Initial Experience With Single Cannulation for Venovenous Extracorporeal Oxygenation in Adults Christian A. Bermudez, MD, Rodolfo V. Rocha, MD, Penny L. Sappington, MD, Yoshiya Toyoda, MD, PhD, Holt N. Murray, MD, and Arthur J. Boujoukos, MD Heart, Lung, and Esophageal Surgery Institute, and Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Purpose. Historically, venovenous extracorporeal membrane oxygenation has required dual cannulation. A single-venous cannulation strategy may facilitate implantation and patient mobilization. Here we present our early experience with a single cannulation technique. Description. Review of venovenous extracorporeal membrane oxygenation support using internal jugular vein insertion of the Avalon elite bicaval dual lumen catheter (Avalon Laboratories, Rancho Dominguez, CA) in 11 consecutive patients with severe respiratory failure. Evaluation. Adequate oxygenation was obtained in all patients: 115 mm Hg Pa0 2 (median), 53 to 401 mm Hg (range). Median time of support was 78 hours (range, 3 to 267 hours). No mortality was directly related to the cannulation strategy. There were three nonfatal cannulation-related events. Two patients had proximal cannula displacement requiring repositioning. One patient suffered an acute thrombosis of the cannula. Conclusions. Our series supports single-venous cannulation in venovenous extracorporeal membrane oxygenation as a promising technique. It may be an excellent alternative to current cannulation strategies in patients requiring prolonged support and specifically for those considered for a bridge-to-lung transplantation. (Ann Thorac Surg 2010;90:991 5) 2010 by The Society of Thoracic Surgeons Severe acute respiratory failure is associated with a high mortality [1]. When mechanical ventilation and other respiratory support techniques fail to maintain adequate oxygenation, then extracorporeal membrane oxygenation (ECMO) is a useful method of support to allow lung recovery or as a bridge-to-lung transplantation [2, 3]. Although encouraging results have been reported on the use of ECMO in patients with progressive respiratory failure, several complications have also been described, such as bleeding, thrombosis, and infection [4, 5]. Venovenous extracorporeal membrane oxygenation (VV ECMO) is the preferred type of support in patients with acute respiratory failure due to lower risk of thromboembolic complications and weaning simplicity. Historically, VV ECMO has required dual cannulation [6]. The need for dual peripheral cannulation (jugular and femoral) complicates the initiation of support in emergent situations and in patients with previous vascular interventions (ie, cava filters). In addition, the ability to mobilize the patient is limited due to cannula size and location, becoming a serious consideration in patients Accepted for publication June 4, 2010. Address correspondence to Dr Bermudez, UPMC-Presbyterian University Hospital, 200 Lothrop St, Ste C900, Pittsburgh, PA 15213; e-mail bermudezc@upmc.edu. requiring prolonged support. These patients are kept intubated during their ECMO support and are rarely mobilized or ambulatory. The use of a single jugular cannula would potentially increase the chances of mobilizing these patients in the bed, facilitating pulmonary toilet and extubation, and increasing the likelihood of physical rehabilitation. Technology Using an original design by Wang, Zwischenberger, and colleagues [7], Avalon Laboratories (Rancho Dominguez, CA) developed a dual-stage cannula (the Avalon Elite Bicaval Dual Lumen Catheter) that allows VV ECMO support with a single-venous cannulation strategy. Here, we review our experience at University of Pittsburgh Medical Center using the Avalon elite bicaval dual lumen catheter (DLC) for advanced respiratory failure. We conducted an institutional review boardapproved retrospective review of 11 consecutive patients with advanced respiratory failure who were placed on VV ECMO support using single-venous cannulation between September 2009 and February 2010. The cannulation was performed through the internal jugular vein using the Avalon elite bicaval DLC (Avalon Laboratories). Data was collected from 2010 by The Society of Thoracic Surgeons 0003-4975/$36.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2010.06.017
