Left tilt position for easy extracorporeal membrane oxygenation cannula insertion in late pregnancy patients

Abstract

The aim was to describe how to avoid technical difficulties during venous femoral cannula insertion for extracorporeal membrane oxygenation (ECMO) in a woman in late pregnancy. A 28-year old pregnant woman presented at 32 weeks of gestation after developing an acute respiratory distress syndrome (ARDS) of an unknown origin that required venovenous ECMO insertion via the femoral vein. A cannula insertion by the Seldinger visual control technique was impossible in the supine position. A left lateral tilt between 15° and 30° was performed by placing a wedge-shaped cushion under the right hip permitting the cannula insertion. We proposed a systematic 15°-30° left lateral tilt position during the ECMO femoral cannula insertion in late pregnancy cases needing ECMO. This precaution should avoid an injury to the vessels due to multiple insertion attempts.

Extracorporeal life support during pregnancy

“…This condition may explain the difficulty faced when advancing a femoral venous cannula through the inferior vena cava into the right atrium. Ngatchou and colleagues 23 proposed using a 15 to 30 left lateral tilt position during femoral cannula insertion to reduce aortocaval compression in late pregnancy; however, this maneuver was not necessary in our patient, who presented at 18 weeks gestation.…”

“…Four additional publications on the use of ECLS during pregnancy included 5 patients, including 1 case of hypoxic cardiac arrest, 22 1 case of ARDS of unknown origin, 23 1 case of refractory cardiac arrhythmia with cardiogenic shock, 24 1 case of mycoplasma ARDS, 25 and 1 case of cardiogenic shock likely of viral origin. 25 The mean gestational age of the 45 patients was 26.5 weeks (range, 12-38 weeks).…”

Extracorporeal Membrane Oxygenation in Pregnancy

“…A moderate lateral left supine decubitus position (if the right femoral vein is accessed) might facilitate the advancement of the drainage cannula from the iliac vein towards the right atrium. Left tilt position reduces caval compression by the gravid uterus; we did not experience any difficulty in guidewire and cannula positioning in our patient . Alternative cannulation strategies, such as bilateral femoral access in case of an unreliable transjugular route, are also possible, although this strategy might be less effective from the point of view of ECMO flow and systemic oxygenation.…”

“…The majority of single case reports describe ECMO as a rescue therapy in ARDS during pregnancy due to A/H1N1 influenza; no instances of fatal maternal outcome are reported in these isolated cases . ARDS requiring ECMO during pregnancy has also been attributed to other less common etiologies, such as staphylococcal septicemia, chickenpox pneumonia or spontaneous intrapulmonary hemorrhage; ARDS of unknown etiology during pregnancy has also been treated by ECMO . Similarly, the final maternal outcome was favorable in all of these reports.…”

Clinical Characteristics of 10 Pregnant and Postpartum Women With Extracorporeal Membrane Oxygenation: A Retrospective Study

“…Operating on pregnant patients requires heightened attention, regardless of gestational stage. Antoine et al proposed a technique of ECMO cannulation using a left lateral tilt position of 15–30° during femoral cannula insertion to avoid aortocaval compression ( 20 ). We have found that careful cannula insertion with ultrasound or X-ray can help, but more clinical studies are required to confirm this finding.…”