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Vercaemst L. Year in review: Highlights in ECLS Innovation and Technology, Anno 2022-2023. Perfusion 2024; 39:31-35. [PMID: 37621074 DOI: 10.1177/02676591231195691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND In the field of extracorporeal life support (ECLS), the rapid influx of novel technologies and innovative techniques presents an ongoing challenge for professionals to stay informed about these advancements. To address this issue and ensure the ECLS community remains up-to-date, we have compiled a concise overview of recent technological innovations in ECLS. PURPOSE This overview focuses primarily on academically investigated and reported advancements in the ECLS domain. It underscores the importance of transparent communication regarding technological limitations in healthcare and advocates for collaboration between medical professionals and engineers to elevate patient care. RESEARCH DESIGN This manuscript presents a compilation of recent technological advancements in ECLS, with an emphasis on innovations that have been academically explored and documented. The research approach involves gathering information from scholarly sources, reports, and studies to provide a comprehensive overview. STUDY SAMPLE The study sample comprises a diverse range of recent technological innovations in the field of extracorporeal life support (ECLS). These innovations span various aspects of ECLS technology and have been investigated and reported on within the academic literature. ANALYSIS Data collection involved systematically reviewing academic literature, reports, and studies related to recent technological advancements in ECLS. The collected information was then analyzed to identify common trends, notable developments, and the impact of these innovations on patient care. RESULTS The compilation highlights several significant technological innovations within the ECLS domain. Notable advancements include the development of new dual lumen cannulae, innovative devices for left ventricular (LV) unloading, lightweight ECMO transport systems, streamlined driving consoles to facilitate patient mobility, intricate systems for extracorporeal cardiopulmonary resuscitation (ECPR), standardized driving consoles for networking, and non-invasive circuit pressure monitoring. Some of these innovations have obtained regulatory approvals for distribution in the United States and/or authorization for the European market. CONCLUSIONS The manuscript underscores the critical role of collaboration between clinicians, researchers, and industry in driving recent technological innovations within the ECLS field. It emphasizes the necessity of open communication about technological limitations and the potential for repurposing established technologies in novel ways. However, the resourcefulness of physicians in repurposing devices requires validation through comprehensive scientific and technical investigation. Thus, fostering broader collaboration among stakeholders is recommended to ensure the rigorous evaluation and validation of new applications for established ECLS devices.
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Affiliation(s)
- Leen Vercaemst
- Department of Perfusion, University Hospital Gasthuisberg, University Hospital Leuven (BE), Leuven, Belgium
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Park Y, Drucker NA, Gray BW. Device updates in pediatric and neonatal ECMO. Semin Pediatr Surg 2023; 32:151334. [PMID: 37925997 DOI: 10.1016/j.sempedsurg.2023.151334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Since the early use of extracorporeal life support (ECLS), new innovations and technological advancements have augmented the ability to use this technology in children and neonates. Cannulae have been re-designed to maintain structure and allow for single cannula venovenous (VV) ECLS in smaller patients. Circuit technology, including pumps and tubing, has evolved to permit smaller priming volumes and lower flow rates with fewer thrombotic or hemolytic complications. New oxygenator developments also improve efficiency of gas exchange. This paper serves as an overview of recent device developments in ECLS delivery to pediatric and neonatal patients.
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Affiliation(s)
- Yujin Park
- Department of Surgery, Indiana University, Indianapolis, IN, USA; Section of Pediatric Surgery, Indiana University, Indianapolis, IN, USA
| | - Natalie A Drucker
- Department of Pediatric Surgery, University of Texas in Houston, USA
| | - Brian W Gray
- Section of Pediatric Surgery, Indiana University, Indianapolis, IN, USA.
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Robertson JO, Shanaz Hossain M, Khan FA, Cass DL. Use of Image Guidance During Pediatric Venovenous Extracorporeal Membrane Oxygenation Cannulation: A Survey of the American Pediatric Surgical Association. ASAIO J 2023; 69:687-694. [PMID: 36947852 DOI: 10.1097/mat.0000000000001920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
This study evaluated practices for image guidance during placement of bicaval dual-lumen (BCDL) venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas in pediatric and adolescent patients and elucidates reasoning behind surgeon practices. A survey covering VV-ECMO practice and opinions was distributed by the American Pediatric Surgical Association (APSA) to all attending members. A total of 110 pediatric surgeons responded (11.3%). During initial BCDL cannula placement, 67.7% of surgeons reported using bimodal imaging with either fluoroscopy (38.4%) or x-ray (29.3%) plus echocardiography. Although 37.4% of surgeons used serial x-rays during cannula placement, only 5.9% believed it was best practice to do so ( P < 0.0001). Rather, 60.4% believed that fluoroscopy was the standard. Among surgeons not using fluoroscopy, 27.6% (13.3% of respondents) reported fluoroscopy added unnecessary complexity or that they preferred another modality. More frequently, reasons for not using fluoroscopy are related to resource limitations. Echocardiography use to confirm cannula position was considered best practice by 92.1% of surgeons, with 86.9% utilization. Therefore, most pediatric surgeons use multimodal imaging during cannulation and consider it best practice. Fluoroscopy is preferred, but its use is frequently limited by hospital resources. Echocardiography is widely available and used. These data represent increased consensus among surgeons and present opportunities for modernization of hospital resources and standards.
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Affiliation(s)
- Jason O Robertson
- From the Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH and
| | - Mir Shanaz Hossain
- From the Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH and
| | - Faraz A Khan
- Department of Pediatric Surgery, Loma Linda Children's Hospital, Loma Linda, CA
| | - Darrell L Cass
- From the Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH and
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Hossain MS, Khan FA, Cass DL, Robertson JO. Discontinuation of the OriGen® Dual-lumen Right Atrial Cannula Decreased Venovenous ECMO Usage in Neonates and Older Children: A Survey of the American Pediatric Surgical Association. J Pediatr Surg 2023; 58:1185-1190. [PMID: 36914461 DOI: 10.1016/j.jpedsurg.2023.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/10/2023] [Indexed: 02/21/2023]
Abstract
INTRODUCTION Dual-lumen cannulas for venovenous (VV)-ECMO are widely used in pediatric patients. The popular OriGen® dual-lumen right atrial cannula was discontinued in 2019 without a comparable replacement. METHODS A survey covering VV-ECMO practice and opinions was distributed to attending members of the American Pediatric Surgical Association. RESULTS 137 pediatric surgeons responded (14%). Prior to discontinuation of the OriGen®, 82.5% offered VV-ECMO to neonates, and 79.6% cannulated with the OriGen®. Following its discontinuation, those that offered only venoarterial (VA)-ECMO to neonates increased to 37.6% from 17.5% (p = 0.0002). An additional 33.8% changed their practice to sometimes use VA-ECMO when VV-ECMO was indicated. Reasons for not incorporating dual-lumen bi-caval cannulation into practice included risk of cardiac injury (51.7%), inexperience with bi-caval cannulation in neonates (36.8%), difficulty with placement (31.0%), and recirculation and/or positioning problems (27.6%). For the pediatric/adolescent population, 95.5% of surgeons offered VV-ECMO prior to OriGen® discontinuation. Few switched to exclusive VA-ECMO (1.9%) when the OriGen® was discontinued, but 17.8% of surgeons began to incorporate selective use of VA-ECMO. CONCLUSION Discontinuation of the OriGen® cannula drove pediatric surgeons to alter their cannulation practices, dramatically increasing VA-ECMO use for neonatal and pediatric respiratory failure. These data may suggest a need for targeted education accompanying major technological shifts. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Mir Shanaz Hossain
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Faraz A Khan
- Department of Pediatric Surgery, Loma Linda Children's Hospital, Loma Linda, CA, USA
| | - Darrell L Cass
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Jason O Robertson
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
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Spencer BL, Mychaliska GB. Updates in Neonatal Extracorporeal Membrane Oxygenation and the Artificial Placenta. Clin Perinatol 2022; 49:873-891. [PMID: 36328605 DOI: 10.1016/j.clp.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Extracorporeal life support, initially performed in neonates, is now commonly used for both pediatric and adult patients requiring pulmonary and/or cardiac support. Data suggests the clinical feasibility of Extracorporeal Membrane Oxygenation for premature infants (29-33 weeks estimated gestational age [EGA]). For extremely premature infants less than 28 weeks EGA, an artificial placenta has been developed to recreate the fetal environment. This approach is investigational but clinical translation is promising. In this article, we discuss the current state and advances in neonatal and "preemie Extracorporeal Membrane Oxygenation" and the development of an artificial placenta and its potential use in extremely premature infants.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Fetal Diagnosis and Treatment Center, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA.
