Cannula and circuit management in peripheral extracorporeal membrane oxygenation: An international survey of 45 countries

Abstract

Effective and safe practices during extracorporeal membrane oxygenation (ECMO) including infection precautions and securement of lines (cannulas and circuits) are critical to prevent life-threatening patient complications, yet little is known about the practices of bedside clinicians and data to support best practice is lacking. Therefore, the aim of this study was to identify and describe common line-related practices for patients supported by peripheral ECMO worldwide and to highlight any gaps for further investigation. An electronic survey was conducted to examine common line practices for patients managed on peripheral ECMO. Responses were obtained from 45 countries with the majority from the United States (n = 181) and United Kingdom (n = 32). Standardised infection precautions including hand hygiene, maximal barrier precautions and skin antisepsis were commonplace for cannulation. The most common antisepsis strategies included alcohol-based chlorhexidine gluconate (CHG) for cannula insertion (53%) and maintenance (54%), isopropyl alcohol on circuit access ports (39%), and CHG-impregnated dressings to cover insertion sites (36%). Adverse patient events due to line malposition or dislodgement were reported by 34% of respondents with most attributable to ineffective securement. Centres ‘always’ suturing peripheral cannula sites were more likely to experience a cannula adverse event than centres that ‘never’ sutured (35% [95% CI 30, 41] vs 0% [95% CI 0, 28]; Chi-square 4.40; p = 0.04) but this did not meet the a priori significance level of <0.01. An evidence-based guideline would be beneficial to improve ECMO line management according to 78% of respondents. Evidence gaps were identified for antiseptic agents, dressing products and regimens, securement methods, and needleless valves. Future research addressing these areas may provide opportunities for consensus guideline development and practice improvement.

In vitro testing of cyanoacrylate tissue adhesives and sutures for extracorporeal membrane oxygenation cannula securement

“…There is currently no published literature which has tested sutures against TA for the purpose of ECMO cannula securement, but sutures are routinely used in the securement of smaller-gauge intravascular devices [ 31 ]. A recent global survey of ECMO cannula management reported 93% of centres use sutures to secure ECMO cannulae [ 7 ] however, sutures are not standard clinical practice in our hospital. Furthermore, unpublished data from a recently conducted study of ECMO cannula management in Australia and New Zealand has highlighted only 50% of Australian sites routinely suture cannulae, and 73% of cannulae insertion sites are covered with a transparent dressing alone.…”

“…The true incidence of cannula malposition has not been quantified, but in a recent global survey of ECMO practices 34% of respondents stated that an adverse patient event had occurred in the last five years as a result of cannula malposition or dislodgement [ 7 ]. One-third of these cannula malpositions were directly attributed to suboptimal cannula securement [ 7 ].…”

“…The true incidence of cannula malposition has not been quantified, but in a recent global survey of ECMO practices 34% of respondents stated that an adverse patient event had occurred in the last five years as a result of cannula malposition or dislodgement [ 7 ]. One-third of these cannula malpositions were directly attributed to suboptimal cannula securement [ 7 ]. This indicates that there is an urgent clinical need to improve methods used to secure ECMO cannulae at the insertion site, which is particularly relevant given the current management practices of less sedation [ 8 ] and increased mobilisation [ 9 ] in patients receiving ECMO.…”

“…Due to the paucity of research in this area, there are currently no standardised, evidence-based clinical practice guidelines informing ECMO cannula dressing and securement practice. As a result, there is wide variation in cannula securement practices globally [ 7 ] and no ECMO-specific evidence regarding the most effective dressing and securement method.…”

Chlorhexidine bathing of the exposed circuits in extracorporeal membrane oxygenation: an uncontrolled before-and-after study

“…Notwithstanding, individual infection prevention policies are adopted according to institutional preference [29,30]. Most of the represented strategies used CHG disinfection only for the cannula insertion sites [31]. Despite the critical importance of infection precaution in patients on ECMO, evidence is still lacking.…”