Cannulation &

Recirculation IN VV ECMO

Assistant ProfessorCritical Care Medicine

Cairo University

Dr. Akram Abdelbary, MD

Access

Options For Cannulation in VV ECMO

Two Cannulas One double-lumen cannula

D Brodie, M Bacchetta; N Engl J Med 2011; 365:1905-14.

• Drainage cannula– As central as possible– Not too close to the

return cannula• Return cannula

– Close to the tricuspid valve

– But not too close to the drainage cannula

Cannula Placement

Significantly less flow was required during Femoro-Atrial VV ECMO

Cardiopulmonary Support and PhysiologyA Prospective Comparison of Atrio-Femoral and Femoro-Atrial Flow in Adult Venovenous Extracorporeal Life Support

Preston B. Rich, MD; Samir S. Awad, MD; Stefania Crotti, MD; Ronald B. Hirschl, MD, MS; Robert H. Bartlett, MD; Robert J. Schreiner, MD

Flow required to maintain equivalent SvO2

Fem – Fem Cannulation

IndicationCannulation

in jugular vein not possible.

Higher risk for femoral vein/caval

thrombosis(?)

Cannula

Choice

Influence of ECMO Flow

Schmidt et al., Intensive Care Med., 2013.

Pedersen et al., Ann Thorac Surg 1997

Hemolysis & Cannula Diameter

Q =DP p r4

8 h L

Flow is proportional to the power of 4 of radius

inversely proportional to tubing length and viscosity

1797-1869

Poiseuille’s Law

Joseph-Frédéric-Benoît Charrière 1803-1876

1 Charrière = 1 Fr = 1/3 mm

29 Fr.

25 Fr.

23 Fr.

21 Fr.

19 Fr.Drainage cannula

French size, Flow tables

23 Fr.

21 Fr.

19 Fr.

17 Fr.15 Fr.

Return cannula

French size, Flow tables

AdmissionReturn

Double Lumen Cannula

– Less Recirculation.

– Single access.

– Possible ambulation.

– Bigger cannula and smaller lumen.

– Image guidance is mandatory.

Double Lumen Cannula

Avantages:

Drawbacks:

Cannulation

Two Cannulas

Double-lumen

Specific Details Bi-Caval Dual Lumen

Mobilization: ECMO Devices

Mobilization is possible .

It probably reduces critical illness polyneuropathy, delirium and muscle atrophy.

It may reduce time on ventilation and improve outcome post lung transplantation.

Double-Lumen NovaPort Femoral

Size: 24 Fr. Bloodflow approx. 2.0 L/min. Recirculation. Indication: CO2 removal.

Also available: 18 Fr, 22 Fr jugular.

Insertion

Percutaneous insertion

Guide-wire – Dilators – Cannulas: Use the right tools

188 cannulation attempts.

11 cannulation failures.

3 arterial punctures.

• One leading to distal necrosis.

1 SVC laceration VCS.

1 fatal hemothorax.

• SVC perforation by Reinfusion Cannula.

Venovenous Extracoporeal Life Support Via Percutaneous Cannulation in 94 Patients*

Thomas Pranikoff, MD; Ronald B. Hirschl, MD’; ‘Robert Remenapp, RRT; Fresca Swaniker, MD and Robert H. Bartlett, MD, FCCP

Chest 1999; 115:818-822.

Transesophageal Echocardiographic Guided Placement of a Right Internal Jugular Dual-Lumen

Venovenous Extracorporeal Membrane Oxygenation (ECMO) Catheter

Mazzeffi M J Cardiothorac Vasc Anesth, 2013

Mid-esophageal four-chamber TEE view with white arrow

showing improperly positioned cannula in the right ventricle.

Modified mid-esophageal bicaval TEE view using color Doppler

compare mode showing return blood flow in the center of the

right atrium directed towards the tricuspid valve. (Color version of

figure is available online).

Dolch et al, ASAIO, 2011.

Always use ultrasound guidance…

Ultrasonic locating devices for central venous cannulation: meta-analysis

Daniel Hind, Neill Calvert, Richard McWilliams, Andrew Davidson, Suzy Paisley, Catherine Beverley, Steven Thomas

Complications

Damage to Vessel and Tamponade

Malpositioning

Dislocation of Cannula

Risk of Thrombosis

78 post-mortem examinations in VA-

ECMO:

Venous thrombosis in 25 patients.

Fatal PE in 2 patients.

“The true incidence of thromboembolic

events is highly underestimated by

clinical evaluation”.

Rastan AJ et al., Int J Artif Organs 2006; 29:1121-31.

Further Problems

infection

Air

Recirculation with

VV ECMO

Limitations to Oxygenation

Blood flow / drainage.

Fraction of oxygen delivered through membrane.

Membrane function / efficiency.

Recirculation.

What is Recirculation?

Abrams et al, ASAIO 2014

Proportion of oxygenated blood captured by the ECMO system and reinjected into the ECMO circuit, instead of being pumped

Does not share in patient oxygenation

Increasing Spre O2 without other clinical change

Spre O2 > Peripheral SaO2

When to suspect Recirculation?

O2 post oxy

venous O2 Without ECMO

O2 preoxy

How to calculate Recirculation?

FR = Recirculation flow Drained blood flow

Recirculation =

SpreO2 - SvO2

SpostO2 - SvO2

Anderson et al., Trans, 1989

SvO2 = SmvO2

CVL method – venous sat from SVC or IVC.

