Highlights from the Paris ECMO Course
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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
- Clamp on tubing
- Start slow, 2000 rpm then slowly declamp
- Start sweep at 6 lpm (or 1:1 with flow)
- Go up to the max flow you can get at first to see your max
- You want to provoke reflow
- You should be able to get big flows (6-7 lpm)
- Dial Back to 5-6 Liters or 3 L/m2 (>60% of CO is what you should be aiming to capture)
- You should be able to get to 100% sat quickly
- 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
Hi Scott I was at the Paris cannulation course too and agree Guillame was excellent value. I would question the drainage cannula positioning in the Right atrium he recommends though from the femoral vein. I would say that more common is to place the drainage cannula in the intrahepatic ivc but below the hepatic vein. This avoids the potentially catastrophic complication of suck down of the atrium into the cannula. Be interested in other views on this
With the multi-stage it shouldn’t happen; with single-stage it would be poor form for the reason you mention. I too would be curious what others are doing. Guillame should be writing in with some comments as well.
Yes agree shouldnt happen. I am aware of a couple of patients with hepatic vein obstruction due to cannulas crossing the hepatic vein, they were multi hole cannula too. I guess what I am interested in is whether flow from drainage cannula placed below the hepatic vein are significantly worse than those placed higher into the RA. I would also have thought recirculation likely more of an issue too.