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Morales Castro D, Ferreyro BL, McAlpine D, Evangelatos N, Dragoi L, Teijeiro-Paradis R, Del Sorbo L, Fan E, Douflé G. Echocardiographic Findings in Critically Ill COVID-19 Patients Treated With and Without Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00524-X. [PMID: 39198124 DOI: 10.1053/j.jvca.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/30/2024] [Accepted: 08/04/2024] [Indexed: 09/01/2024]
Abstract
OBJECTIVES To describe echocardiographic findings among mechanically ventilated patients with COVID-19 acute respiratory distress syndrome, comparing those with and without venovenous extracorporeal membrane oxygenation (VV ECMO) support. DESIGN Single-center, retrospective cohort study. SETTING Intensive care unit (ICU) of a quaternary academic center. PARTICIPANTS Patients with COVID-19 admitted between March 2020 and June 2021 receiving mechanical ventilation, with an echocardiogram within 72 hours of admission. INTERVENTIONS Admission and follow-up echocardiograms during ICU stay. MEASUREMENTS Patient characteristics and echocardiographic findings were analyzed. Mortality odds ratio (OR) for right ventricular (RV) systolic dysfunction and acute cor pulmonale (ACP) was calculated. MAIN RESULTS Among 242 patients, 145 (60%) received VV ECMO. Median (IQR) PaO2/FiO2 was 76 (65-95) and 98 (85-140) in ECMO and non-ECMO patients, respectively (p ≤ 0.001). Initial echocardiograms showed no significant differences in left ventricular systolic dysfunction (10% v 15 %, p = 0.31) and RV systolic dysfunction (38% v. 27%, p = 0.27) between ECMO and non-ECMO patients. ACP was more frequent in the ECMO group at baseline (41% v. 26 %, p = 0.02). During the ICU stay, patients on ECMO exhibited a higher prevalence of RV systolic dysfunction (55% v 34%, p = 0.001) and ACP (51% v 26%, p = 0.002). RV systolic dysfunction (OR 1.99; 95% CI 1.09-3.63) and ACP (OR 2.95; 95% CI 1.55-5.62) on the follow-up echocardiograms were associated with higher odds of ICU mortality. CONCLUSIONS The prevalence of echocardiographic abnormalities, in particular RV dysfunction, was frequent among patients with COVID-19 receiving VV ECMO support and was associated with worse clinical outcomes.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - David McAlpine
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaos Evangelatos
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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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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Castro DM, Morris I, Teijeiro-Paradis R, Fan E. Monitoring during extracorporeal membrane oxygenation. Curr Opin Crit Care 2022; 28:348-359. [PMID: 35275878 DOI: 10.1097/mcc.0000000000000939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) offers advanced mechanical support to patients with severe acute respiratory and/or cardiac failure. Ensuring an adequate therapeutic approach as well as prevention of ECMO-associated complications, by means of timely liberation, forms an essential part of standard ECMO care and is only achievable through continuous monitoring and evaluation. This review focus on the cardiorespiratory monitoring tools that can be used to assess and titrate adequacy of ECMO therapy; as well as methods to assess readiness to wean and/or discontinue ECMO support. RECENT FINDINGS Surrogates of tissue perfusion and near infrared spectroscopy are not standards of care but may provide useful information in select patients. Echocardiography allows to determine cannulas position, evaluate cardiac structures, and function, and diagnose complications. Respiratory monitoring is mandatory to achieve lung protective ventilation and identify early lung recovery, surrogate measurements of respiratory effort and ECMO derived parameters are invaluable in optimally managing ECMO patients. SUMMARY Novel applications of existing monitoring modalities alongside evolving technological advances enable the advanced monitoring required for safe delivery of ECMO. Liberation trials are necessary to minimize time sensitive ECMO related complications; however, these have yet to be standardized.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Idunn Morris
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Discipline of Intensive Care Medicine, Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Institute of Health Policy, Management and Evaluation
- Department of Medicine, University of Toronto, Toronto, Canada
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AlKhalifah AS, AlJassim NA. Venovenous extra corporeal life support in an infant with foreign body aspiration: A case report. Respir Med Case Rep 2022; 37:101636. [PMID: 35330590 PMCID: PMC8938911 DOI: 10.1016/j.rmcr.2022.101636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/28/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022] Open