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Jensen AR, Davis C, Gray BW. Cannulation and decannulation techniques for neonatal ECMO. Semin Fetal Neonatal Med 2022; 27:101404. [PMID: 36437185 DOI: 10.1016/j.siny.2022.101404] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In neonates with cardiac and/or respiratory failure, extracorporeal membrane oxygenation (ECMO) continues to be an important method of respiratory and/or cardiovascular support where conventional treatments are failing. ECMO cannulation involves a complex decision-making process to choose the proper ECMO modality and cannulation strategy to match each patient's needs, unique anatomy, and potential complication profile. Initially, all ECMO support involved cannulating both the carotid artery and the internal jugular vein (IJV), known as veno-arterial (VA-ECMO) for cardiac and/or respiratory support. Rarely was cannulation through the chest used. The development of dual-lumen cannulae in the early to mid 1990s addressed the concerns about carotid artery ligation and its impact on neurological outcomes, and allowed single vascular access for veno-venous respiratory support (VV-ECMO). We present a review of cannulation and decannulation techniques for both VA and VV-ECMO in neonates.
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Affiliation(s)
- Amanda R Jensen
- Riley Hospital for Children Indiana University School of Medicine Indianapolis, IN, USA.
| | - Carl Davis
- Lead for the Paediatric & Adolescent Chest Wall Defect Service the Royal Hospital for Children, Glasgow, Scotland, United Kingdom.
| | - Brian W Gray
- Surgical Director of ECMO, Program Director, Pediatric Surgery Fellowship, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
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Ramaraj A, Jensen G, Rice-Townsend S, DiGeronimo R, Yalon L, Stark R. Similar frequency of atrial perforation between atrial and bicaval dual lumen veno-venous ECMO cannulas in a pediatric population. Perfusion 2021; 37:752-756. [PMID: 34264146 DOI: 10.1177/02676591211030767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Complications associated with use of dual-lumen venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas are of concern in pediatric patients. While the risk of atrial perforation is believed to be higher with bicaval cannulas, direct comparison of complication rate between atrial and bicaval cannulas has not been conducted in this population. METHODS A retrospective review was conducted at a free-standing children's hospital of all patients 0-18 years old, placed on VV-ECMO with a dual-lumen cannula from January 2009 to December 2018. Patients were grouped based on cannula type. Complications were assessed over the entire duration of the ECMO run. Logistic regression analyses were used to evaluate for an association between cannula type and risk of pericardial effusion or cannula-related complication requiring median sternotomy or pericardial drain placement. RESULTS During the study period 119 patients were placed on VVECMO using a dual-lumen cannula. Eighty-two patients (69%) were <2 years old, 19 (16%) were 2-10 years old, and 18 (15%) were 11-18 years old. Seventy-three were cannulated with an atrial cannula and 46 patients received a bicaval cannula. Pericardial effusions were seen in 30% and 24% of these patients respectively while severe complications were seen in 9.6% and 8.7% of patients respectively. Compared to patients treated with a bicaval cannula, those who received an atrial cannula had similar odds of effusions (OR: 1.41, 95% CI: 0.62-3.36) and severe complications (OR 0.89, 95% CI: 0.27-3.18). After adjusting for age, weight, cannula and circuit manipulations, and use of echocardiography, the OR of effusion was 1.91 (95% CI: 0.65-6.42), and the adjusted OR of severe complication was 0.69 (95% CI: 0.16-3.33). CONCLUSIONS There were no significant differences in frequency of pericardial effusions or severe cannula-related complications between the treatment groups across all pediatric patients and within the subgroup of patients under 2 years of age.
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Affiliation(s)
- Akila Ramaraj
- Department of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Guy Jensen
- General Surgery, Naval Hospital Bremerton, Bremerton, WA, USA
| | - Samuel Rice-Townsend
- Department of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Robert DiGeronimo
- Department of Neonatology, Seattle Children's Hospital, Seattle, WA, USA
| | - Larissa Yalon
- Extracorporeal Life Support Services, Seattle Children's Hospital, Seattle, WA, USA
| | - Rebecca Stark
- Department of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
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Choi BH, Verma S, Cicalese E, Dapul H, Toy B, Chopra A, Fisher JC. Morbidity of conversion from venovenous to venoarterial ECMO in neonates with meconium aspiration or persistent pulmonary hypertension. J Pediatr Surg 2021; 56:459-464. [PMID: 33645507 DOI: 10.1016/j.jpedsurg.2020.09.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 09/15/2020] [Accepted: 09/24/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Outcomes in neonates receiving extracorporeal membrane oxygenation (ECMO) for meconium aspiration syndrome (MAS) and/or persistent pulmonary hypertension (PPHN) are favorable. Infants with preserved perfusion are often offered venovenous (VV) support to spare morbidities of venoarterial (VA) ECMO. Worsening perfusion or circuit complications can prompt conversion from VV-to-VA support. We examined whether outcomes in infants requiring VA ECMO for MAS/PPHN differed if they underwent VA support initially versus converting to VA after a VV trial, and what factors predicted conversion. METHODS We reviewed the Extracorporeal Life Support Organization registry from 2007 to 2017 for neonates with primary diagnoses of MAS/PPHN. Propensity score analysis matched VA single-runs (controls) 4:1 against VV-to-VA conversions based on age, pre-ECMO pH, and precannulation arrests. Primary outcomes were complications and survival. Data were analyzed using Mann-Whitney U and Fisher's exact testing. Multivariate regression identified independent predictors of conversion for VV patients. RESULTS 3831 neonates underwent ECMO for MAS/PPHN, including 2129 (55%) initially requiring VA support. Of 1702 patients placed on VV ECMO, 98 (5.8%) required VV-to-VA conversion. Compared with 364 propensity-matched isolated VA controls, conversion runs were longer (190 vs. 127 h, P < 0.001), were associated with more complications, and decreased survival to discharge (70% vs. 83%, P = 0.01). On multivariate regression, conversion was more likely if neonates on VV ECMO did not receive surfactant (OR = 1.7;95%CI = 1.1-2.7;P = 0.03) or required high-frequency ventilation (OR = 1.9;95%CI = 1.2-3.3;P = 0.01) before ECMO. CONCLUSION Conversion from VV-to-VA ECMO in infants with MAS/PPHN conveys increased morbidity and mortality compared to similar patients placed initially onto VA ECMO. VV patients not receiving surfactant or requiring high-frequency ventilation before cannulation may have increased risk of conversion. While conversions remain rare, decisions to offer VV ECMO for MAS/PPHN must be informed by inferior outcomes observed should conversion be required. LEVEL OF EVIDENCE Level of evidence 3 Retrospective comparative study.
