Extracorporeal Membrane Oxygenation Cannulation

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W22 Extracorporeal Membrane Oxygenation Cannulation

Penny Lynn Sappington

Before Procedure

Indications

Equipment

• Permanent equipment:

• BioMedicus 540 centrifugal pump console/Rotoflow/Levitronix

• TX-40 flow transducer for BioMedicus

• ECMO cart (including instrument tray)

• Oxygenator bracket (for Affinity or Quadrox D)

• Pump external drive

• Heater/cooler with appropriate water lines and connectors (BioCal or Sarns) or heating blanket

• Oxygen medical air blender with appropriate-length (20 feet each) gas lines and connectors for all operating rooms and intensive care areas

• Cardiotomy reservoir holder

• Hemochron Jr Signature + activated clotting time (ACT) device

• Manifold for pressure readings on the BioPump 540 transducer, Medtronic DLP pressure display

• 6 Tubing clamps and scissors

• Bed plate with two long poles

• Blue roller clamp assembly for recirculation line (10-mm Keck roller clamp from Cole Parmer)

• 2 Full 100% oxygen E cylinders with tubing adapter

• Set of each: 4 types of gas connectors

• Possible Accessory Equipment

• Hemoconcentrator bracket

• Extra supplies for ECMO site:

• Avalon cannula (double lumen cannula): 23F, 27F. 31F

• Insertion kits for cannulae (RMI PIKV for 23, 25, 27, and 29 venous)

• Extra oxygenator (CB Affinity), Quadrox D

• Fresenius hemoconcentrator (with Terumo tubing assembly)

• SCUF custom tubing pack

• IV tubing for hemofiltration

• Extra CB VAD/liver pack

• Extra length CB 6 feet 3/8-inch × 3/32-inch tubing (sterile) and 1/4-inch × 3/32-inch sterile tubing

• CB 3/8-inch connectors with Luer-Loks

• 8F pediatric arterial CB cannula with 1/4-inch × 3/8-inch connector and 1/4-inch tubing CB (for distal femoral artery perfusion)

• Walrus large-bore stopcock and extension assemblies

• Terumo high-flow extension stopcocks

• Isolator (pressure veils), 3/16-inch male connectors, and stopcocks

• 3-, 10-, and 60-mL syringes

• 18-gauge needles and sterile safety blades or sterile scissors

• Plasmalyte-A pH 7.4

• Blood filter (40-micron)

• Heparin (1 : 1000 units/mL)

• ACT Jr. cuvettes

• Electronic quality controls for Hemochron Jr Sig+ and QC log

• 210-cm guidewire

• 100-cm guidewire

• Small biohazard bags

• Panduit ties and gun

• Appropriate charts, ECMO pre-bypass checklist, ECMO shift schedule, and shift checklist

Anatomy

For femoral cannulation, one should locate the patient’s femoral triangle, the name given to an area of the anterior aspect of the thigh formed as different muscles and ligaments cross each other, producing an inverted triangular shape. Contained within this area, placed medially to laterally, are the femoral vein, artery, and nerve (remember “van”). The borders of the triangle are composed of (1) the medial border of the sartorius, which forms the lateral border of the triangle, (2) the inguinal ligament, which forms the superior border, and (3) the medial border of the adductor longus, which forms the medial border. Within the triangle, the femoral artery lies at the midinguinal point, which is the midway point between the pubic symphysis and anterior iliac spine. This midway point is an important landmark in locating the femoral artery. It is also an important landmark within the leg, because medial to the femoral artery is the femoral vein. So in effect, one can locate the femoral vein by palpating the femoral pulse and moving the needle medially.

The internal jugular vein lies within the triangle made up by the lateral head of the sternocleidomastoid muscle, medial head of the sternocleidomastoid muscle, and the clavicle inferiorly. Locate the apex of the triangle and move inferiorly to the center to locate the internal jugular vein. The apex of this triangle is a good landmark in locating the internal jugular vein. The carotid artery lies lateral and inferior to the internal jugular vein.

