Cannulation technique: femoro-femoral

Arterial oxygen pressure during veno-venous extracorporeal membrane oxygenation may be increased by advancing the tip of the drainage cannula into the superior vena cava: a case report

A simple and robust method for veno-venous extracorporeal membrane oxygenation (V-V ECMO) involves a drainage cannula into the inferior vena cava via the femoral vein (FV) and a reinfusion cannula into the right atrium (RA) via the internal jugular vein (IJV) (F-J configuration). However, with this method, the arterial oxygen (PaO2) is said to remain below 100 mmHg.Since recently, in our ICU, to prevent drainage failure, we apply a modification from the commonly practiced F-J configuration by advancing the tip of the drainage cannula inserted via the FV into the superior vena cava (SVC) and crossing the reinfusion cannula inserted via the IJV in the RA (F(SVC)-J(RA) configuration). We experienced that this modification can be associated with unexpectedly high PaO2 values, which here we investigated in detail.Veno-arteriovenous ECMO was induced in a 65-year-old male patient who suffered from repeated cardiac arrest due to acute respiratory distress syndrome. His chest X-ray images showed white-out after lung rest setting, consistent with near-absence of self-lung ventilation. Cardiac function recovered and the system was converted to F(SVC)-J(RA) configuration, after which both PaO2 and partial pressure of pulmonary arterial oxygen values remained high above 200 mmHg. Transesophageal echocardiography could not detect right-to-left shunt, and more efficient drainage of the native venous return flow compared to common F-J configuration may explain the increased PaO2.Although the F(SVC)-J(RA) configuration is a small modification of the F-J configuration, it seems to provide a revolutionary improvement in the ECMO field by combining robustness/simplicity with high PaO2 values.

An intensivist-led ECMO accreditation pathway and safety data over the first 4 years

Objective

To describe the training and accreditation process behind an intensivist-led extracorporeal membrane oxygenation (ECMO) cannulation program, and identify the rate of complications associated with the ECMO cannulation procedure.

Design

A narrative review of the accreditation process, and a retrospective review of complications related to cannulation during the first four years of the intensivist program.

Setting

Royal Prince Alfred Hospital, a quaternary referral hospital in Sydney.

Participants

All patients initiated onto ECMO during the first four years of the intensivist cannulation program (August 2018 to August 2022).Main outcome measures: All cases were reviewed for identification of 14 pre-defined adverse events which were classified as low, medium or high clinical significance complications.

Results

A total of 402 cannulations were attempted by the intensivist group in 194 separate cannulation episodes involving 179 patients. This included 93 V-V initiations, 69 V-A initiations (36 of these ECMO-CPR), 3 V-AV (veno-arteriovenous) initiations, 25 ECMO reconfigurations and four patients cannulated for peripheral cardiopulmonary bypass in cardiothoracic theatre. One of the 402 cannulations was halted as resuscitation was ceased, and one was halted and the patient transferred to theatre for central arterial cannulation. 394 out of the remaining 400 cannulations were successful (98.5%). Of 402 total cannulations, 32 complication events occurred (7.96% event rate), of which 15 (3.7% event rate) were low significance complications, 10 medium significance (2.5% event rate), and seven high clinical significance (1.7% event rate).

Conclusions

Our experience of the first four years of an intensivist-led ECMO service demonstrates that our training process and cannulation technique result in the provision of a complex therapy with low levels of complications, on par with those in the published literature.

Dual lumen cannulation and mobilization of patients with venovenous extracorporeal membrane oxygenation

BACKGROUND

Mobilization is important in longer courses in intensive care unit (ICU), typical for patients requiring venovenous extracorporeal membrane oxygenation (V-V ECMO). For patients supported with ECMO, especially out-of-bed mobilizations improve outcome. We hypothesized that utilization of a dual lumen cannula (DLC) for V-V ECMO would facilitate out-of-bed mobilization compared to single lumen cannulas (SLC).

METHODS

Retrospective single center registry study including all V-V ECMO patients cannulated between 10/2010 and 05/2021 for respiratory failure.

