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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 380-382

Extracorporeal Membrane Oxygenation Cannula Malposition

1 Department of Pediatric Cardiovascular Surgery, Ege Universitiy Hospital, İzmir, Turkey
2 Department of Pediatric Cardiology, Ege Universitiy Hospital, İzmir, Turkey

Date of Submission10-Jun-2020
Date of Decision26-Jul-2020
Date of Acceptance15-Aug-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Dr. Osman Nuri Tuncer
Department of Pediatric Cardiovascular Surgery, Ege Universitiy Hospital, 35100 Bornova, İzmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_26_20

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Malposition of the extracorporeal membrane oxygenation (ECMO) cannulas is not frequently reported in central cannulation technique: we aimed to present an ECMO cannula malposition in follow-up in a neonate case. The patient was followed up three days on ECMO support with optimum hemodynamics. On the third day swelling occurred in the left face area within hours. Chest radiography showed that the arterial cannula tip was identified upwardly facing, which implied malposition of the cannula in the left carotid artery. After repositioning the cannula, swelling on the left side of the face completely disappeared in 4 hours. Clinicians should be alert for ECMO cannula malposition. Chest radiography which can be accessed quickly and easily can be beneficial for the diagnosis.

Keywords: Cannula malposition, cardiac imaging, extracorporeal membrane oxygenation

How to cite this article:
Tuncer ON, Akkaya G, Aydin D, Atay Y. Extracorporeal Membrane Oxygenation Cannula Malposition. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:380-2

How to cite this URL:
Tuncer ON, Akkaya G, Aydin D, Atay Y. Extracorporeal Membrane Oxygenation Cannula Malposition. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2021 Apr 13];4:380-2. Available from: https://www.jiaecho.org/text.asp?2020/4/3/380/303933

  Introduction Top

Extracorporeal membrane oxygenation (ECMO) is increasingly being used in pediatric population following failure to wean from cardiopulmonary bypass (CPB).[1] ECMO cannula malposition can be seen both during application and follow-up. We present ECMO cannula malposition in a patient undergoing Norwood Stage I operation.

  Clinical Presentation Top

A female neonate with a gestational age of 38 weeks and birth weight of 2720 g was delivered via cesarean section. Hypoplastic left heart syndrome had been diagnosed on antenatal echocardiography. Postnatal transthoracic echocardiography (TTE) showed aortic and mitral atresia, hypoplasia of the left ventricle and ascending aorta, and large patent ductus arteriosus. Cannula locations were confirmed by direct radiography [Figure 1].
Figure 1: Chest radiography after Norwood Stage 1 operation. Cannulas are seen in right place

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The infant underwent standard Norwood Stage 1 palliation using porcine pericardial patch for the reconstruction of the ascending and transverse aorta. Pulmonary blood flow was supplied with a 6 mm polytetrafluoroethylene right ventricle-to-pulmonary artery (Sano) shunt graft. Venoarterial (V-A) ECMO (Maquet Quadrox_ID Pediatrics) was administered to patient with the same cannulas of the cardiopulmonary bypass circuit due to failure to wean from CPB.

The ECMO flow was maintained at 100–130 ml/kg/min based on hemodynamics and laboratory parameters. The infant tolerated ECMO well without major complications for 3 days. On the 3rd day, swelling was detected on the left side of the face [Figure 2]. Chest X-ray was taken to confirm the cannula locations. It was determined that the endotracheal tube was directed to the right main bronchus and collapsed left lung and arterial cannula was directed up toward the left carotid artery [Figure 3]. There was no sudden change in the patient ventilatory parameter because the patient was being followed up with very low mechanical ventilator support.
Figure 2: Third-day swelling on the left side of the infant

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Figure 3: Chest radiography on the 3rd day the endotracheal tube was directed to the right main bronchus and collapsed left lung. Arterial cannula is seen directed upward towards the left carotid artery in red circle. Enlarged image can be seen on the right

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The infant was transferred to the operating room for ECMO cannula reposition. After chest was explored, intubation tube was retracted about 1 cm above until both right and left lungs were seen that adequately inhalating. Arterial cannula of ECMO was also repositioned back to the ascending aorta, verifying the location by palpation of cannula. Cannula locations were confirmed by direct radiography after reposition [Figure 4].
Figure 4: Chest radiography after cannula and endotracheal tube

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Swelling on the left side of the face was completely disappeared after 4 h and no pathology was detected in the neurological examination performed at the 24th h. The infant was supported by V-A ECMO for 12 days without any more complication. On the 13th day, necrotizing enterocolitis developed. The infant expired on the 16th day cause of severe metabolic acidosis despite ECMO support.

