EKMO’da Kanülasyon ve Dekanülasyon

ecmo-kapak

Doç. Dr. Celalettin GÜNAY
GATA, Kalp ve Damar Cerrahisi AD, Ankara

Özet

Ekstrakorporal membran oksijenizasyonu (EKMO) için kanülasyon stratejisi; hastanın yaşına ve vücut ağırlığına, verilecek EKMO desteğinin türüne ve EKMO endikasyonunu doğuran spesifik klinik senaryoya uygun olarak belirlenmelidir.
İki temel EKMO uygulaması vardır. Veno-arteriyel (VA) EKMO’da hastanın sistemik venöz kanı sağ atriyum veya büyük bir periferik artere yerleştirilen kanül aracılığıyla drene edilerek asendan aortaya veya büyük bir periferik artere yerleştir-ilen bir kanül aracılığıyla sistemik arteriyel dolaşıma reinfüzyon yapılır. Veno-venöz (VV) EKMO’da ise hastanın sistemik venöz kanı drene edilerek yine sistemik venöz dolaşıma reinfüzyon yapılır.
VA EKMO genellikle kalp cerrahisinde peroperatif dönemde kalp yetmezliğinde gerekli olmaktadır. Bu durumda ekstrakorporal dolaşım kanülleri duruyorsa aynı kanüller EKMO hattına bağlanarak santral kanülasyonla EKMO uygulanabilir. Göğüs açık değilse genellikle yenidoğanlarda venöz drenaj için sağ internal juguler ven, reinfüzyon için sağ ana karotid arter, erişkinlerde ise venöz drenaj için femoral ven, reinfüzyon için femoral arter kanüle edilir. Optimal drenaj ve akım sağlamakla birlikte santral kanülasyonda mediastenit ve daha fazla hemoraji riski nedeni ile mümkün olan durumlarda periferal kanülasyon tercih edilir.

VV EKMO’da birkaç olası kanül konfigürasyonu uygulanabilir;
A) İki kanül tekniği;

  1. Femoro-atriyal kanülasyon: Drenaj kanülü femoral ven, reinfüzyon kanülü sağ internal juguler ven aracılığıyla yerleştirilir.
  2. Femoro-femoral kanülasyon: Drenaj kanülü bir taraf femoral ven, reinfüzyon kanülü, diğer taraf femoral ven aracılığıyla yerleştirilir.
  3. Atriyo-femoral kanülasyon: Drenaj kanülü sağ internal juguler ven, reinfüzyon kanülü femoral ven aracılığıyla yerleştirilir.
    B) Çift lümen kanül tekniği: Tek bir kanülde hem drenaj lümeni hem de reinfüzyon lümeni birbirinden bir bölmeyle ayrılarak birbirine paralel seyreder. Genellikle sağ internal juguler ven yoluyla yerleştirilir.
    EKMO kanülasyonunda perkütan seldinger, modifiye seldinger ve açık cerrahi (cut-down) olmak üzere üç teknik kullanılmaktadır. EKMO’dan ayırırken önce reinfüzyon hattı, daha sonra da drenaj hattı klemplenir ve pompa durdurulur.

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