Jenna Miller, MD and Dr John Daniel discuss the different cannulas used in VV ECMO, the importance of proper cannula placement, and the risks associated with movement. They also explore the benefits of lung rest and extubation strategy for respiratory kids on ECMO, along with important aspects such as neurosedation, bottle feeding, and monitoring cannula placement.
Proper cannulation technique is crucial for VV ECMO in neonates to avoid complications and ensure effective oxygenation.
Rest settings in VV ECMO should be personalized based on patient age and condition, with close monitoring of the right ventricle to prevent RV failure.
Deep dives
Selecting and positioning cannulas for VV ECMO
When cannulating pediatric and neonatal patients for VV ECMO, the most common approach is to cannulate through the right internal jugular vein using a dual-lumen bicable cannula, such as the Avalon. The size of the cannula should be determined based on the patient's body weight and desired flow characteristics. It is important to ensure proper cannula length for patients who are underweight or overweight. While single-site bicable cannulas are most commonly used, there is emerging literature on the use of multi-site VV cannulation, although it is less common and more challenging. Echo guidance is crucial for positioning the cannulas correctly, ensuring that the re-infusion port is oriented towards the tricuspid valve to avoid venous admixture and desaturation.
Considerations for cannulation in neonates
Cannula size and position are particularly important considerations in neonates due to their limited anatomy. Neonates have less real estate for cannulation compared to older patients. The choice of cannula, such as bicaval cannulas or the new dual lumen non-bicaval cannulas like Crescent, must be carefully selected and positioned to avoid complications like recirculation or right atrial perforation. Achieving the optimal position of the re-infusion port is critical for effective oxygenation and preventing venous admixture. Cannula position and monitoring should be done using echocardiography, and close attention should be paid to the patient's lung inflation and deflation as well as volume status, as these factors can affect cannula placement.
Rest settings and monitoring of the right ventricle
Rest settings in VV ECMO aim to minimize ventilator-induced lung injury and support the patient's pulmonary system. While there is no fixed definition of rest settings, common guidelines include maintaining low peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP), respiratory rate, and fraction of inspired oxygen (FiO2). Personalized rest settings should be established based on patient age and condition. Monitoring the right ventricle (RV) is crucial because ECMO only supports the pulmonary system, and RV failure can be incompatible with VV ECMO. Serial echocardiograms and markers like NT-pro BNP can help assess RV health. If changes in the RV are observed, interventions like Milrinone may be considered to optimize RV function and prevent further deterioration.
Monitoring and adjusting cannula position
Regular monitoring of cannula position is essential to ensure optimal VV ECMO support. Daily chest X-rays are necessary to assess cannula location, and echocardiograms can provide more detailed information on the positioning of the re-infusion port and detect any changes in cannula placement. The patient's volume status should also be closely monitored, as changes in fluid balance can affect cannula position. It is important to maintain a stable fluid balance and ensure adequate flow without cutting out or excessive negative returns. By paying attention to cannula position and making adjustments as needed, potential complications and patient desaturation can be prevented.
Jenna Miller, MD is an Associate Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine. She completed her medical school and residency in Kansas City before moving to Texas Children’s for critical care fellowship. She is the director of the pediatric ECMO program and the pediatric critical care medicine fellowship at Children’s Mercy Kansas City. Her professional and research interests include trimethoprim-sulfamethoxazole ARDS, ECMO and medical education.
Dr John Daniel, MD is an Associate Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine. He completed his pediatric residency at the University of South Carolina and his neonatology fellowship at the University of Kentucky. He now is a practicing Neonatal Cardiac Intensivist and the director of the neonatal ECMO program at Children’s Mercy Kansas City.
Learning Objectives:
After listening to this episode, learners should be able to:
The Identify key networking opportunities within the ECMO world.
Understand the risks and benefits of VV-ECMO cannulation.
Discuss common and newer indications for VV-ECMO cannulation in neonates and school-aged children.
ECMO Patient Stories from Children’s Mercy Kansas City:
Maclare, Graeme, et al. Extracorporeal Life Support: The ELSO Red Book. 6th Edition.
Pelosi, er al. Close down the lungs + keep them resting to minimize ventilator induced lung injury.
Maharaj et al, Right Ventricular Dysfunction is Associated with Increased Mortality in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019
Nirmal S Sharma et al. Flexible Bronchoscopy Is Safe and Effective in Adult Subjects Supported With Extracorporeal Membrane Oxygenation.
Rosner EA et al. Flexible Bronchoscopy in Pediatric Venovenous Extracorporeal Membrane Oxygenation.
Gurnani et al. Outcomes of Extubated COVID and Non-COVID Pat
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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
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