  Discussion Top

ECMO is an important mechanical support for infants and children with both circulatory and respiratory failure. Its use is now increasing for failure to wean from CPB in both adult and pediatric groups. The success of ECMO is dependent on effective placement and securement of these lines, among other factors.[2] There are many centers that reported the occurrence of a cannula malposition, dislodgement, or accidental decannulation, leading to an adverse patient outcome at their center, and inadequate/ineffective securement is reported as the leading cause at short term. Cannula malposition can also occur during positioning for care, spontaneous movements of the patient, transport, or ambulation in intensive care unit.[3] Displacement of a cannula too little can cause malposition or vascular injury, especially in small-sized patients such as neonates.

Imaging plays an important role in evaluating the position of the cannulas, monitoring underlying pathology especially in respiratory failure group and identifying ECMO-related complications.[4] There are various case reports related to the subject in the literature. In some of these cases, malposition was detected by computerized tomography (CT), and transesophageal echocardiographic (TEE) imaging was used in some cases.

TTE or TEE is beneficial during initial cannula placement, and also recovery of cardiac function can be evaluated. Neonatal ECMO is mostly applied by central cannulation with leaving the sternum open. This situation restricts the use of TTE in this age group. The risk of gastrointestinal system bleeding due to anticoagulant use for ECMO limits the use of TEE in follow-up. In addition, the fact that both examinations require special training and experience reduces the widely availability of use.[5]

CT provides excellent anatomic detail so may be used in evaluating cannula position, arterial or venous thrombus in large vessels, hematoma formation, hemothorax, pneumothorax, and lung parenchymal abnormalities. CT is infrequently used to image the chest because of the perceived risks associated with transfer to the CT scanner and back to the ICU.[6]

Chest radiography is an effective examination for cannula position. It can offer clue toward complications such as hemothorax, pneumothorax, or mediastinal fluid collections.[4] It is widely used because it is an examination that every physician can easily apply and evaluate at the bedside in a very short time. This imaging examination is practiced daily in routine patient follow-up, so provides convenience in comparison with previous examinations.

In our case, we could not use TTE because of open sternum, TEE due to bleeding risk, and CT cause of risks associated with transfer. We preferred chest radiography due to ease of use and low risks. The examination was very useful in detecting cannula malposition and allowed us to intervene early.

  Conclusion Top

Malposition ECMO cannulas can be seen during follow-up, especially in small-sized patients such as neonates, and it should be kept in mind that direct radiography which can be accessed quickly and easily can be beneficial for the diagnosis.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Organization ELS. ECLS Registry Report International Summary January 2020. Available from: https://www.elso.org/Portals/0/Files/Reports/2020_JanuaryInternational%20Summary%20January%202020_page1.pdf. [Last accessed on 2020 Jan 31].  Back to cited text no. 1
Butt W, Heard M, Peek GJ. Clinical management of the extracorporeal membrane oxygenation circuit. Pediatr Crit Care Med 2013;14:S13-9.  Back to cited text no. 2
Bull T, Corley A, Lye I, Spooner AJ, Fraser JF. Cannula and circuit management in peripheral extracorporeal membrane oxygenation: An international survey of 45 countries. PLoS One 2019;14:e0227248.  Back to cited text no. 3
Lee S, Chaturvedi A. Imaging adults on extracorporeal membrane oxygenation (ECMO). Insights Imaging 2014;5:731-42.  Back to cited text no. 4
Douflé G, Roscoe A, Billia F, Fan E. Echocardiography for adult patients supported with extracorporeal membrane oxygenation. Crit Care 2015;19:326.  Back to cited text no. 5
Goodwin SJ, Randle E, Iguchi A, Brown K, Hoskote A, Calder AD. Chest computed tomography in children undergoing extra-corporeal membrane oxygenation: A 9-year single-centre experience. Pediatr Radiol 2014;44:750-60.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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