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Cha S, Kostibas MP. Echocardiographic and Point-of-Care Ultrasonography (POCUS) Guidance in the Management of the ECMO Patient. J Clin Med 2024; 13:2630. [PMID: 38731160 PMCID: PMC11084171 DOI: 10.3390/jcm13092630] [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: 03/15/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/13/2024] Open
Abstract
Veno-arterial (V-A) and Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) support is increasingly utilized for acute cardiogenic shock and/or respiratory failure. Echocardiography and point-of-care ultrasonography (POCUS) play a critical role in the selection and management of these critically ill patients, however, there are limited guidelines regarding their application. This comprehensive review describes current and potential application of echocardiography and POCUS for pre-ECMO assessment and patient selection, cannulation guidance with emphasis on dual-lumen configurations, diagnosis of ECMO complications and trouble-shooting of cannula malposition, diagnosis of common cardiac or pulmonary pathologies, and assessment of ECMO weaning appropriateness including identification of the aortic mixing point in V-A ECMO.
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Affiliation(s)
- Stephanie Cha
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street Suite 6216, Baltimore, MD 21287, USA;
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2
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Bianzina S, Singh Y, Iacobelli R, Amodeo A, Guner Y, Di Nardo M. Use of point-of-care ultrasound (POCUS) to monitor neonatal and pediatric extracorporeal life support. Eur J Pediatr 2024; 183:1509-1524. [PMID: 38236403 DOI: 10.1007/s00431-023-05386-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/19/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an invasive life support technique that requires a blood pump, an artificial membrane lung, and vascular cannulae to drain de-oxygenated blood, remove carbon dioxide, oxygenate, and return it to the patient. ECMO is generally used to provide advanced and prolonged cardiopulmonary support in patients with refractory acute cardiac and/or respiratory failure. After its first use in 1975 to manage a severe form of meconium aspiration syndrome with resultant pulmonary hypertension, the following years were dominated by the use of ECMO to manage neonatal respiratory failure and limited to a few centers across the world. In the 1990s, evidence for neonatal respiratory ECMO support increased; however, the number of cases began to decline with the use of newer pharmacologic therapies (e.g., inhaled nitric oxide, exogenous surfactant, and high-frequency oscillatory ventilation). On the contrary, pediatric ECMO sustained steady growth. Combined advances in ECMO technology and bedside medical management have improved general outcomes, although ECMO-related complications remain challenging. Point-of-care ultrasound (POCUS) is an essential tool to monitor all phases of neonatal and pediatric ECMO: evaluation of ECMO candidacy, ultrasound-guided ECMO cannulation, daily evaluation of heart and lung function and brain perfusion, detection and management of major complications, and weaning from ECMO support. Conclusion: Based on these considerations and on the lack of specific guidelines for the use of POCUS in the neonatal and pediatric ECMO setting, the aim of this paper is to provide a systematic overview for the application of POCUS during ECMO support in these populations. What is Known: • Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary support for patients with refractory acute cardiac and/or respiratory failure and requires appropriate monitoring. • Point-of-care ultrasound (POCUS) is an accessible and adaptable tool to assess neonatal and pediatric cardiac and/or respiratory failure at bedside. What is New: • In this review, we discussed the use of POCUS to monitor and manage at bedside neonatal and pediatric patients supported with ECMO. • We explored the potential use of POCUS during all phases of ECMO support: pre-ECMO assessment, ECMO candidacy evaluation, daily evaluation of heart, lung and brain function, detection and troubleshooting of major complications, and weaning from ECMO support.
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Affiliation(s)
- Stefania Bianzina
- Pediatric Anaesthesia and Intensive Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Yogen Singh
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Roberta Iacobelli
- Area of Cardiac Surgery, Cardiology, Heart and Lung Transplant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonio Amodeo
- Heart Failure, Transplantation and Cardio-Respiratory Mechanical Assistance Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Yigit Guner
- Pediatric Surgery, Children's Hospital of Orange County and University of California Irvine, Orange, CA, USA
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Martin-Villen L, Martin-Bermudez R, Perez-Chomon H, Fuset Cabanes MP. Role of ultrasound in the critical ill patient with ECMO. Med Intensiva 2024; 48:46-55. [PMID: 38171717 DOI: 10.1016/j.medine.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/12/2023] [Indexed: 01/05/2024]
Abstract
Ultrasound is an essential diagnostic tool in critically ill patients with extracorporeal membrane oxygenation (ECMO). With it, we can make an anatomical and functional (cardiac, pulmonary and vascular) evaluation which allows us to execute an adequate configuration, guides implantation, helps clinical monitorization and detects complications, facilitates withdrawal and complete post-implant evaluation. In patients with ECMO as respiratory support (veno-venous), thoracic ultrasound allows monitoring pulmonary illness evolution and echocardiography the evaluation of biventricular function, especially right ventricle function, and cardiac output to optimize oxygen transport. In ECMO as circulatory support (veno-arterial), echocardiography is the guide of hemodynamic monitoring, allows detecting the most frequent complications and helps the weaning. In ECMO teams, for a proper management of these patients, there must be trained intensivists with advanced knowledge on this technique.
