dual display system such as Maxivista 13 Installation Administrative privileges are required in order for the installation to proceed To install the system double click on the Microsoft Installer File MSE ECMO msi which can be found in the installation folder of the delivery medium CD DVD FD Memory Stick or Unzipped Zip file Follow the instructions of the Installer Wizard to complete the installation At the completion of the installation 5 new items should have appeared on the lt Start gt menu 2010 MSE Australia PL to ECMO Simulation User Manual v5 7 1 4 A Windows Movie Maker C NVIDIA Corporation F
75. e a width of lt 800 pixels and a height of lt 1000 pixels e Place a copy of the file in the ScenarioData folder e Start the system in lt Maintenance Mode gt e Click lt System gt lt Scenario Editor gt e Navigate to the ScenarioData folder inthe lt Folder Navigator gt window e Click on the file MSEScenario mdb to select it e Right mouse button click this file to open it in the database editor In the right hand lt Database Editor gt window O 2010 MSE Australia PL 6 5 Scenarios e Navigate to the scenario in which the addition is to be made e Click on the lt gt sign to expand the scenario e Click on the lt Investigations gt folder itself e An lt Add an Investigation gt dialog window should now appear e Select the item which you want to add as an investigation from the lt Folder Navigator gt window e This item should appear as the lt File Name gt in the dialog window e Add a short description of the investigation in the lt Investigation Title gt field eg Preoperative ECG e Click lt Save gt e Click lt Save Exit gt e Click lt System gt lt Exit gt Scenarios Required Files The lt Scenario Editor gt provides you with two tools for helping you ensure that all your necessary scenario files are in the ScenarioData folder To use the tools you must first in the lt Folder Navigator gt window navigate to the scenario database file MSEScenario mdb which
76. e gt lt Central Venous Pressure gt and lt SaO2 gt and e Click the lt Display gt button again to close this window and display the physiological signals Ventilate the patient e Click the lt Devices gt lt Ventilator gt menu item in the lt Inspector gt window e Click the power switch at the top right hand side of the device and then set the tidal volume Vt to 500 mls the rate to 12 bpm the FiO2 to 100 and the PEEP to 5 cms H20 Paralyse the patient e Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt window e Drag the green slider until it says 8 mgs and click the lt Give gt button And perform a baseline blood gas analysis e Click lt Investigations gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt window You elect to cannulate the patient percutaneously via the right femoral artery and vein using the Seldinger technique and ultrasonic guidance Imagine now that you have e Placed the Seldinger wires in the artery and vein e Given the patient 7500 units of heparin lt Therapeutic Interface gt lt Bolus Drug gt lt Heparin gt lt Give gt 7500 units and e Positioned the cannulae under ultrasonic control The cannulae have been connected to the ECMO system The entire system is heparin coated The system s centrifugal pump is responsible both for generating the negative pressure which is required to facilitate drainage and the positive pressure which
77. e it flows into the right ventricle and through the patient s own lungs In theory if we can capture the patient s entire venous return his native lung will have no need to participate in gas exchange at all and so can be completely rested not ventilated in order to permit healing to occur To visualize the interface of the ECMO system itself N Click lt Devices gt lt ECMO System in the lt Inspector gt window The key components of the interface are shown in Figure 3 Figure 3 2010 MSE Australia PL os ECMO Simulation User Manual v5 7 Notes Investigations Devices Resources Help To the left of the interface are three controls which control respectively the inspired oxygen concentration of gas flowing through the oxygenator the gas flow rate lpm to the oxygenator and the temperature setting control Co for the heater cooler In the context of VV ECMO the FiO2 control should always be set at 100 The gas flow rate control is used to control CO2 elimination the higher the gas flow rate the greater the rate of CO2 clearance The heater cooler can be used to vary the patient s temperature and metabolic rate Between these three controls and the data display area is the electronic clamp which controls flow through the outlet Arterial side of the pump When the slider is at the bottom the clamp is fully closed when at the top fully open The data display area displays the current val
78. e stimulator itself 2010 MSE Australia PL ECMO Simulation User Manual v5 7 In order to assess the patient s gas exchange Click the lt Display gt button in the lt Patient Monitor gt window Check lt Capnography gt and lt Gases gt in the lt Display gt window Click the lt Display gt button in the lt Patient Monitor gt window Click lt Investigations gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt window You may also wish to paralyse the patient and control his ventilation To do this 2 Ey Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt A window Click the lt Devices gt lt Nerve Stimulator gt menu item in the lt Inspector gt window Click the lt TOF gt button on the nerve stimulator itself Sedation may be administered by selecting the appropriate bolus or infusion drugs using the lt Therapeutic Interface gt and monitoring the depth of sedation by turning on the lt BIS gt display on the physiological monitor You elect to cannulate the patient percutaneously via the right internal jugular and femoral veins using the Seldinger technique and ultrasonic guidance Imagine now that you have e Placed the Seldinger wires e Given the patient 7500 units of heparin Select lt Heparin gt from the lt Therapeutic Interface gt lt Bolus Drug gt page and lt Give gt 7500 units and e Positioned the cannulae under ultrasonic cont
79. election is intended for use by unsupervised trainees In this mode a variety of previously recorded scenarios and or tutorials can be undertaken but no intervention by a supervisor is possible The trainee is able to load different patients pre recorded physiological states and to experiment with the use of various drugs and therapeutic techniques In lt Unsupervised gt mode the main menu items are e lt System gt lt Exit gt e lt View gt lt Patient Monitor gt e lt View gt lt Inspector gt 2010 MSE Australia PL Introduction 15 e lt View gt lt Therapeutic Interface gt e lt Tools gt lt Load Patient gt e lt Tools gt lt Load Scenario gt 1 6 Version Differences The Evaluation version of this software has been modified in various ways In particular e The application will only run for 10 minutes e Data Recording has been disabled e The ECG Editor has been disabled e The Scenario Editor has been disabled e The Application will only function for a period of 30 days The Personal version of the software e Limits network connectivity between the Main Trainee application and the Supervisor application Communication between these applications is only permitted if the applications are running on the same device or if a direct connection between two devices using Automatic Private IP Addressing APIPA has been implemented This restricts the range of IP addresses used by the two devices to 169 25
80. enario is shown below 2010 MSE Australia PL ECMO Simulation User Manual v5 7 6 8 E ECMO Tutorial 1 To Clinical Notes ECMO Tutorial 1 pdf E Investigations ARDS_X Rayjpg CHAV jpg SVH ECMO Protocol pdf VV ECMO Parameters pdf CHRV jpg Stagnation Pressure pdf In the example The ECMO tutorial scenario consists of e A set of Clinical Notes contained in the document ECMO Tutorial 1 paf e A single investigation Chest X Ray ARDS_X Ray jpg in jpg format and e Six resources in either jpg or paf format Scenarios ECG Editor The ECG database editor can be accessed from the lt System gt lt ECG Editor gt menu in the main environment when running in lt Maintenance Mode gt The editor is not available in the Evaluation Version The user interface of the editor is shown below 2010 MSE Australia PL Scenarios 83 MSE ECG Editor Pattern BBB 0 0 175 l 10 18 E 0 115 0 120 El New Profile Button B lt gt er jm j EIA Zero Line 2 3 4 o sf 24 3 4 AMA A IA ee CMA AMM gt 4 gt L See McSharry PE Clifford GD Tarassenko L Smith LA A dynamical model for generating synthetic electrocardiogram signals IEEE Trans Biomed Eng 2003 Mar 50 3 289 94 In order to use the editor take the following steps e Start the system in lt Maintenance Mode gt e Click lt System gt lt ECG Editor gt e Click
81. ent of the system has been developed in the Windows 7 32 and 64 bit environments It has not been tested in earlier versions of the operating system If you are using Logitech cameras you should only install the appropriate drivers The application may not function correctly if the Webcam Vid software is also installed Camera Overview The lt Camera gt window is made available within the lt Trainee gt program but effectively functions as a separate application It can either be used to film the supervisor during the pre simulation briefing for example if making a PowerPoint presentation or alternatively it can be used to record the activities of the trainee during the simulation itself In order to save on display space the lt Monitor gt and lt Therapeutic Interface gt windows should be turned off when making PowerPoint presentations The camera window has 3 menu items e lt Tools gt lt Select Camera gt e lt Tools gt lt Start Recording gt e lt Tools gt lt Start Streaming gt 2010 MSE Australia PL Camera 51 None Y Local Device IP Device PEACE Logitech HD Pro Webcam C910 y Camera Resolution 1640x480 ow Record Audio Video File Size Session Name E CMO Small Medium Large You must lt Select a Camera gt before lt Recording gt can be commenced The selection dialog is shown above Two camera types are currently supported 1 Any Web or other digital camera whi
82. er of the lt ScenarioData gt folder 2 2 2 CVS ECG Page The lt CVS ECG gt page of the supervisory application is used to make adjustments to the ECG and circulation of the patient 2010 MSE Australia PL so ECMO Simulation User Manual v5 7 EF MSE Supervisor CVS ECG Lung Misc ECMO Sinus Asystole VF Vent Ectopic ST Depression Brugada O Diathermy O ECG Lead Off The values set on this page are all nominal e they represent the value of the parameter before any intervention or therapy has occurred The lt HR gt slider is used to set the nominal heart rate of the patient The lt SVR gt slider is used to set the nominal vascular resistance of the patient The scale is arbitrary because manipulation of the control affects more than one system parameter but a value of 3 4 may be considered Normal The lt Cb slider is used to set the nominal Cardiac Index of the patient A value of 2 2 L Min M2 is typical of patients under anaesthesia and before bypass The lt Gain gt slider is used to increase the circulating blood volume of the patient The scale is in mls min The lt Loss gt slider is used to reduce the circulating blood volume of the patient The scale is in mls min The lt Freq gt slider is used to set the frequency of ectopic heart beats The lt Set as Primary gt button sets the selected ECG rhythm as the primary cardiac rhythm 2010
83. erminate automatically if you fail to comply with any term hereof No notice shall be required from MSE Australia PL to effect such termination You may also terminate this Agreement at any time by notifying MSE Australia PL in writing of termination On termination you must destroy all copies of the Software Your obligation to pay accrued charges and fees shall survive any termination of this Agreement 14 ASSIGNMENT 14 1 Neither this Agreement nor any rights granted hereunder may be sold leased assigned or otherwise transferred in whole or in part by you whether voluntary or by operation of law Any such attempted assignment shall be void and of no effect without the prior written consent of MSE Australia PL 15 ENTIRE AGREEMENT 15 1 This Agreement contains the entire agreement between MSE Australia PL and you related to the software and supersedes all prior agreements and understandings whether oral or written It may be amended only by a writing executed by both parties 2010 MSE Australia PL Index A ACT Machine 45 APIPA 15 154 Audio 21 Axis Camera 52 B BIS 32 Blood Gas Analysis 19 56 59 BMR 32 68 Bolus Drugs 27 Ter Camera 19 52 Cannula Position 7 37 40 65 Size 7 37 40 65 Cardiac Index 29 148 CO2 SetPoint 32 148 D Data Recorder 46 151 Defibrillator 43 Devices 24 37 40 43 44 45 46 Diathermy 29 Distractors 29 Dongle 9 15 Drug Administration 10 27 59 Dual Di
84. esia Venous Pool Tissue Pool Arterial Pool All blood gas results are corrected to 37 and reported at this temperature See Dickinson CJ 1977 A Computer Model of Human Respiration MTP Press Limited ISBN 0852001738 Hardman JG Wills JS Aitkenhead AR Investigating hypoxemia during apnea validation of a set of physiological models Anesth Analg 2000 Mar 90 3 614 8 Riley RL and Cournand A 1949 Ideal Alveolar air and the analysis of ventilation perfusion relationships in the lungs J Appl Physiol 1 825 847 2010 MSE Australia PL s ECMO Simulation User Manual v5 7 5 2 Qs Qt and Cardiac Output The relationship between Qs Qt of the native lung and the cardiac output has been modeled with some reference to the data of Dantzker et al These authors found that Qs Qt varied in a more or less linear fashion with cardiac output in a group of 20 patients with severe ARDS 8 Cardiac Output Baseline 50 100 Shunt Baseline The relationship between Qs Qt and Cardiac Output in the group of patients with ARDS is shown in black in the figure above In this study the authors remarked that The marked influence of cardiac output on intrapulmonary shunt shown in this study emphasizes that interpretation of improvements in gas exchange seen in ARDS must take into account accompanying hemodynamic changes Interventions which appear to improve lung function may be acting predominantly by depres
85. evices gt lt ECMO System gt e Click the lt Main Power gt button at the top right of the interface e Turn on 6 LPM of oxygen using the middle knob at the left of the interface To initiate VA ECMO e Turn up the lt RP M gt until the stagnation pressure is 10 mm Hg gt the patients mean arterial pressure e Fully open the lt arterial clamp gt by sliding the slider upwards e Now slowly further increase the lt RP M gt until a flow rate of 5 lpm is achieved e Start the lt Timer gt on the physiological monitor The mean arterial pressure is very high but for the purposes of this exercise we ll just accept it After five minutes 2010 MSE Australia PL Tutorials 141 e Perform an lt Arterial Blood Gas Analysis gt e Perform an lt Oxygenator Blood Gas Analysis gt and e Return to the lt ECMO System gt As there is no ventricular ejection there is little difference between the arterial and oxygenator samples In both cases the PO2 should be about 400 mm Hg and the PCO2 about 35 mm Hg Note also that the pre membrane pressure is 305 mm Hg and that the rom are about 3500 Now ask the Supervisor to cause the oxygenator to fail Over the next few minutes observe that e The pre membrane pressure has risen to 330 mm Hg e The blood flow has fallen to 3 5 Ipm and that e Some ventricular ejection has become apparent Start the lt Timer gt and after five minutes e Repeat the lt Arterial
