Early mobility is associated with improved outcomes (improved quality of life, reduced delirium, reduced duration of mechanical ventilation, and reduced intensive care unit (ICU) and hospital length of stay) in critically ill patients, particularly those with acute respiratory failure. Critically ill patients who do not receive early physical therapy and ICU mobilization are at significant risk for neuromuscular weakness, impaired functional outcomes, and prolonged deficiencies in physical functioning.1,2
Early ICU mobilization and rehabilitation while on extracorporeal membrane oxygenation (ECMO) have been shown to be safe.3 Additionally, in order for patients receiving ECMO as a bridge to lung transplantation to maintain their transplant candidacy, many programs (58%) require a minimum ambulatory distance of 600 feet during ECMO support.4
The development of a bicaval dual-lumen cannula (DLC) capable of providing venovenous (VV)-ECMO support via the internal jugular vein has greatly facilitated ECMO ambulation and rehabilitation programs. Dual-lumen cannula requires optimal positioning, and even minor migration of the cannula can significantly alter ECMO flows given the proximity of the right atrium, inferior vena cava, and hepatic veins. Published ECMO cannula migration and dislodgement rates are in excess of 10%.5–7 We review an optimal technique to secure DLC to prevent migration and dislodgement and to facilitate activity and early mobility and ambulation.
We use the Avalon Elite bicaval DLC (Maquet Getinge Group, Rastatt, Germany, www.maquet.com) for adult VV-ECMO, placed percutaneously under fluoroscopic guidance at our institution. Once the cannula is positioned and functioning appropriately, we then secure it to prevent migration and dislodgement.
Securing the ECMO DLC for VV-ECMO is standardized. Nylon cable ties are used to secure all circuit connections. Given a previous high observed incidence of device-associated pressure ulcer, we place a DuoDERM (ConvaTEC, Greensboro, NC) dressing over the skin of the neck where the ECMO cannula will sit. The ECMO cannula is then secured to the skin ensuring the medial lumen (oxygenated blood) is facing medially (central port facing the tricuspid valve). The DLC is then sutured to the skin using 0 silk sutures. Purse-string sutures are placed at the insertion site, and additional 0 silk sutures are used to secure the DLC on the medial (oxygenated blood) and lateral (nonoxygenated blood) lumen.
This technique provides adequate stabilization of the ECMO cannula with the patient resting in bed but is inadequate for early activity, mobility, and ambulation. The weight of the ECMO lines requires additional stabilization during significant activity to prevent patient discomfort at the insertion site and potential cannula dislodgement.
We had previously utilized Coban self-adherent wrap (3M, Maplewood, MN) to securely hold the DLC in place to the patient’s forehead. However, this practice was associated with patient complaints of headache due to the tight wrap, and we noted a high rate of Coban slipping, loss of adherence, and skin necrosis (Figure 1).
We subsequently changed our practice 12 months ago to utilize a 30-inch Hold-n-Place Leg Band (Dale Medical, Franklin, MA) which is commonly used for Foley urinary catheter stabilization. This Velcro band is placed over the patient’s forehead, and the ECMO cannula is secured using the green Velcro anchor around the lateral lumen or around both lumen of the DLC (Figure 2). This Velcro band is now also used for stabilization of single-lumen ECMO cannula in the internal jugular position (Figure 3).
The Velcro band provides an easy method for readjustment of the tightness of the band around the forehead for optimal patient comfort and provides secure stabilization of the ECMO cannula which can also be easily readjusted. The Velcro band is adjusted by the ECMO and nursing team and the patient for comfort and appropriate DLC stabilization. Coban is changed only by the ECMO and nursing team because once it is repositioned it frequently loses its self-adherent properties and needs to be fully changed. The Velcro band can be opened intermittently to assess the forehead for pressure lesions, whereas Coban cannot. The Velcro band tension be modified as desired, i.e., released when the patient is supine in bed for improved patient comfort, and tightened before ambulation and activity. This is challenging to do with Coban as there are multiple wraps around the entire head which have to be undone. The acquisition cost of the Velcro band is similar to Coban ($3–$6), but Coban requires frequent changes during an ECMO run, whereas the Velcro band does not need to be changed unless it becomes soiled.
Furthermore, medical staff are very familiar with the use of this device for Foley catheter stabilization (Figure 4), and minimal additional education is required for its use for ECMO cannula securement. Other Velcro catheter holders may also be appropriate for this use.