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Affiliation(s)
- Luis Martin-Villen
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Rafael Martin-Bermudez
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Helena Perez-Chomon
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Mari Paz Fuset Cabanes
- Servicio de Medicina Intensiva, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Kipfmueller F, Bo B, Schmitt J, Sabir H, Schroeder L, Mueller A, Dresbach T. Percutaneous, ultrasound-guided single- and multisite cannulation for veno-venous extracorporeal membrane oxygenation in neonates. Pediatr Pulmonol 2023; 58:2574-2582. [PMID: 37314186 DOI: 10.1002/ppul.26555] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/08/2023] [Accepted: 06/03/2023] [Indexed: 06/15/2023]
Abstract
AIMS Extracorporeal membrane oxygenation (ECMO) is a widely used technique to support neonates with severe respiratory failure. Data on percutaneous, ultrasound-guided veno-venous (VV) ECMO cannulation in neonates is still scarce. Aim of this study was to describe our institutional experience with ultrasound-guided percutaneous, VV ECMO cannulation in neonates with severe respiratory failure. METHODS Neonates receiving ECMO support at our department between January 2017 and January 2021 were retrospectively identified. Patients receiving VV ECMO cannulation performed by the percutaneous Seldinger technique by single- or multisite cannulation were analyzed. RESULTS A total of 54 neonates received ECMO cannulation performed by the percutaneous Seldinger technique. In 39 patients (72%) a 13 French bicaval dual-lumen cannula was inserted and in 15 patients (28%) two single-lumen cannulae were used. Cannulae positioning using the multisite approach was in all cases as desired. The tip of the 13 French cannula was located in the IVC in 35/39 patients, in four patients position was too proximal but did not dislocate during the ECMO run. One (2%) preterm neonate (weight 1.75 kg) developed a cardiac tamponade which was successfully managed with drainage. Median duration of ECMO was 7 days (interquartile range: 5-16 days). Forty-four patients (82%) were successfully weaned from ECMO and in 31/44 (71%) the ECMO cannulae were removed with a delay of 0.9-7.2 days (median 2.8 days) after weaning without noticing complications. CONCLUSIONS A correct cannula placement using the ultrasound-guided percutaneous Seldinger technique, for both single- and multisite cannulation, seems feasible in most neonatal patients receiving VV ECMO.
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Affiliation(s)
- Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
- Division of Congenital Malformations, Center for Rare Diseases Bonn, University Hospital Bonn, Bonn, Germany
| | - Bartolomeo Bo
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Joachim Schmitt
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Lukas Schroeder
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
- Division of Congenital Malformations, Center for Rare Diseases Bonn, University Hospital Bonn, Bonn, Germany
| | - Till Dresbach
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
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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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Skidmore KL, Rajabi A, Nguyen A, Imani F, Kaye AD. Veno-venous Extracorporeal Membrane Oxygenation: Anesthetic Considerations in Clinical Practice. Anesth Pain Med 2023; 13:e136524. [PMID: 38021335 PMCID: PMC10664155 DOI: 10.5812/aapm-136524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/28/2023] [Accepted: 06/04/2023] [Indexed: 12/01/2023] Open
Abstract
Context After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO). Purpose In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline. Methods We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation. Results Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 μg/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 μg/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval. Conclusions The limitation of this review is that it necessarily covers a broad range of ECMO decisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.