86. f oxygen using the middle knob at the left of the interface At this point we re ready to initiate ECMO However we must remember that unlike the case for VV ECMO there is a pressure gradient across the circuit and if we simply open the clamp blood will flow from the arterial side of the circuit to the venous side and a large left to right shunt will be created In order to avoid this effect we need to generate a stagnation pressure that is a little bit above the patient s mean arterial pressure To do this slowly turn up the flow control until the indicated pressure is 10 mm Hg above the patient s mean arterial pressure with the clamp still fully closed Now progressively release the arterial clamp by moving the slide control upwards and observe that flow increases to about 1 lpm Increase the flow further by slowly rotating the flow control and note how the patient s pulse pressure becomes progressively smaller until it eventually disappears altogether Also note that if you go on rotating the flow control the indicated flow reaches a maximum at about 4 7 lpm and then starts to decrease We ll explore the reasons for this in a future tutorial but for the moment just accept it and Adjust the flow control knob so that the maximum blood flow rate is achieved At this point the patient is on full cardio pulmonary bypass the aortic valve remains closed throughout the cardiac cycle and there is no flow through the pulmo
87. f the window The main menu items are e Notes e Investigations e Devices e Resources and e Help Clicking on the lt Notes gt menu item loads the patient s clinical notes into the window If the lt Notes gt have more than one page two additional menu items lt Prev gt and lt Next gt become active and can be used to navigate between pages of the document Clicking on the lt Investigations gt menu item allows the trainee to examine the investigations which are available for the current scenario Arterial Venous and Oxygenator Blood Gas Analyses always appear as the first three items in the list Other investigations are listed if they appear in the database for the particular scenario which has been selected The investigations may include e Static Images eg 12 Lead ECG Chest X Ray in jpg bmp or pdf format e Video Images eg Echo Loop in wmv or avi format or e Text Documents eg Printed Laboratory Report in paf format Clicking on the lt Devices gt menu item allows the trainee access to the virtual devices which are available in the environment These devices are the 2010 MSE Australia PL Applications 25 e Ventilator e VV ECMO System e VA ECMO System e ACT Monitor e Nerve Stimulator e Defibrillator and e Stethoscope Note that the VA and VV ECMO systems are both accessed through lt Devices gt lt ECMO System gt menu item and that the ECMO system is switched
88. g function e Changes in cardiac function In all the system comprises about 30 separate models which execute synchronously The architecture and behaviour of some of the more significant models is outlined in the Models section of this manual System Requirements The system has been developed in the Windows XP 32 bit environment The hard and soft ware requirements of the system are outlined below The Main Application MSEHDTV exe requires at least e A Pentium Dual Core E52xx series processor or equivalent e A WUXGA 1920 1200 pixels or HDTV 1920 1080 pixels display e Local Area Network Connectivity 100 mbits sec or greater e Internet Connectivity at any speed e 1 GB disk space e Windows XP with service pack 3 e Net Framework 3 5 e DirectX 9 0 e Adobe Acrobat Reader 9 0 The Supervisor Application MSESupervisor exe can be run on a second PC or Netbook and requires at least e An Intel Atom processor e An XGA 640 480 display e Wired Local Area Network Connectivity 100 Mbps or greater or e Wireless Connectivity 54 Mbps e Internet Connectivity at any speed e 100 KB disk space e Windows XP with service pack 3 e Net Framework 3 5 If you wish to perform Full HD video recording you should read the section entitled Compatible Equipment in the lt Camera gt section of this manual A second version of the supervisory application which runs in the Windows Mobil
89. g the lt Display gt button on the Patient Monitor allows you to select the parameters which you want to view Check lt ECGs lt Direct Arterial Pressure gt lt Central Venous Pressure gt and lt Sa02 gt in the lt Display gt window Click the lt Display gt button in the lt Patient Monitor gt window The lt Display gt window will now close and the ECG Direct Arterial Pressure Central Venous Pressure and SaQ2 signals will be displayed in the lt Patient Monitor gt window It should be noted that the arterial pressure is being measured in the right radial artery As you can see the patient is normotensive with a pulse rate of about 70 bpm and a central venous pressure of 3 mm Hg The pulse oximeter is indicating a saturation of 98 In order to eliminate the effects of spontaneous ventilation and to make the scenario more typical of a real patient on VA ECMO we ll also ventilate him Currently the system always assumes that the patient is intubated so in order to do this simply Click the lt Devices gt lt Ventilator gt menu item in the lt Inspector gt window When the ventilator appears in the lt Inspector gt window Figure 1 Figure 1 2010 MSE Australia PL Tutorials 119 l Muse VENTILATOR ces 400 600 0 E 5 15 200 800 r i y 0 1 000 o 20 Vt mis Rate BPM 10 60 40 1180 5 t y z a 20 100 o 1 15 0 Fi02 PEEP cm H20 oS
90. gen tension into saturation J Appl Physiol 1966 Jul 21 4 1375 6 Kelman GR 1967 Digital computer procedure for the conversion of PCO2 into blood CO2 content Resp Physiol 3 111 115 Severinghaus JW Simple accurate equations for human blood O2 dissociation computations J Appl Physiol 1979 Mar 46 3 599 602 5 4 Pharmacokinetic Model The pharmacokinetic model is loosely based on the work of Maitre and Shafer who described a method of predicting anaesthetic drug concentrations based on a three compartment model of drug distribution and elimination Their model has been subject to three additional refinements 1 The ability to calculate drug concentrations at effector sites has been added 2 The ability to define the potency of any drug at any effector site has been added 3 A mechanism of competitive antagonism has been added The basic structure of the model is shown bellow 2010 MSE Australia PL ECMO Simulation User Manual v5 7 V2 litres Kie Y etea fene Kio min CL litre min 1 Pharmacokinetics Pharmacodynamics The output of the model is illustrated by the response of the patient to the administration of heparin and its reversal by protamine in the graph below 350 a Protamine 100 mg 6 bis e ee 300 z eesse rare ACT Secs N S ok a o 100 x Heparin 10 000 IU 50 07 T T T T T 1 0 100 200 300 400 500 600 700 800 900 1 000 Time Secs
91. he blood flow rate has fallen from lt 3 5 gt lpm to lt 0 6 gt lpm Note also that the lt Oxygenator Blood Gas Analysis gt results have paradoxically improved the PO2 is higher and the PCO2 is lower but that the patient s arterial blood gas values have deteriorated again So what s happening here If we look at the pressure and flow data first we see that the pre membrane pressure is now nearly equal to the stagnation pressure at this rpm and that the flow rate has fallen dramatically Nearly all of the pump s energy is being used to overcome the additional resistance of the obstructed outlet line and very little flow is occurring Figure 2 Figure 2 2010 MSE Australia PL ne ECMO Simulation User Manual v5 7 y a es The low blood flow through the oxygenator in the face of an unchanged gas flow results in inadvertent hyperventilation of the artificial lung so in the blood leaving the oxygenator the PCO2 falls quite markedly and the PO2 rises Thus the hallmarks of outlet line obstruction can be summarized as a rising pre membrane pressure and falling blood flow rate in association with Supernormal oxygenator blood gases This can be compared with oxygenator failure which may have a similar impact on 2010 MSE Australia PL 7 7 Tutorials 117 oxygenator blood pressure and flow but which is associated with a failure of gas transfer and deterioration in oxygenator blood gas val
92. he table below Lignocaine meteram Miaon miaon OOOO Metaram mope iP Meroprooi noraarerain Midazolam Propofol Morine remiten Noracrenain snp Pencuonium Popo Protaning miope i vecuronium i The current release of the system does not include a drug database editor 2 2 Supervisor The Supervisor Application is used to control the behaviour of the simulation system in real time The program is intended to be runona second PC or Netbook which is in communication with the Main Application over a Local or Wide Area Network The application uses the IP4 addressing but will function under both the Vista and 7 operating systems In order to start the application e Run the Main Application in lt Supervised Mode gt e Note the IP Address at the top right hand corner of the lt Patient Monitor gt 2010 MSE Australia PL 28 ECMO Simulation User Manual v5 7 Now e Ensure that the supervisor s device has an active network connection e Run the Supervisor Application MSESupervisor exe on the supervisor s device e Enter the Patient Monitor s IP Address in the lt Address gt field of the application e Click lt Connect gt You should now see a screen which looks like this E MSE Supervisor Scenarios CVS ECG Lung Misc ECMO Getting Started Annoying Alarm2 wav VV ECMO Tutorial 1 Car Alarm wav VA ECMO Tutorial 1 Fire Alarm wav Mobile Ringtone wav
93. his Agreement with programs or data not furnished by MSE Australia PL if such infringement would have been avoided by the use of the Software without such programs or data 7 LIMITED WARRANTIES 7 1 the software is provided on an as is basis MSE Australia PL makes no warranty of any kind express or implied including without limitation any implied warranty or merchantability or fitness for a particular purpose Without limitation you assume sole responsibility for selecting the software to achieve your intended results and for the installation use and results obtained from the software MSE Australia PL makes no warranty that the software will be error free or free from interruptions or other failures In particular the software is not designed for use in hazardous environments requiring fail safe performance MSE Australia PL expressly disclaims any warranty of fitness for high risk activities 7 2 MSE Australia PL warrants that it holds the proper rights allowing it to license the Software and is not currently aware of any actions that may affect its rights to do so 7 3 MSE Australia PL cannot guarantee that the Software will work at all times If you change your operating system the software may not work anymore You acknowledge and agree that such changes are fair and reasonable 7 4 You should make sure that it is legal to use the Software in your country or jurisdiction MSE Australia PL only provides a license for you to
94. id producing rapid marked changes in some variables as this will result in transient anomalous behaviour for some minutes In particular instantaneous changes in body temperature of more than a few degrees and rapid changes in haematocrit of more than a few should both be avoided If such changes are made the partial pressures of the respiratory gases in all compartments will take some time to reach a new steady state and for many minutes the reported blood gas values will be clearly erroneous This compares very unfavourably with the sustained VO2 achieved by Alberto Contador who apparently was able to utilise 7000 mlis minute for over half an hour ina recent Tour De France 2010 MSE Australia PL 154 ECMO Simulation User Manual v5 7 9 7 9 8 Absence of Haptic technology The present implementation includes no haptic technology In general this has no implications on the fidelity of the simulation However in real life the rom controllers of ECMO pumps exhibit considerable force feedback so that it is relatively difficult to produce sudden marked changes in pump output Clearly this is not the case in the simulated environment and unless care is taken in control adjustment sudden unrealistic changes in pump output can be produced Displaying PowerPoint Files When you try to open a a Microsoft Office PowerPoint 2007 document in the Inspector window the document may not open in this window but
95. ider of the electronic clamp downwards until all forward flow ceases Finally reduce the rpm to zero and turn the ECMO system off This technique of weaning ensures that the arterial line is fully occluded before the rom are reduced below a level which permits backflow to occur This concludes our introductory tutorial to VA ECMO In future tutorials we ll examine the problem of backflow explore the impact of VA ECMO ona patient in cardiogenic shock and take a look at some of the complications of this form of therapy VA ECMO 2 During the conduct of this simulation ventricular ejection ceases completely This form of support is not recommended in the management of most patients The learning objectives of the session are e To explore the cardiovascular effects of VA ECMO in a patient with cardiogenic shock We will be simulating the use of a system in a patient with severe left ventricular failure which is associated with significant respiratory impairment Scenario You are called urgently to see a 24 year old man in the Emergency Department of your hospital The patient had been brought in by ambulance complaining of chest pain and dyspnoea You arrive in the department just after the patient has been intubated by the resident The resident tells you that the patient deteriorated shortly after having a portable chest x ray He performed the intubation because the patient became profoundly hypotensive unresponsive to commands an
96. ilure 3 4 Getting Started Conventions e In the early tutorials essential mouse or keyboard input is indicated by a mouse icon e Computer controls items or windows are referred to in the text between Less than 2010 MSE Australia PL Tutorials 87 and Greater than symbols e The terms Click and Select refers to usage of the left mouse button The tutorials are all viewable by clicking the lt Notes gt menu item of the lt Inspector gt window however it s a good idea to print off the first few tutorials and work through them from a hard copy In order to reduce constant switching between the various functions of the lt Inspector gt window Unsupervised tutorials like this one are designed to be run as stand alone applications whereas Supervised tutorials require input from the supervisory application and cannot be run in isolation The supervisory status of the tutorial is indicated at the top left hand corner of the first page of the tutorial Okay let s get started The learning objective of this tutorial is to become familiarized with the basic elements of the MSE simulation environment Click on the lt Start gt lt All Programs gt lt MSE ECMO Simulator gt lt MSE ECMO gt menu item of the desktop You will be given the opportunity to start the application in one of three modes 1 Unsupervised Simulation Mode 2 Supervised Simulation Mode