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Affiliation(s)
- Beatrix Hyemin Choi
- Division of Pediatric Surgery and Department of Surgery, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Sourabh Verma
- Divisions of Neonatology and NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Erin Cicalese
- Divisions of Neonatology and NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Heda Dapul
- Pediatric Critical Care and Department of Pediatrics, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Bridget Toy
- Transplant Institute, NYU Langone Health, New York, NY
| | - Arun Chopra
- Pediatric Critical Care and Department of Pediatrics, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone
| | - Jason C Fisher
- Division of Pediatric Surgery and Department of Surgery, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone.
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O'Neil ER, Coleman RD, Vogel AM, Chartan CA, Kukreja KU. Safely repositioning dual-lumen ECMO cannulas with a transfemoral lasso snare. Perfusion 2020; 36:777-780. [PMID: 33225837 DOI: 10.1177/0267659120969031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Dual-lumen cannulas were designed to provide venovenous extracorporeal membrane oxygenation (VV ECMO) with single-vessel access. Anatomic and size considerations may make appropriate placement challenging in children. Dual-lumen cannulas are repositioned in 20-69% of pediatric patients, which can be difficult without transient discontinuation of ECMO support. METHODS We repositioned three dual-lumen ECMO cannulas introduced via the right internal jugular vein using a transfemoral snare technique under real-time ultrasound and fluoroscopy. RESULTS Two of three patients were supported on VV ECMO and one on veno-veno-arterial (VV-A) ECMO. Two of the three patients had their dual-lumen cannula repositioned under ultrasound and fluoroscopy guidance and one was repositioned just with ultrasound. No patient experienced a complication from the transfemoral snare technique such as femoral hematoma, hemorrhage or limb ischemia. CONCLUSION We describe three patients who successfully had dual-lumen cannulas repositioned without cessation of ECMO using a transfemoral "lasso" technique.
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Affiliation(s)
- Erika R O'Neil
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Ryan D Coleman
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Adam M Vogel
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA.,Division of Pediatric Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Corey A Chartan
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Kamlesh U Kukreja
- Division of Interventional Radiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
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Drucker NA, Wang SK, Markel TA, Landman MP, Gray BW. Practice patterns in imaging guidance for ECMO cannulation: A survey of the American Pediatric Surgical Association. J Pediatr Surg 2020; 55:1457-1462. [PMID: 31837841 DOI: 10.1016/j.jpedsurg.2019.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 11/10/2019] [Accepted: 11/19/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Surgeon-specific variations in pediatric extracorporeal membrane oxygenation (ECMO) cannulation technique are not well characterized. Advances in technology have led to changing techniques with no formal consensus statement for reference. METHODS A survey was e-mailed to 1301 members of the American Pediatric Surgical Association (APSA). Categorical data was compared with Chi-squared and Kendall's tau-β tests, and multiple column comparisons were performed with the Bonferroni correction. RESULTS Response rate was 19%, with 248 pediatric general surgeons responding to the survey. 89.4% of respondents stated that cannulation was typically performed in the ICU. Venoarterial (VA) ECMO cannulation was more often performed open (88.6%) than venovenous (VV) ECMO (42.2%). Surgeons cannulate for VA ECMO and VV ECMO without imaging guidance 44% and 21.5% of the time, respectively. There was no difference in estimated rate of cannula repositioning by cannulation strategy. For venous and arterial cannulation in VA ECMO, surgeons were more likely to use the femoral as opposed to the neck when children were older than 13 years and weighed more than 35 kg regardless of the presence or absence of preexisting femoral arterial or venous access. CONCLUSION Practice patterns for ECMO cannulation are variable among pediatric surgeons. Standardization could reduce the occurrence of unsafe practices and potentially decrease complications and improve patient outcomes. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Natalie A Drucker
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202.
| | - S Keisin Wang
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202.
| | - Troy A Markel
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202; Department of Surgery, Section of Pediatric Surgery, 705 Riley Hospital Dr. RI 2500, Indianapolis, IN 46202.
| | - Matthew P Landman
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202; Department of Surgery, Section of Pediatric Surgery, 705 Riley Hospital Dr. RI 2500, Indianapolis, IN 46202.
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Emerson Hall 545 Barnhill Drive, Room 125, Indianapolis, IN 46202; Department of Surgery, Section of Pediatric Surgery, 705 Riley Hospital Dr. RI 2500, Indianapolis, IN 46202.
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Kim W, Kwon HW, Min J, Cho S, Kwak JG, Kim WH. Extracorporeal Membrane Oxygenation in Pediatric Patients with Respiratory Failure: Early Experience with the Double-Lumen Cannula Over 2 Years. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:132-139. [PMID: 32551294 PMCID: PMC7287224 DOI: 10.5090/kjtcs.2020.53.3.132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/02/2019] [Accepted: 12/25/2019] [Indexed: 12/04/2022]
Abstract
Background The double-lumen cannula (DLC) has begun to be used worldwide for venovenous (VV) extracorporeal membrane oxygenation (ECMO). We aimed to examine whether the DLC could be an effective tool in the treatment of pediatric respiratory failure in Korea. Methods We reviewed the records of patients weighing under 15 kg who underwent ECMO due to respiratory failure between January 2017 and December 2018. Outcomes of ECMO using a DLC and conventional ECMO using central method or 2 peripheral cannulas were compared. Results Twelve patients were treated with ECMO for respiratory failure. Among them, a DLC was used in 5 patients, the median age of whom was 3.8 months (interquartile range, 0.1–49.7 months). In these patients, the median values of pH, partial pressure of carbon dioxide, and partial pressure of oxygen were 7.09, 74 mm Hg, and 37 mm Hg before ECMO and corrected to 7.31, 44 mm Hg, and 85 mm Hg, respectively, after ECMO cannulation. Median blood flow rate in the patients treated with ECMO using a DLC was slightly higher than that in the conventional ECMO group, but this difference was not statistically significant (86.1 mL/kg/min and 74.3 mL/kg/min, respectively; p=1.00). One patient from the DLC group and 3 patients from the conventional group were weaned off ECMO. Conclusion VV ECMO using a DLC provided adequate oxygenation, ventilation, and blood flow rate in Korean pediatric patients with respiratory failure. Further prospective and randomized studies are warranted.