Abstract
Background Foreign body aspiration (FBA) is a life-threatening emergency and a common cause of morbidity and morbidity in children. FBA can lead to rapidly progressive respiratory failure. Stabilizing patients after FBA for bronchoscopic removal of the aspirated object can be complex and may necessitate advanced support such as high-frequency oscillatory ventilation (HFOV) or extracorporeal membrane oxygenation (ECMO). This case report presents the feasibility of using ultrasound (US) in percutaneous catheterization in infants and the benefit of using venovenous ECMO (VV-ECMO) as rescue therapy in FBA. Case summary A 10-month-old girl accidently aspirated a metallic piece that was dislodged further to the right main bronchus after failed trials to remove it. She was intubated and mechanically ventilated, complicated by milk aspiration and bilateral pneumothoraces secondary to high-pressure lung ventilation. She had refractory mixed respiratory failure despite high settings of HFOV and inhaled nitric oxide. Venovenous ECMO (VV-ECMO) was initiated for stabilization and a bridge for bronchoscopic foreign body removal and awaiting lung recovery. She was weaned off ECMO after 166 hours. The patient was extubated after a few days and discharged home 28 days after admission without clinical evidence of neurological or respiratory complications. ECMO has been described in the literature as rescue therapy for FBA resulting in respiratory failure. However, ECMO cannulation in children under these circumstances is challenging because of vessel size restrictions. Two-vessel cannulation or dual-lumen cannulation are available options via open cut-down or percutaneous cannulation techniques, depending on the general expertise. The use of vascular ultrasound to assess vessel size is a helpful tool for cannulating infants. Conclusion VV-ECMO support is expanding for respiratory failure in pediatric patients. Percutaneous cannulation in infants and children for VV-ECMO is safe and feasible.
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5
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesth Analg 2021; 133:1459-1477. [PMID: 34559089 DOI: 10.1213/ane.0000000000005738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
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Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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6
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Mazzeffi MA, Rao VK, Dodd-O J, Rio JMD, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 35:3496-3512. [PMID: 34774252 DOI: 10.1053/j.jvca.2021.07.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
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Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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7
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[Intraoperative transesophageal echocardiography as monitoring procedure in noncardiac surgery patients]. Anaesthesist 2021; 70:1059-1072. [PMID: 34762164 DOI: 10.1007/s00101-021-01035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 11/27/2022]
Abstract
Transesophageal echocardiography (TEE) is firmly established in cardiac surgery for diagnostics, hemodynamic monitoring and as a guiding tool. Dynamic and (patho)physiological processes of the heart can be immediately depicted. Ideally, therapeutic changes can be derived. For this reason, TEE is increasingly used in high-risk non-cardiac surgery interventions and in the interventional setting. In the first part of this advanced training series, general aspects regarding TEE examinations as well as indications and contraindications are presented. Clinical fields of application, where TEE can play a role in hemodynamic monitoring are outlined. The second part focusses on an emergency examination pathway and differential diagnoses, which can be made in the event of intraoperative hemodynamic instability or unexplained hypoxemia using TEE. The article concludes with an outlook on the use of computer-aided evaluation of TEE images.
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8
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B, Vicente Guillén R. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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9
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez AI, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B, Vicente Guillén R. SEDAR/SECCE ECMO management consensus document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:443-471. [PMID: 34535426 DOI: 10.1016/j.redare.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/14/2020] [Indexed: 06/13/2023]
Abstract
ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.