RESULTS

The registry included 355 V-V ECMO patients (median age 55.6 years, 31.8% female, 27.3% with preexisting pulmonary disease), 289/355 (81.4%) primary cannulated with DLC, and 66/355 (18.6%) using SLC. Both groups had similar pre-ECMO characteristics. The runtime of the first ECMO cannula was significantly longer in DLC compared to SLC (169 vs. 115 h, p = 0.015). The frequency of prone positioning during V-V ECMO was similar in both groups (38.4 vs. 34.8%, p = 0.673). There was no difference in in-bed mobilization (41.2 vs. 36.4%, for DLC and SLC, respectively, p = 0.491). Patients with DLC were more often mobilized out-of-bed (25.6 vs. 12.1%, OR 2.495 [95% CI 1.150 to 5.268], for DLC and SLC, respectively, p = 0.023). Hospital survival was similar in both groups (46.4 vs. 39.4%, for DLC and SLC, respectively, p = 0.339).

CONCLUSION

Patients cannulated with a dual lumen cannula for V-V ECMO support were significantly more often mobilized out-of-bed. Since mobilization is important in prolonged ICU courses typical for ECMO patients, this might be an important benefit. Other benefits of DLC were the longer runtime of the initial cannula set and fewer suction events.

Neutrophil-to-Lymphocyte Ratio as a Predictor of Mortality for COVID-19-Related Acute Respiratory Distress Syndrome (ARDS) Patients Requiring Extracorporeal Membrane Oxygenation Therapy

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has been studied as an indicator of systemic inflammation and as a prognostic tool in multiple areas of medicine. Previous research has suggested that higher NLR and rapid increase to peak NLR are associated with poorer outcomes in patients with coronavirus disease 2019 (COVID-19), particularly in those experiencing acute respiratory distress syndrome (ARDS). Within vascular surgery, there is data to suggest a positive correlation between elevated pre-extracorporeal membrane oxygenation (ECMO) NLR and higher rates of mortality following major procedures. This study explores the prognostic value of peri-ECMO NLR in patients requiring veno-venous ECMO (VV-ECMO) therapy for COVID-19-related ARDS. The objective of this study was to explore the utility of pre-ECMO NLR as an easily accessible prognostic factor for patients suffering from COVID-19-associated ARDS that require VV-ECMO.

METHODS

This was a retrospective cohort study within a tertiary care hospital conducted between April 2020 and January 2021. Patients requiring VV-ECMO therapy for COVID-19-associated ARDS were included. Peri-ECMO NLR values, length of stay (LOS), duration on VV-ECMO, and discharge status were recorded. Receiver operating characteristic (ROC) curve analysis and Youden's J statistics were performed to calculate a cut-off value of 11.005 for pre-ECMO NLR and 17.616 for on-ECMO NLR. Pre-ECMO and on-ECMO Kaplan-Meyer curves were generated for two groups of patients, those above and below NLR cutoff thresholds. Two-sample T-test was performed to test for significant differences in LOS and duration on VV-ECMO.

RESULTS

Twenty-six patients were included in the study for final analyses. There was an overall mortality of 39% (n = 10). ROC curve analysis and Youden's J statistic revealed an optimal cut-off value of pre-ECMO NLR = 11.005 and on-ECMO NLR = 17.616. Results showed that the patient group placed on VV-ECMO with a pre-ECMO NLR less than 11.005 experienced no mortality (n = 7) and a median LOS of 28 days (IQR = 14.5-64.5 days). The patient group on VV-ECMO with a pre-ECMO NLR greater than 11.005 (n = 19) included all mortality (n = 10) and had a median LOS of 49 days (IQR = 25.5-63.5 days). The patient group with on-ECMO NLR less than 17.616 also conferred a survival advantage. There was no significant difference in LOS or duration on VV-ECMO between the two groups, pre-ECMO or on-ECMO.

CONCLUSIONS

 A pre-ECMO NLR cutoff was identified and offered statistically significant prognostic value in predicting mortality. A lower on-ECMO NLR value also indicated a survival advantage. Future studies should include NLR within multivariate models to better discern the effect of NLR and elucidate how it can be factored into clinical decision-making. Importantly, this data can be expanded to assess the predictive value of NLR pertaining to the COVID-19-induced ARDS population and matched cohorts.