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Affiliation(s)
- Woojung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Won Kwon
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jooncheol Min
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sungkyu Cho
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woong Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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Pediatric extracorporeal membrane oxygenation: Our experience with single-vessel cannulation. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:92-100. [PMID: 32175148 DOI: 10.5606/tgkdc.dergisi.2020.18359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/07/2019] [Indexed: 11/21/2022]
Abstract
Background In this study, we present our experience with bicaval, dual-lumen, venovenous extracorporeal membrane oxygenation in pediatric patients with severe respiratory failure. Methods Between September 2015 and May 2019, a total of nine pediatric patients (7 males, 2 females; median age 3.1 years; range, 0.3 to 7.4 years) hospitalized in the pediatric intensive care unit due to severe respiratory failure who were cannulated using a bicaval, dual-lumen, venovenous catheter were retrospectively analyzed. Patient demographics, cannulation details, complication of catheter use, and outcomes were recorded. Results The median duration of extracorporeal membrane oxygenation support was nine (range, 2 to 32) days. One patient required conversion to venoarterial extracorporeal membrane oxygenation and one patient required conversion to conventional double-cannulated venovenous extracorporeal membrane oxygenation. Of the patients, 33% suffered from bleeding complications. There were no cannula- or circuit-related complications. Adequate oxygenation and flow were obtained in all patients, except one. No mortalities were directly associated with the cannulation strategy used. Conclusion The bicaval, dual-lumen cannula can be safely used in pediatric patients with minimal complication rates and is our preferred method for venovenous extracorporeal membrane oxygenation support.
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Houmes RJ, Krasemann T, Keyzer-Dekker CM. Reposition of a Bi-caval Dual Lumen ECMO cannula using a trans-femoral lasso. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2019.101329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Kovler ML, Garcia AV, Beckman RM, Salazar JH, Vacek J, Many BT, Rizeq Y, Abdullah F, Goldstein SD. Conversion From Venovenous to Venoarterial Extracorporeal Membrane Oxygenation Is Associated With Increased Mortality in Children. J Surg Res 2019; 244:389-394. [DOI: 10.1016/j.jss.2019.06.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/25/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
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Jamil M, Rezaeimoghaddam M, Cakmak B, Yildiz Y, Rasooli R, Pekkan K, Salihoglu E. Hemodynamics of neonatal double lumen cannula malposition. Perfusion 2019; 35:306-315. [DOI: 10.1177/0267659119874697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective: Malposition of dual lumen cannula is a frequent and challenging complication in neonates and plays a significant role in shaping the in vitro device hemodynamics. This study aims to analyze the effect of the dual lumen cannula malposition on right-atrial hemodynamics in neonatal patients using an experimentally validated computational fluid dynamics model. Methods: A computer model was developed for clinically approved dual lumen cannula (13Fr Origen Biomedical, Austin, Texas, USA) oriented inside the atrium of a 3-kg neonate with normal venous return. Atrial hemodynamics and dual lumen cannula malposition were systematically simulated for two rotations (antero-atrial and atrio-septal) and four translations (two intravascular movements along inferior vena cava and two dislodged configurations in the atrium). A multi-domain compartmentalized mesh was prepared to allow the site-specific evaluation of important hemodynamic parameters. Transport of each blood stream, blood damage levels, and recirculation times are quantified and compared to dual lumen cannula in proper position. Results: High recirculation levels (39 ± 4%) in malpositioned cases resulted in poor oxygen saturation where maximum recirculation of up to 42% was observed. Apparently, Origen dual lumen cannula showed poor inferior vena cava blood–capturing efficiency (48 ± 8%) but high superior vena cava blood–capturing efficiency (86 ± 10%). Dual lumen cannula malposition resulted in corresponding changes in residence time (1.7 ± 0.5 seconds through the tricuspid). No significant differences in blood damage were observed among the simulated cases compared to normal orientation. Compared to the correct dual lumen cannula position, both rotational and translational displacements of the dual lumen cannula resulted in significant hemodynamic differences. Conclusion: Rotational or translational movement of dual lumen cannula is the determining factor for atrial hemodynamics, venous capturing efficiency, blood residence time, and oxygenated blood delivery. Results obtained through computational fluid dynamics methodology can provide valuable foresight in assessing the performance of the dual lumen cannula in patient-specific configurations.
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Affiliation(s)
- Muhammad Jamil
- Department of Mechanical Engineering, Koç University, Istanbul, Turkey
| | | | - Bilgesu Cakmak
- Department of Mechanical Engineering, Koç University, Istanbul, Turkey
| | - Yahya Yildiz
- Department of Anesthesiology and Reanimation, Medipol Mega University Hospital, Istanbul, Turkey
| | - Reza Rasooli
- Department of Mechanical Engineering, Koç University, Istanbul, Turkey
| | - Kerem Pekkan
- Department of Mechanical Engineering, Koç University, Istanbul, Turkey
| | - Ece Salihoglu
- Department of Pediatric Cardiovascular Surgery, Faculty of Medicine, Demiroğlu Bilim Üniversitesi, Istanbul, Turkey
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Intensivists Performed Percutaneous Bicaval Double-Lumen Echo-Guided Extracorporeal Membrane Oxygenation Cannulation at Bedside in Newborns and Children: A Retrospective Analysis. Pediatr Crit Care Med 2019; 20:551-559. [PMID: 30925572 DOI: 10.1097/pcc.0000000000001918] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe a single institution experience on echo-guided percutaneous bicaval double lumen extracorporeal membrane oxygenation cannulation performed at the bedside by intensivists. DESIGN Retrospective observational study. SETTING Extracorporeal membrane oxygenation team of a tertiary care children's hospital. PATIENTS All patients 0-14 years old undergoing venovenous extracorporeal membrane oxygenation from January 1, 2013, to January 1, 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirty children underwent 32 extracorporeal membrane oxygenation runs. Median age at enrollment was 2 months (interquartile range, 0-20.5 mo), 65.6% of the runs (21 patients) were performed in newborns (n = 13, 40.6%) or infants (n = 8, 25%). Median preextracorporeal membrane oxygenation index was 66.9 (interquartile range, 50-85.6). Major comorbidities were present in 50% of patients. All patients were cannulated percutaneously. In two cases cannulation occurred from the left internal jugular vein. Extracorporeal membrane oxygenation was effective in increasing pH, arterial oxygen saturation, PaO2, and lowering PaCO2. The overall differences in pre and postextracorporeal membrane oxygenation values were statistically significant, while stratifying patients according to the cannula diameter (mm)/major diameter of the cannulated internal jugular vein (mm) ratio (> 0.67 or ≤ 0.67), statistical significance was reached only for the highest ratio. Complications were observed in three runs: two cannula tip dislocations in the right atrium and one limited flow in the only case in which an Avalon cannula was not used. In 20 cases (62.5% of 32 runs), the cannulated vessel was patent at follow-up or autopsy. A ratio less than or equal to 0.67 or greater than 0.67 did not influence the occurrence rate of complications, nonpatency of the internal jugular vein, death for intracranial bleeding and death at 30 days from extracorporeal membrane oxygenation discontinuation. Overall cumulative survival at 30 days from extracorporeal membrane oxygenation discontinuation was 60% (95% CI, 40-75), with a survival advantage in the case of ratio greater than 0.67 (65%; 95% CI, 44-80 vs 25%; 95% CI, 0-60). CONCLUSIONS The described technique proved to be feasible, safe, and effective. Further investigation is needed.
