Intraoperative Ultrasound Reduces ECMO Catheter Malposition
Requiring Surgical Correction
By Keith A. Kuenzler, L. Grier Arthur, Andrew E. Burchard, Stephen T. Lawless, Philip J. Wolfson,
and Stephen G. Murphy
Wilmington, Delaware and Philadelphia, Pennsylvania
Background/Purpose: One hundred ninety-three cannulation
procedures for extracorporeal membrane oxygenation
(ECMO) have been performed at the authors’ institution from
1994 to now. Before 1996, their practice had been to position
these catheters exclusively by clinical assessment and chest
radiograph. Since then, the authors have utilized intraoper-
ative ultrasound guidance during cannulation procedures to
conﬁrm proper tip position. This retrospective analysis was
undertaken to establish whether this practice has reduced
the rate of surgical repositioning of ECMO catheters in these
Methods: A retrospective chart review was performed for all
infants who underwent ECMO cannulation procedures at the
authors’ institution. Numbers of infants requiring surgery to
readjust ECMO catheter position were totaled. Cases were
categorized according to the presence or absence of intraop-
erative ultrasound scan. Statistical signiﬁcance was deter-
analysis, Student’s t test, or analysis of
variance where appropriate.
Results: There were 193 ECMO cannulations performed. Of
the 101 procedures done without ultrasound scan, 18 neces-
sitated surgical repositioning. In contrast, only 3 of the 92
catheters placed with ultrasound assistance required reop-
eration. This represents a reduction the rate of repositioning
from 17.8% to 3.3% of cannulations (P ϭ .003).
Conclusions: Based on these ﬁndings, the authors advocate
the use of intraoperative ultrasound imaging to optimize the
position of ECMO catheters. This high rate of initial success
helps avoid the potential morbidity of ECMO circuit malfunc-
tion, repeat neck dissection, and catheter manipulation in
these critically ill, anticoagulated patients.
J Pediatr Surg 37:691-694. Copyright 2002, Elsevier Science
(USA). All rights reserved.
INDEX WORDS: Extracorporeal membrane oxygenation,
cannula, reposition, complication, ultrasound scan, echocar-
XTRACORPOREAL membrane oxygenation
(ECMO) has been a lifesaving intervention for
neonates with respiratory failure since its introduction by
Bartlett et al in 1976.
Despite reports of recent success
with newer modalities such as high-frequency oscillatory
ventilation, surfactant therapy, and inhaled nitric oxide,
The Extracorporeal Life Support Organization (ELSO)
data indicate that between 800 and 900 cannulations
have been performed annually over the last 3 years.
number of ECMO runs at our center has increased
moderately during this time.
Adequate ECMO circuit ﬂow requires proper catheter
placement. The preferred location of the venous cannula
tip is in the right atrium, whereas an arterial cannula
should terminate in the aortic arch above the aortic
Venous cannula obstruction can be caused by
tip malposition in the superior vena cava, the subclavian
vein, or against the atrial septum or tricuspid valve.
Rarely, the catheter can traverse the foramen ovale into
the left atrium. Insertion of an arterial cannula in close
proximity to the aortic valve may cause increased after-
load and compromise left ventricular outﬂow.
Conventional practice had been to position cannulas
by clinical assessment and to conﬁrm proper tip location
by postoperative chest radiograph. With this approach, a
malpositioned catheter requires a repeat neck dissection
and introduces risks of infection, bleeding, and a delay in
ECMO therapy. Evidence-based medicine investigations
have suggested that accuracy of central line placement is
improved with utilization of ultrasound scan.
investigators have advocated intraoperative ultrasound
guidance to optimize ECMO cannula placement.
Through a retrospective chart review, we attempted to
ascertain whether recent use of intraoperative ultrasound
scan to conﬁrm proper cannula placement has signiﬁ-
cantly reduced the need for reoperation in our infants on
From Nemours Children’s Clinic–Wilmington and Alfred I. duPont
Hospital for Children, Wilmington, DE, and Thomas Jefferson Univer-
sity Hospital, Philadelphia, PA.
Address reprint requests to Stephen G. Murphy, MD, A.I. duPont
Hospital for Children, Department of Surgery, 1600 Rockland Rd,
Wilmington, DE 19899.
Copyright 2002, Elsevier Science (USA). All rights reserved.
691Journal of Pediatric Surgery, Vol 37, No 5 (May), 2002: pp 691-694