EDECMO Episode 11 – The Paris ECMO Course

Paris ECMO Course

The excellent lecturer was Dr. Guillaume Lebreton,

Associate Professor and Cardiothoracic Surgeon
Director of the CPB and ECMO program,
Department of Cardio-Thoracic Surgery
Pitié Salpêtrière Hospital

How Not to Frack Up

  • DO NOT ADAPT TECHNIQUE TO YOUR CAPACITY
  • Fixed Point for Wire–meaning wire must be held stationary as you dilate, otherwise dilator will back wall through vessel with anything but the stiffest guidewire. We get a false sense of security from smaller line placement.
  • Discussed being fooled by echo
  • They do cutdowns for all ECPR

Inflow

  • Crap flow if too small
  • If you measure from the puncture site directly to the middle of the sternum, that should be your insertion. Too deep is better, with Maquet you want the tip in the RA
  • 24-29 F with 25 being the sweet spot
  • 55 cm Maquet for all adults
  • When the holes are through the vessel, PULL Back the Dilator

Outflow

  • Hemolysis if too small
  • 17-21 F for VA
  • 19-23 F for VV
  • IJ catheter length-15 cm on right, 23 cm on left
  • Don't pull back dilator for arterial placement

Placement

  • Pad behind buttocks to straighten vessels 4″ or so
  • Needle bevel facing up and wire's j facing up
  • Gentle Angle for  Needle Placement
  • Guidewire-go fast and it goes straight
  • Always use the 150 cm guidewire. Leave 1 meter out, 50 cm in pt
  • Scalpel-1 cm cut and plunge
  • Doesn't bother rotating the dilators
  • VV-do the femoral first as it is harder to knock out

Femoral-Femoral VV

  • Return close to tricuspid, not multi-stage
  • Drainage as central as possible, but in IVC, not RA
  • Put in both guidewires first
  • Put the longer cannula (return) in first
  • Inflow-21-23 short insertion, but same length cannula (Maquet)
  • Outflow-17-19, single stage (Medtronic)

TroubleShooting

  • If at the same speed, decreased flow–think thrombosis

Starting VVECMO

  1. Clamp on tubing
  2. Start slow, 2000 rpm then slowly declamp
  3. Start sweep at 6 lpm (or 1:1 with flow)
  4. Go up to the max flow you can get at first to see your max
  5. You want to provoke reflow
  6. You should be able to get big flows (6-7 lpm)
  7. Dial Back to 5-6 Liters or 3 L/m2 (>60% of CO is what you should be aiming to capture)
  8. You should be able to get to 100% sat quickly
  9. If you are seeing recirc, pull back inflow slightly (max 1-3 cm)
  • Treat the pt not the xray when it comes to cannula positioning

Factors that increase Recirc

  • Proximate venous tips
  • Low CO
  • Hypovolemia
  • Increased pump flow rates

Avalon

Turn Head all the way to the left to align IVC and SVC

VA

FEM/FEM
do venous 1st if doing cutdown

Image by Cedric Lange

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