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17
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Ellis WC, Schafer M, Barrett CS, Butler K, Sprowell A, Twite M, Buckvold S, Jone PN, Ing RJ. Vascular anatomical considerations and clinical decision making during insertion of the Avalon® Elite Dual Lumen single-site veno-venous ECMO cannula in children weighing less than 20 kg. Perfusion 2018; 34:267-271. [DOI: 10.1177/0267659118815104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The correct selection and placement of a single-site Avalon® Elite Dual Lumen Cannula for veno-venous extracorporeal membrane oxygenation (ECMO) in children weighing less than 20 kg is dependent on both the mechanical characteristics of the catheter, including length and diameter, as well as the unique vascular anatomic considerations of the patient. This manuscript describes the development of a clinical strategy, over a four-year period from 2012-2016, for cannula selection to reduce the risk of migration and malposition in 20 critically ill children weighing less than 20 kg who presented for veno-venous ECMO.
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Affiliation(s)
- William Cory Ellis
- Perfusion, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michal Schafer
- Cardiology, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cindy S. Barrett
- Cardiology, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
| | - Katie Butler
- Perfusion, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andrew Sprowell
- University of Colorado Medical School, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mark Twite
- Anesthesiology, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shannon Buckvold
- Cardiology, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
| | - Pei-Ni Jone
- Cardiology, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard J. Ing
- Anesthesiology, Heart Institute, Children’s Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO, USA
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18
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Yan GF, Lu GP, Lu ZJ, Chen WM. [Application of extracorporeal membrane oxygenation in children with acute respiratory distress syndrome]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:701-705. [PMID: 30210019 PMCID: PMC7389178 DOI: 10.7499/j.issn.1008-8830.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/27/2018] [Indexed: 06/08/2023]
Abstract
The children with acute respiratory distress syndrome (ARDS) usually require ventilatory support treatment. At present, lung protective ventilation strategy is recommended for the treatment of ARDS. Extracorporeal membrane oxygenation (ECMO) can improve oxygenation and remove carbon dioxide by extracorporeal circuit, and can partially or completely take over cardiopulmonary function. ECMO support showed many advantages in treating severe ARDS, such as reducing ventilator-induced lung injury and correcting hypoxemia. Over the past few years, there has been an increase in the use of ECMO for ARDS in children. This paper reviews the applications of ECMO for the treatment of ARDS in children.
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Affiliation(s)
- Gang-Feng Yan
- Department of Pediatric Emergency and Critical Care Medicine, Children's Hospital of Fudan University, Shanghai 201102, China.
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19
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Chen Z, Mondal NK, Zheng S, Koenig SC, Slaughter MS, Griffith BP, Wu ZJ. High shear induces platelet dysfunction leading to enhanced thrombotic propensity and diminished hemostatic capacity. Platelets 2017; 30:112-119. [PMID: 29182470 DOI: 10.1080/09537104.2017.1384542] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Thrombosis and bleeding are devastating adverse events in patients supported with blood-contacting medical devices (BCMDs). In this study, we delineated that high non-physiological shear stress (NPSS) caused platelet dysfunction that may contribute to both thrombosis and bleeding. Human blood was subjected to NPSS with short exposure time. Levels of platelet surface GPIbα and GPVI receptors as well as activation level of GPIIb/IIIa in NPSS-sheared blood were examined with flow cytometry. Adhesion of sheared platelets on fibrinogen, von Willibrand factor (VWF), and collagen was quantified with fluorescent microscopy. Ristocetin- and collagen-induced platelet aggregation was characterized by aggregometry. NPSS activated platelets in a shear and exposure time-dependent manner. The number of activated platelets increased with increasing levels of NPSS and exposure time, which corresponded well with increased adhesion of sheared platelets on fibrinogen. Concurrently, NPSS caused shedding of GPIbα and GPVI in a manner dependent on shear and exposure time. The loss of intact GPIbα and GPVI increased with increasing levels of NPSS and exposure time. The number of platelets adhered on VWF and collagen decreased with increasing levels of NPSS and exposure time, respectively. The decrease in the number of platelets adhered on VWF and collagen corresponded well with the loss in GPIbα and GPVI on platelet surface. Both ristocetin- and collagen-induced platelet aggregation in sheared blood decreased with increasing levels of NPSS and exposure time. The study clearly demonstrated that high NPSS causes simultaneous platelet activation and receptor shedding, resulting in a paradoxical effect on platelet function via two distinct mechanisms. The results from the study suggested that the NPSS could induce the concurrent propensity for both thrombosis and bleeding in patients.
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Affiliation(s)
- Zengsheng Chen
- a Department of Surgery , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Nandan K Mondal
- b Department of Cardiovascular and Thoracic Surgery , School of Medicine, University of Louisville , Louisville , KY , USA
| | - Shirong Zheng
- b Department of Cardiovascular and Thoracic Surgery , School of Medicine, University of Louisville , Louisville , KY , USA
| | - Steven C Koenig
- b Department of Cardiovascular and Thoracic Surgery , School of Medicine, University of Louisville , Louisville , KY , USA.,c Department of Bioengineering , Speed School of Engineering, University of Louisville , Louisville , KY , USA
| | - Mark S Slaughter
- b Department of Cardiovascular and Thoracic Surgery , School of Medicine, University of Louisville , Louisville , KY , USA
| | - Bartley P Griffith
- a Department of Surgery , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Zhongjun J Wu
- a Department of Surgery , University of Maryland School of Medicine , Baltimore , MD , USA.,d Fischell Department of Bioengineering , A. James Clark School of Engineering, University of Maryland , College Park , MD , USA
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Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has saved thousands of newborns. Population comparisons for research and quality initiatives require risk-matching, but no indices exist for this population. We sought to create a pre-ECMO risk index using the registry data from the Extracorporeal Life Support Organization. We analyzed 5,455 neonatal (<30 days old) respiratory VA-ECMO patients for the period 2000-2010. Multivariate regression examining the impact of pre-ECMO variables on survival to hospital discharge was performed to create the Pittsburgh Index for Pre-ECMO Risk (PIPER), which was ultimately was based on seven pre-ECMO variables. Each PIPER quartile demonstrated increasing mortality by 15% (R = 0.98) and was associated with increased complications on ECMO. Further modeling to include on-ECMO complications (PIPER), including complications and length of time on ECMO, increased the predictive power of the model, with 21% increases in mortality per PIPER quartile (R = 0.97). Our developed indices provide the first steps towards risk-adjusting patients for meaningful comparisons amongst patient populations. There may be additional clinically relevant measures, both pre- and on-ECMO, which could provide better predictive capability. Future work will focus on finding these additional measures and expansion of our techniques to include other patient populations.