For central venoarterial ECMO cannulation, the ascending aorta (located within the mediastinum) is cannulated with the arterial cannula, and the right atrium is cannulated with the venous cannula. For central venovenous ECMO, cannulae are placed in the right atrium (venous cannula) and pulmonary artery (arterial cannula).

Procedure

• Venovenous percutaneous: cannulation is usually performed at the patient’s bedside with the assistance of nursing staff. Percutaneous venous cannulation for ECMO is achieved with the use of a modified Seldinger technique. The right neck and the appropriate groin region are prepared and draped in a sterile fashion, and anesthesia is achieved with a local anesthetic. Unless contraindicated by immediate postoperative status, all patients receive a bolus of 3000 to 5000 units of heparin (or 100 units/kg) for the cannulation procedure (percutaneous or open). The vein (femoral or jugular) is accessed at an angle of approximately 30 degrees with the skin, and the guidewire is passed through the needle. As for any percutaneous technique, the guidewire should pass unimpeded. Occasionally, the onset of cardiac ectopy provides evidence regarding the location of the wire’s tip. We commonly temporarily replace the wire with an Angiocath or small dilator to verify that the access achieved is venous and not arterial. The wire is then replaced, and using it as a guide, sequentially larger dilators are passed. Manual compression of the insertion site is used to prevent excessive bleeding as the dilators are sequentially removed and reinserted. It is very important to ensure that the wire moves freely during dilatation as well as cannula insertion. Free movement of the guidewire indicates that the dilator or cannula is following the path of the wire and not kinking and taking an alternative path, such as through the vessel wall. Kinking can be prevented by gentle traction on the wire applied by an assistant as the dilator or cannula is passed. Creation of a skin incision slightly smaller than the cannula being inserted facilitates passage of the cannula while still providing good hemostasis. Occasionally, difficulty is encountered with passage of the cannula under the inguinal ligament or through the dilated opening in the vessel wall. Redilatation with a smaller dilator can facilitate passage. The preferred drainage site is the femoral vein; the cannula is advanced to just below the caval-atrial junction. The flows are usually the maximum capable with consideration to negative inlet pressures, RPMs and positive resistance. Inflow to the patient is usually the right internal jugular vein, using a CB arterial BioMedicus cannula (usually 19 or 21 CB BioMedicus).

• If a secondary site is needed, femoral and internal jugular may be used and “Y’d” to the venous tubing for venoarterial ECMO.

• Avalon cannula can be inserted into the internal jugular using the 23F, 27F, or 31F. This cannula allows drainage from the cannula holes sitting in the inferior vena cava and superior vena cava and returns blood to the right atrium. A baffle in the cannula separates inflow from outflow.

• After cannulation, it is important to assess cannula position by obtaining a radiograph.

• Venoarterial percutaneous: the preferred site is the femoral artery. Surgical (as well as percutaneous) insertion of arterial cannulae in the femoral artery can sometimes be complicated by malperfusion of the distal extremity. This complication may be addressed in several fashions but should be dealt with expeditiously to avoid severe injury. We prefer the insertion of a modified, cut, high-pressure monitoring line (arterial line tubing) down the femoral artery of the affected limb. This can be achieved in the open wound just distal to the reinfusion cannula insertion site or, in the case of a percutaneous cannula, via an incision at a separate site. The tubing is connected to a CB 3/8- × 3/8-inch connector with a Luer-Lok between the arterial cannula and the ECMO arterial pump tubing. If decreased heparinization and low flow in this system is a concern, heparin (0.5 to 2 units/kg/h) may be infused by a pressure pump into this system for anticoagulation.

• Venovenous/venoarterial surgical cutdown using the same cannulae: when there is difficulty with percutaneous cannulation or the body habitus is not conducive, surgical cutdown to gain access to the femoral vessels can be done either at the bedside or, if time allows, in the operating room.

