Veno-venous Extracorporeal Membrane Oxygenation Cannula Research Articles

Axillary vein as an alternative venous access site for VV-ECMO cannulation: a case report

BackgroundUltrasound-guided percutaneous axillary vein cannulation can reduce cannulation failure and mechanical complications, is as safe and effective as internal jugular vein cannulation, and is superior to subclavian vein cannulation using landmark technique. As far, reports of venovenous extracorporeal membrane oxygenation (VV-ECMO) with percutaneous axillary vein cannulation are rare.Case presentationA 64-year-old man presenting with dyspnea and chest tightness after aspirating sewage was admitted to the emergency department. Computed tomography (CT) showed diffuse exudation of both lungs and arterial blood gas analysis showed an oxygenation index of 86. He was diagnosed with aspiration pneumonia-induced acute respiratory distress syndrome (ARDS) and intubated for deteriorated oxygenation. Despite the combination therapy of protective mechanical ventilation and prone position, the patient’s oxygenation deteriorated further, accompanied with multiple organ dysfunction syndrome, which indicated the requirement of support with VV-ECMO. However, vascular ultrasound detected multiple thrombus within bilateral internal jugular veins. As an alternative, right axillary vein was chosen as the access site of return cannula. Subsequently, femoral-axillary VV-ECMO was successfully implemented under the ultrasound guidance, and the patient’s oxygenation was significantly improved. Unfortunately, the patient died of hyperkalemia-induced ventricular fibrillation after 36 h of VV-ECMO running. Despite the poor prognosis, the blood flow during ECMO run was stable, and we observed no bleeding complication, vascular injury, or venous return disorder.ConclusionsAxillary vein is a feasible alternative access site of return cannula for VV-ECMO if internal jugular vein access were unavailable.

Derivation of a Procedural Performance Checklist for Bifemoral Veno-Venous Extracorporeal Membrane Oxygenation Cannula Placement in Operational Environments.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a low-frequency, high-intensity procedure used for severe lung illness or injury to facilitate rapid correction of hypoxemia and respiratory acidosis. This technology is more portable and extracorporeal support is more frequently performed outside of the hospital. Future conflicts may require prolonged causality care and more specialized critical care capabilities including VV ECMO to improve patient outcomes. We used an expert consensus survey based on a developed bifemoral VV ECMO cannulation checklist with an operational focus to establish a standard for training, validation testing, and sustainment. A 36-item procedural checklist was provided to 14 experts from multiple specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback. Three rounds of the study were performed, resulting in a final 32-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist. A procedural performance checklist was created for bifemoral VV ECMO using the modified Delphi method. This is an objective tool to assist procedural training and validation for medical providers performing VV ECMO in austere environments.

PULM9: Development of a Novel Cannula for Durable Venovenous Extracorporeal Membrane Oxygenation

Background: Fifteen million Americans suffer from chronic obstructive pulmonary disease (COPD). After failed optimal medical therapy, the only definitive treatment is lung transplantation, which is limited due to donor scarcity. Extracorporeal membrane oxygenation (ECMO) can be used in acute exacerbations of COPD or as a bridge to transplant for waitlisted COPD patients, but it is not currently suited for long-term respiratory support. Existing venovenous (VV) ECMO configurations often utilize a dual lumen cannula that is inserted into the jugular vein and is designed for short term use. While effective, dual lumen cannulas are associated with high resistance and malposition which limits blood flow, promotes cavitation, and increases blood trauma. Furthermore, patient ambulation is cumbersome because of the difficulty of securing the dual lumen cannula safely to the patient. A novel ECMO system that provides durable respiratory support could reduce morbidity and mortality in patients and facilitate ambulatory use. To this end, a dual lumen cannula that is attached to the heart and tunneled to a more ergonomic position could provide more durable, long term ECMO support. Here, we describe our initial efforts to develop a durable VV ECMO cannula with reduced resistance. Methods: A novel cannula for long-term VV ECMO support was developed using computer aided design. The cannula is designed for surgical attachment to the right atrium with the cannula’s drainage tip at the cavoatrial junction and the reinfusion port directed towards the tricuspid valve to minimize recirculation. Pressure drop was evaluated for the novel cannula, 28Fr, and 32Fr Crescent cannulas (MC3, Dexter, MI) for comparison (N≥5) in circuits primed with deionized water at ambient temperature. A Rotaflow (Maquet, Wayne, NJ) blood pump was operated at 2700-3625 RPM, and pressure drop was assessed for flow rates between 0.1 – 5 LPM. Porcine hearts were harvested from healthy pigs and utilized for ex vivo cannula fit studies. Water flow through the cannula into the right atrium was evaluated using videography. Results: The novel cannula drainage pressure drop (-12±1.1mmHg) was similar to the 28Fr Crescent (-13± 0.3mmHg) and 32Fr Crescent (-9±0.3mmHg) at 2LPM (Figure 1). Reinfusion pressure drop was similar between the novel cannula (22±1.2mmHg) and the 32Fr Crescent (21±0.4mmHg), and higher for the 28Fr Crescent (43±0.9mmHg) at 2LPM. Total pressure drop was similar between the novel cannula (33.4±1.2mmHg) and 32Fr Crescent (29.4±0.5mmHg) and higher for the 28Fr Crescent (57±1.0mmHg) at 2LPM. In ex-vivo heart studies flow through the novel cannula was directed towards the tricuspid valve and entered the right ventricle. Conclusions: Our novel cannula possesses an excellent pressure-flow profile, comparable to the largest-bore commercially available dual lumen cannulas. This novel cannula will enhance durability and ease of use for patients requiring durable mechanical respiratory support.Figure 1. Pressure Flow Curve for Novel VV ECMO Cannula

