Echocardiographic Guidance and Troubleshooting for Venovenous Extracorporeal Membrane Oxygenation Using the Dual-Lumen Bicaval Cannula

Echocardiographic Findings in Critically Ill COVID-19 Patients Treated With and Without Extracorporeal Membrane Oxygenation

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.

Use of Image Guidance During Pediatric Venovenous Extracorporeal Membrane Oxygenation Cannulation: A Survey of the American Pediatric Surgical Association

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.

Monitoring during extracorporeal membrane oxygenation

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.

Venovenous extra corporeal life support in an infant with foreign body aspiration: A case report

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.

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

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.

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

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.

[Intraoperative transesophageal echocardiography as monitoring procedure in noncardiac surgery patients]

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.

SEDAR/SECCE ECMO management consensus document

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.

Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration

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.

Transesophageal Echocardiography Compared to Fluoroscopy for Avalon Bicaval Dual-Lumen Cannula Positioning for Venovenous ECMO

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.

Management of Adult Patients Supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO)

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.

Semiquantification of Systemic Venous Admixture During Venovenous Extracorporeal Oxygenation Via Bicaval Double-Lumen Cannula in Critically Ill Patients

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.

Bedside veno-venous ECMO cannulation: A pertinent strategy during the COVID-19 pandemic

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.

Overview of the bicaval dual lumen cannula

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.

Hemodynamic monitoring in the extracorporeal membrane oxygenation patient

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.

Echocardiography-Guided Dual-Lumen Venovenous Extracorporeal Membrane Oxygenation Cannula Placement in the ICU-A Retrospective Review

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.

[Management of a bi-caval dual lumen cannula clot obstruction after TEE guided diagnosis: a case-report]

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.

Images in Anesthesiology: Inadvertent Extracorporeal Membrane Oxygenation Cannulation across a Patent Foramen Ovale

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