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Affiliation(s)
- Kimberly L. Skidmore
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Alireza Rajabi
- Department of Anesthesiology and Critical Care, Iran University of Medical Sciences, Tehran, Iran
| | - Angela Nguyen
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
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Kraai E, Teixeira JP, Patel IA, Wray TC, Mitchell JA, George N, Kamm A, Henson J, Mirrhakimov A, Guliani S, Tawil I, Dettmer T, Marinaro J. An Intensivist-Led Extracorporeal Membrane Oxygenation Program: Design, Implementation, and Outcomes of the First Five Years. ASAIO J 2023; 69:451-459. [PMID: 36525671 DOI: 10.1097/mat.0000000000001870] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.
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Affiliation(s)
- Erik Kraai
- From the Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - J Pedro Teixeira
- From the Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Ishan A Patel
- From the Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Trenton C Wray
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Jessica A Mitchell
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Naomi George
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Ashley Kamm
- Comprehensive Care Services, Albuquerque, NM
| | | | | | - Sundeep Guliani
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Isaac Tawil
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Todd Dettmer
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
| | - Jonathan Marinaro
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Emergency Medicine, niversity of New Mexico Health Sciences Center, Albuquerque, NM
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Muhammad H, L'Huillier JC, Benson Ham P, Vali K. Strategies for appropriate positioning and repositioning the Avalon ECMO cannula in a 17-year-old with left hepatic vein malposition. Perfusion 2023; 38:645-650. [PMID: 34927476 DOI: 10.1177/02676591211063829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a well-recognized therapy in children with refractory hypoxia. Different cannulas have been used with reported complications with placement, such as cardiac perforation, and multiple reports focusing on avoiding this. However, strategies to avoid hepatic vein cannulation and reposition when it occurs are not well described. CASE REPORT Here, we report a case where a 27-Fr Avalon bicaval double lumen cannula in the left hepatic vein was successfully repositioning using serial chest X-rays (CXR) and transthoracic echocardiography (TTE) in a 17-year-old female. DISCUSSION While venovenous (VV) ECMO is preferred by many, placement of the Avalon catheter, a cannula available for VV ECMO, may be challenging due to migration or positioning issues. Specific techniques of wire and catheter advancement as well as confirming wire position in the infra-hepatic inferior vena cava can help ensure appropriate positioning while avoiding hepatic vein cannulation and enabling successful repositioning when it occurs. CONCLUSION Wire position in the infra-hepatic inferior vena cava helps ensure safe and appropriate Avalon cannula position and placement. The Avalon cannula can be successfully repositioned from the left hepatic vein by retracting the cannula, reinserting the wire and introducer together, and then manipulation techniques using serial CXR and TTE.
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Affiliation(s)
- Haris Muhammad
- Department of Pediatric Surgery, 23561John R. Oishei Children's Hospital Buffalo, NY, USA
| | - Joseph C L'Huillier
- Department of Pediatric Surgery, 23561John R. Oishei Children's Hospital Buffalo, NY, USA.,Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Phillip Benson Ham
- Department of Pediatric Surgery, 23561John R. Oishei Children's Hospital Buffalo, NY, USA.,Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Kaveh Vali
- Department of Pediatric Surgery, 23561John R. Oishei Children's Hospital Buffalo, NY, USA.,Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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Using Transesophageal Echocardiography in Liver Transplantation with Veno-Venous Bypass Is a Tool with Many Applications: A Case Series from an Italian Transplant Center. J Cardiovasc Dev Dis 2023; 10:jcdd10010032. [PMID: 36661927 PMCID: PMC9866160 DOI: 10.3390/jcdd10010032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Hemodynamic instability (HDI) is common during liver transplantation (LT); veno-venous bypass (VVB) is a tool used in selected cases to ensure hemodynamic stability and for surgical needs. Transesophageal echocardiography (TEE) allows the transplant team to identify the causes of HDI and to guide therapies. We present a case series of four patients showing the valuable role of TEE during LT in VVB. METHODS We report four explicative cases of TEE use in LT with VVB performed at IRCCS Azienda Ospedaliero-Universitaria di Bologna. Four transplants were performed between 2016 and 2022. RESULTS Many authors have highlighted the diagnostic value of TEE during LT in the case of HDI. However, its specific role during LT with VVB is poorly described. This paper illustrates multiple potential uses of TEE in LT with VVB: TEE as a guide for catheterization and optimal cannula positioning, TEE as a tool for intraoperative Patent Foramen Ovale management, TEE as help for anticoagulation therapy and finally, TEE as support when evaluating bypass efficiency and correcting hypovolemia. CONCLUSION TEE is a useful instrument during LT with VVB. However, further studies are needed to assess the suitable applications of TEE during LT in patients with HDI requiring VVB. TEE should be part of the anesthetist's cultural background.