992 BERMUDEZ ET AL Ann Thorac Surg EXPERIENCE WITH SINGLE CANNULA VV ECMO 2010;90:991 5 Fig 1. Dual lumen catheter placement position. (IVC inferior vena cava; RA right atrium; SVC superior vena cava.) our ECMO prospective database and the patient s medical records. Technique The ECMO support was initiated after cannulation of the internal jugular vein using the Seldinger technique. A radio-opaque (0.965 mm) wire was inserted in the right internal jugular vein under ultrasound guidance and was passed distally to the inferior vena cava (IVC) in all cases. After confirmation of the position of the wire, the cervical incision was dilated and the DLC was inserted (Fig 1). The DLC is constructed with Elast-Eon (Aortech International, Surrey, United Kingdom) and contains a deflectable inner membrane that allows a single-piece, duallumen design. In adults, 23-French (F), 27-F, and 31-F cannulas can be used. In our population, we preferred the use of 27-F and 31-F cannulas that would allow 3.5 to 5 L/min flow under standard conditions. The distal part of the cannula is placed in the IVC (Fig 2) with the outflow exit orifice pointed 280 toward the tricuspid valve. After implantation, the correct placement of the cannula was confirmed using transthoracic ultrasound, and lately portable radiologic confirmation was also performed. In all patients, ECMO was performed using a centrifugal pump (BP-80 [Medtronic Biomedicus, Eden Prairie, MN]) and a Medtronic Carmeda heparin-bonded affinity oxygenator. Heparin (5,000 to 10,000 units) was administered before cannula insertion, and in the absence of bleeding an activated clotting time of 140 to 160 seconds was maintained for the duration of ECMO support. In light of the absence of a recommended activated clotting time or partial thromboplastin time for this cannula, we assumed the same protocol as for regular VV ECMO support. Eleven patients were included in this series. The causes of respiratory failure necessitating ECMO support were as follows: postcardiotomy complications (4 patients), hemagglutanin-1 and neurominadase-1 (H1N1) influenza virus infection (2 patients), decompensated cystic fibrosis requiring a bridge-to-lung transplant (2 patients), pneumonia (1 patient), acute respiratory distress syndrome (1 patient), and multiple trauma (1 patient). Six patients (54%) were female. The median patient age was 34 years old (range, 25 to 54 years old). The median weight was 77 kg (range, 52 kg to 125 kg). The median time of support was 78 hours, with a range from 3 hours to 267 hours. Other patient characteristics are elaborated in Table 1. Adequate oxygenation was obtained in all patients. For each patient, we calculated the median partial pressure of oxygen (PaO 2 ) from all recorded PaO 2 measurements during ECMO support. The median PaO 2 for the entire group was 115 mm Hg, ranging from 53 to 401 mm Hg. Respiratory, hemodynamic, and perfusion measurements before and during ECMO support are presented in Table 2. Direct weaning from ECMO was possible in 8 of 11 patients (72%). Five patients died. Three patients had early mortality while on ECMO support. The cause of death included progressive hepatic bleeding from trauma injury (1 patient) and multiple organ failure (2 patients). The other two mortalities occurred later in the course of hospitalization, with one death 38 days after ECMO weaning as a consequence of intracranial hemorrhage, and another death that occurred 16 days after ECMO discontinuation due to fungal sepsis after a ven- Clinical Experience Fig 2. Cannula positioning under ultrasound guidance. (IVC inferior vena cava.)
