From
StayCurrentMD
Update Course Rewind: ECMO 2018
With Dr. Ron Herschel · hosted by Dr. Rod Gerardo & Dr. Alex Cassar
Chapter 1 of 8 · Fundamentals
Introduction
Introduction and Conference Promotion
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
VV ECMO is markedly preferred over VA ECMO unless there are specific reasons requiring VA support
VV ECMO provides normal left ventricular afterload and reduced risk for systemic emboli compared to VA ECMO
VA ECMO offloads the right heart and increases afterload of the left heart with no recirculation
High stroke rates in ECMO patients may be related to patient illness severity rather than specifically to carotid cannulation
In critically ill patients requiring ECMO, it is more important to achieve rapid cannulation and stabilization than to avoid carotid access
At University of Michigan, for VA ECMO in children less than 35 kg, carotid-IJ cannulation is used
For patients over 35 kg requiring VA ECMO, femoral cannulation or carotid-IJ may be used, though VV is still preferred when possible
Posterior tibial artery cannulation is performed routinely in older patients at University of Michigan to prevent limb ischemia
Alternative techniques for preventing limb ischemia include placing a side graft onto the femoral artery or using subclavian artery access
Subclavian access for ECMO is used routinely by many adult practitioners and is better tolerated than femoral access because the arm tolerates ischemia better than the leg
For VV ECMO using separate femoral and IJ cannulas, the M-bridge configuration (draining from femoral, reinfusing into atrial) minimizes recirculation
The Avalon catheter requires placement of the distal tip into the inferior vena cava, which is not easy and requires getting a wire into the IVC
The Avalon single cannula is well tolerated and allows more patient mobility
Chest tubes should not be placed in ECMO patients with pneumothorax unless the patient is physiologically compromised or gas exchange is affected
Approximately 50% of chest tubes placed in ECMO patients result in bleeding requiring thoracotomy
When chest tube placement leads to bleeding in ECMO patients, management involves packing the chest and leaving it open
North-South syndrome occurs with femoral vein to femoral artery VA ECMO, where hypoxic blood from the heart perfuses the head and coronaries while oxygenated blood from ECMO perfuses the lower body
North-South syndrome can be addressed by infusing oxygenated blood from the ECMO circuit into the right IJ to perfuse the upper torso
A Hoffmann clamp can be placed on the ECMO circuit to adjust blood flow between the femoral artery (for blood pressure support) and right atrium (for upper body oxygenation)
In a registry of 30,000 patients, stroke rate with carotid cannulation is about 5%, compared to about 4% without carotid cannulation
In a study of femoral artery cannulation in patients aged 2-22 years, 9 out of 11 patients developed limb ischemia even with distal perfusion cannula
The Avalon double-lumen catheter is the preferred VV ECMO access across the country and world
For double-lumen VV ECMO catheter placement, it is acceptable to use the operating room, and fluoroscopy and echo should be used when possible
When using femoral artery cannulation for VA ECMO, prophylactic posterior tibial artery cannulation should be performed without waiting for ischemia to develop