Transcript
8/10/2019 Vascular Access & Cannulation
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Vascular Access &
Cannulation
Dr Osama Bawazir Assistant Professor , Consultant Pediatric surgeon
FRCSI, FRCS(Ed), FRCS (glas), FRCSC,
FAAP,FACS.
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• ECMO is a supportive measure, whichcan be instituted as an urgent, semi
elective or elective procedure
• Time in relation to the event is the
limiting factor when going through the
assessment cascade in order toaccomplish a successful result
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• PRE-ECMO ASSESSMENT
• CANNULATION
• INITIATION AND MAINTENANCE OFECMO
• EVALUATION
Introduction
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CANNULATION
The establishment and
maintenance of
adequate vascularaccess is essential
for ECMO
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CANNULATION
- Patient age and size- Underlying disease &
condition
- Cause of the cardiorespiratory
compromise
- Type of support:
– Veno-venous (VV) ECMO
– Veno-arterial (VA) ECMO
- Time of the event in relation to
the peri-operative period
- Location
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CANNULATION
For each modality, there aredifferent kinds and sizes of
cannulae that can be used
Target activated clotting time(ACT) should be
accomplished first before
ECMO (heparin 100 units/kg)
3 minutes before cannulation.Consent
GA
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Guidelines for Cannula size
Weight (Kg) Venous cannula arterial cannula
2-4 8-14 8-10
5-15 15-19 12-15
16-20 19-21 15-17
21-35 21-23 17-19
35-60 23 19-21
>60 23 21
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Poiseuille’s Law
• Poiseuille's law: In anartificial system, flowthrough a cylindrical tubeor any segment of a tube isdirectly proportional to ΔP,
the driving pressure alongthe tube, and the fourthpower of the radius, r. Flowis inversely proportional toL the length of thesegment and to η, theviscosity of the liquid. Theproportionality constant isπ/8.
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Cannula Consideration
• Venous cannula should be with the largest
lumen and shortest length possible
(gravity).
• Venous cannula should have side holes.
• M-number
• Resist kinking• The smallest double lumen cannula is size
12 F ( for V V ecmo in neonate)
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CANNULATION
• Veno -Venous (V-V) ECMO
- Mainly used for respiratory
support (ARDS & Congenital
Diaphragmatic Hernia)
- V-V ECMO provides adequate
oxygenation and CO2
removal- The venous access can be
established by using the
system in one site, or two
different sites
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CANNULATION
• Veno -A rterial (VA)
ECMO
provides cardiac as
well as respiratory
support and is mainlyused for post op
cardiac case
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(V-V) ECMO Advantage offer
(V-A) ECMO
• Eliminate the potential for arterial
embolization and ischemia
• Arterial ligation or repair is unnecessary
• Improve the blood flow and oxygenation to
pulmonary circulation.
• No hemodynamic effects
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CANNULATION TECHNIQUE
• Open
• Semi-open• Percutaneous
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CANNULATION
Internal jugular vein
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CANNULATION
Subclavian vein &
Right atrium
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CANNULATION
Femoral vein
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CANNULATION
One site
- A double lumen cannula isinserted into the internal jugular vein
- Only one site for venousaccess
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CANNULATION
Two different sites
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CANNULATION
• Veno -A rterial (VA) ECMO
provides cardiac as well asrespiratory support and is
mainly used for post op
cardiac case
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CANNULATION
Internal jugular vein
and the common
carotid artery
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CANNULATION
Right atrium and
ascending aorta
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CANNULATION
Femoral vein and
artery
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CANNULATION
In situations where ECMO
support is anticipated
- Chest will be left open
and covered by a Silastic
patch
- Purse-string sutures will
be left snared in place
- Standby preprimed pump
will be kept in ICU
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CANNULATION PROBLEMS
• Threading the venous
catheter
• Vein division
• Proximal vein lost in
mediastinum
• Lack of venous return
• Intrathoracic vein
perforation
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Complication
• Vascular injury( tear,intimal dissection,perforation).
• Obstruction (kinking,positional).
• Misplacement( AI,
afterload
LV failure).• Bleeding.
• Recirculation.
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Thank You
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