Percutaneous cannulation is associated with lower rate of severe neurological complication in femoro-femoral ECPR: results from the Extracorporeal Life Support Organization Registry

BACKGROUND

Percutaneous cannulation is now accepted as the first-line strategy for extracorporeal cardiopulmonary resuscitation (ECPR) in adults. However, previous studies comparing percutaneous cannulation to surgical cannulation have been limited by small sample size and single-center settings. This study aimed to compare in-hospital outcomes in cardiac arrest (CA) patients who received femoro-femoral ECPR with percutaneous vs surgical cannulation.

METHODS

Adults with refractory CA treated with percutaneous (percutaneous group) or surgical (surgical group) femoro-femoral ECPR between January 2008 and December 2019 were extracted from the international Extracorporeal Life Support Organization registry. The primary outcome was severe neurological complication. Multivariable logistic regression analyses were performed to assess the association between percutaneous cannulation and in-hospital outcomes.

RESULTS

Among 3575 patients meeting study inclusion, 2749 (77%) underwent percutaneous cannulation. The proportion of patients undergoing percutaneous cannulation increased from 18% to 89% over the study period (p < 0.001 for trend). Severe neurological complication (13% vs 19%; p < 0.001) occurred less frequently in the percutaneous group compared to the surgical group. In adjusted analyses, percutaneous cannulation was independently associated with lower rate of severe neurological complication (odds ratio [OR] 0.62; 95% CI 0.46-0.83; p = 0.002), similar rates of in-hospital mortality (OR 0.93; 95% CI 0.73-1.17; p = 0.522), limb ischemia (OR 0.84; 95% CI 0.58-1.20; p = 0.341) and cannulation site bleeding (OR 0.90; 95% CI 0.66-1.22; p = 0.471). The comparison of outcomes provided similar results across different levels of center percutaneous experience or center ECPR volume.

CONCLUSIONS

Among adults receiving ECPR, percutaneous cannulation was associated with probable lower rate of severe neurological complication, and similar rates of in-hospital mortality, limb ischemia and cannulation site bleeding.

Alternative position of cannulae in veno-venous extracorporeal membrane oxygenation for maintaining sufficient flow support

Blood flow disturbance of veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be a risk factor of weaning failure. We report an alternative position of cannulae of VV-ECMO which can maintain blood flow. The recirculation rate could be controlled by adjusting a position of return cannula using dilutional ultrasound monitoring.

Successful treatment with femoro-femoral venovenous extracorporeal membrane oxygenation in traumatic tracheal injury: a case report

Background

Traumatic tracheal injury is a rare type of trauma. In this type of injury, catastrophes may occur owing to a failure to secure the patient's airway. Extracorporeal membrane oxygenation (ECMO) is rescue therapy available for the treatment of urgent cardiorespiratory distress until the patient's vital signs have stabilized. The various applications of ECMO configurations have expanded the scope for this therapy.

Case presentation

We describe the case of a 66-year-old man with tracheal rupture with thyroid cartilage fracture due to cultivator handle who was treated with veno-venous ECMO. This case reflects the role and limitations of veno-venous ECMO, in which patient survival was possible with a bi-femoral configuration while also ensuring a clear airway.

Conclusion

We shared our experience with bi-femoral veno-venous ECMO as a therapeutic option to contribute to choosing an appropriate approach. Based on our review of the literature, the present case was an uncommon report of survival after tracheal rupture due to trauma without other complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01991-8.

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.

Imaging for Temporary Mechanical Circulatory Support Devices

Heart failure is an important cause of mortality and morbidity in the world. Changes in organ allocation for solid thoracic (lung and heart) transplantation has increased the number of patients on mechanical circulatory support. Temporary mechanical support devices include devices tht support the circulation directly or indirectly such as extracorporeal membrane oxygenation (ECMO) and temporary support for right-sided failure, left-sided failure or biventricular failure. Most often, these devices are placed percutaneously and require either guidance with echocardiography, continuous radiography (fluoroscopy) or both. Furthermore, these devices need imaging in the intensive care unit to confirm continued accurate placement. This review contains the imaging views and nuances of the temporary assist devices (including ECMO) at the time of placement and the complications that can be associated with each individual device.

Pediatric arterial femoral cannulations for extracorporeal membrane oxygenation: Does size really matter?