97. in for a noramally functioning oxygenator The lt AL Res gt slider is used to set the resistance of the arterial return line The scale represents the pressure drop across the Arterial line in mm Hg dL min Typically the value of this parameter is lt 1 mm Hg L Min for unobstructed tubing If you wish to simulate more or less complete kinking of the arterial line set the lt AL Res gt slider to 20 The lt VL Res gt slider is used to set the resistance of the venous drainage line The 2010 MSE Australia PL Applications 35 scale represents the pressure drop across the drainage line in mm Hg dL min Typically the value of this parameter is lt 1 mm Hg L Min for unobstructed tubing If you wish to simulate more or less complete kinking of the drainage line set the lt VL Res gt slider to 20 2010 MSE Australia PL 3 3 1 3 2 Devices 37 Devices Nerve Stimulator TOF Button The current version of the nerve stimulator can only be used for Train of Four measurement Click the lt TOF gt button to observe the response of adductor pollicis Veno Venous ECMO Note that the VA and VV ECMO systems are both accessed through lt Devices gt lt ECMO System gt menu item and that the ECMO system is switched between these modes using the control at the bottom right hand side of the ECMO system interface The Veno venous ECMO module is intended for use by those undergoing training in thi
98. in of Four If you want to reposition the lt Inspector gt window place the mouse at the top right hand corner of the window s title bar and drag it while holding down the left mouse button The position of the window will be retained when you next start the application Refer to the section entitled Inspector for a complete description of the functionality of this window 2010 MSE Australia PL 12 ECMO Simulation User Manual v5 7 Patient Monitor The lt Patient Monitor gt is based on a modern physiological monitor and is used to display the patient s current vital signs Click the lt Display gt button on the Patient Monitor and select the parameters which you want to view for example ECG Direct Arterial Pressure and Central Venous Pressure Click the lt Display gt button again to close the parameter selection window The parameters which can be displayed include e ECG e NIBP e Direct Arterial Pressure e Central Venous Pressure e SaQ2 e Sa02 waveform e BIS e Temperature e Capnographic Waveform and e Inspired and Expired Gas values If you want to reposition the lt Patient Monitor gt place the mouse at the top right hand corner of the monitor and drag it while holding down the left mouse button The position of the window will be retained when you next start the application Refer to the section entitled Patient Monitor for a complete description of the functionality of this window Ther
99. information regarding the ECMO system can be found by clicking on the lt Resources gt menu of the lt Inspector gt window and selecting the resource which you want to view These resources include lectures on ECMO images of various systems relevant websites and various descriptions and protocols relating to the technique To visualize the interface of the ECMO system itself e Click lt Devices gt lt ECMO System in the lt Inspector gt window We re going to start by initiating ECMO with a single drainage cannula positioned in the infra hepatic region of the IVC and a single 21F correctly positioned return cannula To initiate VV ECMO e Turn the ECMO power switch lt On gt e Set a flow of oxygen of about 6 lpm 2010 MSE Australia PL 104 ECMO Simulation User Manual v5 7 e Set an inspired oxygen concentration of 100 e Fully release the outlet clamp by sliding the clamp control to the top of the scale and e Slowly increase the pump rpm until the maximum blood flow rate of 3 4 lpm is reached Note that if the rom continue to be increased after 3 4 lpm is reached flow progressively declines until eventually it ceases altogether This plateauing and subsequent decline of ECMO blood flow with increasing rpm is known as Inflow Limitation Remember that the centrifugal pump is generating a positive pressure on its outlet side and a negative pressure on its inlet drainage side In this case beca
100. instead a new PowerPoint 2007 2010 window opens to display the document This is a feature of newer versions of PowerPoint To prevent this from happening you should alter the Windows registry by double clicking on the file PowerPointFix reg which can be found in the executable directory This operation only needs to be performed once For further information refer to http support microsoft com kb 927009 APIPA The Personal version of the software limits network connectivity between the Main Trainee application and the Supervisor application Communication between these applications is only permitted if the applications are running on the same device or if a direct connection between two devices using Automatic Private IP Addressing APIPA has been implemented APIPA is a DHCP failure mechanism Under APIPA DHCP clients obtain IP addresses when a DHCP server is not available and for this reason connection between two separate computers will not occur if either is connected to a router APIPA restricts the range of IP addresses used by the two devices to 169 254 0 0 169 254 255 255 and and both must reside on the same subnet A side effect of this architecture is that access to the Internet is not possible using the Personal version if the Main application is running in Supervised mode whilst under the control of an attached device 2010 MSE Australia PL Trouble Shooting T
101. is required to pump blood through the artificial lung and back into the patient The pump head and oxygenator are integrated into a single disposable unit which is mounted on the system console Figure 1 Figure 1 2010 MSE Australia PL VA ECMO We re now nearly ready to commence VA ECMO To complete our preparations we need to e Click lt Devices gt lt ECMO System gt and select the lt VA ECMO gt option at the bottom right of the interface e Click the lt Adjust Cannula gt button and advance the drainage cannula as far as it will go using the slide control on the left hand side of the window e Re open the ECMO interface by clicking lt Devices gt lt ECMO System gt e Click the lt Main Power gt button at the top right of the interface e Turn on 6 LPM of oxygen using the middle knob at the left of the interface To initiate VA ECMO e Turn up the lt RP M gt until the stagnation pressure is 10 mm Hg gt the patients mean arterial pressure e Fully open the lt arterial clamp gt by sliding the slider upwards e Now slowly further increase the lt RP M gt until the maximum flow rate of 5 lpm is achieved e Start the lt Timer gt on the physiological monitor Because the mean arterial pressure is high commence an infusion of SNP by e Selecting lt Therapeutic Interface gt lt Infusion Drug gt lt SNP 100mcg ml gt 2010 MSE Australia PL 134 ECMO Simulation User Manual v5 7 And
102. itor can be accessed from the lt System gt lt Scenario Editor gt menu in the main environment when running in lt Maintenance Mode gt The editor is not available in the Evaluation Version The user interface of the editor is shown below 2010 MSE Australia PL Scenarios MSE Scenario Editor Database F Simulation Projects MSE_ECMO ScenarioData MSEScenario mdb Folder Navigator Database Editor ES Getting Started pdf fd MSEScenario mdb BA HB FBC HCT 30 pdf 5 5 Getting Started HS_Normal wav Es WV ECMO Tutorial 1 Maquet Priming wmv fea VA ECMO Tutorial 1 Missing Document pdf MSEData ds Ninomiya Perfusion Simulator pdf Normal BS wav Normal Fundoscopy jpg Normal Patient pat Pulmonary Oedema jpg Sickle1 JPG Y re a o 5 a ES 5 E E D Ga A 5 a A 5 H P y wo a o 3 a 6 5 D g a a b Q Mn 2 x m O s x a 3 8 2 ped a TGSAX_Normal wmv TO4 wmv ee Pe a Q s z E 2 The editor is modal which is to say that it must be closed with the lt Save amp Exit gt button or lt Cancel amp Exit gt button before any other activities can be undertaken In order to navigate the file system you must either click on the folders themselves or on the lt gt signs at the left hand side of the folders Adding a new scenario We ll now work through adding a complete new scenario to the database in order to illustrate the use of the editor To d
103. kg min The parameters of the underlying models are generally indexed to body weight and are appropriate for adults in the range 20 100 kgs However it should be noted that some parameters such as FRC and other lung volumes are defined in absolute values and will not change if body weight is altered The pharmacokinetic parameters have been modelled using data obtained from adults How do move one of the main windows If you want to move the lt Patient Monitor gt lt Inspector gt or lt Therapeutic Interface gt window e Place the mouse at the top right hand corner of the window and e Drag it while holding down the left mouse button The position of the window will be retained when you next start the application What s the difference between loading a Patient and loading a Scenario on the lt Tools gt menu If you load a Patient you will load a patient s nominal physiological state but all other components of the current scenario notes investigations and resources will remain unchanged If you load a Scenario you will load the patient who is represented in that scenario together with the notes investigations and resources which are associated with the selected scenario Refer to the Scenarios section for more detailed information on the structure of a scenario Can Irun the system using a direct ethernet connection between two computers Yes you can For advice on how to set up such a connection see f
104. king on the lt Tools gt lt Load Scenario gt menu option of the main environment In lt Supervised gt mode the supervisor selects the scenario on the lt Scenarios gt page of the Supervisor Application The basis structure of a record in the scenario database is shown below la ECMO Tutorial 1 z Clinical Notes BA ECMO Tutorial 1 pdf E Investigations ARDS_X Ray jpg E D G 4 p Vi amp y O lt a 10 SVH ECMO Protocol pdf J VV ECMO Parameters pdf CHRV jpg O PA Stagnation Pressure pdf In the example The ECMO Tutorial 1 scenario consists of e A set of Clinical Notes contained in the document ECMO Tutorial 1 paf e A single investigation Chest X Ray ARDS_X Ray jpg in jpg format and 2010 MSE Australia PL ECMO Simulation User Manual v5 7 e Six resources in either jpg or paf format Although not shown in the diagram the database record also includes a reference to the initial patho physiological state in the form of a pat file Refer to the section Scenarios Creating Resources for a description of the techniques which may be used to create a resource 6 2 Scenarios File Formats The file formats which can be used as resources by the system are File Extension Intended Use PAT Patient File PDF Document or Image display WMV Video Display in PAL or NTSC Video format AVI Video Display in PAL or NTSC Video format JPG
105. l quite quickly set up our monitoring e Click the lt Display gt button in the lt Patient Monitor gt window e Check lt ECGs lt Direct Arterial Pressure gt lt Central Venous Pressure gt and lt SaO2 gt and 2010 MSE Australia PL Tutorials 1 13 e Click the lt Display gt button again to close this window and display the physiological signals Ventilate the patient e Click the lt Devices gt lt Ventilator gt menu item in the lt Inspector gt window e Turn on the ventilator and set the tidal volume Vt to 500 mis the rate to 12 bpm the FiO2 to 100 and the PEEP to 5 cms H20 Paralyse the patient e Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt window e Drag the green slider until it says 8 mgs and click the lt Give gt button And perform a baseline blood gas analysis e Click lt Investigations gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt window You elect to cannulate the patient percutaneously via the right and left internal jugular and right femoral veins using the Seldinger technique and ultrasonic guidance Imagine now that you have e Placed the Seldinger wires e Given the patient 7500 units of heparin Select lt Heparin gt from the lt Therapeutic Interface gt lt Bolus Drug gt page and lt Give gt 7500 units and e Positioned the cannulae under ultrasonic control The ECMO circuit we ll be using is shown in Figure 1 We re acti
106. license file oonmoccnonnnnnncnnnnnnnconnnnnncnnnnnnrn nn 151 Error Messages iia 151 HDTV Connection acacia cri ci iii dia 153 Aberrant Beha vViOulicas c s22ccccccceeccctescuaee cates dos cecuaescctandsanecccassect sfecsececousscctswcssesecunsceaestocceees 153 Displaying PowerPoint Files ccceeeseceeeeeeeeeeeeeeeeeeeeeseeeeeeeseeeeeeeseeeeeeseeeeeeeseeeeeeeseeeeeeess 154 2010 MSE Australia PL Contents 5 8 SARI P A caian act aae aaa aa a Ae Ea aa ai ea aA abaden EnA aaneen ai 154 Part X References 157 1 Reference Siesau cece ee aaae ia aa lada Dacia sa a 157 Part XI License Agreement 161 Index 165 2010 MSE Australia PL 1 1 Introduction Introduction Overview The ECMO simulator is a screen based implementation of a much larger high fidelity simulation system The Modular Simulation Environment MSE It is intended for those working in the fields of Anaesthesia Intensive Care and Perfusion and has been designed for use by single users or small groups in a tutorial setting The simulator can be installed on computers running under the 32 or 64 bit versions of the Microsoft Windows XP Vista or Windows 7 operating systems It incorporates various MSE components which include e A virtual patient consisting of about 20 real time physiological models which can be adjusted to reproduce a wide variety of clinical states e A centrifugal pump based ECMO system e A hollow
107. lt Help System gt e lt System gt lt Miscellaneous Settings gt The lt Help System gt option opens this help file The Help File is also made available in pdf format from the Windows lt Start gt menu 2010 MSE Australia PL ta ECMO Simulation User Manual v5 7 1 5 2 1 5 3 The lt Miscellaneous Settings gt option allows you to change the units of measurement for blood gases kPa mm Hg set the aspect ratio of the Inspector Window to be used when viewing PowerPoint files and set the background colour of the main applications desktop Units of Measurement Powerpoint Aspect Ratio mmHg kPa Supervised Simulation Mode lt Supervised Simulation Mode gt is used when active interventions by a simulation supervisor are required during the course of a simulation session Events such as oxygenator failure catastrophic haemorrhage or the occurrence of a malignant cardiac arrhythmia can only be initiated when the supervisor is connected to the Main Application in lt Supervised Simulation Mode gt The supervisor controls the flow of events using the supervisory application In lt Supervised Simulation gt mode the main menu items are e lt System gt lt Exit gt e lt View gt lt Patient Monitor gt e lt View gt lt Inspector gt e lt View gt lt Therapeutic Interface gt e lt Tools gt lt Save Patient gt Unsupervised Simulation Mode lt Unsupervised Simulation Mode gt the default s
108. ly partial support Very slowly rotate the flow control knob so that a blood flow rate of 2 5 lpm is achieved Note that pulsatile blood flow returns and that the pulse oximeter starts working again Note also that carbon dioxide has now re appeared in the capnograph trace and that the end tidal CO2 is about 12 15 mm Hg After a few minutes in this state Perform an arterial blood gas analysis Investigations gt lt Arterial Blood Gas Analysis gt Perform an oxygenator blood gas analysis Investigations gt lt Oxygenator Blood Gas Analysis gt Examine the two blood gas reports and note the differences 1 The radial arterial PO2 is much lower than the oxygenator PO2 2 The radial arterial PCO2 is much lower than the oxygenator PCO2 3 There is a marked respiratory alkalosis in the radial sample So what s going on here Well this is an example of Differential Hypoxia Because the patient is only on partial cardio pulmonary bypass and has a considerable amount of blood flowing through his own lungs the upper part of the body including the right radial artery is being perfused with blood which has been pumped out of the left ventricle This blood has reached the left ventricle from the native lung which is being relatively over ventilated with a gas mixture containing only 21 oxygen Hence the lower PO2 and PCO2 In contrast the lower part of the patient s body is being perfused with blood e
