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Is There EVER a Role for Veno-Venous ECMO (VV-ECMO) in the Emergency Department?
Here is a case of a young man who presented to our Emergency Department in June, 2106 with profound anaphylaxis. This was a rare “CAN Intubate/CAN’T VENTILATE” scenario:
- Max Epinephrine
- Max antihistamines
- Max steroids
- Max ventilator
…and you still cannot ventilate. PaCO2 is going up. pH is going down.
What options do you have? Find out in this episode.
Here is the video produced by Sharp Memorial Hospital (@SharpHealthcare) about this case:
Special thanks to:
Kevin Shaw MD
Intensive Care
Sharp Memorial Hospital
Andrew Eads MD
Emergency Medicine
Sharp Memorial Hospital
Melissa Brunsvold MD
Department of Surgery
University of Minnesota
Conrad Soriano
Brynn Shinar
Cutest Girl on Earth
Very nice save, gentlemen.
Plenty of our colleagues in medicine view ECMO as a therapy limited to CT surgery or a small group of intensivists. With you guys continuing to push the ED ECMO envelope I am certain this will change.
I would like to share some thoughts on your approach to VV ECMO, specifically the decision to place an Avalon cannula under emergency circumstances without real time imaging. While I am aware of only one published case report of RV perforation during Avalon placement (Hirose H, Yamane K, Marhefka G, Cavarocchi N. Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation. Journal of cardiothoracic surgery. 2012;7:36.), informal and word of mouth reports are abundant. One potential mechanism is placing the tip of the wire into the RV, causing the wire to coil when advancing it, and then inserting the cannula with resultant RV perforation. Without imaging there is no way to ascertain the location of the wire before advancing the cannula. Neither lack of resistance when passing the wire nor absence of arrhythmias are sufficient to accomplish this task. Central lines, dialysis catheters, and even short ECMO cannulas placed in the IJ vein are not inserted far enough to perforate the RV. A properly placed Avalon traverses the RA and enters the IVC, an insertion depth easily sufficient to perforate the RV with incorrect placement. Utilizing ultrasound to demonstrate the wire in the IVC is intuitively attractive and is used in some institutions. However, this does not visualize the entire path of the wire and is thus an incomplete solution.
Placing Avalon cannulas under fluoro guidance and observing the behavior of the wire demonstrates why its entire course must be visualized before inserting the cannula (See the figure 1 in the following article: Teman NR, Haft JW, Napolitano LM. Optimal endovascular methods for placement of bicaval dual-lumen cannulae for venovenous extracorporeal membrane oxygenation. ASAIO J. 2013;59(4):442-447.) Often multiple attempts are required to get the wire to pass through the RA and into the IVC. Even when this is accomplished, there is a tendency for the wire to bow into the heart during serial dilation and manipulation. When the wire bows far enough, a coil can develop in the RV with the distal portion of the wire remaining in the IVC. Inserting the cannula under these circumstances will result in a very short hospital length of stay. TEE performed by a skilled operator may be sufficient to identify this potential complication before it happens. However, in my opinion, real time fluoroscopy is the most effective way to place the Avalon cannula safely. Fluoroscopy and TEE together are even better and thus my preferred strategy. Additionally, some centers utilize a stiff guidewire (as described in the Teman article) to decrease the chance of wire migration or looping during cannulation.
I am an EP, intensivist and ECMOphile like you. I understand the circumstances you were faced with and am not advocating that you bring a TEE and fluoro machine to the ED in the midst of a resuscitation. However, I do think a Fem-IJ or Fem-Fem VV ECMO configuration would probably have accomplished your objectives with much less risk. Both of these cannulations approaches are routinely performed at the bedside without imaging. Accessing two vessels does take longer than accessing one, but the time to completion of the procedure would likely have been no different than placing the Avalon due to the smaller cannula sizes and fewer dilations required.
If the ED ECMO movement continues expanding to VV ECMO it might be worthwhile to share these techniques with your audience.
Again, great save. Despite my comments above it is hard to argue with your results.
Sincerely,
Phillip Mason, MD
Phillip,
(disclaimer: we have obtained full release from this patient to discuss his medical information freely, in the interest of education)
You make excellent points. Zack and I presented this case to raise some awareness and availability of this salvage therapy… and to start this discussion exactly. I agree with all of your points and agree that “blind” Avalon placement is a risky move. I said it in the podcast episode: I don’t look forward to the day that this is my only option. But it may have been Dr. Shaw’s only option here.
I spoke with Dr. Shaw about his decision in this case. As you stated, In almost every situation, a fem-fem or fem-IJ approach would be a safer alternative. After all, we have considerable experience with fem-fem VA-ECMO in ECPR situations and my go-to approach would likely be fem-fem VV-ECMO in this situation. According to Dr. Shaw, his first choice of access would have been fem-fem…but this patient had severe eczema (the atopy that lead to the anaphylaxis) and his inguinal region was apparently like leather….and he felt that percutaneous fem-fem access would have been challenging, given the condition of the skin in the inguinal region. In the moment, Dr. Shaw felt that US-guided IJ access had a better chance of success than percutaneous fem-fem. we can’t argue with his success, but your cautionary words are appreciated.
Thanks again for your comments. I expected to receive some controversy on this one!
Joe
Phil-
Amazing to have you here reading/listening to the edecmo stuff. Ever care to come on the show?
–Scott
Agreed. Your precautions are right on, as is Joe’s explanation. This patient has unusual anatomy with very thick, leathery skin in the groin. After ECMO initiation, I did end up placing femoral arterial and venous lines for access, and had a tremendous amount of difficulty despite a very nice ultrasound machine.
With the retrospectascope in use, my approach would have been different. At the time, I had no ability to use TEE or fluoroscopy. If in the exact same circumstance again, I would recommend serial CXR with ultrasound of the IVC.
Zack and Joe, another cool pod.
Dr Brusvold considers VV ECMO for anyone with ARDS, prone, FiO2 100%, PaO2 120… which if i recall is how much of this took off in australia with H1N1 epidemic 2009(?).
a still another truly incredible pod, Z and J.
conrad now has two birthdays.
great description/presentation, work Dr Shaw. (and the team).
question for Joe and Zack, then: if a conrad (purely pulmonary failure with good heart) came into your ER, would you do VV or VA? if VV, how ? north/south? Avalon? does anyone ever do right fem vein , left fem vein? or would that just defeat the purpose by stealing the decarbonated blood from the patient?
all very cool. thank y all.
tom
so sorry.
just read all the comments below, which more than answer my questions. (i think). still wonder if VV fem/fem wouldn’t just steal all the good blood just returned. i guess you’d need to place the tip of the cannula removing the blood several cm’s away from the tip of the cannula returning , but which more distal? i suspect the returning port should be more proximal, since you would want the returning blood closer to vital organs (?).