Transesophageal Echocardiography-Guided Technique for Extracorporeal Membrane Oxygenation Dual-Lumen Catheter Placement

Abstract

In acute respiratory distress syndrome (ARDS) with severe hypoxemia or respiratory acidosis, veno-venous extracorporeal membrane oxygenation (VV-ECMO) ensures oxygenation and decarboxylation. Commonly, simultaneous cannulation of jugular and femoral veins is used for VV-ECMO. A recently introduced dual-lumen cannula for VV-ECMO promises single vessel access through the right internal jugular vein and patient ambulation. However, correct direction of the reinfusion jet toward the tricuspid valve during ECMO treatment requires more demanding cannula placement control. We present a new ultrasound-guided technique for the placement of a dual-lumen VV-ECMO cannula in a patient with ARDS and extreme obesity.

Single or Double Site Cannuation for Veno-Venous Ecmo in Severe Obese Patient?

“…The distal opening should be placed into the inferior vena cava, while the proximal tip should be in the right atrium facing the tricuspid valve. The correct positioning should be verified through fluoroscopy, transthoracic echocardiogram or TEE which is strong recommended (3,4,5).…”

Monitoring during extracorporeal membrane oxygenation

“…The second lumen containing the oxygenated blood terminates via an orifice sitting in the RA. Optimal position of the reinjection orifice is the mid-RA, facing the tricuspid valve [32]. Double lumen catheters are prone to dislodgment with potential deleterious consequences on oxygenation [22].…”

Quantification of recirculation as an adjuvant to transthoracic echocardiography for optimization of dual-lumen extracorporeal life support

“…in extreme obesity. Dolch et al [5] described a method using transoesophageal echocardiography together with microbubbles present in saline for cannula placement visualization. Ideally, image guidance should simultaneously provide position validation and functional testing during dual-lumen cannula placement.…”

“…Recirculation is defined as the fraction of the oxygenated blood that exits the infusion port, and which is immediately drained back into the drainage ports. During dual-lumen vv-ELS, cannula position can be verified using transoesophageal echocardiography combined with fluoroscopy [2] or saline injection [5]. Recirculation and resultant inadequate lung assist, however, may still occur.…”