109. m The learning objectives of the session are to investigate e The effect of cannula position on ECMO system performance e The effect of temperature control on metabolic rate and oxygenation We will be simulating the use of a system in a patient with essentially normal cardiovascular function but with severe respiratory failure The patient is a 24 year old man weighing 75 kgs who has been transferred to your Intensive Care Unit for Veno Venous ECMO He had been admitted to the Intensive Care Unit of a large regional hospital 3 days before transfer to your institution At that time he presented a four day history of increasing respiratory distress fever and a productive cough The patient had been sedated intubated and ventilated shortly after admission to the regional ICU Blood and sputum cultures grew a methicillin sensitive staphylococcus aureus Despite treatment with appropriate antibiotics the use of prone ventilation permissive hypercarbia and inhaled nitric oxide he continued to deteriorate Following discussions with the clinicians at the regional hospital he has been transferred to your institution for initiation of veno venous ECMO On arrival in your ICU the patient is being given assisted ventilation via an Ambu bag on 100 oxygen Blood gas analysis is reported as Pa02 43 mm Hg PacO2 41 mm Hg pH 7 35 BXS 1 0 Temp 37 0 O 2010 MSE Australia PL Tutorials 101 Sa02 68 The patient has an Acute
110. m flow ceases completely We ll explore the reasons for this in a future tutorial but for the moment just note it and return the rom to about 2250 2010 MSE Australia PL Tutorials 99 so that flow is maximized Start the timer on the patient monitor Click the lt Timer gt button in the lt Patient Monitor gt window And after five minutes repeat the blood gas analysis Compare the results with the previous analysis The salient differences are that e The PaQ2 is higher e The SaQ2 is higher e The PaCO2 is markedly lower Note that we have successfully raised the PaO2 to a safe level 60 mm Hg and that the PaCO2 is now quite low However the PaO2 while improved is hardly excessive These blood gas results effective normalization of PaCO2 but with a lesser impact on Pa02 are typical of patients undergoing VV ECMO In future tutorials we ll explore ways of achieving a greater impact on arterial oxygenation in patients on ECMO Now let s experiment with the effect of changing the gas flow rate through the oxygenator Leave the rom unchanged but reduce the gas flow rate from 8 lpm to 1 Ipm and re start the timer by clicking it twice After five minutes repeat the blood gas analysis and note how the PaCO2 has risen markedly but with little change in PaO2 Thus we can see that we use the gas flow rate through the oxygenator to control the patients PaCO2 In the final part of this tutorial we ll explo
111. m Hg e The pump flow rate has increased to 5 lpm and e The CVP has fallen 2010 MSE Australia PL Tutorials 131 Why is this so The SNP is both an arterial and veno dilator As the plasma level of the drug rises so SVR and MAP both fall As a result it is now easier for the ECMO system to pump and so pump output increases despite the fact that the rom remain unchanged The CVP also falls because of the veno dilatation induced by the drug This concludes VA ECMO tutorial 2 7 9 VAECMO 3 Some of the manoeuvres performed in this simulation must never be performed on a real patient The learning objectives of the session are e To recognise the signs of oxygenator gas supply failure We will be simulating the use of a system in a patient with severe left ventricular failure which is associated with significant respiratory impairment Scenario You are called urgently to see a 24 year old man in the Emergency Department of your hospital The patient had been brought in by ambulance complaining of chest pain and dyspnoea You arrive in the department just after the patient has been intubated by the resident The resident tells you that the patient deteriorated shortly after having a portable chest x ray He performed the intubation because the patient became profoundly hypotensive unresponsive to commands and started to have frequent ventricular ectopy History According to the family the young man had suffered
112. mall cannulae is inevitably associated with higher circuit velocities at any given flow rate These higher velocities are associated with higher shear stresses on both red cells and platelets Shear stress on red cells is a potential cause of haemolysis and shear stress on platelets a potential cause of platelet activation 2 Smaller cannulae require higher rom to achieve a given flow rate These higher rom require more energy delivery by the pump which in turn tends to increase the operating temperature of the system and the thermal stress on the blood 3 Smaller cannulae are associated with a greater amount of exit turoulence and a more marked sand blasting effect 4 Higher circuit pressures pose a greater risk of circuit disruption 2010 MSE Australia PL 112 ECMO Simulation User Manual v5 7 7 6 Thus the take home message in adults is to use a 21F return cannula if possible This concludes the exercise VV ECMO 4 The manoeuvres performed in this simulation must never be performed on a real patient In this simulation we ll continue to explore the characteristics of a Veno Venous Extra Corporeal Membrane Oxygenation VV ECMO system The learning objectives of the session are to investigate e The impact of obstruction of the inlet or outlet line on ECMO system performance We will be simulating the use of a system in a patient with essentially normal cardiovascular function but with severe respirat
113. mg ml 2010 MSE Australia PL ECMO Simulation User Manual v5 7 Clicking on the lt Bolus Drug gt lt Infusion Drug gt and lt Fluids gt tabs allows you to administer drugs or fluids in any of these categories Clicking on the lt History gt tab lets you review your previous therapies If you initiate a drug infusion it will be continued indefinitely or until the infusion rate is set to 0 mls hr If you initiate a fluid infusion it will be continued until the indicated volume had been given or the rate is set to 0 mls hr To explore the effect of giving adrenalin to a normal patient click on the lt Bolus Drug gt tab and select lt Adrenalin 100mcg ml gt by clicking on it A new window will appear Slide the green slider until a dose of 125 micrograms is indicated and click the lt Give gt button Observe the effect of the drug on heart rate blood pressure and ectopic activity over the ensuing minutes Click on the lt History gt tab to review details of your therapeutic interventions Bolus Drug Infusion Drug Fluids History Selected Drug Adrenalin 125 mcg The complete listing of the drugs and fluids which are available can be found in the section entitled Available Drugs Fluids 2010 MSE Australia PL Applications 27 2 1 4 2 Available Drugs Fluids The drugs and fluids which are available through the lt Therapeutic Interface gt in this release of the simulator are shown in t
114. n by pinging the desired host using its host name If the ping command fails with an Unable to resolve target system name message verify that the host name is correct and that the host name can be resolved by your DNS server e Confirm TCP IP connectivity by typing net view ComputerName in the command prompt window The net view command lists the file and print shares of a computer running Windows by establishing a temporary connection If there are no file or print shares on the specified computer the net view command displays a There are no entries in the list message If the net view command fails with a System error 53 has occurred message verify that ComputerName is correct that the computer running Windows is operational and that all of the gateways routers between this computer and the computer running Windows are operational If the net view command fails with a System error 5 has occurred Access is denied message verify that you are logged on using an account that has permission to view the shares on the remote computer The buttons on the monitor are the wrong size Make sure that the text size is set to 100 not 125 or 150 in the Screen Display options 9 3 Installing a new license file The following procedure should be followed if you are asked to install a different license for the MSE ECMO system e Stop the MSE Application if it is running e Using Windows Explorer navigate to the applicati
115. nary circulation or the left side of the heart After a few minutes note that carbon dioxide has virtually disappeared from the capnography trace and that the end tidal CO2 is close to zero Also note that the pulse oximeter has stopped reporting the patient s saturation 2010 MSE Australia PL 14 ECMO Simulation User Manual v5 7 because pulsatile blood flow has ceased Perform a blood gas analysis lt Investigations gt lt Arterial Blood Gas Analysis gt and note that the PaO2 is now 450 500 mm Hg and that there is mild hypocarbia These results are typical for a normally functioning VA ECMO system when 100 oxygen is administered under full bypass conditions Under these conditions we could if we wanted turn the ventilator completely off However in this tutorial we won t do this It is debatable whether or not a patient should be maintained on full bypass if clinically satisfactory conditions can be obtained by using only partial support Full bypass abolishes pulmonary arterial flow and entails the risks of left heart distension pulmonary or left heart thrombosis and coronary ischaemia due to increased left ventricular wall stress In contrast partial bypass maintains pulmonary flow and reduces the risks of left heart distension and thrombosis but creates the possibility of differential hypoxia and mandates some form of ongoing ventilation We ll now examine what happens if we adjust the ECMO system to provide on
116. necessary steps to protect the License Key and Dongle against unauthorized use 3 2 You may not alter merge modify adapt or translate the Software or decompile reverse engineer disassemble or otherwise reduce the Software to a human perceivable form 3 3 You may not sell rent lease sub license transfer resell for profit or otherwise distribute the Software or any part thereof 3 4 You may not modify the Software or create derivative works based upon the Software 3 5 You may not remove or obscure any copyright and trademark notices relating to the Software 4 OWNERSHIP AND INTELLECTUAL PROPERTY RIGHTS 4 1 This Agreement gives you limited rights to use the Software MSE Australia PL retains all rights title and interest in and to the Software and all copies thereof including copyrights patents trade secret rights trademarks and other intellectual property rights All rights not specifically granted in this Agreement including International Copyrights are reserved by MSE Australia PL The structure organization and code of the Software are valuable trade secrets and confidential information of MSE Australia PL 5 LIMITATION OF LIABILITY 5 1 MSE Australia PL s cumulative liability to you or any other party for any loss or damages resulting from any claims demands or actions arising out of or relating to this Agreement shall not exceed the license fee paid to MSE Australia PL for use of the Software 5 2 MSE Au
117. o return to the ECMO interface You can periodically return to the ACT Monitor to check on the progress of the estimation Give more Heparin if you think it is needed We re now nearly ready to commence VA ECMO To complete our preparations we need to 2010 MSE Australia PL Tutorials 129 e Click lt Devices gt lt ECMO System gt and select the lt VA ECMO gt option at the bottom right of the interface e Click the lt Adjust Cannula gt button and advance the drainage cannula as far as it will go using the slide control on the left hand side of the window e Re open the ECMO interface by clicking lt Devices gt lt ECMO System gt e Click the lt Main Power gt button at the top right of the interface e Turn on 6 LPM of oxygen using the middle knob at the left of the interface At this point we re ready to initiate ECMO However we must remember that unlike the case for VV ECMO there is a pressure gradient across the circuit and if we simply open the clamp blood will flow from the arterial side of the circuit to the venous side and a large left to right shunt will be created In order to avoid this effect we need to generate a stagnation pressure that is a little bit above the patient s mean arterial pressure To do this e Slowly turn up the flow control until the indicated pressure is 10 mm Hg above the patient s mean arterial pressure with the clamp still fully closed e Progressively release the arterial cl
118. o this e Create all the files which are required for the scenario and place them in the ScenarioData folder refer to the section entitled Scenarios Creating Resources for a description of the technique e Start the system in lt Maintenance Mode gt e Click lt System gt lt Scenario Editor gt Inthe lt Folder Navigator gt window e Click on the lt gt sign by the side of the drive which contains the application e Keep on clicking on the lt gt signs until you reach the lt ScenarioData gt folder and its contents are visible to you e Click on the file MSEScenario mdb to select it e Right mouse button click this file to open it in the database editor The database should now appear in the lt Database Editor gt window as in the figure 2010 MSE Australia PL ECMO Simulation User Manual v5 7 above In the lt Database Editor gt window e Click on the MSEScenario mdb folder An lt Add a new scenario gt dialog box will appear e In the lt Scenario Title gt field enter something like Test e Move the cursor to the lt File Name gt field e Click ona pat file in the left hand window eg Normal Patient pat This file name should appear in the lt File Name gt field of the lt Add a new scenario gt dialog box e Click lt Save gt At this stage a new folder names lt Test gt should appear in the database tree of the right hand window You have successfully created a new scenario whi
119. obe and Microsoft both of whom are working on the problem The dialog window shown below appears The exception appears to have no adverse consequences sw MSEHDTV exe Application ET The instruction at 0x0e2d609c referenced memory at 0x00000014 The memory could not be read Click on OK to terminate the program O Connection Refused Change Mode of Main Application This error is generated when you try to Supervise the Main Application when it is in Unsupervised mode Re start the Main Application in Supervised mode and then re start the supervisory application and click the connect button License Validation Failed Invalid data has been found in the license file Contact your software supplier License File Missing The license file MSE lic is missing from the executable directory Contact your software supplier No Valid MSE ECMO Dongle Was Found You are attempting to run a licensed version of the application without the Dongle No variables selected for recording You are attempting to run the data recorder without having first selected the variables which you wish to record Run the application in lt Maintenance Mode gt and select lt System gt lt Recorded Variables Editor gt in order to specify a recorded variable dataset Refer to the section entitled lt Data Recorder gt for full details Invalid Desktop Font 2010 MSE Australia PL Trouble Shooting 153 You are at