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Affiliation(s)
- I Zarragoikoetxea
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - I Moreno
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J Porta
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - T Koller
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - V Cegarra
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A I Gonzalez
- Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain
| | - M Eiras
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain
| | - E Sandoval
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Aurelio Sarralde
- Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - B Quintana-Villamandos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Yu X, Gu S, Li M, Zhan Q. Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration. Front Med (Lausanne) 2021; 8:682526. [PMID: 34277659 PMCID: PMC8282255 DOI: 10.3389/fmed.2021.682526] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/01/2021] [Indexed: 01/18/2023] Open
Abstract
With the goal of protecting injured lungs and extrapulmonary organs, venovenous extracorporeal membrane oxygenation (VV-ECMO) has been increasingly adopted as a rescue therapy for patients with severe acute respiratory distress syndrome (ARDS) when conventional mechanical ventilation failed to provide effective oxygenation and decarbonation. In recent years, it has become a promising approach to respiratory support for awake, non-intubated, spontaneously breathing patients with respiratory failure, referred to as awake ECMO, to avoid possible detrimental effects associated with intubation, mechanical ventilation, and the adjunctive therapies. However, several complex clinical issues should be taken into consideration when initiating and implementing awake ECMO, such as selecting potential patients who appeared to benefit most; techniques to facilitating cannulation and maintain stable ECMO blood flow; approaches to manage pain, agitation, and delirium; and approaches to monitor and modulate respiratory drive. It is worth mentioning that there had also been some inherent disadvantages and limitations of awake ECMO compared to the conventional combination of ECMO and invasive mechanical ventilation. Here, we review the use of ECMO in awake, spontaneously breathing patients with severe ARDS, highlighting the issues involving bedside clinical practice, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.
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Affiliation(s)
- Xin Yu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Sichao Gu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
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Hemamalini P, Dutta P, Attawar S. Transesophageal Echocardiography Compared to Fluoroscopy for Avalon Bicaval Dual-Lumen Cannula Positioning for Venovenous ECMO. Ann Card Anaesth 2021; 23:283-287. [PMID: 32687083 PMCID: PMC7559967 DOI: 10.4103/aca.aca_75_19] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The Avalon elite bicaval dual-lumen cannula for single site VenoVenous Extracorporeal Membrane Oxygenation (VV ECMO) offers several advantages. Correct placement of the Avalon cannula is safe using image guidance and needs either fluoroscopy or Transesophageal echocardiography (TEE). We assessed our institutional ECMO performance, cannulation related complications, instances of cannula malposition among patients cannulated using the two imaging modalities. We reviewed all patients who had Avalon cannula placement for VV ECMO at our institute. Ten patients were included in the study. Patients were cannulated using either fluoroscopy (Group A, n = 5) or TEE (Group B, n = 5). Data included patient demographics, diagnosis, evidence of cannula malposition, ECMO performance, cannulation related complications. The primary outcomes ease of cannulation; cannula malposition and the need for repositioning were compared between the two groups. Visualisation of guidewire, Avalon cannula and the average number of attempts to cannulate were similar (P > 0.05) between the two groups. Four patients cannulated using fluoroscopy had low flows whereas none of the patients cannulated using TEE had flow problems which was statistically significant (P = 0.024). Four cannulas (80%) placed under fluoroscopy required repositioning whereas one cannula (20%) placed under TEE needed repositioning. This difference was not statistically significant though (P = 0.099). TEE is the ideal imaging modality to guide Avalon elite cannula placement for VV ECMO.
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Affiliation(s)
- P Hemamalini
- Department of Cardiac Anesthesia, Institute of Heart and Lung Transplantation, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Prabhat Dutta
- Department of Anesthesia and Critical Care, Institute of Heart and Lung Transplantation, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Sandeep Attawar
- Department of Cardiac Sciences Thoracic Organ Transplants, Institute of Heart and Lung Transplantation, Gleneagles Global Health City, Chennai, Tamil Nadu, India
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12
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Tonna JE, Abrams D, Brodie D, Greenwood JC, Rubio Mateo-Sidron JA, Usman A, Fan E. Management of Adult Patients Supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO). ASAIO J 2021; 67:601-610. [PMID: 33965970 PMCID: PMC8315725 DOI: 10.1097/mat.0000000000001432] [Citation(s) in RCA: 254] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Disclaimer: The use of venovenous extracorporeal membrane oxygenation (VV ECMO) in adults has rapidly increased worldwide. This ELSO guideline is intended to be a practical guide to patient selection, initiation, cannulation, management, and weaning of VV ECMO for adult respiratory failure. This is a consensus document which has been updated from the previous version to provide guidance to the clinician.
