Use of a circulation simulator for teaching and

skills maintenance in an ECLS Program

A.Cogswell, S.Pitfield, M.Chalmers, R.Mintak, D.Salt
ECLS Program
British Columbia Childrens Hospital
Vancouver, BC, Canada

Design concepts

Simulation has been accepted as a vital component of training in critical care. Use
of simulation has increased as the cost of the technology decreases and range of
choice of simulator model increases and most PICUs now have access to at least
one of the many different simulator manikins available for training.
Simulation in ECLS has been limited by paucity of commercially available models
and hence use restricted to centres with generously funded simulation budgets
We set out to design a simulator model of an extracorporeal circuit which could be
used for staff training and skills maintenance. Essential design constraints included
a very limited budget
a system which was portable and small enough to be used in a typical PICU bed space
for mock code type training exercises rather than a dedicated simulation laboratory
a system which would work with the different computer driven simulator manikins
available in the hospital
A system which would work with all of the different ECLS circuits used in the institution
including ECMO, VAD, CRRT , haemodialysis and plasmaphoresis

The circulation simulator

The circulation simulator consists of two fluid reservoirs, the CVP or
pre-load and the MAP or afterload which connect to the venous and
arterial ends of the ECLS circuit respectively. The height , in cm of
water, of those columns can be adjusted by means of a height
adjustable reservoir drain : that drain empties into a large holding tank.
The two reservoirs are in turn filled by a pump submerged in that
holding tank.
The ECLS circuit connects to the reservoirs and is turned on, with circuit
flow as per scenario to be tested. The circuit sees the CVP and MAP
reservoirs at the set heights and continuous circuit flow is enabled by
the MAP reservoir draining to the holding tank. Fluid is pumped from the
holding tank back to the CVP reservoir to the height determined by the
adjustable drain.
A variable clamp, remotely controlled, is placed on both the arterial and
venous limb of the circuit close to the connection with the simulator, so
that resistance to flow in one or both lumens may be applied.
A wide range of scenarios may be tested by varying combinations of CVP, MAP and resistance to flow on either the venous or arterial limb of
the circuit : hypovolemia, hypervolemia, tamponade, tension pneumothorax, cannula displacement, recirculation, inadequate sedation are all
tested in our ECLS training course and mock code scenarios. Whilst we use centrifugal pumps in our Program, this circulation simulator could
also be used in a roller pump system. In addition to ECMO circuits, the simulator is also perfectly applicable to VAD, haemodialysis, CRRT and
plasmaphoresis circuit training and testing.

The circulation simulator : evolution from prototype

Prototype 1

The origins of the device on which our development work has been done are obscure : it is thought to
have been built for Biomedicus as a teaching device. It is quite complex in its construction and would be
difficult to duplicate easily or cheaply, and has some features superfluous to our needs, although it
remains very useful as a teaching tool. (See at left Prototype 1)
Much of the plumbing, including the holding tank and pump, are hidden within the box. The tall towers
are the two reservoirs which simulate pre-load and afterload, and the ECLS circuit connections are
seen at the bases of those reservoirs. Having the reservoirs visible, or even present at all, is not
essential to a functioning circulation simulator : the final design of the simulator can be determined by
the institution that builds it . Visible reservoirs are good for teaching but make for difficulties in mobility
and positioning of the unit. The entire unit could be compressed to a black box no more than two feet
high/wide/deep if desired. Heavy duty wheels on the base are strongly suggested if the unit is to be
used for simulation in point of care settings, to aid in transport when loaded with fluid.
Three different prototypes have been constructed and all work to provide the same ultimate end-point :
a circulation to which an ECLS circuit can be attached. The prototypes vary mainly in their ease of
construction and their usefulness for teaching purposes. The authors will be happy to share the plans
for the devices with anyone interested in constructing their own : there are no plans for commercial
production at this stage.

Simulation of the ECLS patient and circuit

As a starting point, the ECLS patient is simulated by a commercially available,
computer driven simulator manikin (eg Laerdal SimBaby). The monitor screen for the
simulator is programmed to match as closely as possible the patient monitors used in
the PICU (Picture A) to improve the comfort and familiarity of the trainees. The rest of
the patient care area is set up as for a real ECLS run with standard ward/ECLS IV
pumps, chest / wound drains, ventilator and supplies area (Picture B). The simulator
manikin can be run on a custom computer scenario or driven real time by one of the
observers/instructors
The ECLS circuit is crystalloid primed and food coloring added to mimic blood. All of the
usual ECLS monitoring is set up as for a normal run, including functional circuit hydraulic
pressure (DLP monitors) and flow monitoring. We normally use a Spectrum Medical
monitor for circuit SvO2, SaO2 and Hct : this is replaced by a computer monitor screen
set up to play a powerpoint presentation that has been custom designed to simulate the
Spectrum monitor readings during the ECLS troubleshooting scenario to be tested (eg,
tamponade, hypovolemia, etc)(Picture C).
The ECLS circuit is connected to the circulation simulator near the neck of the manikin,
but concealed, to mimic a true cannulated patient (Picture D)

Laerdal monitor calibrated

to match ICU monitor

Spectrum monitor simulation

on powerpoint

SimBaby cannulated

ECLS patient simulation set-up 1

Patient / manikin monitor

SIMULATION
CONTROL
AREA
(not shown
In photo)

Ventilator
Spectrum monitor

ECLS Circuit

PATIENT SIMULATION
AREA SHOWN
IN PHOTO
(on right)

The patient simulation area is set up precisely as normal in the ward setting and the simulation
control personnel and equipment are kept as concealed and out of the picture, as possible.

