This interview with Joe Bellezzo is what caused Scott to pursue ECLS.
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This is the interview that started all of the trouble. Scott got to interview Joe on the amazing resuscitative ECMO program at Sharp Memorial in San Diego on an episode of the EMCrit podcast.
Do you think giving a bolus of bicarbonate (10 mL) and looking at EtCO2 would help confirm the cannula is in the vein rather than in artery? I use this method from time to time with central lines.
Great (new) blog, congratulations.
I haven’t tried it. Unlikely to be helpful in the arrested patient though. In fact, I know of no really good way to confirm line location during arrest. If pulses temporarily return I do use the bubble test – but that doesn’t help with finding the artery – which is the holy grail during arrest. I admit that there times when we aren’t 100% sure and only discover an inadvertent veno-venous cannulation after the pump is turned on. In that situation I’d stop the pump and continue to attempt to cannulate an artery. IF you do that, DON’T pull the extra venous cannula or you’ll create hemorrhagic shock! Just clamp it, it can be fixed later.
Agree with Joe. If you are in an artery, you will see the same increase in EtCO2. One way that works is looking for your guidewires in the IVC and Aorta, but this can be challenging during CPR.
Thank you very much.
Maybe next time you’re cannulating please do try this test – just to prove me wrong. I’ll be more than happy to know the result.
Michal,
doing arterial injections is really not the most clever of moves, so I’ll leave it to you next time you pop in an a-line : )
What about istat gases off both lines? Or not helpful in arrest phase since likely very similar?
What do you think you are cannulating if you inadvertently VV someone? I assume you’ve placed 2 lines next to each other so deep and superficial femoral vein? Instead do common femoral vein and fem art?
Great thoughts. We’ve tried iStat gasses/ABGs. Still too similar to truly distinguish, especially after prolonged arrest. In reality there often isn’t that much time. The most common problem is VV cannulation. Its almost never AA cannulation. Exactly which Vein? not clear but likely both in the common femoral vein one above the other. Sometimes you just aren’t sure and the patient is dying in front of you. A brief trial on the pump will usually unveil the inadvertent VV cannulation and there is no real harm…other than delay of VA ECMO, to temporary VV ECMO. If you turn on the pump and both cannulas contain bright red blood then you are either VV or AA…most likely VV. So stop the pump, continue CPR, and perhaps make another attempt at cannulating the artery, perhaps on the contralateral side.