Extracorporeal membrane oxygenation cannulation

Indications

• Venovenous extracorporeal membrane oxygenation (ECMO)

  • Acute severe respiratory failure with high mortality risk, reversible and nonresponsive to optimal conventional therapy. ECMO is considered when there is approximately at 50% mortality (PaO ₂ /FiO ₂ <150 on FiO ₂ <90% and Murray score 2–3) and indicated at 80% (PaO ₂ /FiO ₂ <100 on FiO ₂ 100% and Murray score 3–4 despite optimal care for ≥6 hours) using ARDSNET criteria with low tidal volume ≤6 cc/kg and high positive end-expiratory pressure (PEEP) ≥10 cm H ₂ O; maintaining P _LAT >30 cm H ₂ O.

  • Trial of diuresis

  • Trial of sedation/paralytics

  • Trial of prone positioning

• See Table E22.1 for respiratory etiologies.

  TABLE E22.1

  Respiratory Etiologies for Venovenous ECMO

  Acute Respiratory Injury	Trauma
  Pneumonectomy	Pulmonary contusion
  Lobectomy	Pre–lung transplantation
  ARDS	Chronic respiratory failure
  Pneumonia	Post–lung transplantation
  Viral illness – H1N1	Severe primary graft dysfunction
  Aspiration	Severe rejection – cellular and/or humoral
  Sepsis	Chronic respiratory disease
  Inhalation injury	Asthma
  	COPD

  ARDS, Acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease.

• Venoarterial ECMO: indication for ECMO in adult cardiac failure is cardiogenic shock: Inadequate tissue perfusion manifests as hypotension and low cardiac output

  • Shock persists despite the following therapies:

    • Volume administration

    • Inotropes and vasoconstrictors

    • Mechanical support with intraaortic balloon counterpulsation or Impella if appropriate

See Table E22.2 for cardiac etiologies. Contraindications

• Absolute contraindications

  • Significant life-limiting disease

  • Significant baseline lung disease, including home O ₂ dependence or heart disease

  • Not a transplant candidate

  • Multiple organ failure

  • Significant immunosuppression, bone marrow with absolute neutrophil count (ANC) <500

  • Cancer survival <2 years

  • Cirrhosis

  • AIDS or untreated HIV disease

  • Recent stroke/intracranial hemorrhage

  • Suspicion of anoxic brain injury

  • Specific to venoarterial (VA) ECMO:

    • Aortic regurgitation

    • Aortic dissection

    • Severe peripheral vascular disease

• Relative contraindications

  • Age

  • Bleeding diathesis

  • Gastrointestinal bleed

  • Greater than 14 days of mechanical ventilation

  • Encephalopathy

  • Morbid obesity

Equipment

Permanent equipment:

• Centrifugal pump

• Marquet Cardiohelp

  • Integrated pump and oxygenator

  • Provides real-time arterial and venous pressures, hemoglobin and SVO ₂

• Thoratec Centrimag

  • Magnetically levitated pump Impella—contract free for less hemolysis

  • No hand crank, must have backup console

  • ROTOFLOW

  • Inexpensive pump

• ECMO cart (including instrument tray)

• Oxygenator bracket (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 ft each) gas lines and connectors for all operating rooms and intensive care areas

• Cardiotomy reservoir holder

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

• Tubing clamps and scissors

• Hand crank

• Bed plate with two long poles

• 3/8″ Keck roller clamp for an additional outflow or inflow cannula

• Full 100% oxygen E cylinders with a tubing adapter

• Set of each: four types of gas connectors

  • Possible accessory equipment

  • Hemoconcentrator bracket

Disposable supplies:

• ECMO CarMeda-bonded (CB) Medtronic custom tubing pack or a Maquet custom tubing pack–Quadrox Bioline or Levitronix pump head

• Cardiotomy reservoir

• Walrus extension connectors with high-flow stopcocks

• Terumo extensions high flow (one positive and one negative for kidney)

• Pressure veil and isolator tubings or DLP pressure display set

• 3/16″ to male connectors

• Extra 3/8″ CB straight connectors with a Luer-Lok

• 3/8″ non-Carmeda bonded connector

• 3/8″ perfusion adapter

• PlasmaLyte-A pH 7.4—2000 mL (prime the circuit)

• Sterile water for irrigation for BioCal or Sarns water heater (approximately 3–4 L)

  • Syringes: 3 mL, 10 mL, and 60 mL

  • Blood filter

  • Extra supplies for ECMO site

• BioMedicus Medtronic NextGen cannulae

• Multistage cannula for venous insertion: 21F, 23F, 25F, 27F

• Arterial: 25F (for venous insertion as an outflow cannula), 15F, 17F, 19F, and 21F

• CB Medtronic DLP malleable venous cannulae: 32F, 36F, and 40F

• CB EOPA cannulae: 20F, 22F, 24F

• CB/non-CB right angle venous: 40F

• CB Edwards RMI 36F RA

• CB two-stage 36/46

• Avalon cannulae dual lumen cannula: 23F, 27F, and 31F

• Crescent dual-lumen cannulae: 24F, 26F, 28F, 30F, 32F

• Insertion kits for cannulae (LivaNova Vascular dilator kit)

• Extra oxygenator Quadrox D

• Fresenius hemoconcentration (with Terumo tubing assembly)

• SCUF custom tubing pack

• IV tubing for hemofiltration

• Extra CB VAD/liver pack

• Extra length CB 6-ft. 3/8″ × 3/32″ tubing (sterile) and {1/4} × 3/32″ sterile tubing

• CB 3/8″ connectors with Luer-Lok

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

• Walrus large-bore stopcock and extension assemblies

• Terumo high-flow extension stopcocks

• Isolator (pressure veils), {3/16}″ male connectors, and stopcocks

• 3-mL, 10-mL, and 60-mL syringes

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

• PlasmaLyte-A (pH 7.4)

• Blood filter (40 microns)

• Heparin (1:1000 units/mL)

• 210-cm guide wire

• 100-cm guide wire

• 145- and 260-cm Amplatz Super Stiff PTFE-coated guide wires

• Small biohazard bags

• Panduit ties and gun

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