CPT® Code 33969

1. Indications

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) are indicated for patients experiencing severe cardiac or respiratory failure. The specific indications for the procedure involving the removal of peripheral cannula(e) include:

• Severe Respiratory Failure Patients who are unable to maintain adequate oxygenation or ventilation due to conditions such as pneumonia, acute respiratory distress syndrome (ARDS), or other pulmonary disorders.
• Cardiac Failure Patients with significant cardiac dysfunction, such as cardiogenic shock or severe heart failure, requiring temporary support to allow for recovery or surgical intervention.
• Post-Surgical Support Patients who have undergone cardiac or thoracic surgery and require ongoing support for heart and lung function during recovery.

2. Procedure

The procedure for the removal of peripheral arterial and/or venous cannula(e) using an open technique involves several critical steps to ensure safety and effectiveness:

• Step 1: Patient Positioning The patient is positioned in a slight Trendelenburg or supine position to facilitate access to the cannula insertion site and to help reduce the risk of air embolism during the procedure.
• Step 2: Circuit Preparation The ECMO/ECLS circuit tubing is clamped to prevent blood flow during the removal process, ensuring that the patient remains stable and minimizing the risk of bleeding.
• Step 3: Accessing the Cannula The dressing and/or sutures securing the cannula(e) to the skin are carefully removed. The vessel is accessed by making an incision in the skin or by reopening a previous incision if the cannula was inserted using an open technique.
• Step 4: Cutting Sutures The sutures that secure the cannula(e) to the vessel are cut, allowing for the safe withdrawal of the cannula(e) from the vascular system.
• Step 5: Cannula Removal The cannula(e) is withdrawn from the vessel using rapid, steady pressure in a parallel line to the skin. This technique is crucial to minimize trauma to the vessel.
• Step 6: Timing of Removal To reduce the risk of air embolism, the removal should be performed during the inspiratory phase of the ventilator cycle for intubated patients. If the patient is conscious and able to follow directions, the cannula(e) should be withdrawn during exhalation or while performing a Valsalva maneuver.
• Step 7: Closing the Vessel After the cannula(e) has been removed, the opening in the vessel is closed with sutures to ensure hemostasis and prevent bleeding.
• Step 8: Skin Closure The skin is then closed using sutures or staples, followed by the application of a sterile dressing to protect the site and promote healing.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any signs of complications, such as bleeding or infection at the cannula removal site. The patient should be observed for any changes in vital signs and overall stability. Follow-up assessments may include checking the integrity of the closure and ensuring that the patient is recovering appropriately from the ECMO/ECLS support. Additional considerations include providing appropriate pain management and ensuring that the patient receives adequate respiratory support as needed during the recovery phase.