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Morales Castro D, Abdelnour-Berchtold E, Urner M, Dragoi L, Cypel M, Fan E, Douflé G. Transesophageal Echocardiography-Guided Extracorporeal Membrane Oxygenation Cannulation in COVID-19 Patients. J Cardiothorac Vasc Anesth 2022; 36:4296-4304. [PMID: 36038441 PMCID: PMC9338225 DOI: 10.1053/j.jvca.2022.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVES A paucity of data supports the use of transesophageal echocardiography (TEE) for bedside extracorporeal membrane oxygenation (ECMO) cannulation. Concerns have been raised about performing TEEs in patients with COVID-19. The authors describe the use and safety of TEE guidance for ECMO cannulation for COVID-19. DESIGN Single-center retrospective cohort study. SETTING The study took place in the intensive care unit of an academic tertiary center. PARTICIPANTS The authors included 107 patients with confirmed SARS-CoV-2 infection who underwent bedside venovenous ECMO (VV ECMO) cannulation under TEE guidance between May 2020 and June 2021. INTERVENTIONS TEE-guided bedside VV ECMO cannulation. MEASUREMENTS Patient characteristics, physiologic and ventilatory parameters, and echocardiographic findings were analyzed. The primary outcome was the number of successful TEE-guided bedside cannulations without complications. The secondary outcomes were cannulation complications, frequency of cannula repositioning, and TEE-related complications. MAIN RESULTS TEE-guided cannulation was successful in 99% of the patients. Initial cannula position was adequate in all but 1 patient. Fourteen patients (13%) required cannula repositioning during ECMO support. Forty-five patients (42%) had right ventricular systolic dysfunction, and 9 (8%) had left ventricular systolic dysfunction. Twelve patients (11%) had intracardiac thrombi. One superficial arterial injury and 1 pneumothorax occurred. No pericardial tamponade, hemothorax or intraabdominal bleeding occurred in the authors' cohort. No TEE-related complications or COVID-19 infection of healthcare providers were reported during this study. CONCLUSIONS Bedside TEE guidance for VV ECMO cannulation is safe in patients with severe respiratory failure due to COVID-19. No tamponade or hemothorax, nor TEE-related complications were observed in the authors' cohort.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | | | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Marcelo Cypel
- Department of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada,Department of Medicine, University of Toronto, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada.
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11
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Patterson CM, Shah A, Rabin J, DiChiacchio L, Cypel M, Hoetzenecker K, Catarino P, Lau CL. EXTRACORPOREAL LIFE SUPPORT AS A BRIDGE TO LUNG TRANSPLANTATION: WHERE ARE WE NOW? J Heart Lung Transplant 2022; 41:1547-1555. [DOI: 10.1016/j.healun.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/21/2022] [Accepted: 06/05/2022] [Indexed: 11/16/2022] Open
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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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A Dual-lumen Extracorporal Membrane Oxygenation Cannulation Technique Using a Mobile X-ray Device. Ann Thorac Surg 2022; 114:1050-1054. [PMID: 35504359 DOI: 10.1016/j.athoracsur.2022.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/25/2022] [Accepted: 04/10/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Dual-lumen extracorporal membrane oxygenation (ECMO) cannulation is considered technically challenging and harbors the risk for potential life-threatening complications during cannulation. Dual-lumen cannula insertion is either performed under ultrasound or fluoroscopy guidance. Both techniques have significant disadvantages, such as examiner-dependence or the necessity for transportation of the patient from the intensive care unit (ICU) to the operating room. DESCRIPTION Digital, mobile X-ray devices provide a novel, examiner-independent imaging modality for bedside dual-lumen ECMO cannulation. EVALUATION From 11/2019 to 11/2021, 23 dual-lumen cannulations were performed in 20 patients at the Department of Thoracic Surgery, Medical University of Vienna. 12/23 (52.2%) were inserted in the ICU using a mobile X-ray device. The remaining patients (47.8%) were cannulated in the operating room with conventional fluoroscopy guidance. In none of the procedures cardiovascular injuries occurred. Insertion site bleeding was the most common ECMO-related complication (n=2). CONCLUSIONS Dual-lumen cannulation using sequential X-rays can be performed safely. Especially in infectious patients or patients who require an awake ECMO, this technique overcomes disadvantages of established imaging modalities.