SvO2 method – Turning off sweep gas

while maintaining patients’ SaO2 via

ventilator.

Limited role in practice.

Van Heijst ASAIO, 2001

Ultrasound

Dilution

Darling et al., ASAIO 2006.

Cannula type.

Cannula position.

Pump Flow

Volume status.

Cardiac function.

Patient Position.

Factors Affecting Recirculation

210 410 610 76002468

1012141618

0

8

17

13

2

9

17.5

11

Dilutional Ul-trasound

Pump Flow Rate (ml/min)

NS

NS

NS

NS

Recirculation Fraction at Different Flow Rates in Nine Animals*

Nine lambsUnicaval dual-lumen cannula

CVL Method (%)

SvO2 Method (%)

Ultrasound Dilution

Method (%)

Flow Rate (ml/kd –

min)

62.5+6.9 45.0+6.9 36.0+12.8 150

54.8+13.5 39.3+9.5 32.8+9.3 125

39.1+17.6 31.7+8.2 24.6+9.4 100

29.5+15.7 24.5+12.6 20.2+6.5 75

29.6+15.7 12.4+10.0 13.0+4.0 50

Extra drainage cannula can help achieve

target flow at less RPMs

Ichiba, Ann Thorac Surg 2000

J Artif Organ 14

Impact Of Bypass Flow Rate And Catheter Position In Veno-venous Extracorporeal Membrane

Oxygenation On Gas Exchange In VivoKonomi Togo, Yoshiaki Takewa, Nobumasa Katagiri

J Artif Organ 14

Impact Of Bypass Flow Rate And Catheter Position In Veno-venous Extracorporeal Membrane

Oxygenation On Gas Exchange In VivoKonomi Togo, Yoshiaki Takewa, Nobumasa Katagiri

J Artif Organ 14

Impact Of Bypass Flow Rate And Catheter Position In Veno-venous Extracorporeal Membrane

Oxygenation On Gas Exchange In VivoKonomi Togo, Yoshiaki Takewa, Nobumasa Katagiri

A novel strategy to improve systemic oxygenation in venovenous extracorporeal membrane oxygenation: The “X-configuration”

Massimo Bonacchi, MD; Guy Harmelin, MD; Adriano Peris, MD and Guido Sani, MD

The Journal of Thoracic and Cardiovascular Surgery, November 2011

A novel strategy to improve systemic oxygenation in venovenous extracorporeal membrane oxygenation: The “X-configuration”

Massimo Bonacchi, MD; Guy Harmelin, MD; Adriano Peris, MD and Guido Sani, MD

The Journal of Thoracic and Cardiovascular Surgery, November 2011

RCT of 30 patients with severe ARDSX-configuration (n = 16)

VsStandard 2-site setup (n = 14)

Less recirculation – 5.3% vs 29.4%

Higher SaO2

Facilitated less ventilator support

V-RV Configuration

Recirc at 4L/min: 8.4% vs 37.9%∆ Recirc per L/min: 2.9% vs 11.1%

Lindstrom, perfusion 2012

Oxygenated return blood

Tricuspid valve

prevents recirculation

Venous drainage (to

circuit)

Mixed drainage (to

circuit)

Recirculation

Effective flow

Oxygenated return

blood

Bicaval Dual-Lumen Cannula

Abrams et al., 2014

Wang-Zwische Double Lumen Cannula – Toward a Percutaneous and Ambulatory Paracorporeal Aritificial Lung

Dongefang Wang, Xiaoqin Zhou, Xiaojun Liu, Biu Sidor, James Lynch, and Joseph B. Zwischenberger

ASAIO Journal, 2008

DLC tip in IVC DLC tip dislodged into RA0

10

20

30

40

50

60

Rec

ircu

lati

on

(%

)

ICM, 2012

Quantification Of Recirculation As An Adjuvant To Transthoracic Echocardiography For Optimization Of Dual-lumen Extracorporeal

Erik P.J. Körver Yuri M. Ganushchak Antoine P. Simons Dirk W. Donker Jos G. Maessen Patrick W. Weerwind

Management

Trend SpreO2 and peripheral SaO2.

Reposition cannulae and patient.

Dual-lumen cannulae when feasible.

Q 3+0.5 ml/min/m2

FmO2 100%-SGF adapted for normal pH & PCO2

SaO2 88-92% - Ultraprotective ventilation

Reduced QECMO+Hemolysis

Adaquate QECMO

SaO2 < 88%

SvmO2 > 60%

Excessive recirculation

Cannula replacement

Fibrin depositionPmO2/FmO2 < 300

Oxygenator dysfunction

High VO2

QECMO

Lung contribution (PEEP/FiO2)

Hb CO?

Kicking?Fluctuating QECMO?

High inflow pressure?

Kicking of the lines?

Mechanical Problem

Cannulas/membrane thrombosis

Change circuit+ check for cannulas permeability

Recannulation

Inadequate venous drainage

HypovolemiaCannulas malposition

Pneumothorax/Tamponade

Summary

Cannula Choice: The bigger the better. Careful positioning preferably

ultrasound gided. Transesophageal echocardiography or

fluoroscopic guidance is advisable (esp. Avalon).

Good monitoring to avoid complications.

Summary

Recirculation compromises ECMO efficiency

Ultrasound dilution may help quantify recirculation.

Development of bicaval dual-lumen cannulae have helped minimize recirculation.

Efforts to decrease recirculation are helpful in maximizing oxygen delivery.