120. on s installation directory By default this directory is C Program Files MSE Australia PLIMSE ECMO Simulator e Delete the MSE license file MSE lic from this directory e Copy the license file which has been provided to you into the installation directory e Rename this file MSE lic e Re start the application Note that it is not necessary to re install the complete application in order to install a new license 9 4 Error Messages Scenario Data Source not Found This error message is generated if the scenario data folder cannot be found on the system To fix the problem e Restart the application e Select lt Maintenance Mode gt e Click on the lt System gt menu 2010 MSE Australia PL 182 ECMO Simulation User Manual v5 7 e Select lt Scenario Data Source gt e Navigate to the lt ScenarioData gt folder e Highlight this folder e Click lt OK gt e Click lt System gt e Click lt Exit gt e Restart the application e Click lt Start gt The instruction at Xxxxxxxxxx referenced memory at 0x00000014 The memory could not be read This is a known bug in the Adobe Acrobat Reader plug in which is used by the lt Inspector gt module If you have been browsing the web using the inspector and you open a web based pdf document the plug in occasionally generates an exception on subsequent closure of the MSE The exception occurs after closure of MSE itself and is known to Ad
121. opens up the Cannula Selector window Return Cannula Selector Interface MSE Cannula Selector Select the cannula size that you want and then click lt Save gt to close the window Click lt Devices gt lt ECMO System gt to return to the ECMO system itself Veno Arterial ECMO Note that the VA and VV ECMO systems are both accessed through lt Devices gt lt ECMO System gt menu item and that the ECMO system is switched between these modes using the control at the bottom right hand side of the ECMO system interface The Veno arterial ECMO module is intended for use by those undergoing training in this technique and is intended for use in a patient suffering from circulatory failure with or without the presence of respiratory failure The module has three user interfaces The Pump Control Interface PC is loosely based on the Maquet CardioHelp perfusion system 2010 MSE Australia PL Devices a To the left of the interface are three controls which control respectively the inspired oxygen concentration of gas flowing through the oxygenator the flow rate lpm to the oxygenator and the temperature setting control C for the heater cooler In the context of VV ECMO the FiO2 control should always be set at 100 The flow rate control is used to control CO2 elimination the higher the gas flow rate the greater the rate of CO2 clearance The heater cooler can be used to vary the patient s temperature and thei
122. or example Conniq com Can Irun the system under Windows 7 operating system The application runs under the 32 amp 64 bit versions of Windows 7 Ultimate Release to Manufacturers version How do install the Supervisor Application on another computer Copy the file MSESupervisor exe from the installation directory to the computer of your choice No other files are needed Refer to the section entitled System Requirements for a description of the hard and soft ware requirements of the supervisory device 2010 MSE Australia PL Trouble Shooting 1 Can Irun the Main Application and the Supervisor Application on the same computer Yes you can but the screen may become rather crowded unless you have a 2560 1600 display How as Supervisor can make the patient hypoxic Two techniques are available e Progressively increase the lt QsQt gt value on the lt Lung gt page of the Supervisor Application e Administer a hypoxic mixture using the lt FiO2 gt control However it should be noted that it is not possible to administer a hypoxic mixture to the patient if the ventilator is turned on How as Supervisor can make a spontaneously breathing patient hypercarbic Progressively increase the lt CO2 SP gt value on the lt Misc gt page of the Supervisor Application How as Supervisor can make a ventilated patient hypercarbic Progressively increase the lt VdVt gt value on the lt Lung gt page
123. or reduced using the lt Zoom gt lt Zoom gt and lt Zoom gt lt Zoom gt options 2 1 2 Patient Monitor The lt Patient Monitor gt window represents a typical modern physiological monitor 2010 MSE Australia PL 22 ECMO Simulation User Manual v5 7 ME NARA Timer ltt IP Address 192 168 0 146 12 02 e gt II OT Ee ye a Pe yen 36 9 ETO2 0 94 FIO2 1 00 ETCO2 34 RR 15 lt Display gt Button si o The displayed parameters are selected by clicking on the lt Display gt button at the left hand end of the toolbar The parameters which can be viewed include e ECG e SaQ2 e BIS e NIBP e Invasive BP e CVP e Temperature e Inspired Gases e Expired Gases and e Capnography The lt Scroll Graphs gt check box turns waveform scrolling on and off Click the lt Display gt button again to close the parameter selection window 2010 MSE Australia PL Applications 23 lt Freeze gt Button Freezes Unfreezes the graphical display lt NIBP gt Button The settings of the NIBP system are accessed by clicking on the lt NIBP gt button on the toolbar Click the button again to close the parameter selection window NIBP measurement turns off automatically if invasive blood pressure measurement is in use lt Audio gt Button The pulse oximeter tone can be turned on by clicking the lt Audio gt button on the toolbar Click the button again to
124. ory failure The patient is a 24 year old man weighing 75 kgs who has been transferred to your Intensive Care Unit for Veno Venous ECMO He had been admitted to the Intensive Care Unit of a large regional hospital 3 days before transfer to your institution At that time he presented a four day history of increasing respiratory distress fever and a productive cough The patient had been sedated intubated and ventilated shortly after admission to the regional ICU Blood and sputum cultures grew a methicillin sensitive staphylococcus aureus Despite treatment with appropriate antibiotics the use of prone ventilation permissive hypercarbia and inhaled nitric oxide he continued to deteriorate Following discussions with the clinicians at the regional hospital he has been transferred to your institution for initiation of veno venous ECMO On arrival in your ICU the patient is being given assisted ventilation via an Ambu bag on 100 oxygen Blood gas analysis is reported as Pa02 44 mm Hg PaCO2 41 mm Hg pH 7 35 BXS 3 5 Temp 37 0 Sa02 74 The patient has an Acute Lung Injury Score Murray Score of 3 5 but has no other significant co morbidities He has a Haemoglobin of 12 gm dL and you estimate his shunt fraction Qs Qt to be about 65 The results of some ancillary investigations Echo CXR and ECG are also available We ll assume that you have already worked your way through the previous VV ECMO tutorials so we l
125. oxygenator failure We will be simulating the use of a system in a patient with severe left ventricular failure which is associated with significant respiratory impairment Scenario You are called urgently to see a 24 year old man in the Emergency Department of your hospital The patient had been brought in by ambulance complaining of chest pain and dyspnoea You arrive in the department just after the patient has been intubated by the resident The resident tells you that the patient deteriorated shortly after having a portable chest x ray He performed the intubation because the patient became profoundly hypotensive unresponsive to commands and started to have frequent ventricular ectopy History According to the family the young man had suffered a flu like illness some weeks before and had been complaining of increasing shortness of breath and lethargy ever since His family practitioner had prescribed two courses of broad spectrum antibiotics and some bronchodilator therapy Initial Examination The endotracheal tube appears to be correctly positioned and breath sounds are symmetrical The patient is hypotensive tachycardic and has an irregular pulse He is afebrile His ventilation is being assisted using 100 oxygen and anAmbu bag Pulse oximetry indicates a saturation of 80 Previous Medical History The family tells you that the patient has previously been in good health that he takes no regular medications and that
126. patient in order to lower his oxygen consumption Given that the patient is mildly hypocarbic we can also reduce his total ventilation To do this e Reduce the gas flow to the oxygenator to 3 0 lpm e Reduce his tidal volume to 200 mls and e Reduce the ventilatory frequency to 5 bpm After ten minutes or so note that his saturation has risen further to 93 and that his temperature has fallen to 35 C At this stage a repeat blood gas analysis should show a PO2 of about 65 and a PCO2 of 40 The effect of temperature on metabolic rate has been studied by various authors In this simulator the data of Kirklin et al has been used to determine the magnitude of the effect In Figure 2 the effect of temperature on oxygen consumption VO2 in a patient with a VO2 of 200 mls min 37C is shown Figure 2 2010 MSE Australia PL 106 ECMO Simulation User Manual v5 7 BMR amp Temperature 300 250 200 150 BMR Mls min 100 0 5 10 15 20 25 30 35 40 Temperature C We can formulate the relationship between VO2 and temperature as a third rule of ECMO VO2 is proportional to Heater Cooler Temperature The impact of changing the patient s temperature on SaO2 is shown in Figure 3 Figure 3 2010 MSE Australia PL 7 5 Tutorials 100 99 98 97 96 95 Sa02 94 93 92 91 90 Time secs In this case I ve taken
127. pressure falls from 115 to 50 and the pulse rate increases from 70 to 115 O 2010 MSE Australia PL 62 ECMO Simulation User Manual v5 7 5 6 140 00 120 00 Pulse Rate 100 00 o O 80 00 S 3 YN gt a o 60 00 Systolic BP 40 00 y 1L Blood Loss 20 00 0 00 1 0 00 20 00 40 00 60 00 80 00 100 00 120 00 140 00 160 00 Time Seconds References Stergiopulos N Westerhof BE Westerhof N Total arterial inertance as the fourth element of the windkessel model Am J Physiol 1999 Jan 276 1 Pt 2 H81 8 Oxygenator Model The oxygenator is modelled as a classical Riley three compartment lung placed either in series VV ECMO or in parallel VA ECMO with the patient s native lung 2010 MSE Australia PL Venous Pool Arterial Pool Qs Qt Venous Pool Tissue Pool Arterial Pool By default Qs Qt Shunt Fraction of the oxygenator at a nominal blood flow of 3 0 Ipm is set to 0 08 and is varied ina linear manner according to the blood flow through the device Segers et al 2010 MSE Australia PL e ECMO Simulation User Manual v5 7 Qs Qt 0 30 Quadrox y 0 0151x 0 1592 Capiox y 0 0261x 0 1123 i J 97 5 0 25 4 Optima y 0 0289x 0 0954 Fort y 0 0417x 0 0297 Hilite y 0 0553x 0 0378 0 20 4 _ Affinity NT y 0 0449x 0 0279 Quantum y 0 0593x 0 0879 0 15
128. r metabolic rate Between these three controls and the CardioHelp data display area is the electronic clamp which controls flow through the outlet Arterial side of the pump When the slider is at the bottom the clamp is fully closed when at the top fully open The data display area displays the current values of e Flow through the system in lpm e Circuit pressure measured at a point between the pump head and the oxygenator e Venous oxygen saturation e Pump speed in rpm e Haematocrit and e Blood Temperature To the right of the display area are four controls e The main power switch enables the flow control knob which is situated just beneath it e The flow control is used to adjust the speed of the centrifugal pump in the range 0 O 2010 MSE Australia PL e ECMO Simulation User Manual v5 7 5000 rpm e The lt adjust cannula gt button allows you to move the drainage cannula e in or out and to select size of your return cannula e Finally the lt Mode gt button is used to set the system up for either VV or VA ECMO By default the PCI assumes that venous drainage is via a femoral vein through a 24F catheter and that arterialised return is via a femoral artery through a 21F catheter The lt Dual Cannulation gt option is not available in VA ECMO mode Cannula Adjustment Interface The cannula adjustment interface is used to advance or withdraw the femoral drainage catheter using the slide
129. ralia PL 150 ECMO Simulation User Manual v5 7 9 2 If I don t heparinise the patient will the oxygenator clot It will not do this automatically However the supervisor may choose to fail the oxygenator if you do not heparinise the patient in a supervised session Why do many of the tutorials advocate paralysing and ventilating the patient The patient has a considerable amount of innate respiratory behaviour If ventilation is not controlled it makes it harder for the trainee to identify the effects of the various manoeuvres which are being performed Why do the PaO and SaO rise transiently if initiate ECMO without any fresh gas flow The oxygenator is assumed to have been flushed with oxygen before use The transient rise represents oxygen delivery from the shell Functional Residual Capacity of the oxygenator How do change the units of partial pressure of blood gases Start the application in Maintenance mode and select the Miscellaneous Settings option Check the kPa or mm Hg item and then click on Save and Exit The next time you run the application in Supervised or Unsupervised mode the selected units will be used and will continue to be used until changed in Maintenance Mode again How do I change the background colour of the system Start the application in Maintenance mode and select the Miscellaneous Settings option Check the Colour button and select the background colour that you
130. re the effect of reducing the blood flow through the oxygenator We ll do this by progressively clamping the outlet line This is not the way in which we would normally achieve this but it will also allow us to illustrate another feature of the behaviour of centrifugal pumps Whilst leaving the rom unchanged slowly clamp the outlet by moving the slider downwards over the course of a few minutes Note how the flow decreases while the driving pressure increases until eventually the stagnation pressure of about 150 mm Hg is achieved and flow ceases completely By progressively applying the clamp we are effectively converting the kinetic energy of the moving blood to static potential energy At the same time if you look at the patient monitor the saturation will have fallen and the heart rate and incidence of ectopy will have increased If we repeat the blood gas analysis we will see that once again PaO2 has dropped Thus we can see that blood flow through the oxygenator is an important determinant of arterial oxygenation The observation that the kinetic and static energies of a fluid were interchangeable and that the total energy of a fluid could be considered as the sum of its kinetic and static components was first described by Daniel Bernoulli in 1738 Itis the cause of the afterload dependence of centrifugal pumping systems and is the explanation of the flow variability which is seen in some clinical situations lt can be contra
