Difficult cannulations in neonatal and pediatric ECMO: Illuminating obstructions to timely therapy

IntroductionExtracorporeal membrane oxygenation (ECMO) provides life-saving support for patients with advanced cardiorespiratory failure, yet unanticipated difficulties with peripheral cannulation can delay therapy. This study describes challenging neonatal and pediatric ECMO cannulations and identifies common features among affected patients.MethodsWe conducted a 5-year retrospective review at a single tertiary care center of neonatal and pediatric patients who experienced difficult peripheral cannulations or required multiple cannulations. Cannulations were defined as "difficult" based on surgeon judgment and identified through review of the institutional ECMO database. Outcomes included cannulation details, patient demographics and anatomy, and survival outcomes.ResultsAnalysis of 65 cannulations (median = 2, range = 1-4) in 38 patients showed that 82% (<i>n</i> = 31) of patients had congenital heart disease. Half of cannulations occurred post-operatively (<i>n</i> = 33, 51%), often after cardiotomy, and 45% (<i>n</i> = 29) were during ECPR events. Intraoperative challenges were attributed to small vessel size (<i>n</i> = 17), aberrant anatomy (<i>n</i> = 16), and obstructions to catheter advancement (<i>n</i> = 9). Mortality directly attributable to cannulation difficulty was 16% (<i>n</i> = 6), and overall group mortality was 71% (<i>n</i> = 27).ConclusionsNeonatal and pediatric patients with congenital heart disease frequently required ECMO cannulation in the post-cardiotomy period and often presented technical challenges. This cohort exhibited increased overall mortality, with several deaths directly attributable to surgical difficulty. Improved surgical planning, including preoperative assessment of vascular anatomy and documentation of an ECMO strategy, may enhance outcomes in children requiring ECMO.