Vascular access in ECMO
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REVIEW ARTICLE
Vascular access in ECMO Suneel Kumar Pooboni 1
&
Krishna Mohan Gulla 2
Received: 12 March 2020 / Revised: 19 June 2020 / Accepted: 23 June 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
Abstract In critically ill patients, deserving extracorporeal membrane oxygenation (ECMO), choosing the right pattern of cannulation such as veno-venous (VV), veno-arterial (VA), veno-veno-arterial (VVA), and central; selecting the appropriate size cannulae; and good cannulation techniques are all pre-requisites for the successful outcome of ECMO. We are describing the selection criteria for choosing appropriate size cannulae, cannulation configurations, available cannulae, and possible complications. A brief note on anticoagulation was added. Keywords VA-ECMO . VV-ECMO . VVA-ECMO . Cannulae
Introduction Choosing an appropriate cannulation site, cannula size, and cannulation technique is essential for successful extracorporeal membrane oxygenation (ECMO) support. ECMO comprises two major divisions: veno-arterial (VA) and veno-venous (VV). In the VA-ECMO, a drainage cannula is inserted into a large vein (femoral vein or internal jugular vein) and a return cannula into a large artery (femoral artery or carotid artery or ascending aorta) [1]. It is used to support circulation in patients with cardiogenic shock refractory to maximum medical therapy or extracorporeal cardiopulmonary resuscitation (E-CPR). In the VV configuration, a drainage cannula as well as a return cannula is placed in the major veins. It is used in patients with respiratory failure (oxygenation/ventilation) which is refractory to conventional medical treatment.
Age as the criteria for selection of cannulation In all age groups, for respiratory indications of ECMO, venovenous cannulation is the preferred option (unless there is * Suneel Kumar Pooboni [email protected] 1
Department of Pediatric Critical Care Medicine, Mediclinic Hospital, Dubai Healthcare City, Dubai, UAE
2
Division of Pediatric Emergency and Critical Care Department of Pediatrics PGIMER, Chandigarh-12, India
associated cardiac failure). In a typical newborn, weighing approximately 4 kg, the internal jugular vein can accommodate the smallest available 13-F double-lumen Avalon cannula. If their weight is less than 4 kg, it is ideal to go for a VA configuration using the right internal jugular venous cannula size of 12 F and a carotid arterial cannula size of 8 F (despite the indication being respiratory). Below 2 years of age or 10 kg of weight, femoral vessels should not be used for cannulation as they are ill-developed to allow desired flow [2]. Below 34-week gestation or 2 kg weight, one has to weigh the risks against the benefits of ECMO as the preterm babies tend to have increased incidence of intra-ventricular hemorrhage, in view of smaller size and fragile blood vessels.
Exceptional situations It is customary to look for the patency of blood vessels by using vascular ultrasound before we attempt cannulation. This is an opportunity to visualize the
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