Drainage Insufficiency Should be Sought and Addressed During Extracorporeal Membrane Oxygenation (ECMO).

Introduction: Extracorporeal membrane oxygenation (ECMO) has been rapidly developed and is widely used for respiratory and cardiac support in adults. Inadequate support of a patient during ECMO due to impaired drainage is a common problem. This case report represents the importance of considering mechanics of ECMO support. Case: Forty-two-year-old male with a past medical history of diabetes mellitus presented to the emergency department with unconciousnes and worsening of breath after suicide with Janumet 50/1000 (metformin and sitagliptin, n=60). On admission to ICU, his Glasgow Coma Scale was 9, respiratory rate was 23 breaths/min, heart rate was 120 bpm and mean blood pressure (mBP) was 35 mmHg despite high dose of vazopressors and inotropes. He was intubated and femoral-femoral veno-arterial (VA) ECMO was initiated at a blood flow of 4.5 L/min and gas flow at 3.0 L/min of 100% oxygen. In the following hours chattering of the lines was occured and blood flow of ECMO decreased to 1-1.5 L/min. Firstly, we reduced the pump speed. Then fluid challenge was done to resolve ongoing problem but it was useless. The cannulae was 25 French so it was large enough for drainage. The Chest X-ray showed that inappropriate position of drainage canula that was in the lower level which it should had been (Figure 1). Then we sent the catheter up to the right atrium entrance under steril condition and checked position by transthoracic echocardiography. The ECMO blood flow returned to normal and chattering of the lines disappeared. Discussion: Management of technical issues during ECMO is complex but essential to improving outcomes. The chattering of ECMO line is very common and the causes include kinks in the circuit, hypovolemia, inadequate cannula size, or cannula malposition. In this case, femoral drainage cannulae position was checked by Chest-xray and then inserted sufficiently deep to access the right atrium to provide effective drainage pressures. [ABSTRACT FROM AUTHOR]