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21
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Jarboe MD, Gadepalli SK, Church JT, Arnold MA, Hirschl RB, Mychaliska GB. Avalon catheters in pediatric patients requiring ECMO: Placement and migration problems. J Pediatr Surg 2017; 53:S0022-3468(17)30658-9. [PMID: 29092770 DOI: 10.1016/j.jpedsurg.2017.10.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The Avalon dual-lumen venovenous catheter has several advantages, but placement techniques and management have not been adequately addressed in the pediatric population. We assessed our institutional outcomes and complications using the Avalon catheter in children. METHODS We reviewed all pediatric patients who had Avalon catheters placed for respiratory failure at our institution, excluding congenital heart disease patients, from April 2009 to March 2016. All patients were managed using our standard ECMO protocol, and cannula position was followed by daily chest x-ray and intermittent echocardiography (ECHO). Data included demographics, diagnosis, PRISM3 predicted mortality, ECMO duration, complications, and survival. The primary outcome was the need for catheter repositioning. RESULTS Twenty-five patients were included, with mean age 8.3±6.9years and 15±22days of ECMO support. Overall survival was 68% (17/25). Fourteen patients (56%) underwent placement with fluoroscopy in addition to ultrasound and ECHO, primarily after 2013. Overall, thirteen patients (52%) had problems with cannula malposition. 9 of these (69%) required cannula repositioning. Three of 14 (21%) cannulas placed with fluoroscopy required repositioning, compared to 7/11 (64%) placed without fluoroscopy (p=0.05). CONCLUSIONS Complications are common with the Avalon catheter in children. Safe percutaneous access requires ultrasound guidance, and use of intraoperative fluoroscopy in addition to echocardiography decreases malposition rates. LEVEL OF EVIDENCE IV (Prognosis study).
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Affiliation(s)
- Marcus D Jarboe
- Pediatric Surgery, Department of Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan, Ann Arbor, MI, USA.
| | - Samir K Gadepalli
- Pediatric Surgery, Department of Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Joseph T Church
- Pediatric Surgery, Department of Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Meghan A Arnold
- Pediatric Surgery, Department of Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ronald B Hirschl
- Pediatric Surgery, Department of Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - George B Mychaliska
- Pediatric Surgery, Department of Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan, Ann Arbor, MI, USA
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22
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Kanao-Kanda M, Kunisawa T, Yamamoto K, Kanda H, Iwasaki H. Successful administration of venovenous extracorporeal membrane oxygenation through the modified Blalock-Taussig operation in an infant with graft dysfunction after the Norwood procedure. Ther Clin Risk Manag 2015; 11:1579-80. [PMID: 26508866 PMCID: PMC4610770 DOI: 10.2147/tcrm.s95408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Megumi Kanao-Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takayuki Kunisawa
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kunihiko Yamamoto
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiroshi Iwasaki
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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23
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Emergency percutaneous, bicaval double-lumen, ECMO cannulation in neonates and infants: insights from three consecutive cases. Int J Artif Organs 2015; 38:517-21. [PMID: 26428509 DOI: 10.5301/ijao.5000432] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation (ECMO) is probably the preferable configuration to assist children with respiratory failure who do not respond to maximized conventional therapies. The single-vessel, double-lumen approach through the internal jugular vein is extremely advantageous, especially in infants, where femoral access presents limitations related to the small dimensions of the veins. In case of emergencies, ECMO might need to be started at the bedside, without the availability of fluoroscopic guidance. To our knowledge, a completely percutaneous approach has not been reported before in children younger than 1 year and weighing less than 5 kg. METHODS We describe 3 cases of emergency bedside, percutaneous, bicaval double-lumen cannulation under real-time transthoracic ultrasound control in 2 neonates and 1 infant. RESULTS In our experience, this approach proved to be safe, effective and time saving, while minimizing bleeding from the cannula insertion site. Cannulation times, from decision making to the beginning of ECMO flow, were 30, 28, 25 minutes respectively, from patient 1 to 3. We do not report any cannula-related injury to vessels and heart structures. CONCLUSIONS Our preliminary data suggest that, with the described precautions, percutaneous, echo-guided, bicaval double-lumen cannulation in neonates and infants could be effective and free from major complications. Further evaluation should be warranted in the neonatal population.
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Geiger JD, Hirschl RB. Innovation in surgical technology and techniques: Challenges and ethical issues. Semin Pediatr Surg 2015; 24:115-21. [PMID: 25976146 DOI: 10.1053/j.sempedsurg.2015.02.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The pace of medical innovation continues to increase. The deployment of new technologies in surgery creates many ethical challenges including how to determine safety of the technology, what is the timing and process for deployment of a new technology, how are patients informed before undergoing a new technology or technique, how are the outcomes of a new technology evaluated and how are the responsibilities of individual patients and society at large balanced. Ethical considerations relevant to the implementation of ECMO and robotic surgery are explored to further discussion of how we can optimize the delicate balance between innovation and regulation.
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Affiliation(s)
- James D Geiger
- Michigan Pediatric Device Consortium, University of Michigan, CS Mott Children's Hospital, Ann Arbor, 1540 E Hospital Dr SPC 4211, Michigan 48109.
| | - Ronald B Hirschl
- Section of Pediatric Surgery, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Michigan
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Zamora IJ, Shekerdemian L, Fallon SC, Olutoye OO, Cass DL, Rycus PL, Burgman C, Lee TC. Outcomes comparing dual-lumen to multisite venovenous ECMO in the pediatric population: the Extracorporeal Life Support Registry experience. J Pediatr Surg 2014; 49:1452-7. [PMID: 25280645 DOI: 10.1016/j.jpedsurg.2014.05.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 04/15/2014] [Accepted: 05/19/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study is to evaluate outcomes associated with single site dual-lumen venovenous cannulas (VVDL) and to compare them to those associated with multisite VV ECMO (VVMS) cannulation. METHODS The Extracorporeal Life Support (ELSO) Registry was reviewed to identify all children 31days to 18years treated with venovenous ECMO from 1998 to 2011 using either VVDL or VVMS techniques. Patient demographics, cannula type, ECMO variables, complications, and patient survival were analyzed. RESULTS From 1998 to 2011, 1323 children underwent venovenous ECMO. The annual utilization of VVDL cannulas has increased and recently surpassed VVMS. Fifty-four percent (n=717) of patients had VVDL cannulation. This group was significantly younger and weighed less than the VVMS group. VVDL cannulas demonstrated improved weight-adjusted flow performance than traditional cannulation. Overall survival was comparable, 64.4% and 68.6%, for VVMS and VVDL respectively. VVDL cannulas experienced higher mechanical (26.2% vs. 22.5%; p=0.004) and cardiovascular complications rates (24.4% vs. 21.7%; p=0.03) than VVMS cannulas, but when stratified by VVDL cannula type, there were no differences between wire-reinforced and non-wire reinforced cannulas. CONCLUSIONS VVDL cannulation has become the preferred modality for ECMO therapy in children with respiratory failure and it is mainly utilized in younger patients. The use of newer VVDL cannulas may provide improved pump flow performance without substantial additional risk.
