A Case Report of ECMO Patient with Cerebrovascular Complication Caused by a Broken Dual Lumen Cannula

ABSTRACT

Introduction: Dual-lumen cannula is used for extracorporeal membrane perfusion (ECMO) to support patients with ARDS due to COVID-19 as a bridge to lung recovery. It tends to be a longer support and there are several factors that can degrade the physical structure of the ECMO cannula and put the cannula at risk for breakage. Case Report A 63-year-old woman was admitted to the hospital with COVID-19 pneumonia. Two days later, she was intubated and VV-ECMO was initiated due to treatment-resistant acute respiratory failure;a 28Fr CrescentTM dual-lumen cannula (Medtronic, MN) was inserted through the left subclavian vein and connected to a centrifugal oxygen pump with a centrifugal oxygenator. Within six weeks after onset, the patient was unable to be weaned from the ventilator and was transferred to our center with ECMO connected for consideration of lung transplantation. Two days after transfer, the patient developed acute aphasia, altered mental status, disturbed consciousness, and left arm seizures. A suction sound was heard from the left subclavian cannula insertion site and the ECMO bubble detector alarmed, but local inspection, chest X-rays, and CT scans of the brain and chest showed no obvious abnormalities. The patient was reintubated for encephalopathy and subsequently underwent a tracheostomy. The patient regained normal neurological function over the next 7 days. However, the air bubble sensor alarmed and suction sound was heard at the cannulation site again, and air bubbles were seen in the oxygenator. Due to concerns about air entrapment and cannula failure, we changed to a dual-canal VV-ECMO configuration using a right internal cervical and a left femoral cannula. The removed cannula had a 2 cm fracture distal to the skin insertion site. After resumption of ECMO, no new neurological episodes occurred. While awaiting lung transplantation, the patient died due to sepsis and multiple organ failure. An autopsy revealed a possible cause of cerebrovascular disease patent foramen ovale and air embolism to the brain. If a patient has been on ECMO for a long time and the bubble sensor warns of air detection, cannula breakage and impending air embolism should be suspected clinically, even if the defect is not found on examination and is not evident on imaging. If the COVID-19 epidemic continues, increased transport events may increase ECMO cannula breakage.