An Interprofessional Approach to Mobilizing Patients With COVID-19 Receiving Extracorporeal Membrane Oxygenation.

To assess survival outcomes with the intervention of an interprofessional mobilization program for patients with COVID-19 who were receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). Preintervention and postintervention retrospective cohort study. Survival outcomes of nonmobilized, adult patients (n = 16) with COVID-19 who were receiving VV-ECMO (May 2020 through December 2020) were compared with those of 26 patients who received a mobility care plan (January 2021 through November 2021). In the preintervention group, full sedation and paralysis were used. In the postintervention group, an early mobilization strategy involving interprofessional collaboration was introduced. The postintervention group had improved survival (73.1% vs 43.8%; P < .04); fewer days of receiving paralytics, fentanyl, and midazolam (P < .01 for all); but more days of dexmedetomidine, morphine, and ketamine administration (P < .01 for all). Concomitantly, more patients in the postintervention cohort received oral or transdermal analgesics, oral anxiolytics, and oral antipsychotics (P < .01 for all), and also required more VV-ECMO cannula adjustments (P = .03). Early mobilization of patients with COVID-19 who were receiving VV-ECMO improved survival rates but led to more cannula adjustments.

Pilot Study of a Novel Gelatin-based Model for Venovenous Extracorporeal Membrane Oxygenation Cannula Insertion Simulation

Pilot Study of a Novel Gelatin-based Model for Venovenous Extracorporeal Membrane Oxygenation Cannula Insertion Simulation

Bridging to lung transplantation with double-lumen venovenous extracorporeal membrane oxygenation.

Double-lumen venovenous extracorporeal membrane oxygenation may be used as a bridge to lung transplantation. Predictors of outcome with this strategy have not been well described. All patients with irreversible lung disease who developed acute pulmonary failure and required double-lumen venovenous extracorporeal membrane oxygenation as a bridge to decision or lung transplant at our institution were included in this study. Survival of the extracorporeal membrane oxygenation patients was compared with listed patients who did not require extracorporeal membrane oxygenation with lung allocation score in the highest 10% for the same period. Fifteen patients (46 ± 17 years old) received double-lumen venovenous extracorporeal membrane oxygenation cannula. Mean length of extracorporeal membrane oxygenation support was 18.2 (1-60) days. Of these, seven patients were bridged to lung transplant, six died on extracorporeal membrane oxygenation, and two weaned to recovery. Amount of red blood cell transfusion was significantly higher (3.3 vs 18.5 U, p = 0.003) and lowest oxygen saturation was significantly lower in non-survivors (84.5% vs 66.3%, p = 0.002). Of the seven patients who were already listed for lung transplant at the onset of extracorporeal membrane oxygenation, five were transplanted. Overall survival to hospital discharge was 60%. Survival of patients with lung allocation score in the highest 10% (average lung allocation score 83.4) in the same period was 80%. Double-lumen venovenous extracorporeal membrane oxygenation cannula is a feasible option to bridge patients to decision or lung transplantation. Blood transfusion requirement and low oxygen saturation are markers of poor prognosis. Listing status at the time of cannulation and ambulation during extracorporeal membrane oxygenation support may be important indicators of good outcome.

A Real-time Color Doppler Marker for Echocardiographic Guidance of an Acoustically Active Extracorporeal Membrane Oxygenation Cannula.

