P. A. Salazar1, D. Blitzer2, S. C. Dolejs1, J. J. Parent3, B. W. Gray1 1Indiana University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Division Of Cardiothoracic Surgery, Department Of Surgery,Indianapolis, IN, USA 3Indiana University School Of Medicine,Section Of Pediatric Cardiology, Department Of Pediatrics,Indianapolis, IN, USA
Introduction: Internal jugular cannula position is traditionally confirmed via plain film at the conclusion of the ECMO cannulation procedure. However, it may be difficult to estimate the location of the right atrium on plain films. A misplaced cannula can result in need for repositioning and increased morbidity. Echocardiography (ECHO) may be used during cannulation as a more accurate means of guiding cannula position. The aim of this study is to study the effect of a protocol encouraging the routine use of ECHO at the time of cannulation.
Methods: We performed a retrospective review of patients at Riley Hospital for Children who received ECMO support using jugular venous cannulation from January 2013 through October 2016. We compared those who underwent ECHO (ECHO+) at the time of cannulation with those who did not (ECHO-). Our primary outcome was need for cannula repositioning after initial cannulation, with secondary outcome being cannula-related morbidity. For categorical variables, Fisher's exact or Chi-square tests were used to assess for significance. For continuous variables, the median with interquartile ranges (IQR) are presented, and the Wilcoxon rank sum test was used to assess for significance. All statistical analysis was performed on SAS version 9.4 (Cary, NC).
Results: 89 patients met inclusion criteria: 26 ECHO+ (29%), 63 ECHO- (71%). Most of ECHO+ patients underwent dual-lumen VV cannulation (n=17, 65%), while 32% of ECHO- patients required VV support (p<0.003). Seven (27%) ECHO+ patients and 18 (28%) ECHO- patients had a history of cardiac surgery prior to ECMO (p=0.88). All patients had CXR to verify cannula position, and fluoroscopy was used in 4 ECHO+ patients but no ECHO- patients. There was a major mechanical complication in each group: atrial perforation from a guidewire during cannulation in ECHO+ and late atrial perforation from a loose cannula in ECHO-. Subsequent to cannulation, there were 0.58 ECHO studies per patient to verify cannula position in the ECHO+ group compared to 0.22 ECHO per patient in the ECHO- group (p=0.02). Two (8%) ECHO+ patients required a cannula repositioning procedure for misplacement during the ECMO run, while 6 (10%) ECHO- patients required repositioning procedures (p=0.78). In the VV ECMO subgroup, ECHO+ patients required no respositioning, while 4 (20%) ECHO- VV patients required repositioning (p=0.1). Repositioning procedures resulted in no additional complications. Survival to discharge was similar in both groups: 54% ECHO+ and 62% ECHO- (p=0.51).
Conclusion: Implementation of a protocol to perform ECHO during jugular cannulations for neonatal and pediatric peripheral ECMO did not result in significantly less repositioning procedures, complications, or ECHO studies performed per patient. ECHO should be used to guide VV cannulation, as need for repositioning approached significance, and it may be a useful adjunct for surgeons during difficult cannulations.