131. ressure and volume traces appear somewhat disorganised In order to fix this you may wish to control the patient s ventilation To do this e Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt window e Drag the green slider until it says 8 mgs and click the lt Give gt button If you wish to monitor the onset of muscle paralysis by monitoring his Train of Four e Click the lt Devices gt lt Nerve Stimulator gt menu item in the lt Inspector gt window e Click the lt TOF gt button on the nerve stimulator itself Sedation may be administered by selecting the appropriate bolus or infusion drugs using the lt Therapeutic Interface gt and monitoring the depth of sedation by turning on the lt BIS gt display on the physiological monitor In order to assess the patient s gas exchange you may want to turn on the gas analyser e Click the lt Display gt button in the lt Patient Monitor gt window e Check lt Capnography gt and lt Gases gt in the lt Display gt window 2010 MSE Australia PL 102 ECMO Simulation User Manual v5 7 e Click the lt Display gt button again to close this window and display the additional signals And perform a baseline blood gas analysis e Click lt Investigations gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt window You elect to cannulate the patient percutaneously via the right internal jugular and femoral veins using the Sel
132. right of the display area are four controls e The main power switch enables the flow control knob which is situated just beneath it e The flow control is used to adjust the speed of the centrifugal pump in the range O O 2010 MSE Australia PL Devices 39 5000 rpm e The lt Adjust Cannula gt button allows you to move the drainage cannula e in or out and to select size of your return cannula e Finally the lt Mode gt button is used to set the system up for either VV or VA ECMO By default the PCI assumes that venous drainage is via a femoral vein through a 24F catheter and that arterialised return is via a jugular vein through a 21F catheter The tip of the jugular catheter has been correctly positioned using ultrasound with its tip in the mid atrial position Cannula Adjustment Interface E Dual Cannulation The cannula adjustment interface is used to advance or withdraw the femoral drainage 2010 MSE Australia PL ECMO Simulation User Manual v5 7 3 3 catheter using the slide control at the left If the tips of the drainage and return cannulae are positioned too closely re circulation will start to occur and oxygenation will be impaired If satisfactory conditions cannot be obtained using a single drainage cannula the Dual Cannulation box should checked and a second slide will appear which will enable the positioning of a second SVC cannula Clicking the lt Select Return Cannula gt button
133. rol The cannulae are connected to the ECMO system The entire system is heparin coated Active venous drainage from the inferior vena cava is via a 24F femoral cannula and arterialised return to the right atrium via a 21F Internal Jugular cannula The system s centrifugal pump is responsible both for generating the negative pressure which is required to facilitate drainage and the positive pressure which is required to pump blood through the artificial lung and back into the patient The pump head and oxygenator are integrated into a single disposable unit whichis mounted on the system console 2010 MSE Australia PL Tutorials 95 Before commencing ECMO you may wish to confirm that the patient is effectively anti coagulated Select lt Devices gt lt ACT Monitor gt and click lt Start gt in order to commence the measurement The ECMO circuit we ll be using is shown in Figure 2 We re actively draining Sucking blood from a point in the inferior vena cava just below the diaphragm pumping it through the oxygenator and returning it via the superior vena cava to the right atrium Figure 2 In essence what we re trying to do when we put a patient on VV ECMO is to capture as large a proportion of his venous return as we can and pump it through an artificial lung where carbon dioxide will be removed and oxygen added This oxygenated blood is then pumped back into the circulation close to the tricuspid valve from wher
134. ronment e Using the Windows Explorer confirm the presence of a file named Hypovolaemia pat in the scenario data folder The patho physiological state contained within the Hypovolaemia pat file can then be used in any scenario in which a hypovolaemic patient is required at start up Creating the clinical notes of the patient The clinical notes of the patient should be written in a format which would typically be provided by the admitting physicians of your institution They can be created using any word processor The notes should include at least e The height weight and age of the patient e The history of the presenting complaint e The previous medical history e A description of the relevant findings on examination e A description of current drug therapy 2010 MSE Australia PL ECMO Simulation User Manual v5 7 6 4 e A listing of any drug or other allergies Additionally the clinical notes can contain data such as ECG s Laboratory Results Respiratory Function tests etc However it should be noted that it is generally more appropriate to allocate these data to the Investigations section of the Scenario There is no restriction on the number of pages which can be contained within the Clinical Notes Once the notes have been composed they must be converted to pdf format and placed in the scenario data folder If you wish to improve verisimilitude by providing hand written ie illegi
135. rt of the oxygenator If pure oxygen is being supplied to the oxygenator the effluent gas should contain about 95 oxygen and 5 carbon dioxide The absence of carbon dioxide implies that the gas supply to the oxygenator has been disconnected Finally repeat the oxygenator blood gas analysis If hypoxia and hypercarbia persist urgently consider the possibility of oxygenator failure We will deal with this in the next tutorial However before we conclude this exercise we ll use the simulator to explore the effect of inadvertently administering air rather than 100 oxygen 2010 MSE Australia PL 138 ECMO Simulation User Manual v5 7 7 10 To do this e Ask the Supervisor to re connect the gas supply to the oxygenator e Reduce the lt inspired oxygen concentration gt on the ECMO system to 21 e Leave the other ECMO controls unchanged e Re start the lt timer gt After five minutes e Repeat the lt Oxygenator Blood Gas Analysis gt Note that the effluent blood from the oxygenator is relatively hypoxic PaO2 75 mm Hg but hypo rather than hyper carbic PCO2 34 mm Hg This picture relative hypoxia in association with normo or hypo carbia is characteristic of an oxygenator which is being supplied with air rather than oxygen VA ECMO 4 Some of the manoeuvres performed in this simulation must never be performed on a real patient The learning objectives of the session are e To recognise the signs of
136. s technique and is intended for use in a patient suffering from extreme respiratory failure Qs Qt gt 50 Vd Vt gt 50 The module has three user interfaces The Pump Control Interface PC is loosely based on the Maquet CardioHelp perfusion system 2010 MSE Australia PL 3 ECMO Simulation User Manual v5 7 Notes Investigations Devices Resources Help To the left of the interface are three controls which control respectively the inspired oxygen concentration of gas flowing through the oxygenator the flow rate lpm to the oxygenator and the temperature setting control C for the heater cooler In the context of VV ECMO the FiO2 control should always be set at 100 The flow rate control is used to control CO2 elimination the higher the gas flow rate the greater the rate of CO2 clearance The heater cooler can be used to vary the patient s temperature and their metabolic rate Between these three controls and the CardioHelp data display area is the electronic clamp which controls flow through the outlet Arterial side of the pump When the slider is at the bottom the clamp is fully closed when at the top fully open The data display area displays the current values of e Flow through the system in lpm e Circuit pressure measured at a point between the pump head and the oxygenator e Venous oxygen saturation e Pump speed in rpm e Haematocrit and e Blood Temperature To the
137. s gt To check the integrity of the oxygen supply chain the gas supply should be systematically checked from the wall to the oxygenator At the wall Figure 2 confirm that 1 The gas supply is oxygen 2 The rotameter is securely connected 3 The gas is flowing 4 The supply line is connected 2010 MSE Australia PL Tutorials Figure 2 If the system includes a blender confirm that it is set to deliver 100 oxygen Figure 3 Figure 3 2010 MSE Australia PL 136 ECMO Simulation User Manual v5 7 A patent ARIAS Ti Next make sure that there is no obstruction anywhere along the course of the supply line Figure 4 Figure 4 And finally confirm that the supply line is connected to the oxygenator Figure 5 Figure 5 2010 MSE Australia PL Tutorials If the oxygenator supply chain appears intact you should now perform a Bobbin Drop test To perform this test transiently clamp the oxygen supply line at the oxygenator whilst observing the bobbin During clamping the bobbin should transiently fall If the bobbin does not fall it suggests that there is a leak somewhere in the supply chain and this check should be repeated If the supply chain check and the Bobbin Drop tests fail to reveal any form of disconnection exhaust gas analysis should be performed To do this place the tip of a side stream gas analyser catheter into the exhaust po
138. sion of cardiac output without improving the pulmonary pathologic process and may be deleterious 2010 MSE Australia PL to overall tissue oxygenation In the MSE system the change in Qs Qt which follows a change in cardiac output is shown superimposed in red In this case cardiac output has been changed from 1 0 Ipm to 7 0 Ipm Note that the curve is somewhat steeper than the data of Dantzker and that even at very low cardiac outputs a significant shunt is still apparent This apparent discrepancy is intentional Clearly if Qs Qt falls to zero at a cardiac output of about 25 of baseline phenomena such as differential circulation could not occur Accordingly in the MSE model the intercept of the shunt line has been set at about 40 of the baseline shunt value Reference Dantzker DR Lynch JP Weg JG Depression of cardiac output is a mechanism of shunt reduction in the therapy of acute respiratory failure Chest 1980 May 77 5 636 42 5 3 Blood Gas Calculations Blood gases are calculated in the various compartments at a frequency of 0 5 Hz using standard techniques and equations Kelman Severinghaus and Christoforides et al have provided the most important algorithms in this area References Christoforides C Laasberg LH Hedley Whyte J Effect of temperature on solubility of O2 in human plasma J Appl Physiol 1969 Jan 26 1 56 60 Kelman GR 1966 Digital computer subroutine for the conversion of oxy
139. splay 8 15 148 ECG 29 43 70 82 Ectopic Frequency 29 Error Messages 151 FAQ 148 Fluids 27 FRC 31 Gain 29 2010 MSE Australia PL Haematocrit 32 153 Heart Rate 29 61 Heparin 27 59 148 Infusion Drugs 27 Inspector 10 24 Installation 8 9 151 Investigations 24 75 76 80 81 ipconfig 150 K K SetPoint 32 Ss Latency 50 License 150 151 161 Logitech 52 Loss 29 Mode of Operation 10 13 Models 56 59 61 62 65 68 70 MSE 7 145 Nerve Stimulator 37 NIBP 21 O Oxygenator Failure 33 62 P Pat Files 13 19 73 74 75 148 Patient Monitor 10 21 ping 150 PowerPoint 74 150 154 Protamine 27 59 148 Qu Qs Qt 31 56 58 148 R Re circulation 37 65 166 ECMO Simulation User Manual v5 7 Record 21 Resources 24 75 76 80 81 Su Scenarios 29 73 74 81 DataSource 13 80 151 Editing 75 76 79 80 82 Loading 19 29 SessionName 50 Stethoscope 46 Supervisor 7 13 27 29 31 32 33 SVR 29 148 System Requirements 8 153 T TCP IP 8 21 27 150 Temperature 32 68 153 Therapeutic Interface 10 27 Timer 21 Trainee 7 19 21 24 27 TroubleShooting 148 150 151 Tutorials 86 91 100 107 112 117 125 131 138 V VA ECMO 7 33 40 Vd Vt 31 148 Ventilator 44 Versions 15 46 154 Video Bit Rate 50 VV ECMO 7 33 37 Ze Zoom 19 2010 MSE Australia PL
140. splay gt button again to close this window and display the physiological signals Ventilate the patient e Click the lt Devices gt lt Ventilator gt menu item in the lt Inspector gt window e Click the power switch at the top right hand side of the device e Set the tidal volume Vt to 500 mls the rate to 10 bpm the FiO2 to 100 and the PEEP to 5 cms H20 Paralyse the patient e Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt window e Drag the green slider until it says 8 mgs and click the lt Give gt button And perform a baseline blood gas analysis e Click lt Investigations gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt window You elect to cannulate the patient percutaneously via the right and left internal jugular O 2010 MSE Australia PL Tutorials 109 and right femoral veins using the Seldinger technique and ultrasonic guidance Imagine now that you have e Placed the Seldinger wires e Given the patient 7500 units of heparin Select lt Heparin gt from the lt Therapeutic Interface gt lt Bolus Drug gt page and lt Give gt 7500 units and e Positioned the cannulae under ultrasonic control You are using the same ECMO system that is similar to that described in VV ECMO Tutorials 1 and 2 except that we are using two drainage cannulae Active venous drainage from the inferior vena cava IVC is via a 24F femoral cannula drainage of the S
141. splay gt button in the lt Patient Monitor gt window e Check lt ECGs lt Direct Arterial Pressure gt lt Central Venous Pressure gt and lt SaO2 and e Click the lt Display gt button again to close this window and display the physiological signals As you can see the patient is profoundly hypoxic SaO2 70 and is having frequent ventricular ectopic beats To ventilate the patient e Click the lt Devices gt lt Ventilator gt menu item in the lt Inspector gt window The ventilator should now appear in the lt Inspector gt window Turn the ventilator on by e Clicking the power switch at the top right hand side of the device and then e Setting the tidal volume Vt to 500 mis the rate to 12 bpm the FiO2 to 100 and the PEEP to 5 cms H20 Note that the ventilator s controls are not enabled until the ventilator is turned lt On gt The ventilator is based on a simple anaesthesia system which is in Synchronised Intermittent Mandatory Ventilation SIMV mode In order to assess the patient s gas exchange you may want to 2010 MSE Australia PL Tutorials 127 Turn on the gas analyser e Click the lt Display gt button in the lt Patient Monitor gt window e Check lt Capnography gt and lt Gases gt in the lt Display gt window e Click the lt Display gt button again to close this window and display the additional signals And perform a baseline blood gas analysis e Click lt Investiga
142. sted with the behaviour of volumetric Roller pumping systems which are widely used during routine cardio pulmonary bypass In summary we have now explored some of the features of a modern VV ECMO circuit and have experimented with the basic controls of sucha system The impact of VV ECMO on oxygen and carbon dioxide exchange in a patient with severe respiratory 2010 MSE Australia PL 100 ECMO Simulation User Manual v5 7 7 4 failure has been demonstrated We have shown that we can control the patient s arterial oxygenation by varying the blood flow through the system and the patient s PaCO2 by varying the gas flow through the system We can formulate these observations as two rules Pa02 is proportional to ECMO Blood Flow PaCO2 is proportional to ECMO Gas Flow In future tutorials we ll examine the determinants of oxygen transfer in much more detail explore the effect of adjusting cannula position characterize the impact of using dual drainage cannulae and learn to identify clinical problems including re circulation and caval collapse VV ECMO 2 Some of the manoeuvres undertaken in this tutorial generate extreme circuit pressures and are only intended to demonstrate the performance characteristics of the system They should not be employed under clinical conditions In this simulation we ll continue to explore the characteristics of a Veno Venous Extra Corporeal Membrane Oxygenation VV ECMO syste