B-mode ultrasound imaging guidance of cannulas can be compromised by noise, artifacts, and echogenicity that is not distinctive from that of surrounding anatomy. We have modified a venovenous extracorporeal membrane oxygenation cannula by embedding piezoelectric crystals into each of its 3 blood flow ports. Each vibrating crystal acoustically interacts with a Doppler imaging signal and produces an instantaneous color marker. The aim of this study was to compare identification of the extracorporeal membrane oxygenation cannula ports by B-mode imaging versus the color Doppler marker. Unlike B-mode imaging, the color Doppler marker identified the corresponding port even in highly challenging closed-chest scans in anesthetized pigs. The method could improve guidance accuracy of cannulas by ultrasound scans.

Catheter-directed guidance for ECMO cannulation with unfavorable caval anatomy

Extracorporeal membrane oxygenation (ECMO) has become the standard of care for potentially reversible cardiopulmonary conditions intractable to conventional medical management. Single site, dual-lumen veno-venous ECMO has proven to be safe and advantageous with respect to mobilization of the patient. Nevertheless, adequate respiratory support demands optimal cannula positioning and catastrophic cannulation complications have been reported. We describe herein the utilization of an angulated guiding catheter to obtain trans-caval access for the successful placement of a single site dual-lumen cannula for veno-venous ECMO in a patient with unfavorable trans-caval anatomy.

APACHE II score predicts mortality in patients requiring prolonged ventilation in a weaning center.

In the past decade, the rate and utilization of veno-venous extracorporeal membrane oxygenation (VV-ECMO) has increased dramatically. A single catheter technique has recently come into favour for providing VV-ECMO. Although it has been shown that intensivists can safely place these catheters, the safety of decannulation by intensivists has not been reported in the literature. We describe a technique for safely decannulating the Avalon Elite VV-ECMO catheter at the bedside and assess the safety of this technique, as compared with the standard technique of decannulation in the operating room by a surgeon. This was a retrospective cohort design conducted at a tertiary care cardiovascular intensive care unit at an academic medical centre. All patients who underwent VV-ECMO from 2009 to 2014 were included in the study except for those who had been decannulated for withdrawal of care. Complication rates from decannulation were compared between patients who were decannulated by surgeons in the operating room and those decannulated by intensivists in the intensive care unit (ICU). Twenty-eight patients were included in this study, of whom twenty-three patients (82%) were decannulated by intensivists, board certified in Critical Care Medicine through the American Board of Anesthesiology, while five (18%) the patients were decannulated by a surgeon. There was no significant difference in the complications rates between the surgeons (0) and intensivists (1) (P = 1.00). There were no major complications requiring operative intervention associated with decannulation identified in this study. It is safe for intensivists to decannulate the Avalon Elite VV-ECMO cannula in the ICU using our purse-string suture technique. Performing these decannulations at the bedside compared to operating room may have positive clinical ramifications that include improved patient safety, timely patient care and reduced operating room costs.

Safety of intensivist-led bedside decannulation of internal jugular bi-caval dual-lumen veno-venous extracorporeal membrane oxygenation cannulas and report of technique.

In the past decade, the rate and utilization of veno-venous extracorporeal membrane oxygenation (VV-ECMO) has increased dramatically. A single catheter technique has recently come into favour for providing VV-ECMO. Although it has been shown that intensivists can safely place these catheters, the safety of decannulation by intensivists has not been reported in the literature. We describe a technique for safely decannulating the Avalon Elite VV-ECMO catheter at the bedside and assess the safety of this technique, as compared with the standard technique of decannulation in the operating room by a surgeon. This was a retrospective cohort design conducted at a tertiary care cardiovascular intensive care unit at an academic medical centre. All patients who underwent VV-ECMO from 2009 to 2014 were included in the study except for those who had been decannulated for withdrawal of care. Complication rates from decannulation were compared between patients who were decannulated by surgeons in the operating room and those decannulated by intensivists in the intensive care unit (ICU). Twenty-eight patients were included in this study, of whom twenty-three patients (82%) were decannulated by intensivists, board certified in Critical Care Medicine through the American Board of Anesthesiology, while five (18%) the patients were decannulated by a surgeon. There was no significant difference in the complications rates between the surgeons (0) and intensivists (1) (P = 1.00). There were no major complications requiring operative intervention associated with decannulation identified in this study. It is safe for intensivists to decannulate the Avalon Elite VV-ECMO cannula in the ICU using our purse-string suture technique. Performing these decannulations at the bedside compared to operating room may have positive clinical ramifications that include improved patient safety, timely patient care and reduced operating room costs.

Migrated Avalon Veno-Venous Extracorporeal Membrane Oxygenation Cannula: How to Adjust Without Interruption of Flow.