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Affiliation(s)
- Joseph E Tonna
- From the Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - John C Greenwood
- Department of Anesthesiology and Critical Care, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Asad Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network and Sinai Health System, Toronto, Canada
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Carlier L, Devroe S, Budts W, Van Calsteren K, Rega F, Van de Velde M, Rex S. Cardiac interventions in pregnancy and peripartum – a narrative review of the literature. J Cardiothorac Vasc Anesth 2020; 34:3409-3419. [DOI: 10.1053/j.jvca.2019.12.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/19/2019] [Accepted: 12/12/2019] [Indexed: 12/17/2022]
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Semiquantification of Systemic Venous Admixture During Venovenous Extracorporeal Oxygenation Via Bicaval Double-Lumen Cannula in Critically Ill Patients. ASAIO J 2020; 66:23-31. [PMID: 30601181 DOI: 10.1097/mat.0000000000000943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is increasingly utilized in acute reversible cases of severe respiratory failure and as a bridge to lung transplantation. Venovenous extracorporeal membrane oxygenation using a bicaval double-lumen cannula (BCDLC) has several advantages over the traditional ECMO configuration; however, it also presents with several unique challenges. The assessment and quantification of venous admixture is difficult due to the specific position of BCDLC within the circulatory system. We describe the nature of the double-lumen bicaval venovenous ECMO cannula and relevant specific issues associated with monitoring complex details of oxygenation within different parts of circulation, including existing barriers for quantification of recirculation and venous admix. New conceptual approach to the quantification of venous admix is described. Right side echocardiographic contrast, when sequentially injected in separate superior vena cava (SVC) and inferior vena cava (IVC) venous basins, bypasses drainage ports of the catheter in double-lumen bicaval VV-ECMO configuration together with deoxygenated returning from the periphery venous blood. It was easily detectable entering right heart chambers by two- and three-dimensional echocardiography. Amount of bubbles from the agitated fluid contrast within right atrium indicates relative amount of venous admixture in relation to the returning from the oxygenator blood which is bubble free.
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Calcaterra D, Heather B, Kohl LP, Erickson HL, Prekker ME. Bedside veno-venous ECMO cannulation: A pertinent strategy during the COVID-19 pandemic. J Card Surg 2020; 35:1180-1185. [PMID: 32531129 PMCID: PMC7323207 DOI: 10.1111/jocs.14641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Patient selection and cannulation arguably represent the key steps for the successful implementation of extracorporeal membrane oxygenation (ECMO) support. Cannulation is traditionally performed in the operating room or the catheterization laboratory for a number of reasons, including physician preference and access to real‐time imaging, with the goal of minimizing complications and ensuring appropriate cannula positioning. Nonetheless, the patients' critical and unstable conditions often require emergent initiation of ECMO and preclude the safe transport of the patient to a procedural suite. Aims Therefore, with the objective of avoiding delay with the initiation of therapy and reducing the hazard of transport, we implemented a protocol for bedside ECMO cannulation. Matherial and Methods A total of 89 patients required ECMO support at Hennepin County Medical Center between March 2015 and December 2019. Twenty‐eight (31%) required veno‐venous support and were all cannulated at the bedside. Overall survival was 71% with no morbidity or mortality related to the cannulation procedure. Conclusion In the current pandemic, the strategy of veno‐venous bedside cannulation may have additional benefits for the care of patients with refractory acute respiratory distress syndrome due to coronavirus disease‐2019, decreasing the risk of exposure of health care worker or other patients to the novel severe acute respiratory syndrome coronavirus‐2 occurring during patient transport, preparation, or during disinfection of the procedural suite and the transportation pathway after ECMO cannulation.