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Affiliation(s)
- Irving J Zamora
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Lara Shekerdemian
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Oluyinka O Olutoye
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Darrell L Cass
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Peter L Rycus
- Extracorporeal Life Support Organization (ELSO), Ann Arbor, MI
| | - Cole Burgman
- Division of Respiratory Care, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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Berdajs D. Bicaval dual-lumen cannula for venovenous extracorporeal membrane oxygenation: Avalon© cannula in childhood disease. Perfusion 2014; 30:182-6. [DOI: 10.1177/0267659114544714] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Severe acute refractory respiratory failure is considered a life-threatening situation, with a high mortality of 40 to 60%. When conservative oxygenation methods fail, a lifesaving measure is the introduction of extracorporeal membrane oxygenation (ECMO). Venovenous ECMO (VV-ECMO) is a preferred modality of support for patients with refractory acute respiratory failure. Specifically, bicaval VV-ECMO is a well-recognized and validated therapy, where single or double periphery venous access is used for the insertion of two differently sized cannulas in order to achieve adequate blood oxygenation. Compared to venoarterial ECMO, in VV-ECMO, the rate of complications, such as thrombosis, bleeding, infection and ischemic events, is lower. On the other hand, the size and insertion location is an obstacle to patient mobilization. This is a considerable problem for patients where the time interval for lung recovery and the bridge to the transplantation is prolonged. To address this issue, a dual-lumen, single venovenous cannula was introduced. Here, by insertion of one single catheter in one target vessel, in a majority of cases in the right internal jugular vein, satisfactory oxygenation of the patient is achieved. In this form, the instituted VV-ECMO enables patient mobility, better physical rehabilitation and facilitates pulmonary extubation and toilet. However, relatively early, after the first short-term reports were published, a relatively high complication rate became evident. In the recent literature, the complication rate using actual commercially available double-lumen venovenous cannula ranges between 5 and 30%. These cases were mostly conjoined to the implantation phase or the early postoperative phase and vary between right heart perforation to migration of the cannula. This review focuses on complications allied to commercially available dual-lumen, single, venovenous cannula implantation, pointing out the critical segments of the implantation process and analyzing the structure of the device.
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Affiliation(s)
- D Berdajs
- Department of Cardiovascular Surgery, University Hospital Lausanne, Lausanne, Switzerland
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27
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Speggiorin S, Robinson SG, Harvey C, Westrope C, Faulkner GM, Kirkland P, Peek GJ. Experience with the Avalon® bicaval double-lumen veno-venous cannula for neonatal respiratory ECMO. Perfusion 2014; 30:250-4. [PMID: 24972812 DOI: 10.1177/0267659114540020] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We report a single centre experience of neonatal respiratory ECMO using the Avalon® double-lumen venous cannula and compare it with reports in the literature. RESULTS Between 2008 and 2012, the Avalon® cannula was used in 72 neonates: median age at cannulation was 1.8 days (IQR 1.2-2.8 days) and bodyweight 3.4 Kg (3.0-3.7 Kg). Meconium aspiration syndrome (61.1%), persistent hypertension of the newborn (25%) and congenital diaphragmatic hernia (5.6%) were the most common diagnoses. Complications occurred in 19 patients (26.4%): cannula site bleeding in 6 (8.3%), the cannula perforating the right atrial wall and requiring emergency midline sternotomy in 5 (6.9%) and the cannula needing repositioning in 3 (4.2%). Overall survival at discharge or transfer to the referring hospital was 88.8%. Successful wean off ECMO occurred in 68 patients (94.4%) after a median of 90.5 hours (63.4-136.11). ECMO support was withdrawn in 4 patients (5.6%). CONCLUSIONS The Avalon® dual-lumen veno-venous cannula can be used for respiratory ECMO in the neonatal population. However, as the incidence of right atrial perforation is not negligible, we suspended its used in this group of patients.
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Affiliation(s)
- S Speggiorin
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - S G Robinson
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - C Harvey
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - C Westrope
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - G M Faulkner
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - P Kirkland
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - G J Peek
- Heartlink ECMO Centre, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
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A case of avalon cannula malposition and successful conversion to V-A ECMO in a neonate. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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29
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Increased risk of cardiovascular perforation during ECMO with a bicaval, wire-reinforced cannula. J Pediatr Surg 2014; 49:46-49; discussion 49-50. [PMID: 24439579 DOI: 10.1016/j.jpedsurg.2013.09.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 09/30/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE Cardiac or major vascular perforation is a rare but serious risk of ECMO. We sought to determine if perforation rates are related to cannula design. METHODS We utilized three methods to evaluate perforation on ECMO. 1. The ELSO registry was queried to establish the historical rate of hemorrhagic pericardial tamponade. 2. ELSO centers were surveyed regarding cannula related perforation events and brands of cannulas used over a four year time period (January 2008-March 2012). 3. The FDA's MAUDE database was reviewed looking for adverse events related to ECMO cannulas. RESULTS The historical rate of hemorrhagic pericardial tamponade in the ELSO registry was 0.53% (~1985-2010, ELSO registry). In the survey there were eleven reports of cannula-related perforation, 0.74% (11/1482 p-value=0.29) at 7 different ELSO centers with 23 ELSO centers responding (17% response rate). The incidence of perforation was much higher for the wire-reinforced bicaval design 3.6% (10/279) as compared to catheters designed for the atrial position, 0.1% (1/1203, p-value<0.0001). Review of the FDA's MAUDE database revealed 19 adverse events related to the bicaval cannula design, 16 of which were hemorrhagic pericardial effusions or tamponade. CONCLUSION These findings suggest a relatively high rate of cardiac perforation associated with the dual lumen bicaval cannula. This may be related to inherent differences in cannula design or the IVC positioning required by the design.
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Maslach-Hubbard A, Bratton SL. Extracorporeal membrane oxygenation for pediatric respiratory failure: History, development and current status. World J Crit Care Med 2013; 2:29-39. [PMID: 24701414 PMCID: PMC3953872 DOI: 10.5492/wjccm.v2.i4.29] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 09/21/2013] [Accepted: 10/18/2013] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is currently used to support patients of all ages with acute severe respiratory failure non-responsive to conventional treatments, and although initial use was almost exclusively in neonates, use for this age group is decreasing while use in older children remains stable (300-500 cases annually) and support for adults is increasing. Recent advances in technology include: refinement of double lumen veno-venous (VV) cannulas to support a large range of patient size, pumps with lower prime volumes, more efficient oxygenators, changes in circuit configuration to decrease turbulent flow and hemolysis. Veno-arterial (VA) mode of support remains the predominant type used; however, VV support has lower risk of central nervous injury and mortality. Key to successful survival is implementation of ECMO before irreversible organ injury develops, unless support with ECMO is used as a bridge to transplant. Among pediatric patients treated with ECMO mortality varies by pulmonary diagnosis, underlying condition, other non-pulmonary organ dysfunction as well as patient age, but has remained relatively unchanged overall (43%) over the past several decades. Additional risk factors associated with death include prolonged use of mechanical ventilation (> 2 wk) prior to ECMO, use of VA ECMO, older patient age, prolonged ECMO support as well as complications during ECMO. Medical evidence regarding daily patient management specifically related to ECMO is scant, it usually mirrors care recommended for similar patients treated without ECMO. Linkage of the Extracorporeal Life Support Organization dataset with other databases and collaborative research networks will be required to address this knowledge deficit as most centers treat only a few pediatric respiratory failure patients each year.
