Page 34 - JSOM Spring 2024

Derivation of a Procedural Performance Checklist
for Bifemoral Veno-Venous Extracorporeal Membrane Oxygenation
Cannula Placement in Operational Environments

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Elizabeth Powell, MD *; Richard Betzold, MD ; Rishi Kundi, MD ; Douglas Anderson, MD ;
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Daniel Haase, MD ; Meaghan Keville, MD ; Samuel Galvagno, DO, PhD 7
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ABSTRACT
Background: Veno-venous extracorporeal membrane oxygen- Future conflicts with contested airspace may necessitate pro-
ation (VV ECMO) is a low-frequency, high-intensity procedure longed casualty care and use of critical care modalities such
used for severe lung illness or injury to facilitate rapid correc- as VV ECMO by the forward medical teams already in place.
tion of hypoxemia and respiratory acidosis. This technology is Injured Special Operations Forces may be at particular risk
more portable and extracorporeal support is more frequently of delays in evacuation, given potential contested routes of
performed outside of the hospital. Future conflicts may require evacuation to higher roles of care; however, they may benefit
prolonged causality care and more specialized critical care ca- from innovation and implementation of more forward ECMO
pabilities including VV ECMO to improve patient outcomes. capabilities. Feasibility studies of training for forward imple-
We used an expert consensus survey based on a developed bi- mentation of VV ECMO are currently underway, with prelim-
femoral VV ECMO cannulation checklist with an operational inary data presented at the 2023 Extracorporeal Life Support
focus to establish a standard for training, validation testing, Organization (ESLO) in Seattle, Washington. Checklists are
and sustainment. Methods: A 36-item procedural checklist used in a variety of training programs to aid in education and
was provided to 14 experts from multiple specialties. Using the validation of safety and procedural competence. 9–11 As part of
modified Delphi method, the checklist was serially modified training, checklists provide a standard and ensure the sustain-
based on expert feedback. Results: Three rounds of the study ment of knowledge.
were performed, resulting in a final 32-item checklist. Each
item on the checklist received at least 70% expert agreement Patients can be cannulated peripherally for VV ECMO via
on its inclusion in the final checklist. Conclusion: A procedural the internal jugular/femoral vein or bifemoral technique. The
performance checklist was created for bifemoral VV ECMO bifemoral technique offers the advantage of rapid access and
using the modified Delphi method. This is an objective tool to placement of cannulas while allowing access to the patient’s
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assist procedural training and validation for medical providers head, neck, and chest for other procedures. Less space is also
performing VV ECMO in austere environments. required for setup and preparation, making this technique use-
ful in time, resource, and space-limited environments. We used
Keywords: VV ECMO; checklist; prolonged casualty care; ARDS an expert consensus survey based on a developed bifemoral
VV ECMO cannulation checklist with an operational focus to
establish a standard for training, validation testing, and skills
sustainment.
Introduction
Veno-venous extracorporeal membrane oxygenation (VV Methods
ECMO) is used for patients with respiratory failure and acute
respiratory distress syndrome (ARDS) who have failed con- This study was conducted at a high-volume ECMO center.
ventional ventilator management. VV ECMO facilitates rapid It was reviewed by the institutional review board and found
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correction of hypoxemia and respiratory acidosis from hy- to be exempt from human subject research. While there is no
percarbia while also reducing injurious ventilator settings. standard definition of the appropriate number of experts to
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VV ECMO could increase the survivability of patients with include in a modified Delphi study, 10–20 experts are typically
severe thoracic injury who cannot be immediately evacuated recommended. 13–15 We identified a panel of 30 experts from the
and facilitate stabilization and further procedures. The use fields of critical care medicine, vascular surgery, trauma sur-
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of VV ECMO for medical and trauma indications is increas- gery, interventional cardiology, cardiac surgery, and emergency
ing throughout the United States and the world. Notably, the medicine, with demonstrated special interest in operational
technology is durable and portable, making broader access to military medicine, percutaneous access, and ECMO cannula-
extracorporeal support possible. The United States military tion. The experts were then individually contacted by email
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has an experienced ECMO transport and management team. and serially invited to participate in each round of review until
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*Correspondence to elizabeth.powell@som.umaryland.edu
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1 Dr. Elizabeth Powell is affiliated with the Department of Emergency Medicine and Surgery, University of Maryland, Baltimore. Dr. Richard
Betzold is affiliated with the Department of Surgery, University of Alabama at Birmingham Hospital. Dr. Rishi Kundi is affiliated with the De-
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partment of Surgery, University of Maryland, Baltimore. Dr. Douglas Anderson is affiliated with the United States Air Force and affiliated with
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the University of Maryland, Baltimore. Dr. Daniel Haase is affiliated with the Department of Emergency Medicine and Surgery, University of
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Maryland, Baltimore. Dr. Meaghan Keville is affiliated with the United States Air Force and affiliated with the University of Maryland, Balti-
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more. Dr. Samuel Galvagno is affiliated with the Department of Anesthesiology, University of Maryland, Baltimore, MD.
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