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Affiliation(s)
- Domenico Calcaterra
- Department of Cardiothoracic Surgery, Bethesda Heart Hospital Baptist South Florida, Boynton Beach, Florida
| | - Beth Heather
- Division of Pulmonary and Critical Care, Critical Care Nursing, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Louis P Kohl
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Heidi L Erickson
- Division of Pulmonary and Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Matthew E Prekker
- Division of Pulmonary and Critical Care, Department of Emergency Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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Moore B, Morgan N, Selzman C, Zimmerman J. Successful Use of Limited Transthoracic Echocardiography to Guide Veno-venous Extracorporeal Membrane Oxygenator Placement in a Patient With Coronavirus Disease 2019. J Cardiothorac Vasc Anesth 2020; 34:3491-3493. [PMID: 32487446 PMCID: PMC7200348 DOI: 10.1053/j.jvca.2020.04.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Brad Moore
- Division of Perioperative Echocardiography, University of Utah Department of Anesthesiology, Salt Lake City, UT
| | - Ned Morgan
- Division of Perioperative Echocardiography, University of Utah Department of Anesthesiology, Salt Lake City, UT
| | - Craig Selzman
- Division of Cardiothoracic Surgery, University of Utah Department of Surgery, Salt Lake City, UT
| | - Josh Zimmerman
- Division of Perioperative Echocardiography, University of Utah Department of Anesthesiology, Salt Lake City, UT
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Bazan VM, Taylor EM, Gunn TM, Zwischenberger JB. Overview of the bicaval dual lumen cannula. Indian J Thorac Cardiovasc Surg 2020; 37:232-240. [PMID: 33967446 DOI: 10.1007/s12055-020-00932-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/25/2020] [Accepted: 01/28/2020] [Indexed: 01/19/2023] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a form of extracorporeal life support that provides total gas exchange (CO2 and O2) within the central venous circulation. The bicaval dual lumen cannula (DLC) is an option for patients requiring respiratory support with VV-ECMO. The catheter is inserted via the internal jugular vein into the superior and inferior vena cava, drains blood into the ECMO circuit for gas exchange, and then returns arterialized blood to the right heart for circulation. The DLC facilitates physical therapy, ambulation, and early extubation. This chapter will review the uses, advantages, and unique complications of the DLC.
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Affiliation(s)
| | | | - Tyler Michael Gunn
- Graduate Medical Education, Division of Cardiothoracic Surgery, Lexington, KY USA
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Krishnan S, Schmidt GA. Hemodynamic monitoring in the extracorporeal membrane oxygenation patient. Curr Opin Crit Care 2020; 25:285-291. [PMID: 30865613 DOI: 10.1097/mcc.0000000000000602] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Hemodynamic monitoring in ECMO patients requires familiarity with the underlying pathophysiology and circulatory mechanics of extracorporeal flow. This review discusses the various monitoring modalities relevant to the management of patients on venovenous ECMO (VV ECMO) and venoarterial (VA ECMO). We emphasize tools to judge the adequacy of perfusion, predict the response to fluid boluses, measure right ventricular function, assess left ventricular distention (for VA ECMO), and monitor the process of weaning from ECMO. We emphasize how differences between VV ECMO and VA ECMO are reflected in distinct approaches to monitoring. RECENT FINDINGS Point-of-care ultrasound and near-infrared spectroscopy can play a significant role in monitoring of global and regional perfusion. SUMMARY Recent literature in hemodynamic monitoring of ECMO patients is discussed, with comparison of VV ECMO and VA ECMO. Many common monitoring tools lack validity during ECMO: by taking into account the unique physiology of the ECMO circulation, selected methods can aid in the care of these complex patients.
