From the Research
Emergency physicians should be trained to perform ECMO cannulation and manage ECMO settings, as they play a crucial role in the initial resuscitation and stabilization of patients requiring ECMO support. Their primary responsibilities include patient identification, initial resuscitation, and in some centers, performing the cannulation procedure itself. Emergency physicians should be familiar with the equipment, including cannulas (typically 19-25 French for adults), guidewires, dilators, and ultrasound machines. They should also understand potential complications like vascular injury, bleeding, thrombosis, and limb ischemia.
The choice of anticoagulant during ECMO support is critical, and recent studies have compared the efficacy and safety of heparin and bivalirudin. A study published in 2021 1 found that bivalirudin was associated with a decrease in ECMO circuit-related thrombotic complications and a significant decrease in the volume of blood products administered. Another study published in 2020 2 found that bivalirudin consistently maintained activated partial thromboplastin time (aPTT) within the therapeutic range compared to heparin.
Key considerations for emergency physicians performing ECMO cannulation include:
- Patient selection: identifying patients with severe cardiac or respiratory failure refractory to conventional management
- Equipment familiarity: understanding the use of cannulas, guidewires, dilators, and ultrasound machines
- Procedural sedation: using ketamine or etomidate for induction, with fentanyl for analgesia
- Complication management: recognizing and managing potential complications like vascular injury, bleeding, thrombosis, and limb ischemia
- Anticoagulation management: understanding the choice of anticoagulant, including heparin and bivalirudin, and their respective dosing and monitoring requirements, as described in studies such as 3 and 4.
Overall, emergency physicians play a critical role in ECMO cannulation and management, and their training and expertise are essential for optimizing patient outcomes.