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Hussey PT, von Mering G, Nanda NC, Ahmed MI, Addis DR. Echocardiography for extracorporeal membrane oxygenation. Echocardiography 2022; 39:339-370. [PMID: 34997645 PMCID: PMC9195253 DOI: 10.1111/echo.15266] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 11/06/2021] [Indexed: 02/03/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary life support for patients in cardiac and/or respiratory failure. Echocardiography provides essential diagnostic and anatomic information prior to ECMO initiation, allows for safe and efficient ECMO cannula positioning, guides optimization of flow, provides a modality for rapid troubleshooting and patient evaluation, and facilitates decision-making for eventual weaning of ECMO support. Currently, guidelines for echocardiographic assessment in this clinical context are lacking. In this review, we provide an overview of echocardiographic considerations for advanced imagers involved in the care of these complex patients. We focus predominately on new cannulas and complex cannulation techniques, including a special focus on double lumen cannulas and a section discussing indirect left ventricular venting. Echocardiography is tremendously valuable in providing optimal care in these challenging clinical situations. It is imperative for imaging physicians to understand the pertinent anatomic considerations, the often complicated physiological and hemodynamic context, and the limitations of the imaging modality.
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Affiliation(s)
- Patrick T. Hussey
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Gregory von Mering
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Navin C. Nanda
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Mustafa I. Ahmed
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Dylan R. Addis
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, Division of Molecular and Translational Biomedicine, and the UAB Comprehensive Cardiovascular Center, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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15
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Cole SP, Martinez-Acero N, Peterson A, Von Homeyer P, Gebhardt B, Nicoara A. Imaging for Temporary Mechanical Circulatory Support Devices. J Cardiothorac Vasc Anesth 2021; 36:2114-2131. [PMID: 34740543 DOI: 10.1053/j.jvca.2021.09.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/04/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Sheela Pai Cole
- Clinical Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Natalia Martinez-Acero
- Associate Physician, Cardiac Anesthesiology and Critical Care, Kaiser Permanente, Santa Clara, CA.
| | - Ashley Peterson
- Clinical Assistant Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Peter Von Homeyer
- Associate Professor, Department of Anesthesiology, University of Washington, Seattle, WA 98195.
| | | | - Alina Nicoara
- Associate Professor, Department of Anesthesiology, Duke University, Raleigh, NC 27708.
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Rapid Development and Deployment of an Intensivist-Led Venovenous Extracorporeal Membrane Oxygenation Cannulation Program. Crit Care Med 2021; 50:e154-e161. [PMID: 34637417 DOI: 10.1097/ccm.0000000000005282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program. DESIGN A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program. SETTING An adult ICU in a tertiary academic medical center in Camden, NJ. PATIENTS Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation. INTERVENTIONS Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists. MEASUREMENTS AND MAIN RESULTS Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1). CONCLUSIONS There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.
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Lashin H, Shepherd S, Smith A. Contrast-Enhanced Echocardiography Application in Patients Supported by Extracorporeal Membrane Oxygenation (ECMO): A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:2080-2089. [PMID: 34074555 DOI: 10.1053/j.jvca.2021.04.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/25/2021] [Accepted: 04/20/2021] [Indexed: 11/11/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving intervention increasingly used to support patients with severe respiratory and cardiac dysfunction. Echocardiography is an important tool, aiding implantation and monitoring during ECMO therapy, but often its use is limited by poor acoustic windows. This limitation may be overcome by the use of echocardiography contrast agents to improve diagnostic yield and reduce the need for other imaging modalities that may require patient transfer, involve ionizing radiation and, occasionally, nephrotoxic radio-opaque contrast medium. In this article the authors review the literature addressing the use of contrast-enhanced echocardiography (CEE) in ECMO-supported patients. The authors discuss the role of CEE in guiding implantation of ECMO, cardiac assessment and diagnosis of complications during ECMO therapy, as well as the safety of ultrasound-enhancing agents in this cohort of patients.
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Affiliation(s)
- Hazem Lashin
- Adult Critical Care Unit, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, England, United Kingdom; William Harvey Research Institute, Barts, and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, England, United Kingdom.
| | - Stephen Shepherd
- Adult Critical Care Unit, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, England, United Kingdom; William Harvey Research Institute, Barts, and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, England, United Kingdom
| | - Andrew Smith
- Adult Critical Care Unit, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, England, United Kingdom; William Harvey Research Institute, Barts, and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, England, United Kingdom
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