BACKGROUND

No studies exist comparing various femoral artery cannula sizes in children on ECMO. We hypothesize that smaller arterial cannulas provide adequate flow in children while decreasing vascular complications.

METHODS

We performed a retrospective review of the ELSO database from 2012-2017. We included children undergoing femoral venoarterial ECMO between ages 12 and 18 years and weighing more than 30 kg. Arterial cannula sizes were grouped as: 15-16Fr, 17-18Fr, 19-20Fr and ≥21Fr. Arterial pump flow, bleeding complications, limb ischemia, and mechanical complications were compared by cannula size. Distal perfusion catheter and percutaneous placement were also compared for complications.

RESULTS

A total of 429 patients were included with 28.2% 15-16Fr, 32.2% 17-18Fr, 22.8% 19-20Fr, and 16.8% ≥ 21Fr arterial femoral cannulas. Median age was lower in the 15-16Fr group compared to the largest cannula group (14.7 years vs 15.5 years, p < 0.01). The overall mean arterial flow was 57.4 +/- 17.0 mL/kg/min with no difference in mean arterial flow rates among the cannula size groups (p = 0.85). There were no significant differences in all complications, bleeding or mechanical complications by arterial cannula size group. However, there was an increased risk of limb ischemia in the ≥21Fr group compared to the 15-16Fr group (OR 4.38, 95% CI 1.24-15.43; p = 0.02). Distal perfusion catheter was shown to increase the risk of mechanical complications (OR 1.78; 95% CI 1.03-3.07; p = 0.04) but did not make a statistically significant difference in limb ischemia (OR 0.37; 95% CI 0.12-1.11; p = 0.07).

CONCLUSION

Review of the ELSO database demonstrates that the use of larger arterial cannulas compared to 15-16Fr cannulas are not needed to achieve similar pump flows for hemodynamic support but the largest cannula sizes may increase the risk of ischemic complications.

Absent right superior vena cava with persistent left superior vena cava in a patient with COVID-19

Vascular injury associated with cannulation during extracorporeal membrane oxygenation (ECMO) induction is a rare but life-threatening complication. The presence of abnormal vascular anatomy increases the risk of vascular injury and should be recognized before cannulation. We report the case of a patient with coronavirus disease (COVID-19) who was expected to undergo ECMO. By performing computed tomography (CT), we identified the absence of right superior vena cava (RSVC) with a persistent left superior vena cava (PLSVC) that could have caused serious complications associated with ECMO cannulation. PLSVC is observed in less than 0.5% of the general population; however, the combination of PLSVC and an absent RSVC in visceroatrial situs solitus is extremely rare. Attempting cannulation for Veno-venous (VV)-ECMO from the right (or left) internal jugular vein to the right atrium may cause serious complications. Cannulation may fail or lead to complications even in patients with inferior vena cava malformations. Although these vascular abnormalities are rare, it is possible to avoid iatrogenic vascular injury by identifying their presence in advance. Since anatomical variations in the vessels from the deep chest and abdominal cavity cannot be visualized using chest radiography and ultrasonography, we recommend CT, if possible, for patients with severe respiratory failure, including those with COVID-19, who may be considered for VV-ECMO induction.

Tissue adhesives for bacterial inhibition in extracorporeal membrane oxygenation cannulae

BACKGROUND

One of the most serious complications of extracorporeal membrane oxygenation (ECMO) therapy is ECMO cannulae infection, which can occur at quadruple the rate of central venous catheter infections, and significantly impact morbidity and paediatric mortality. The objective of this in vitro observational study was to assess antimicrobial properties of two n-butyl-2-octyl cyanoacrylate tissue adhesive (TA) formulations for bacterial inhibition at peripheral ECMO cannulae insertion sites.

METHODS

Antimicrobial properties were assessed using modified agar disk-diffusion (n = 3) and simulated agar cannulation insertion site (n = 20) models. Both assays used Staphylococcus epidermidis which was seeded at the edge of the TA or dressing. Microorganism inhibition was visually inspected and evidenced by the presence or absence of a TA bacterial inhibition zone at 24 and 72 h.

RESULTS

Both TAs provided effective barriers to bacterial migration under cannula dressings, to cannula insertion sites and down cannula tunnels. Additionally, both TAs demonstrated distinct zones of inhibition produced when left to polymerise onto agar plates seeded with S. epidermidis.