• Central cannulation: ECMO may be performed with central cannulation with a CB Medtronic 35-cm DLP 32F, 36F, or 40F malleable venous CB Medtronic DLP 2 stage 34/46, and DII 40F RA for right or left atrial cannulation. Inflow to the patient may be accomplished with Carmeda EOPA 22F or 24F or other appropriate coated cannula for pulmonary artery or aorta. The median sternotomy is the least favored, as this site is associated with more bleeding complications. The cannula may be tunneled inferior to the sternum and the chest then closed for hemostasis.

After Procedure

Postprocedure Care

• Weaning from venovenous ECMO is done by turning off the gases after placing the patient on reasonable ventilator settings and closely monitoring arterial saturations. Patient is decannulated after being maintained off gases for 24 hours.

• Weaning from a venoarterial system is very different; the arterial-venous bridge is used. The ventilator is set at optimal settings, and additional heparin is given to achieve an ACT of 300 seconds. ECMO flows may be reduced by 1 L/min at intervals, and observations of the patient’s hemodynamics and arterial saturation are critical. Echocardiogram imaging is also useful in determining when the patient may be ready to be cannulated.

Outcomes and Evidence

• Patient outcomes after ECMO cannulation are very much dependent on the coexisting condition at the time of cannulation, as well as the clinical state of the patient on ECMO support:

• Comorbidities precannulation

• Organ dysfunction

• Length of cannulation

• Type of ECMO support

Venovenous versus venoarterial

• Outcomes trial

• CESAR trial (conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure):

Of patients assigned to consideration for treatment by ECMO, 63% (57/90) survived to 6 months without disability, versus 47% (41/87) of those assigned to conventional management (relative risk, 0.69; 95% confidence interval [CI], 0.05–0.97; P = .03).

• There are a lack of quality randomized controlled trials of ECMO outcomes in the adult population, especially venoarterial ECMO.

Suggested Reading

Peek GJ, Elbourne D, Mugford M, et al. Randomised controlled trial and parallel economic evaluation of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR). Health Technol Assess. 2010 Jul;14(35):1-46. [PMID- 20642916]

Bermudez CA, Adusumilli PS, McCurry KR, et al. Extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation: long-term survival. Ann Thorac Surg. 2009 Mar;87(3):854-860. [PMID: 19231405]

Bermudez CA, Rocha RV, Sappington PL, et al. Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults. Ann Thorac Surg. 2010 Sep;90(3):991-995. [PMID: 20732530]

Pipeling MR, Fan E. Therapies for refractory hypoxemia in acute respiratory distress syndrome. JAMA. 2010 Dec 8;304(22):2521-2527. [PMID: 21139113]

Bartlett RH. Acute respiratory failure syndrome: Extracorporeal life support in the management of severe respiratory failure. Clin Chest Med. 2000;21:555-561. [PMID: 11019727]

Bartlett RH, Gattinoni L. Current status of extracorporeal life support (ECMO) for cardiopulmonary failure. Minerva Anestesiol. 2010 Jul;76(7):534-540. [PMID: 20613694]

Elsharkawy HA, Li L, Esa WA, et al. Outcome in patients who require venoarterial extracorporeal membrane oxygenation support after cardiac surgery. J Cardiothorac Vasc Anesth. 2010 Dec;24(6):946-951. [PMID: 20599396 ]

Pranikoff T, Hirschl RB, Remenapp R, et al. Venovenous extracorporeal life support via percutaneous cannulation in 94 patients. Chest. 1999;115:818-822. [PMID: 10084497]

Moran JL, Chalwin RP, Graham PL. Extracorporeal membrane oxygenation (ECMO) reconsidered. Crit Care Resusc. 2010 Jun;12(2):131-135. [PMID: 20513222]

Bartlett RH, Roloff DW, Custer JR, et al. Extracorporeal life support: the University of Michigan experience. JAMA. 2000;283:904-908. [PMID: 10685715]

Brogan TV, Thiagarajan RR, Rycus PT, et al. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med. 2009 Dec;35(12):2105-2114. Epub 2009 Sep 22. [PMID: 19768656]

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