Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon...

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Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor , Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

Transcript of Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon...

Page 1: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

Vascular Access & Cannulation

Dr Osama BawazirAssistant Professor , Consultant Pediatric surgeon

FRCSI, FRCS(Ed), FRCS (glas), FRCSC,FAAP,FACS.

Page 2: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

• ECMO is a supportive measure, which can 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 to accomplish a successful result

Page 3: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

• PRE-ECMO ASSESSMENT

• CANNULATION

• INITIATION AND MAINTENANCE OF ECMO

• EVALUATION

Introduction

Page 4: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

The establishment and maintenance of

adequate vascular access is essential

for ECMO

Page 5: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION- 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

Page 6: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION For each modality, there are

different 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

Page 7: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

Guidelines for Cannula size 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

Page 8: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

Poiseuille’s LawPoiseuille’s Law

• Poiseuille's law: In an artificial system, flow through a cylindrical tube or any segment of a tube is directly proportional to ΔP, the driving pressure along the tube, and the fourth power of the radius, r. Flow is inversely proportional to L the length of the segment and to η, the viscosity of the liquid. The proportionality constant is π/8.

Page 9: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

Cannula ConsiderationCannula 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)

Page 10: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION• 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

Page 11: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

• Veno-Arterial (VA) ECMO

provides cardiac as well as respiratory

support and is mainly used for post op

cardiac case

Page 12: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.
Page 13: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

(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

Page 14: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATION TECHNIQUE

• Open

• Semi-open

• Percutaneous

Page 15: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATIONInternal jugular vein

Page 16: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

Subclavian vein & Right atrium

Page 17: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

Femoral vein

Page 18: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

One site

- A double lumen cannula is inserted into the internal jugular vein

- Only one site for venous access

Page 19: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

Two different sites

Page 20: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

• Veno-Arterial (VA) ECMO

provides cardiac as well as respiratory support and is

mainly used for post op cardiac case

Page 21: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

Internal jugular vein and the common

carotid artery

Page 22: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

Right atrium and ascending aorta

Page 23: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

Femoral vein and artery

Page 24: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

A Left atrial pressure line can be utilized to

monitor the LA pressure

Page 25: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION

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

Page 26: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

CANNULATIONCANNULATION PROBLEMS PROBLEMS

• Threading the venous catheter

• Vein division

• Proximal vein lost in mediastinum

• Lack of venous return

• Intrathoracic vein perforation

Page 27: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

ComplicationComplication

• Vascular injury( tear, intimal dissection, perforation).

• Obstruction (kinking, positional).

• Misplacement( AI, afterload LV failure).

• Bleeding.• Recirculation.

Page 28: Vascular Access & Cannulation Dr Osama Bawazir Assistant Professor, Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

Thank You