The use of the bicaval DLC ECMO cannula is an excellent advance as it facilitates early mobility in critically ill patients requiring extracorporeal support. Although ambulation has been shown to be safe in patients receiving ECMO, it is important to recognize that ECMO cannula migration and dislodgement are still significant risks in this patient population. A review of the optimal techniques to secure ECMO cannulae is therefore essential.
We have used many different techniques over many years to secure ECMO cannulae at our institution and had previously standardized to the use of Coban self-adherent wrap on the forehead to provide increased stability for the internal jugular ECMO cannulae. But this technique was challenging related to the need to completely replace the self-adherent wrap when it was no longer self-adherent, and when it became loose around the forehead and ECMO cannulae. Some ECMO institutions use Stat-lock or Grip-lock dressings, but these are challenging to use for DLC securement due to the dual cannulae, cannot be used at the forehead level due to hair at that site, and work much better for single-lumen femoral cannulae/line securement. Some ECMO sites use sutures with Opsite or Tegaderm dressings, but these are challenging to remove if a change in ECMO cannula position is desired and do not adhere adequately to hair-bearing surfaces.
We have recently recognized that the 30-inch Velcro Hold-n-Place Leg Band is a superior method for securing internal jugular ECMO cannulae. This technique provides easier readjustment of the tension for both the forehead and cannula Velcro band, allowing much greater patient comfort, and also increased reliability in maintaining the ECMO cannula position. This change in our ECMO practice has allowed us to make ECMO cannula dislodgement and migration a never-event at our institution.
The use of the Velcro band provides excellent DLC stabilization at the forehead level, reduces pressure and pulling at the DLC insertion site, and prevents dislodgement or movement of the DLC. But this securement method will still require additional manual stabilization of the ECMO lines during ambulation. The Columbia University ECMO team has developed the “snorkel” method which is a stabilization device consisting of thermoplastic splinting material which provides additional security for both the ECMO cannulae and lines during ECMO ambulation.3 The Papworth Hospital (Cambridgeshire, United Kingdom) ECMO team use a Velcro dressing to secure the ECMO tubing at the forehead above the ear supporting its weight and ensuring that there is no risk of kinks. Further tubing support is provided by Hollister dressings on the anterior chest wall, further securing the cannula for patient mobilization.8 At present, there are no comparative studies assessing risks and complications associated with these two different techniques compared with manual support of ECMO lines during ambulation.
In summary, use of the DLC greatly facilitates ECMO ambulation in critically ill patients with acute respiratory failure and improves outcomes. Optimal securement of the DLC at the level of the forehead is strongly recommended to prevent dislodgement or movement of the DLC. Use of an adjustable Velcro band for DLC stabilization at the forehead provides optimal and adjustable securement and patient comfort.
1. Needham DM. Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. JAMA 2008.300: 1685–1690.
2. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009.373: 1874–1882.
3. Abrams D, Javidfar J, Farrand E, et al. Early mobilization of patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. Crit Care 2014.18: R38.
4. Levine SM; Transplant/Immunology Network of the American College of Chest Physicians: A survey of clinical practice of lung transplantation in North America. Chest 2004.125: 1224–1238.
5. Tanaka D, Pitcher HT, Cavarocchi N, Hirose H. Migrated Avalon Veno-venous extracorporeal membrane oxygenation cannula: How to adjust without interruption of flow. J Card Surg 2015.30: 865–868.
6. Shaheen A, Tanaka D, Cavarocchi NC, Hirose H. Veno-venous extracorporeal membrane oxygenation (V V ECMO): Indications, preprocedural considerations, and technique. J Card Surg 2016.31: 248–252.
7. Chimot L, Marqué S, Gros A, et al. Avalon© bicaval dual-lumen cannula for venovenous extracorporeal membrane oxygenation: survey of cannula use in France. ASAIO J 2013.59: 157–161.
Copyright © 2019 by the American Society for Artificial Internal Organs
8. Rubino A, Vuylsteke A, Jenkins DP, Fowles JA, Hockings L, Valchanov K. Direct complications of the Avalon bicaval dual-lumen cannula in respiratory extracorporeal membrane oxygenation (ECMO): Single-center experience. Int J Artif Organs 2014.37: 741–747.