143. stralia PL shall be relieved of any and all obligations for any portions of the software that are revised changed modified or maintained by anyone other than MSE Australia PL 6 PATENT AND COPYRIGHT INDEMNITY 6 1 MSE Australia PL represents and warrants that the Software shall not infringe or misappropriate any copyrights patents trade secret rights trademarks and other intellectual property rights 6 2 In the event the Software is found to infringe MSE Australia PL will have the option at its expense to a modify the Software to cause it to become non infringing b substitute the Software with other Software reasonably suitable to You or c if none of the foregoing remedies are commercially feasible terminate the license for the infringing Software and refund any license fees paid for the Software 6 3 MSE Australia PL will have no liability for any claim of infringement based on a code contained within the Software which was not created by MSE Australia PL b use of a Superseded or altered release of the Software except for such alteration s or modification s which have been made by MSE Australia PL or under MSE 2010 MSE Australia PL License Agreement 163 Australia PL s direction if such infringement would have been avoided by the use of a current unaltered release of the Software that MSE Australia PL provides to you or c the combination operation or use of any Software furnished under t
144. t MSE Australia PL is not responsible for any content associated links resources or services associated with a third party site You further agree that MSE Australia PL shall not be liable for any loss or damage of any sort associated with your use of third party content Access to these sites is provided for your convenience only 2010 MSE Australia PL 164 ECMO Simulation User Manual v5 7 10 2 The Software contains third party software By accepting this EULA you are also accepting the additional terms and conditions with respect to such software if any forth herein 11 SEVERABILITY 11 1 If any provision hereof shall be held illegal invalid or unenforceable in whole or in part such provision shall be modified to the minimum extent necessary to make it legal valid and enforceable and the legality validity and enforceability of all other provisions of this Agreement shall not be affected 12 GOVERNING LAW 12 1 This Agreement is to be governed by and construed in accordance with the laws and jurisdiction of the defending party Service of process upon either party shall be valid if served by registered or certified mail return receipt requested and to the most current address provided by such party The United Nations Convention on Contracts for the International Sale of Goods shall not apply to this Agreement 13 TERMINATION 13 1 Your license to use the Software continues until terminated This license will t
145. t value in the display window O 2010 MSE Australia PL ECMO Simulation User Manual v5 7 3 7 3 8 Stethoscope Scenario ECMO Tutorial 1 Clinical Notes Investigations Devices Resources Cameras Help The stethoscope is a legacy item from the complete MSE system and is intended for use in systems which are connected to an intubation manikin and Smart Lung In this software implementation of the stethoscope placing the cursor over the red target areas on the thorax and left clicking turns on or off the heart or breath sounds in the area The hardware implementation uses a much larger number of RFID tags implanted inside the manikin which can be interrogated with an RFID stethoscope and which then broadcast the heart or breath sound appropriate to the region Data Recorder Data recording can be turned on by clicking the lt Record gt button on the lt Monitor gt toolbar The recorded data are stored in a Microsoft Excel spreadsheet By default data are recorded every 5 seconds to a file which is named MSEData xls and stored in the ScenarioData folder Click the button again to turn the recorder off When first installed the recorder is set to record the patient s pulse rate SaO2 and 2010 MSE Australia PL mean arterial blood pressure If you wish to record other variables you must select them by running the application in lt Maintenance Mode gt To do this e Start the system in lt M
146. tempting to run the application with the desktop font setto something other than 96 dpi Set the desktop text size to Smaller 100 using the Control Panel gt Display option y Set desktop Font to Smaller 100 Using Control Panel gt Display OK 9 5 HDTV Connection In order to connect the system to a high definition television you will need a video card which supports a 1920 1080 pixelar resolution and has an HDMI or DVI output connector You should also make sure that over scanning is turned off on the television itself If you connect the application using a DVI connector you will also need to separately connect the audio stream to the television system 9 6 Aberrant Behaviour Blood Gas Model Inevitably the blood gas model has limitations although in general it is able to simulate quite extreme conditions The design of the model requires the imposition of some constraints and as a result may produce anomalous behaviour under some circumstances Some of the more important constraints are e That the PCO2 in any compartment is constrained to 500 mm Hg e That the maximum inducible base deficit is constrained to 15 e That the peak sustained oxygen utilisation rate is constrained to about 800 mls minute e That gas exchange does not occur in the ideal compartment if it does not have blood flow e That temperature is constrained to the range 15 40 degrees C The supervisor should avo
147. terface You can periodically return to the ACT Monitor to check on the progress of the estimation If you decide that you need to give more Heparin Select lt View gt lt Therapeutic Interface gt from the main menu When the lt Therapeutic Interface gt window has opened select lt Heparin gt as a bolus drug and give an appropriate dose In the first part of the tutorial we re going to turn on the pump and examine its behaviour when confronted with an excessive afterload Click the power switch of the ECMO system and slowly rotate the flow control clockwise In the display area note how the pump speed and circuit pressure both increase but that no other parameters change Eventually at 5000 rom you should see a circuit pressure of about 750 mm Hg So what s going on here Well we re running the pump with the outlet line fully clamped As we increase the rpm so we increase the total energy delivered to the system but because the blood can t go anywhere the pressure within the pump head stagnation pressure progressively rises This is characteristic behaviour for a non occlusive centrifugal pump and can be contrasted with the behaviour of volumetric roller pumps which are commonly used during routine cardio pulmonary bypass Figure 4 2010 MSE Australia PL os ECMO Simulation User Manual v5 7 800 700 600 500 400 300 Stagnation Pressure mm Hg 200
148. the lt gt button in the database navigator at the top of the window e Enter a new name for the rhythm in the lt Pattern gt box at the top right of the window e Adjust the Beta Alpha and Theta values to produce the morphology you want e Click lt Save 8 Exit gt to store the profile The new profile will be available to the supervisory application when the system is next run When creating new patterns it is essential that the profile start and finish on or close to the zero line Refer to the work of McSharry et al for an explanation of the significance of the Beta Aloha and Theta parameters If you generate a completely unsatisfactory profile click the lt Reset gt button to restore a semblance of normality Existing patterns can also be edited by accessing them using the database navigator buttons at the top of the window By default the available ECG patterns are e Normal Sinus Rhythm e Ventricular Fibrillation e Asystole e Ventricular Ectopy O 2010 MSE Australia PL ECMO Simulation User Manual v5 7 e Deep Q wave e Bundle Branch Block e Peaked T wave e ST elevation e ST elevation e ST elevation e ST Depression e Nodal rhythm References McSharry PE Clifford GD Tarassenko L Smith LA A dynamical model for generating synthetic electrocardiogram signals IEEE Trans Biomed Eng 2003 Mar 50 3 289 94 2010 MSE Australia PL 86 ECMO Simulation User Manual v5 7 7 1 7 2
149. tions gt lt Arterial Blood Gas Analysis gt in the lt Inspector gt window You may also wish to paralyse the patient and control his ventilation To do this e Click lt Bolus Drug gt lt Pancuronium 2mg ml gt in the lt Therapeutic Interface gt window e Drag the green slider until it says 8 mgs and click the lt Give gt button If you wish to monitor the onset of muscle paralysis by monitoring his Train of Four e Click the lt Devices gt lt Nerve Stimulator gt menu item in the lt Inspector gt window e Click the lt TOF gt button on the nerve stimulator itself Sedation may be administered by selecting the appropriate bolus or infusion drugs using the lt Therapeutic Interface gt and monitoring the depth of sedation by turning on the lt BIS gt display on the physiological monitor An inotrope can also be administered using the lt Therapeutic Interface gt You elect to cannulate the patient percutaneously via the right femoral artery and vein using the Seldinger technique and ultrasonic guidance Imagine now that you have e Placed the Seldinger wires in the artery and vein e Given the patient 7500 units of heparin lt Therapeutic Interface gt lt Bolus Drug gt lt Heparin gt lt Give gt 7500 units and e Positioned the cannulae under ultrasonic control The cannulae have been connected to the ECMO system The entire system is heparin coated The system s centrifugal pump is responsible both for generating
150. to assess biomedical signal processing techniques which are used to compute clinical statistics from the ECG 2010 MSE Australia PL By default the available ECG patterns are e Normal Sinus Rhythm e Ventricular Fibrillation e Asystole e Ventricular Ectopy e Deep Q wave e Bundle Branch Block e Peaked T wave e ST elevation e ST elevation e ST elevation e ST Depression e Nodal rhythm References McSharry PE Clifford GD Tarassenko L Smith LA A dynamical model for generating synthetic electrocardiogram signals IEEE Trans Biomed Eng 2003 Mar 50 3 289 94 2010 MSE Australia PL Scenarios 6 Scenarios 6 1 Scenarios Overview Scenarios are collections of resources which can be used to enhance the reality of a simulation session The resources themselves are computer files which may consist of e A definition of an initial physiological state contained within a pat file e The Clinical Notes of the patient e Investigations such as Chest X Rays ECG s or Laboratory Results e Resources such as Educational Videos Scientific Papers or Links to useful web sites All of the resource files must be stored in the ScenarioData folder of the Main Application The scenario database is a Microsoft Access database MSEScenario mdb which contains links to the various constituent components of a scenario In lt Unsupervised gt mode the trainee can select a scenario by clic
151. to the standard Pump Affinity Laws As an example of the performance of the MSE pump in the graph below the stagnation pressure of the pump has been compared with that of a Rotaflow ECMO device at speeds in the range 0 5000 rpm The stagnation pressure is the pressure achieved at the outlet of a centrifugal pump when the pump is working against a completely occluded outflow and is a measure of the total energy of the system at that particular rpm 700 600 500 400 300 Pressure mm Hg 200 100 Ak 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 RPM Black line MSE pump Red triangles published data for Rotaflow pump Thermal Model The patient is modelled as a three compartment thermal model fast medium slow The temperature of the fast compartment is reported to the monitoring system as the naso pharyngeal temperature whereas the metabolic rate is determined by the temperature of the medium compartment The system constrains temperature in the range 15 40C The effect of temperature on basal metabolic rate BMR is modelled according to the data of Kirklin In the figure below the effect of temperature on BMR is shown ina patient with a nominal BMR at 37 centigrade of 200 ml min 2010 MSE Australia PL BMR amp Temperature 300 250 200 150 BMR Mls min 100 50 0 5 10 15 20 25 30 35 40 45 Temperature C The impact of simply cooling a p
152. turn it off The tone is modulated by the current value of SaQ2 lt Record gt Button Data recording can be turned on by clicking the lt Record gt button on the toolbar The recorded data are stored in a Microsoft Excel spreadsheet Data are recorded every 2 5 seconds to a file which by default is named MSEData xls and stored in the ScenarioData folder Click the button again to turn the recorder off lt Network gt Button Various network parameters are displayed when the lt Network gt button is clicked Click the button again to turn the panel off lt Timer gt Button 2010 MSE Australia PL ECMO Simulation User Manual v5 7 Clicking the lt Timer gt button starts a digital timer Clicking it again stops it Clicking it again zeroes it and re starts it y Timer IP Address 192 168 0 146 The IP address of the monitor is shown at the top right of the monitor just below the digital timer display This address is used to initiate communication between the trainee and the supervisor The IP address is in IP4 format The range of the invasive pressure channel can be adjusted using the lt Up gt and lt Down gt arrows to the left of the pressure trace Inspector The lt Inspector gt window gives the trainee access to documents virtual devices images videos and other resources relevant to the scenario or system Access to these resources is achieved by clicking on the menu at the top o
153. ues Let s now examine what happens if we kink the inlet line to the system e Ask the supervisor to unkink the outlet line and e Re start the timer After five minutes note that the pre membrane pressure has returned to 107 mm Hg and the flow rate to 3 5 Ipm Now e Ask the supervisor to kink the inlet line and e Re start the timer After five minutes e Repeat the lt Oxygenator Blood Gas Analysis gt e Repeat the lt Arterial Blood Gas Analysis gt Note the pre membrane pressure has dropped markedly to 15 mm Hg the rom 2125 are unchanged and that the blood flow rate has fallen from lt 3 5 gt lpm to lt 0 5 gt lpm The blood gas pictures in the oxygenator blood and the arterial blood are very similar to those which were found when the outlet line was partially obstructed The explanation of these results is that the pump is being starved of inflow and consequently is unable to generate an outlet pressure because there is quite simply no blood to pump Once again the low blood flow through the oxygenator in the face of an unchanged gas flow results in inadvertent hyperventilation of the artificial lung so in the blood leaving the oxygenator the PCO2 falls quite markedly and the PO2 rises In summary the hallmarks of inlet line obstruction are a falling pre membrane pressure and falling blood flow rate in association with Supernormal oxygenator blood gases In real life how should we prevent inlet or o
