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
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
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
High stroke rates in ECMO patients may be due to patient illness severity rather than specifically carotid cannulation
For VA ECMO in children less than 35 kg, carotid-IJ cannulation is used at University of Michigan
For VA ECMO in patients over 35 kg, femoral cannulation or carotid-IJ may be used, though VV is strongly preferred
At University of Michigan, posterior tibial artery cannulation is performed routinely in older ECMO patients for distal perfusion
Side graft (cortex) onto the subclavian artery is used routinely by many adult practitioners for ECMO access, avoiding leg complications
The Avalon catheter requires placement of the distal tip into the inferior vena cava, which is not easy to do
The Avalon single cannula is well tolerated and allows more patient mobility
Chest tubes should not be placed for pneumothorax in ECMO patients 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 with chest packing
North-South syndrome occurs with femoral vein to femoral artery VA ECMO, where hypoxic blood from the heart perfuses the head and heart 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% (1% less) 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
For VV ECMO with separate femoral and IJ cannulas, draining from femoral and reinfusing into atrial (IJ) minimizes recirculation compared to the reverse configuration
The Avalon double-lumen catheter is the preferred VV ECMO access across the country and world
When a patient is physiologically deranged and very sick, it is acceptable to proceed directly to carotid-IJ cannulation rather than attempting other approaches
Posterior tibial artery should be cannulated prophylactically for distal perfusion when using femoral artery access, rather than waiting for ischemia to develop
For double-lumen VV catheter placement, it is acceptable to use the operating room, and fluoroscopy and echo should be used for guidance