title: Emergency percutaneous, bicaval double-lumen, ECMO cannulation in neonates and infants: insights from three consecutive cases.
abstract: BACKGROUND
  Veno-venous extracorporeal membrane oxygenation (ECMO) is probably the preferable configuration to assist children with respiratory failure who do not respond to maximized conventional therapies. The single-vessel, double-lumen approach through the internal jugular vein is extremely advantageous, especially in infants, where femoral access presents limitations related to the small dimensions of the veins. In case of emergencies, ECMO might need to be started at the bedside, without the availability of fluoroscopic guidance. To our knowledge, a completely percutaneous approach has not been reported before in children younger than 1 year and weighing less than 5 kg.
  
  
  METHODS
  We describe 3 cases of emergency bedside, percutaneous, bicaval double-lumen cannulation under real-time transthoracic ultrasound control in 2 neonates and 1 infant.
  
  
  RESULTS
  In our experience, this approach proved to be safe, effective and time saving, while minimizing bleeding from the cannula insertion site. Cannulation times, from decision making to the beginning of ECMO flow, were 30, 28, 25 minutes respectively, from patient 1 to 3. We do not report any cannula-related injury to vessels and heart structures.
  
  
  CONCLUSIONS
  Our preliminary data suggest that, with the described precautions, percutaneous, echo-guided, bicaval double-lumen cannulation in neonates and infants could be effective and free from major complications. Further evaluation should be warranted in the neonatal population.
authors.affiliation: Neonatal and Pediatric Intensive Care Unit, Department of Critical Care and Perinatal Medicine, Istituto Giannina Gaslini, Genoa - Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Moscatelli
authors.affiliation: Neonatal and Pediatric Intensive Care Unit, Department of Critical Care and Perinatal Medicine, Istituto Giannina Gaslini, Genoa - Italy.
authors.forename: Silvia
authors.initials: S
authors.lastname: Buratti
authors.affiliation: Department of Anesthesia, Città della Salute e della Scienza, Turin - Italy.
authors.forename: Cesare
authors.initials: C
authors.lastname: Gregoretti
authors.affiliation: Neonatal and Pediatric Intensive Care Unit, Department of Critical Care and Perinatal Medicine, Istituto Giannina Gaslini, Genoa - Italy.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Lampugnani
authors.affiliation: Neonatal and Pediatric Intensive Care Unit, Department of Critical Care and Perinatal Medicine, Istituto Giannina Gaslini, Genoa - Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Salvati
authors.affiliation: Division of Cardiology, Department of Cardiothoracic, Abdominal and Transplant Surgery, Istituto Giannina Gaslini, Genoa - Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Marasini
authors.affiliation: Division of Cardiovascular Surgery, Department of Cardiothoracic, Abdominal and Transplant Surgery, Istituto Giannina Gaslini, Genoa - Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Ribera
authors.affiliation: Division of Perinatal Pathology, Department of Translational Research, Laboratory Medicine and Diagnostic Services, Istituto Giannina Gaslini, University of Genoa, Genoa - Italy.
authors.forename: Ezio
authors.initials: E
authors.lastname: Fulcheri
authors.affiliation: Neonatal and Pediatric Intensive Care Unit, Department of Critical Care and Perinatal Medicine, Istituto Giannina Gaslini, Genoa - Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Tuo
mesh_terms: D015199:Extracorporeal Membrane Oxygenation / Q000295:instrumentation*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D012131:Respiratory Insufficiency / Q000628:therapy*; D018084:Ultrasonography, Interventional; D062666:Vascular Access Devices