Anatomic changes after repair of traumatic bilateral diaphragmatic rupture impede bi-caval dual lumen catheter insertion for veno-venous extracorporeal membrane oxygenation treatment
© The Author(s). 2017
Published: 4 April 2017
Extracorporeal membrane oxygenation (ECMO) is a therapeutic option used increasingly in the treatment of severe acute respiratory distress syndrome (ARDS). Choosing an adequate cannula type and insertion site can be a challenge. The insertion of a bi-caval dual lumen (Avalon®) catheter in the superior vena cava instead of two venous single-lumen catheters facilitates mobilisation and physiotherapy of patients, and hence is being used more and more .
A middle-aged patient was admitted to our hospital after severe multiple trauma. Before admission to our hospital, damage control surgery including bilateral diaphragmatic repair and ileotransversostomy was performed.
The postoperative course was complicated by disseminated intravascular coagulation (DIC). Six days after the accident, the patient could be stabilized to be eligible for transportation to the hospital by an air rescue service. The patient was transferred directly to the Surgical ICU under controlled mechanical ventilation.
Within the first 24 h after admission, the respiratory function deteriorated to ARDS. Advanced respiratory support, including veno-venous ECMO, was applied to sustain gas exchange in the hope it could improve survival. Because of the underlying complex abdominal trauma we tried to insert a bi-caval dual lumen catheter into the right jugular vein. Due to surgical reconstruction of the bilateral diaphragmatic rupture and consecutive anatomical changes, several attempts to place either the guide wire or the catheter tip into the inferior vena cava (IVC) under transthoracic and transoesophageal echocardiography visual guidance failed; both guide wire and dual lumen catheter could not bypass the right ventricle to the IVC.
In patients with right-sided diaphragmatic rupture and surgical reconstruction we recommend a three-dimensional reconstruction based on three-dimensional echocardiography or CT of the venous inflow to the right atrium before attempting to insert a bi-caval dual lumen catheter . Notwithstanding that the manufacturer recommends insertion of the guide wire under angiographic control, we assume that use of fluoroscopy most likely would have been associated with the same difficulties.
Acute respiratory distress syndrome
Disseminated intravascular coagulation
Extracorporeal membrane oxygenation
Inferior vena cava
No funding was received.
Availability of data and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request. The clinical data is stored electronically in the intensive care clinical information system software (MetaVision, iMDsoft ®) provided in the intensive care units of the University Hospital Basel.
MS, DT, and AH analyzed and interpreted the patient data regarding the insertion of a bi-caval dual lumen catheter. BJ performed the examination of the CT image. AH wrote the manuscript. All authors have read and approved the final version (Version 3, 21.12.2016) of the manuscript.
The authors declare that they have no competing interests.
Consent for publication
We were unable to seek patient permission for publication because of the patient’s death and could not reach a family member for case discussion. The Editor-in-Chief gives his approval for publication of this manuscript with the patient details being anonymised.
Ethics approval and consent to participate
Ethics approval was given 21 December 2016. The written agreement of the EKNZ (Ethikkommission Nordwest- und Zentralschweiz) composed in German will be uploaded with the submission of this manuscript and is designated as EKNZ UBE 2016-02117.
Accession number to microarray data
Clinical trial registration number
No registration was performed for this investigation.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Gothner M, Buchwald D, Strauch JT, et al. The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS. Scand J Trauma Resusc Emerg Med. 2015;23:30. doi:10.1186/s13049-015-0106-2.View ArticlePubMedPubMed CentralGoogle Scholar
- Yastrebov K, Manganas C, Kapalli T, et al. Right ventricular loop indicating malposition of J-wire introducer for double lumen bicaval venovenous extracorporeal membrane oxygenation (VV ECMO) cannula. Heart Lung Circ. 2014;23(1):e4–7. doi:10.1016/j.hlc.2013.05.643.View ArticlePubMedGoogle Scholar