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Fallon SC, Cass DL, Olutoye OO, Zamora IJ, Lazar DA, Larimer EL, Welty SE, Moise AA, Demny AB, Lee TC. Repair of congenital diaphragmatic hernias on Extracorporeal Membrane Oxygenation (ECMO): does early repair improve patient survival? J Pediatr Surg 2013; 48:1172-6. [PMID: 23845603 DOI: 10.1016/j.jpedsurg.2013.03.008] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 03/08/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The optimal timing of repair for congenital diaphragmatic hernia (CDH) patients that require ECMO is controversial. Early repair on ECMO theoretically allows for restoration of normal thoracic anatomy but entails significant bleeding risks. The purpose of this study was to examine the institutional outcomes of early CDH repair on ECMO. METHODS The records of infants with CDH placed on ECMO from 2001 to 2011 were reviewed. Since 2009, a protocol was instituted for early repair while on ECMO. For this study, three cohorts were analyzed: early repair (<72 h), late repair (>72 h), and post-decannulation. These groups were compared for outcomes regarding morbidity and survival. RESULTS Forty-six CDH patients received ECMO support with an overall survival of 53%. Twenty-nine patients (11 early/18 late) were repaired on ECMO, while 17 patients had repair post-decannulation. Survival was 73%, 50%, and 64% for those repaired early, late, or post-decannulation, respectively. Despite significantly worse prenatal factors, patients repaired early on ECMO had a similar survival. When comparing patients repaired on ECMO, the early group patients were decannulated 6 days earlier (p-value=0.009) and had significantly lower circuit complications (p=0.03). CONCLUSION In conclusion, early repair on ECMO was associated with decreased ECMO duration, decreased circuit complications, and a trend towards improved survival.
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Affiliation(s)
- Sara C Fallon
- Texas Children's Fetal Center, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Initial experience with single-vessel cannulation for venovenous extracorporeal membrane oxygenation in pediatric respiratory failure. Pediatr Crit Care Med 2013; 14:366-73. [PMID: 23548959 PMCID: PMC5800497 DOI: 10.1097/pcc.0b013e31828a70dc] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Venovenous extracorporeal membrane oxygenation has been used to provide cardiopulmonary support in critically ill infants and children. Recently, dual-lumen venovenous extracorporeal membrane oxygenation has gained popularity in the pediatric population. Herein, we report our institutional experience using a bicaval dual-lumen catheter for pediatric venovenous extracorporeal membrane oxygenation support, which has been our unified approach for venovenous extracorporeal membrane oxygenation since 2009. DESIGN This study is a retrospective review. SETTING The setting is a tertiary children's hospital in a major metropolitan area. PATIENTS Between 2009 and 2011, 11 patients were cannulated using a dual-lumen bicaval venous catheter. Patient demographics, cannulation details, circuit complications, complications of catheter use, and patient outcomes were collected from a retrospective chart review. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eleven of the patients were cannulated for venovenous extracorporeal membrane oxygenation using the dual-lumen bicaval cannula. The median age at the time of venovenous cannulation was 1.9 years (range, 0.14-17.1), and the median weight was 10.2 kg (range, 3-84). Three patients (27%) required conversion to venoarterial extracorporeal membrane oxygenation. The median duration of extracorporeal membrane oxygenation support was 10 days (2-38 days). Fifty-five percent of patients suffered from a bleeding complication (disseminated intravascular coagulation, pulmonary hemorrhage, or intraventricular hemorrhage), and 45% had a circuit complication. Adequate flow rates were achieved in all patients. The overall hospital mortality in the series was 55%. There were no cannula-related complications. CONCLUSIONS This review presents the first single-institution experience with the dual-lumen Avalon cannula in pediatric patients. Preliminary results indicate that the catheter can be safely placed and has an acceptable complication profile; however, continued study within larger trials is necessary to fully ascertain the clinical profile of this catheter.
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Bicaval approach to venovenous extracorporeal membrane oxygenation in children: just do it... carefully. Pediatr Crit Care Med 2013; 14:436-7. [PMID: 23648875 DOI: 10.1097/pcc.0b013e31828a8306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hori D, Noguchi K, Nomura Y, Tanaka H. Extracorporeal membrane oxygenation with double venous drainage. Ann Thorac Cardiovasc Surg 2013; 20 Suppl:836-8. [PMID: 23445789 DOI: 10.5761/atcs.cr.12.01993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report on a successful configuration strategy of extracorporeal membrane oxygenation(ECMO) in two consecutive cases of acute lung injury. A 60-year-old woman with Streptococcus pneumoniae infection and a 22-year-old man with hemothorax were admitted to our hospital with failing lungs. Although treatment with a ventilator was started, oxygenation could not be maintained. ECMO with a femoro-femoral circuit was performed, which showed a slight improvement in oxygenation. However, not enough oxygen support was provided. To minimize the venous mixture at the right atrium, we added venous drainage from the right jugular vein which resulted in better oxygenation and patient survival.
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Affiliation(s)
- Daijiro Hori
- Department of Cardiovascular Surgery, Fujigaoka Hospital, Showa University, Yokohama, Kanagawa, Japan
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Hayes RA, Shekar K, Fraser JF. Is hyperoxaemia helping or hurting patients during extracorporeal membrane oxygenation? Review of a complex problem. Perfusion 2013; 28:184-93. [DOI: 10.1177/0267659112473172] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) facilitates organ support in patients with refractory cardiorespiratory failure whilst disease-modifying treatments can be administered. Improvements to the ECMO process have resulted in its increased utilisation. However, iatrogenic injuries remain, with bleeding and thrombosis the most significant concerns. Many factors contribute to the formation of thrombi, with the hyperoxaemia experienced during ECMO a potential contributor. Outside of ECMO, emerging evidence associates hyperoxaemia with increased mortality. Currently, no universal definition of hyperoxaemia exists, a gap in clinical standards that may impact patient outcomes. Hyperoxaemia has the potential to induce platelet activation, aggregation and, subsequently, thrombosis through markedly increasing the production of reactive oxygen species. There are minimal data in the current literature that explore the relationship between ECMO-induced hyperoxaemia and the production of reactive oxygen species – a putative link towards pathology. Furthermore, there is limited research directly linking hyperoxaemia and platelet activation. These are areas that warrant investigation as definitive data regarding the nascence of these pathological processes may delineate and define the relative risk of supranormal oxygen tension. These data could then assist in defining optimal oxygenation practice, reducing the risks associated with extracorporeal support.
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Affiliation(s)
- RA Hayes
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - K Shekar
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - JF Fraser
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia
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Pressure-guided positioning of bicaval dual-lumen catheters for venovenous extracorporeal gas exchange. Intensive Care Med 2012; 39:151-4. [DOI: 10.1007/s00134-012-2751-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 10/29/2012] [Indexed: 11/27/2022]
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