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Affiliation(s)
| | - Gregory A Schmidt
- Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, USA
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Griffee MJ, Zimmerman JM, McKellar SH, Tonna JE. Echocardiography-Guided Dual-Lumen Venovenous Extracorporeal Membrane Oxygenation Cannula Placement in the ICU-A Retrospective Review. J Cardiothorac Vasc Anesth 2020; 34:698-705. [PMID: 31812567 PMCID: PMC7373020 DOI: 10.1053/j.jvca.2019.10.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/06/2019] [Accepted: 10/13/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The most effective method of image guidance for venovenous extracorporeal membrane oxygenation is not known. The authors' objectives were to define the frequency of successful initial cannulation using echocardiographic guidance in the intensive care unit, as well as to determine the frequency of subsequent adjustments. Additional aims were to illustrate cannula malposition problems and to describe features associated with difficult cannulation. DESIGN Retrospective consecutive case series analysis. SETTING Single tertiary care university hospital. PARTICIPANTS Forty-five patients treated with venovenous extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The most common causes of respiratory failure were pneumonia, aspiration, and inhalational burn injury. Sixty-two percent survived to discharge. Initial cannulation was successful in 39 cases (87%). Adverse events included 5 cases of cannula malposition and 1 case of hemorrhagic shock. During the course of extracorporeal membrane oxygenation, 17 patients (38%) required echo-guided cannula position adjustments. There were no fatal complications. Factors associated with difficult cannulation included extremes of size, a prominent Eustachian valve, and an anterior guidewire bending in the right atrium. Younger age was associated positively with survival. There was no significant association between adverse events during cannulation and survival. CONCLUSIONS Dual-lumen venovenous extracorporeal membrane oxygenation cannulation in the intensive care unit under echo guidance has a high initial success rate, but many patients require subsequent repositioning. Echocardiography can define cannula position in sufficient detail to identify malposition precisely and to guide repositioning.
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Affiliation(s)
- Matthew J Griffee
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT.
| | - Joshua M Zimmerman
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Stephen H McKellar
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Joseph E Tonna
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT; Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
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[Management of a bi-caval dual lumen cannula clot obstruction after TEE guided diagnosis: a case-report]. Rev Bras Anestesiol 2020; 70:55-58. [PMID: 32173066 DOI: 10.1016/j.bjan.2019.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/21/2019] [Accepted: 12/01/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation is an established therapy for patients with refractory acute respiratory distress syndrome (ARDS). One complication related to the use of veno-venous extracorporeal membrane oxygenation is thrombosis despite proper anticoagulation. We report the diagnosis and management of a clot-obstruction in a single site cannula placed through the internal jugular vein, guided by transesophageal echocardiography. CASE REPORT A 39 year-old male developed acute respiratory distress syndrome and hemodynamic instability after an episode of pulmonary aspiration in the ICU. Eight hours after placement of a single site veno-venous extracorporeal membrane oxygenation, suddenly the perfusionist noticed a reduction in flow. TEE showed a thrombus-like mass obstructing the inflow port in SVC and inflow at IVC was intact. After unsuccessful attempts to reposition the cannula, the team decided to insert additional femoral inflow cannula through the IVC. The single site catheter was then pulled out until its tip was positioned in the right atrium and all three ports of the catheter were switched to the infusion ports. After this, flows and oxygenation improved significantly. Unfortunately, despite all of the efforts, the patient died 2 days later. DISCUSSION The diagnosis of veno-venous extracorporeal membrane oxygenation cannula obstruction is based on reduced inflow rates, hemodynamic instability and poor oxygenation of blood. TEE allows evaluation of the flows inside the cannula and in this case, an obstruction was found. The management presented points to the fact that in a situation of catheter obstruction caused by a clot, there is a feasible alternative to assure minimal interruption of the hemodynamic support offered by the veno-venous extracorporeal membrane oxygenation.
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Kwak J, Majewski MB, Jellish WS. Extracorporeal Membrane Oxygenation: The New Jack-of-All-Trades? J Cardiothorac Vasc Anesth 2020; 34:192-207. [DOI: 10.1053/j.jvca.2019.09.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 09/03/2019] [Accepted: 09/20/2019] [Indexed: 11/11/2022]
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Images in Anesthesiology: Inadvertent Extracorporeal Membrane Oxygenation Cannulation across a Patent Foramen Ovale. Anesthesiology 2019; 130:309-310. [DOI: 10.1097/aln.0000000000002452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Supplemental Digital Content is available in the text.
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