ECLS patient simulation set-up 2

Simulator
manikin
computer

Circulation simulator

Spectrum monitor computer

This is a view of the set-up from behind the simulation

control area : the patient simulation area is seen on
the left of the picture
The ECLS Coordinator is shown manipulating the
circulation simulator for the scenario at hand :
manipulaions will include varying pre-load, afterload,
and degree of occlusion to venous and arterial lines.
The ECLS Medical Director is shown real time driving
the computer that runs the simulator manikins
physiological responses
One of the ECLS Team Leaders is shown driving the
computer that runs the powerpoint presentation that
reads out as the Spectrum monitor screen : read out
includes the audio alarms as on the real monitor.
One of the operators also has access to a syringe of
blood which can be injected to fill the chest drain or
flood the mediastinal dressing in a post-op scenario
These three individuals would normally be involved in
Training Course teaching or skills maintenance
sessions, and are in a prime position to observe
trainee responses and actions. If necessary, the whole
simulation could be run by only two people.
The connections from the circulation simulator, and the
two computers , to the patient care area are run in a
protective conduit across the floor and up to the
manikin (concealed by patient bedding).

Running the simulation scenario

The staff to be trained / tested gather in the patient treatment area : We endeavour to
simulate our standard clinical practice which includes an RN for general patient care, and
ECLS Tech for circuit care, an RT to attend the ventilator and a physician for some
scenarios. Those staff are blinded to the scenario to be run, and the simulation control
area with circulation simulator, computers and training staff, are kept out of line of sight.

Our experience to date is that it is not too challenging to run simulation scenarios in real
time on the manikin, rather than to a predetermined program : This is dependent on
operator experience and comfort, but is generally more interactive with trainees responses

Our simulation scenarios are all printed out in detail in terms of what is required in the
circulation simulator settings and responses to trainees actions, the spectrum monitor
readout presentation and the simulator manikin physiological responses : each
controller/trainer knows precisely what is required and when it should occur.

Scenarios have been developed for hypovolemia, hypervolemia, hyperthermia,

hypothermia, tamponade, tension pneumothorax, cannula kinking, cannula clotting,
sepsis/decreased SVR, hypertension/increased SVR, seizures/inadequate sedation,
surgical bleeding, accidental decannulation, recirculation on VV ECMO.

Outcome of the development of the simulator

We used to run an animal lab as part of our Training Program : The simulator has now replaced that
entirely. The cost of one single animal lab day would more than pay for the total outlay for all of the
simulator development and construction. Animal ethics concerns, and costs associated with animal
care, laboratory running and drug administration were all becoming prohibitive and that money can now
be more productively used in other areas of staff training.
We have a low volume ECLS Program with an average of 15-18 cases per year, with a mix of neonatal
and pediatric respiratory support and cardiac support. Maintenance of staff skills in that setting is of
paramount importance to quality assurance, and can be challenging to achieve. Access to an
affordable, portable circulation simulator has provided the means for regular staff training exercises
within the PICU itself and we hope to be able to show improvements in outcome as a consequence.
The ability to move the entire simulation set-up into a regular PICU bedspace produces a superior
training experience compared to the simulation laboratory. Feedback from trainees shows that
experiences in a dedicated simulation laboratory are far less realistic that those that can be run in the
point of care setting where the trainees are using equipment that they use on a daily basis, in a
familiar physical environment. We aim to eventually run regular ECLS mock codes using the simulator
and hope that that will further strengthen our skills maintenance program.
The extension of use of the circulation simulator to non-ECMO areas is next on the agenda, in
particular the PICU use of CRRT. Infrequent clinical use of a technique determines that a skills
maintenance program is essential. Several months may elapse between CRRT runs in our ICU and all
the staff find it challenging to renew acquaintance with the process.

Conclusion

We have described the design and use of a circulation simulator which may be used in conjunction
with any type of computer driven patient simulator, and to which may be attached any type of ECLS
circuit : centrifugal or roller pump ECMO circuit, VAD, CRRT or plasmaphoresis. The combined use
of the two simulators has enabled us to discontinue the animal laboratory in our training program and
greatly enhance our skills maintenance program.
This approach should appeal to those centres with relatively low volume ECLS Programs which
already have access to a simulator manikin and want to offer true hands-on ECLS circuit simulation
for skills maintenance.
The circulation simulator is simple in design and construction and could be easily completed by most
hospitals Biomedical Engineering departments at very modest cost. Space constraints in this
presentation format have limited details of the construction of the simulator, but the authors would be
more than happy to assist any other centres who wish to pursue construction of their own version of
such a simulator, and would also be happy to demonstrate the device at any time.
Contacts :
Dr Arthur Cogswell, Critical Care Physician, BC Childrens Hospital, Vancouver
acogswell@cw.bc.ca
Doug Salt, ECLS Coordinator, BC Childrens Hospital. dsalt@cw.bc.ca