ECMO CannulationTechnical Considerations · –Fem-Fem –Fem-IJ –Fem-Axillary. VV Consideration....

transcript

ECMO Cannulation Technical Considerations

Bradford Ledzian, PAC, MHS, DFAAPA,

FAPACVS

Considerations

• Peripheral ECMO

• Central ECMO

Peripheral Approach

Peripheral Cannulation Sites

• Femoral

– Vein & Artery

• Neck

– Vein

• Axillary

– Vein & Artery

Femoral Cannulation

• Order of Access

• Access Ergonomics

• Location of Puncture

• Ultrasound Technique

• Incision & Dilation Technique

• Extremity Selection

• Cannula Selection

• Internal Positioning & External Securing

Femoral Order of Access

Order of Femoral Access

• Emergent

– Venous 1st, Arterial 2nd

– Antegrade Arterial Perfusion

• Controlled

– Venous, Antegrade Arterial Perfusion, Arterial

Order of Femoral Access

Femoral Access Ergonomics

Femoral Arterial Access Ergonomics

• Straight Line Principle

– PA > Operative Site > US Screen

• Fulcrum Effect

• Visual Axis

• Motor Axis

• CoAxial Alignment

Fulcrum Effect

• Left/Right external needle movement =

Right/Left internal needle movement

• Up/Down external needle movement =

Down/Up internal needle movement

Visual Axis

• PA line of vision(Eyes) > Operative site > US

image of operative site

Visual Axis

Motor Axis• PA operative manipulation(Hands) > Operative site fulcrum > Translate

action of US image

Optimal Co-Axial Alignment

Set yourself up for…

…1 stick

…1 pass

…1 puncture

• VENOUS Access

– PA L foot of bed, US Right head of bed

– Right hand US, Left hand needle

• ANTEGRADE ARTERIAL SFA

Access

– PA L head of bed, US Right foot of bed

– Right hand needle, Left hand US

• ARTERIAL Access

– PA L foot of bed, US Right head of bed

– Right hand US, Left hand needle

Femoral Location of Puncture

Location of Puncture Puncture

• Venous

– Above GSV insertion

• Antegrade Arterial Perfusion

– Below DFA/SFA branching in SFA

• Arterial

– Above DFA/SFA branching in CFA

• Right Femoral

• Right Femoral Ideal Wire Placement

• Left Femoral

External Location of Puncture

US Technique

• Skin contour depression deformity

• Intradermal wire tracking

US Technique

US Technique• Geometric limitations

– Angle of Insertion

US Technique

• Trigonometric Relationships

Angle of Insertion Depth of Vascular Structure

Distance from US Probe to Stick Site

Minimum Catheter Length

45 1cm 1cm 1.4cm

45 5cm 5.0cm 7.1cm

30 1cm 1.7cm 2.0cm

30 5cm 8.7cm 10cm

Incision & Dilation Technique

• Incision length

– C = πD

– ½ C = (πD)/2

• D < Incision Length < ½C

• NonElastic Skin Elastic Skin

Incision & Dilation Technique

• Z Tracking

– Too shallow angle of dilator advancement

Femoral Extremity Cannulation Selection

Extremity Cannulation Selection

• Venous

– R leg preference

• Arterial

– Separate A/V leg preference

– Non-dominant leg preference

Extremity Cannulation Selection

Cannula Selection

Cannula Selection Principles

• Systemic flow is indexed to BSA

– 2.2 – 2.4L/min/m2 (50-65 ml/Kg)

– BSA x Systemic Flow needs = L/min flow

• Pressures

– Venous < -100 (-130 to -150 Max)

– Internal < 350

– Arterial < 300

• Catheter Flow Characteristic

Cannula Selection

• Venous

• Arterial

Cannula Selection

• Venous (Drainage)

– 22 or 25 f

Cannula Selection

• Venous (Return)

– 23, 25, 27 f

Cannula Selection

• Arterial

– 17, 19, 21 f

Cannula Selection

• 5-9 F, 11-24cm

Femoral Internal Positioning

Internal Positioning

• Thoraco-Abdominal-Pelvic Fluoroscopy

• SFA Arteriogram

Internal Positioning

External Securing

• Cannula Securing

– Suture

• 2 point

• Skin friction utilization

– Adhesive

• Ioban strip

• Stat-lock

– Zip-Tie

• Hemostasis/Planned closure

– Purse string

– Tourniquet buttons

External Securing

• Surgical Relevant Geometry

Femoral Cannulation

• Video Demonstration

Neck Cannulation

Cannula Selection

• Bi-Directional

Internal Jugular Cannulation

• Avelon Venous

– Thoracic Fluoroscopy

• Placement

– Passing IVC Troubleshooting

– Wire Management

• Positioning

• Cannula technique without heparin

– Transesophageal Echocardiography

• BiCaval View

Dilators

Room SetUp

• Wire Management Technique

• Optimal Co-Axial Alignment

• IJ approaches• Central

• Insertion at bifurcation of SCM directed straight

• Posterior• Insertion lateral to clavicular

head of SCM directed medial

• Anterior• Insertion medial to sternal

head of SCM and directed lateral

Location of Puncture Access

Axillary Cannulation

Axillary Cannulation Arterial

• US Imagable

• Arm Positioning

• Cutdown

• Flow Restriction

Axillary Vascular Cannulation

• Optimal Co-Axial Alignment

Axillary Cannulation Venous

• US Imageable

• Compressable

• NOT Subclavian

• Left Axillary InfraClavicular Fossa

• Arm Tucked vs Arm Right Angle

VV Considerations

VV Consideration

• Cannulation options

– R IJ VV duel lumen

– Fem-Fem

– Fem-IJ

– Fem-Axillary

VV Consideration

• Recirculation

– Recirculation = (SpreOx – SvO2)/(SpostOx-Svo2)

– Effective Flow = Total Flow - (Total Flow *

Recirculation Fraction)

• Contributing Factors

– Pump Flow

– Catheter Position

– Cardiac Output

– RA Size

VV Consideration

VA Considerations

VA Consideration

• Harlequin Syndrome/North-South Syndrome

– R Radial A-Line

– TEE Mixing Imaging

– V-AV

VA Consideration

• LV Stasis/Thrombous

– LV Venting Options

VA Considerations

Central Cannulation

• Tunneling issues

Central Cannulation

Conclusion for now…

Thank you

ECMO CannulationTechnical Considerations · –Fem-Fem –Fem-IJ –Fem-Axillary. VV Consideration....

Documents