The Avalon dual lumen cannula is presently the cannula of choice for veno-venous extracorporeal membrane oxygenation (VV-ECMO) via right internal jugular cannulation. This cannula establishes VV-ECMO with a single cannulation; however, it requires appropriate positioning to gain adequate oxygenation. Malposition of this cannula can cause inadequate ECMO flow, hypoxia, and structural injury. We have experienced two cases of migration: one into the hepatic vein and the other into the right ventricle. The former was repositioned using echocardiographic guidance without using a guidewire. The latter was repositioned using a guidewire from the femoral vein under fluoroscopy, without antegrade wire placement into the Avalon cannula, discontinuation of ECMO, or bleeding.

Carinal resection using an airway exchange catheter-assisted venovenous ECMO technique

To the Editor, Airway management during tracheal resection is one of the great challenges confronting anesthesiologists, especially when carinal resection is involved. When ventilation through the mainstem bronchi is not an option due to surgical exposure, extracorporeal oxygenation techniques become a vital tool. Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a preferred mode of assuring adequate oxygenation in patients with normal right ventricular function. However, its oxygenation efficacy is lower than either cardiopulmonary bypass (CPB) or venoarterial ECMO (VA-ECMO). We describe herein a case where an airway exchange catheter (AEC) was effective in assisting oxygenation during carinal resection with VV-ECMO. A 52-yr-old male presented with hoarseness, chronic cough, and hemoptysis. Flexible bronchoscopy revealed a squamous cell carcinoma located in the distal trachea just proximal to the carina and occluding about 50% of the tracheal lumen. The patient’s medical history was significant for hypertension, gastroesophageal reflux disease, and lumbar disc displacement. Preoperative pulmonary function tests showed a reduced FEV1/FVC ratio compatible with mild airflow obstruction, normal diffusion capacity, and normal measured lung volumes. Mediastinoscopy and distal tracheal and carinal resection with primary anastomosis were planned. In the operating room, after thoracic epidural catheter placement, general anesthesia was induced slowly with titration of sodium thiopental while the patient maintained spontaneous respiration. Once an adequate level of anesthesia was obtained using additional volatile anesthetic, a single-lumen endotracheal intubation was performed under direct laryngoscopy. Pancuronium was administered after adequate ventilation had been confirmed. Traditional lung isolation techniques were not an option due to the presence of the mass lesion at the carina and both main stem bronchi. Thus, the VV-ECMO was planned to assure adequate gas exchange during surgery. While the patient was in the supine position, mediastinoscopy was performed, followed by VV-ECMO cannula placement. The VV-ECMO was instituted via femoral and right internal jugular venous access with a flow rate of 3 L min. In order to assure proper cannula positioning to avoid recirculation phenomenon, the surgical team measured the location of the cannula tips from the insertion site. The patient was then repositioned into the left lateral decubitus position. The trachea and carina were dissected via the extended right thoracotomy incision. After the surgeon obtained adequate exposure to the trachea and carina, ventilation was stopped and VV-ECMO was initiated. With the VV-ECMO, the oxygen saturation persisted close to 80% (Table). At this point, a decision was made to insufflate supplemental oxygen to the patient’s lungs. With its flexibility and small size, a 14 Fr 100-cm soft-tip Cook Airway Exchange Catheter (Cook Medical, Bloomington, IN, USA) was inserted via the endotracheal tube into the right bronchus with a 6 L min oxygen insufflation through its lumen (Figure). We decided not to use a bronchial blocker due to the increased resistance to the gas flow and the possibility of lung overinflation from gas entrapment with the inflated balloon. Upon the completion of the right bronchial anastomosis, W. Keeyapaj, MD (&) Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA e-mail: kworasak@yahoo.com

Transesophageal Echocardiography-Guided Technique for Extracorporeal Membrane Oxygenation Dual-Lumen Catheter Placement

In acute respiratory distress syndrome (ARDS) with severe hypoxemia or respiratory acidosis, veno-venous extracorporeal membrane oxygenation (VV-ECMO) ensures oxygenation and decarboxylation. Commonly, simultaneous cannulation of jugular and femoral veins is used for VV-ECMO. A recently introduced dual-lumen cannula for VV-ECMO promises single vessel access through the right internal jugular vein and patient ambulation. However, correct direction of the reinfusion jet toward the tricuspid valve during ECMO treatment requires more demanding cannula placement control. We present a new ultrasound-guided technique for the placement of a dual-lumen VV-ECMO cannula in a patient with ARDS and extreme obesity.

Extra corporal membrane oxygenation in general thoracic surgery: a new single veno-venous cannulation

Extracorporeal membrane oxygenation (ECMO) is used in severe respiratory failure to maintain adequate gas exchange. So far, this technique has not been commonly used in general thoracic surgery. We present a case using ECMO for peri-operative airway management for pulmonary resection, using a novel single-site, internal jugular, veno-venous ECMO cannula.