Ann Thorac Surg BERMUDEZ ET AL 2010;90:991 5 EXPERIENCE WITH SINGLE CANNULA VV ECMO 993 Table 1. Patient Characteristics and Outcomes #27 French Cannula Patients #31 French Cannula Patients All Patients Patients Characteristics Median (range) Median (range) Median (range) Number 7 4 11 Gender Male 1 4 5 Female 6... 6 Age (years) 39 (29 54) 32 (25 52) 34 (25 54) Weight (kg) 62 (52 79) 105 (89 125) 77 (52 125) Cause of ECMO support ARDS 1... 1 Decompensated cystic fibrosis/pre-lung 2... 2 transplant H1N1 1 1 2 Pneumonia... 1 1 Postcardiotomy 3 1 4 Trauma... 1 1 Time of ECMO support (hr) 78 (24 267) 71 (3 216) 78 (3 267) Cannula events Thrombosis... 1 1 Displacement 2... 2 Successful ECMO weaning 5 3 8 Bridge-to-lung transplantation 2... 2 Survival from discharge 4 2 6 ARDS acute respiratory distress syndrome; ECMO extracorporeal membrane oxygenation; H1N1 hemagglutanin-1 and neurominadase-1 influenza virus infection. tricular septal defect repair. No mortality was directly related to the ECMO support. During single cannula VV ECMO support, three nonfatal cannulation-related adverse events occurred. Two patients had proximal cannula displacement after implantation. In one case, after mobilization of the patient in the intensive care unit, the distal portion of the cannula moved from the implantation position (in the IVC) into the right atrium, producing blood recirculation and rapid oxygen desaturation. In the other case, the Table 2. Respiratory, Hemodynamic, and Perfusion Measurements #27 French Cannula Patients #31 French Cannula Patients All Patients Parameters Median (range) Median (range) Median (range) Pre-ECMO support ph 7.17 (7.07 7.26) 7.28 (6.94 7.47) 7.18 (6.94 7.47) PaCO 2 (mm Hg) 55 (51 120) 38.5 (30 109) 55 (30 120) PaO 2 (mm Hg) 45 (32 92) 42.5 (28 248) 45 (28 248) SaO 2 (%) 85 (59 93) 80 (45 92) 85 (45 93) PaO 2 /FiO 2 45 (32 92) 42.5 (28 248) 45 (28 248) MAP (mm Hg) 52 (39 67) 39 (38 48) 48 (38 67) CVP (mm Hg) 9 (4 18) 9 (5 15) 9 (4 18) During ECMO support Pump flow (L/min) 3.8 (3.5 4.4) 4.3 (3.5 5.3) 3.8 (3.5 5.3) RPM 3,610 (2,480 4,400) 3,120 (2,500 3,600) 3,340 (2,480 4,400) ACT 157 (148 170) 158 (147 160) 157 (147 170) PaO 2 (mm Hg) 115 (53 272) 139 (95 401) 115 (53 401) MAP (mm Hg) 75 (66 91) 67 (65 72) 72 (65 91) CVP (mm Hg) 15 (12-21) 17 (14 20) 15 (12 21) ACT activated clotting time; CVP central venous pressure; ECMO extracorporeal membrane oxygenation; FiO 2 fraction of inspired oxygen; MAP mean arterial pressure; PaCO 2 arterial carbon dioxide tension; PaO 2 arterial oxygen tension; RPM revolution per minute; SaO 2 arterial oxygen saturation.
994 BERMUDEZ ET AL Ann Thorac Surg EXPERIENCE WITH SINGLE CANNULA VV ECMO 2010;90:991 5 Fig 3. Chest roentgenogram revealing cannula displacement into right atrium. distal portion of the cannula moved to a hepatic vein with flow deterioration. Both displacements were confirmed with the use of chest and abdominal roentgenograms performed in the intensive care unit (Figs 3, 4). In both patients, we repositioned the cannula under ultrasonic guidance without difficulties. One patient suffered an acute flow obstruction and thrombosis of the cannula. In this patient, single cannulation ECMO was used as an option for postcardiotomy respiratory failure. Due to early postoperative bleeding, we refrained from treating the patient with anticoagulant (heparin) for a period of 24 hours. After postoperative bleeding slowed ( 100 ml/hr), heparin (10 U/kg) was started without an intravenous bolus dose. After 58 hours of support, we identified an acute absence of blood flow and rapidly removed the cannula. An acute thrombosis in the inflow cannula had developed. The median activated clotting time during this patient support was 128 seconds. At that point, the patient was able to maintain adequate ventilation and oxygenation with conventional mechanical ventilation. considering long-term ECMO support. In addition, the activation of inflammatory and thrombotic responses may be minimized with the use of a single cannula by decreasing the extent of plastic surfaces in contact with the blood [9]. Implantation is performed using fluoroscopy or ultrasonic guidance. We favored ultrasonic guidance because the majority of cases in this series were implanted emergently in the intensive care unit with presence of severe hypoxemia (median pre-implant, PaO 2 of 45 mm Hg). Mobilization to the operating room for fluoroscopy would have delayed implantation, increasing the risk for these critically ill patients. We learned that a roentgenogram immediately after emergent implantation under ultrasound guidance is of significant value for confirming the depth of the distal inflow and absence of displacement into a hepatic vein or right ventricle. The ultrasound guidance allows a rapid confirmation of the wire in the IVC when emergent implantation is needed (as with the majority of the patients in our series), but it does not provide a clear view of the exact depth of the cannula. We maintain a sterile field until confirmation is made by roentgenogram using a portable machine, in case repositioning is needed. The cases of early cannula displacement in our series confirm that the cannula should be advanced well into the IVC, avoiding positioning of the distal inflow of the cannula at the right atrial-ivc junction. Displacement should be suspected in the presence of acute patient Comment The use of ECMO is a proven strategy to support patients in advanced respiratory failure. Significant design improvements in pumps and oxygenators have resulted in more reliable performance and biocompatibility. However, VV ECMO has been historically performed with two or more cannulas. Generally, their sizes and locations are limiting factors for mobilization. Our initial experience with the Avalon elite bicaval DLC supports the use of single-venous cannulation in VV ECMO. The use of a single, dual-chamber cannula could allow greater patient mobilization (by avoiding femoral cannulation) [8], and in conjunction with improvements in pump and oxygenator technology opening the door for Fig 4. Abdominal roentgenogram revealing cannula displacement into the hepatic vein.