154. ues of e Blood flow through the system in lpm e Circuit pressure measured at a point between the pump head and the oxygenator e Venous oxygen saturation e Pump speed in rpm e Haematocrit and e Blood Temperature To the right of the display area are four controls e The main power switch enables the flow control knob which is situated just beneath it 2010 MSE Australia PL Tutorials 97 e The flow control is used to adjust the speed of the centrifugal pump in the range 0 5000 rpm e The lt Adjust Cannula gt button allows you to move the drainage cannula e in or out and to select size of your return cannula e Finally the lt Mode gt button is used to set the system up for either VV or VA ECMO Note that the flow control is not enabled until the ECMO system is turned lt On gt Additional information regarding the ECMO system can be found by clicking on the lt Resources gt menu of the lt Inspector gt window and selecting the resource which you want to view These resources include lectures on ECMO images of various systems relevant websites and various descriptions and protocols relating to the technique Before commencing VV ECMO you may wish to confirm that the patient is effectively anti coagulated Select lt Devices gt lt ACT Monitor gt and click lt Start gt in order to commence the measurement If you do this you ll need to click lt Devices gt lt ECMO System to return to the ECMO in
155. use the central venous pressure is relatively low and the wall of the IVC is quite close to the drainage cannula the wall gets sucked onto the cannula drainage ports and begins to limit inflow As the rom are further increased more and more cava is sucked onto the cannula until eventually drainage ceases altogether and no forward flow is generated at all After five minutes you ll see that the arterial saturation has risen to about 87 and that the end tidal CO2 has fallen quite markedly Repeat the lt Arterial Blood Gas Analysis gt and note that the patient is now mildly hypocarbic and that the Pa02 has risen to 55 mm Hg but is still not great Clearly we ve made some progress but we re not yet in control In this situation there are a few things which we can do in an attempt to improve oxygenation These include e Ensuring that the patient s metabolic rate and oxygen consumption is kept low and e Ensuring that we have optimal venous drainage into the ECMO system If you check the patient s temperature lt Display gt lt Temperature gt you ll see that he is pyrexial We can correct this by cooling the patient using the ECMO system To do this e Adjust the lt HC Temp gt control to lt 33C gt on the ECMO device Ensuring optimal venous drainage is important because we want to pass as great a proportion as possible of the patient s venous return through the ECMO system Theoretically if we are able to capture
156. use the software It is your responsibility to make sure that You are allowed to use the Software 7 5 MSE Australia PL reserves the right at any time to cease the support of the Software and to alter prospectively the prices features specifications capabilities functions licensing terms release dates general availability or other characteristics of the Software 8 SUPPORT 8 1 Except as provided herein support for the Software is provided to you free of charge for a period of two years after purchase of a full license 9 HIGH RISK ACTIVITIES 9 1 The Software is not fault tolerant and is not designed manufactured or intended for use or resale as on line control equipment in hazardous environments requiring fail safe performance such as in the operation of direct life support machines in which the failure of the Software could lead directly to death personal injury or severe physical or environmental damage High Risk Activities MSE Australia PL and its suppliers specifically disclaim any express or implied warranty of fitness for High Risk Activities 9 2 Furthermore under no circumstances must the Software be used as a guide to the medical management of any living person 10 THIRD PARTY SITES AND SOFTWARE 10 1 The Software will direct you to third party Web sites MSE Australia PL does not control endorse or guarantee content including software data or other information found on such third party sites You agree tha
157. utlet line obstruction Two simple measures which can be taken are to e Ensure that long tubing runs are avoided so that redundant circuit loops cannot form e Ensure that the entire circuit is kept exposed and therefore visible and not concealed under sheets This concludes VV ECMO tutorial 4 lam grateful to Claudio Soto Perfusionist St Vincent s Hospital Sydney for permission to use this photograph VA ECMO 1 In this simulation we ll explore the basic behaviour of a modern veno arterial VA Extra Corporeal Membrane Oxygenation ECMO system The learning objectives of the session are e To understand the design of a simple veno arterial ECMO circuit 2010 MSE Australia PL ns ECMO Simulation User Manual v5 7 e To become familiarized with the basic controls of an ECMO system e To understand the mechanism of Differential Hypoxia We will be simulating the use of a system in a patient with normal cardio respiratory function before moving on to treating patients with severe cardio respiratory impairment in subsequent sessions Scenario Briefly the patient is a fit 30 year old who weighs 70 kgs For the purposes of the tutorial we re going to imagine that he s been intubated and perhaps surprisingly is tolerating the endotracheal tube very welll We ll start by connecting him to our monitoring system Click the lt Display gt button in the lt Patient Monitor gt window Clickin
158. vaccusesveesteesveceudeesccetes 8 3 Installation i 9 A Getting tarta cioonicoiocaric A ion ciendo diran canada 10 5 Modes of OperatiON oommccooonnncccnonnnnncnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn rr nn 13 Maintenance Mode t stas ri AAA 13 Supervised Simulation Mode nnnniinnnnninnnnninnicciciriranrar rra 14 Unsupervised Simulation Mode nnnncnninnininninincnininanananrairaicanrrirn rr r 14 6 Version Difference S cia ii d 15 7 Configuring Dual DiSplayS oooomnnccccnnnnnccnonnnncnnnnnnnnnnnnnnnrrnnnnnnn rn 15 Part Il Applications 19 A O O 19 MENU Bars ii died 19 Patient Monti aia dacie 21 Specto porearea raaa eeki Ken AAA Ad dd ed 24 Therapeutic Interface ccccesesesesseeseeseeseeseeseesessesseseesseseeesessoesoesaesaessesseuseeseeseesnesnesaesaesaesaeeeeaneseesouseesesaeeeeas 25 UE ais 25 Available Drugs FIS acta chogeseesuas 27 US ds 27 Scenarios A ta ca 29 CV SIECG Page PE AE TE A E E een 29 LO ti dns 31 MiscPagea E E E E E TATT AR ainia 32 Sn on Pa ii A E EE E 33 Part Ill Devices 37 1 Nerve Stimulator ia A A eee inten Sateen eee 37 2 Veno Venous ECM O aaa aaa a aa aa er a cease st a aa a a dde 37 3 Veno Arterial ECMO ik ciiid medea iiaei aa a ii 40 4 DefibrillA TOT cti eases he ee 43 5 EEAO E A T O O T 44 6 ACT Machine aia sees secu aE paaa theca dees aa aaa a aTa aaa aT a aA aaa aa a Aaa a a Aaaa raha ties ices esz 45 T StOthOSCOPC A o Re EEA EAE AAA EE 46 amp Dat Re Corde T tec a
159. vely draining sucking blood from a point in the inferior vena cava just below the diaphragm pumping it through the oxygenator and returning it via the superior vena cava to the right atrium Figure 1 Figure 1 2010 MSE Australia PL m ECMO Simulation User Manual v5 7 In this exercise we re only interested in the effect of obstruction of the drainage or return lines so initially we ll make sure that the venous drainage is absolutely optimal To do this e Switch to the ECMO system Devices gt lt ECMO System e Click lt Adjust Cannula gt e Slide the bottom left hand slider up to lt 8 gt to advance the IVC cannula e Switch back to the ECMO system Devices gt lt ECMO System e Turn on the lt Main Power gt e Set a gas flow of lt 6 gt lpm e Fully open the outlet arterial clamp e Increase the blood flow to lt 3 5 gt lpm e Start the timer Note the pre membrane pressure 107 mm Hg and the rpm 2125 After five minutes e Perform an lt Oxygenator Blood Gas Analysis gt e Perform an lt Arterial Blood Gas Analysis gt e Now ask the supervisor to kink the outlet arterial line and e Re start the timer 2010 MSE Australia PL Tutorials 1 15 After five minutes e Repeat the lt Oxygenator Blood Gas Analysis gt e Repeat the lt Arterial Blood Gas Analysis gt Note the pre membrane pressure has risen slightly to 130 mm Hg the rpm 2125 are unchanged but that t
160. vides an Intermittent Mandatory Ventilation IMV mode Pybus DA and Kerr JH During IPPV the ventilator acts as a constant flow generator Inspiratory and expiratory flow mouth pressure and delivered tidal volume are shown graphically on the left hand side of the device At the right hand side of the display are the controls for adjusting the gains of the flow pressure and volume channels respectively For the purposes of the ECMO simulation system the patient is assumed to be intubated and connected to the ventilator circuit Unless paralysed the patient will be able to breathe through the circuit whether or not the ventilator is turned on In order to turn the ventilator lt On gt click the button at the top right of the interface Use the lt Vt gt Tidal Volume lt Rate gt lt O2 gt and lt PEEP gt controls to set up the ventilatory parameters which you want If you want to suppress the patient s own respiratory activity use the lt Therapeutic Interface gt to administer a respiratory depressant such as Fentanyl or completely eliminate spontaneous respiratory activity by using a muscle relaxant Pancuronium 2010 MSE Australia PL Devices 4 3 6 ACT Machine y Start Button The effect of heparin or its reversal with protamine can be measured with the ACT machine In order to perform an ACT measurement click the lt Start gt button on the Hemochron device The ACT will then count up to the curren
161. want The next time you run the application in Supervised or Unsupervised mode the selected colour will be used and will continue to be used until changed in Maintenance Mode again Troubleshooting The Supervisor Application will not connect with the Main Application There are two simple solutions to this problem e Make sure that the Main Application is running in lt Supervised Mode gt e Make sure that the IP Address entered in the Supervisor Application is identical to that shown in the Patient Monitor of the Main Application lf neither of these approaches are successful you must ascertain that e Both the Main Application computer and supervisory computer are connected to the network e That the firewall security settings of your LAN permit incoming and outgoing TCP IP streams between these computers on port 8000 The integrity of these streams can be examined with the ipconfig ping and net view system commands To do this e Open a command prompt window and confirm with the ipconfig command that your network adapter is not ina Media disconnected state e Ping the desired host using its IP address If the ping command fails with a Request timed out message verify that the host IP address is correct that the host is operational and that all of the gateways routers between this computer and the host 2010 MSE Australia PL Trouble Shooting 151 are operational e Test host name resolutio
162. xiting the 2010 MSE Australia PL Tutorials 125 7 8 femoral arterial cannula This blood has passed through the oxygenator which is supplied with 100 oxygen and is less markedly over ventilated As a result the PO2 and PCO2 are considerably higher If peripheral arterial cannulation is used the ratio of oxygenator blood flow to total systemic flow determines the point in the aorta where there is a mixing interface between blood which has passed through the oxygenator and blood which has passed through the native lung As oxygenator flow is increased so this point moves closer and closer to the aortic valve until on full bypass aortic valve opening ceases all systemic flow is derived from blood which has passed through the oxygenator and differential hypoxia disappears It should be noted that the two arterial systems which are at greatest risk of differential hypoxia are the coronary and innominate vascular beds It should also be noted that the problem of differential hypoxia relates only to those undergoing VA ECMO and cannot occur in those being treated with VV ECMO We ll conclude this exercise by weaning the patient from VA ECMO To do this slowly reduce the blood flow through the ECMO system by reducing the rom until a flow rate of 1 Ipm is observed Note that pulsatility increases further and that the end tidal CO2 has risen to a more normal level Now progressively clamp the arterial line by dragging the sl
163. you are currently using Now double click on this file The database file will appear in the lt Database Editor gt window and two buttons will appear below this window lt Required gt Button Clicking the lt Required gt button will list all files which are required by the database in a lt Data File List gt window lt Missing gt Button Clicking the lt Missing gt button will list all files which are required by the database but which cannot be found in the ScenarioData folder in a lt Data File List gt window An example of a lt Data File List gt window is shown below The lt Data File List gt window is modal which is to say that it must be closed with the lt Close gt button before any other activities can be undertaken 2010 MSE Australia PL so ECMO Simulation User Manual v5 7 6 6 MSE Scenario Data File List i Files Required For This Database Getting Started pat Running Application pdf W ECMO Tutorial 1 pat WWW ECMO Tutorial 1 pdf Normal Patient pat vA ECMO Tutorial 1 pdf HB FBC HCT 30 pdf HS_Normal waw Getting Started Investigations pdf CXR_Normal3 jpg CWD Ao Sc jpg UEC Normal pdf Sickle1 pdf ARDS_ Ray jpa TGSAX_Normal wmy ECG_VentEctopy2 jpg Pulmonary Oedema ipa ECG_Pericarditis jpg DCM_SAX1 wmy Creating a Scenario pdf CHFY pa YY ECMO Parameters pdf CHRY jpa Stagnation Pressure pdf VV versus YA ECMO pdf V 1C ipa VVC jpg Bernoulli
164. your institution At that time he presented a four day history of increasing respiratory distress fever and a productive cough The patient had been sedated intubated and ventilated shortly after admission to the regional ICU Blood and sputum cultures grew a methicillin sensitive staphylococcus aureus Despite treatment with appropriate antibiotics the use of prone ventilation permissive hypercarbia and inhaled nitric oxide he continued to deteriorate Following discussions with the clinicians at the regional hospital he has been transferred to your institution for initiation of veno venous ECMO On arrival in your ICU the patient is being given assisted ventilation via an Ambu bag on 100 oxygen Blood gas analysis is reported as Pa02 44 mm Hg PaCQ2 41 mm Hg pH 7 34 BXS 3 5 Temp 37 4 Sa02 73 The patient has an Acute Lung Injury Score Murray Score of 3 5 but has no other significant co morbidities He has a Haemoglobin of 12 gm dL and you estimate his shunt fraction Qs Qt to be about 65 The results of some ancillary investigations Echo CXR and ECG are also available We ll assume that you have already worked your way through VV ECMO tutorials 1 and 2 so we ll quite quickly set up our monitoring e Click the lt Display gt button in the lt Patient Monitor gt window e Check lt ECGs lt Direct Arterial Pressure gt lt Central Venous Pressure gt and lt SaO2 gt and e Click the lt Di

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