This case involves a 72-year-old man with a past medical history of end-stage lung disease due to chronic obstructive pulmonary disease who was on 2-3 liters nasal cannula at home. He was admitted to an outside hospital with acute-on-chronic respiratory failure with worsening exercise intolerance. Despite being on maximum noninvasive oxygen support (high flow oxygen at 60 liters and 100 percent FiO2), he remained hypoxic and tachypneic and was unable to get out of bed. Therefore, he was transferred to Vanderbilt University for lung transplant evaluation.  

To avoid intubation in the patient, the surgeons facilitated him in an awake state, and provided the physiologic support he needed for rehabilitation and physical therapy, he was bridged to decision on veno-venous extracorporeal membrane oxygenation (VV-ECMO). 

Below are the steps of VV ECMO cannulation as described in the video. 

1. A sterile table/field with the necessary instruments needed was set up. 
2. The bilateral groins and right neck were prepped with chlorhexidine, and sterile towels and drapes were placed. 
3. Local anesthetics were injected at the targeted sites for cannulation—left femoral and right internal jugular veins. 
4. Ultrasound guidance was used to obtain wire access. 
5. A skin incision was made at the wires, and serial dilation of the veins was sequentially performed. 
6. A low-intensity heparin bolus was administered. A 25 French venous drainage cannula was then inserted over the wire at the left femoral vein, followed by a 21 French short return cannula at the right internal jugular vein. 
7. The circuit tubing was brought onto the field, clamped, and divided. 
8. The drainage and return cannulas were then connected to the ECMO circuit with a wet-to-wet connection. 
9. ECMO flow was slowly initiated with close monitoring of the hemodynamic response. 
10. Multiple anchoring sutures were used to secure the cannulas. 
11. A CXR was obtained to confirm appropriate cannula positions. 

Some takeaways from this technique included the importance of excellent communication to ensure the comfort of the patient; obtaining vascular access with ultrasound guidance and applying the true Seldinger technique during dilation were crucial in preventing kinking of the wire and decreasing the risk of injury to the vasculature. 

It was also essential to ensure that the ECMO pump was adequately warmed up and to slowly initiate ECMO flow to decrease the risk of unstable arrythmias. The patient's hemodynamic status needed to be closely monitored, and if recirculation was suspected, it was important to evaluate cannula position and adjust as needed. 

References

1. Gajkowski, Evan F.*; Herrera, Guillermo†; Hatton, Laura‡; Velia Antonini, Marta§,¶; Vercaemst, Leen‖; Cooley, Elaine#. ELSO Guidelines for Adult and Pediatric Extracorporeal Membrane Oxygenation Circuits. ASAIO Journal 68(2):p 133-152, February 2022. | DOI: 10.1097/MAT.0000000000001630

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