Ann Thorac Surg BERMUDEZ ET AL 2010;90:991 5 EXPERIENCE WITH SINGLE CANNULA VV ECMO 995 oxygen desaturation while on support, and changes notable at the cannula level with signs of steal of oxygenated blood recirculation in the inflow side of the cannula. Repositioning is performed using the same techniques used at initial implantation. Based on our experience with thrombosis of the cannula, we believe that maintenance anticoagulation protocols need closer observation in patients on VV ECMO support with single cannulation than in patients with dual cannulation. The anticoagulation protocol necessary in these cases may be a factor requiring consideration before ECMO implementation and may affect patient selection. Patients with increased bleeding tendencies, requiring decreased use of heparin and low-activated clotting time, should be cautiously considered for this technique. The presence of these adverse events is reflective of an early learning curve for implementation of single-cannula VV ECMO support. The use of a dualchamber cannula for VV ECMO may potentially benefit patients requiring prolonged support, allowing mobilization and potential extubation [10]. In light of its adequate performance, we are now using this approach to VV ECMO as a preferred method for advanced respiratory failure, especially if there is a consideration of long-term support (ie, hemagglutanin-1 and neurominadase-1 [H1N1] virus influenza infection) or as bridge-to-lung transplantation. Disclosures and Freedom of Investigation The authors have no disclosures. Specifically, the authors have no financial or other relationships with Avalon Laboratories (ie, the manufacturer of the DLC used in the study). The authors had freedom of investigation in all aspects of the work. References 1. Vasilyev S, Schaap R, Mortensen J. Hospital survival rates of patients with acute respiratory failure in modern respiratory intensive care units. An international, multicenter, prospective survey. Chest 1995;107:1083 8. 2. Mols G, Loop T, Geiger K, et al. Extracorporeal membrane oxygenation: a ten-year experience. Am J Surg 2000;180:144 54. 3. Manert W, Haller M, Briegel J, et al. Venovenous extracorporeal membrane oxygenation (ECMO) with a heparin-lock bypass system. An effective addition in the treatment of acute respiratory failure (ARDS). Anaesthesist 1996;45:437 48. 4. Hemmila M, Rowe S, Boules T, et al. Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg 2004;240:595 607. 5. Bermudez C, Adusumilli P, McCurry K, et al. Extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation: long-term survival. Ann Thorac Surg 2009;87:854 60. 6. Kolla S, Awad S, Rich P, et al. Extracorporeal life support for 100 adult patients with severe respiratory failure. Ann Surg 1997;226:544 66. 7. Wang D, Zhou X, Liu X, Sidor B, Lynch J, Zwischenberger JB. Wang-Zwische double lumen cannula toward a percutaneous and ambulatory paracorporeal artificial lung. ASAIO J 2008;54:606 11. 8. Garcia J, Iacono A, Kon Z, et al. Ambulatory extracorporeal membrane oxygenation: A new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg 2010;139:e137 9. 9. Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, Davies A, Jones D, Bailey M, et al. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome. JAMA 2009;302:1888 95. 10. Oliver W. Anticoagulation and coagulation management for ECMO. Semin Cardiothorac Vasc Anesth 2009;13:154 75. Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.