Extracorporeal membrane oxygenation with single-site dual-lumen in a patient with SARS-CoV-2–associated acute respiratory distress syndrome: a case report

This case report describes the successful management of a critically ill elderly patient with severe SARS-CoV-2-associated acute respiratory distress syndrome (ARDS) using an integrated strategy of awake veno-venous extracorporeal membrane oxygenation (VV-ECMO) via a single-site, dual-lumen cannula (SDLC) combined with a protocolized early rehabilitation programme. Despite high predicted mortality based on validated prognostic scores, the patient achieved a favorable outcome. The SDLC, inserted via the right internal jugular vein, was instrumental as a technological enabler. By providing unobstructed access to the lower limbs, it permitted unrestricted physiotherapy and early mobilization, which is vital for preserving musculoskeletal and neurocognitive function, supporting nutrition, and enhancing patient autonomy. Furthermore, a single puncture site reduces infectious risks and simplifies care compared to traditional multi-cannula configurations. However, this approach demands flawless technical execution, mandating real-time transesophageal echocardiography (TEE) guidance for precise cannula positioning to avoid recirculation or myocardial injury, and often requires intensified anticoagulation, increasing bleeding risk. The awake ECMO strategy deliberately harnesses spontaneous breathing to promote lung recruitment while facilitating ultra-protective ventilation, though it necessitates careful monitoring to mitigate the risk of patient self-inflicted lung injury (P-SILI). For carefully selected patients requiring prolonged support, the triad of SDLC VV-ECMO, an awake strategy, and early rehabilitation is a feasible and advantageous approach that shifts the treatment goal from mere survival to functional survival. It should be employed in expert centers, and future research is needed to standardize protocols and validate long-term outcomes.