CONCLUSIONS

N-Butyl-2-octyl cyanoacrylate TA appears to inhibit bacterial growth and migration of S. epidermidis. Application of TA to cannulae insertion sites may therefore be a potential bedside strategy for infection prevention in ECMO cannulae, but requires further testing before being used clinically for this purpose.

The role of extracorporeal membrane oxygenation in critically ill patients with COVID-19: a narrative review

Extracorporeal life support treatments such as extracorporeal membrane oxygenation (ECMO) have been recommended for the treatment of severe acute respiratory distress syndrome (ARDS) patients with coronavirus disease 2019 (COVID-19). To date, many countries, including China, have adopted ECMO as a treatment for severe COVID-19. However, marked differences in patient survival rates have been reported, and the underlying reasons are unclear. This study aimed to summarize the experience of using ECMO to treat severe COVID-19 and provide suggestions for improving ECMO management. The effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the pathophysiology of COVID-19 and the effects of ECMO on the clinical outcomes in patients with severe cases of COVID-19 were reviewed. Recent data from frontline workers involved in the use of ECMO in Wuhan, China, and those experienced in the implementation of artificial heart and lung support strategies were analysed. There is evidence that ECMO may complicate the pathophysiological state in COVID-19 patients. However, many studies have shown that the appropriate application of ECMO improves the prognosis of such patients. To expand our understanding of the benefits of ECMO for critically ill patients with COVID-19, further prospective, multicentre clinical trials are needed.

The evolving role of the modern perfusionist: insights from transesophageal echocardiography

Transesophageal echocardiography is a relatively non-invasive, mobile, safe imaging technique that is ideal for providing real-time information on cardiac anatomy and function during heart surgery. The technology has evolved from two-dimensional to real-time three-dimensional imaging during cardiac procedures, which has significantly benefited preoperative planning, intraoperative guidance, evaluation, and postoperative follow-up. Transesophageal echocardiography may serve the clinical perfusionist by providing imaging guidance for identifying potential problems before cardiopulmonary bypass, guiding the proper placement of cannulas, monitoring cardiac performance on cardiopulmonary bypass, and providing useful feedback during weaning from cardiopulmonary bypass. Although the perfusionist should be able to understand all echocardiographic images and measurements in depth, perfusion-related echocardiographic information can or should be used to optimize the clinical practice of the modern perfusionist. Vice versa, whenever the perfusionist suspects a problem, the surgical team including the sonographer should verify this "clinical treat" by echocardiography whenever possible.

Clinical outcomes according to cannula configurations in patients with acute respiratory distress syndrome under veno-venous extracorporeal membrane oxygenation: a Korean multicenter study

BACKGROUND

Recirculation during veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a known drawback that limits sufficient oxygenation. This study aimed to compare the short-term oxygenation and long-term mortality based on cannula configuration in patients with acute respiratory distress syndrome (ARDS) who receive VV-ECMO, especially in the absence of newly developed dual-lumen, single cannula.

METHODS

Data of patients with severe ARDS who received VV-ECMO from 2012 to 2015 at six hospitals were retrospectively analyzed. Primary outcomes were the partial pressure of oxygen (PaO₂) at 1, 4, and 12 h after ECMO initiation and 180-day mortality.

RESULTS

Patients (n = 335) were divided into two groups based on the return cannula site: femoral vein (n = 178) or internal jugular vein (n = 157). The propensity score matching analysis generated 90 pairs, and baseline characteristics at admission, including PaO₂, were similar between the groups. PaO₂ at 1, 4 and 12 h after ECMO initiation were not different according to cannula configuration. Moreover, the increment in oxygenation from the baseline values was not different between the femoral and jugular group. PaCO₂ level at 1, 4 and 12 h were significantly lower in the jugular group. The two groups did not differ in terms of mortality at 180 days after ECMO, however more cannula-related complications occurred in the jugular group.

CONCLUSION

Regardless of the cannula configuration, patients with ARDS managed with VV-ECMO showed comparable clinical outcomes in terms of short-term oxygenation and long-term mortality. Nevertheless, further well-designed randomized control trials are warranted.