Point-of-care ultrasound (POCUS) has emerged as an essential tool in the management of critically ill patients, particularly those requiring extracorporeal membrane oxygenation (ECMO) in intensive care units (ICUs). Although radiographic imaging is routinely used to assess ECMO cannula placement, it may miss complications such as cannula malposition, a condition with serious consequences including vessel trauma, recirculation, and organ congestion, which can lead to cerebral hypoperfusion, hemodynamic instability, and even death. This case series highlights four ECMO patients where POCUS identified cannula malposition that was missed by radiographic imaging. Each case demonstrated how ultrasound facilitated prompt identification and real-time correction of malposition, significantly altering the patient’s ECMO course.
In one case, POCUS detected an outflow jet positioned in the hepatic vein despite a normal chest X-ray (CXR) report, enabling repositioning and improvement of recirculation. Another patient with signs of low flow had POCUS confirmation of improper cannula placement, leading to immediate adjustment and stabilization. Across all cases, radiographic evaluation was reported as reassuring, but POCUS revealed malpositions, underscoring its advantages such as real-time visualization, ease of access, and live guidance for cannula repositioning. The limitations of radiography, exacerbated by conditions like ARDS and pulmonary edema, were evident, making ultrasound an indispensable tool.
This series is the first to demonstrate POCUS’s superiority over radiographs for identifying VV ECMO cannula malposition. It underscores the need for incorporating POCUS into standard ECMO protocols, given its effectiveness in rapidly diagnosing and addressing complications. Further research is warranted to establish formal guidelines and compare outcomes systematically. Institutions should consider training ECMO teams in vascular and cardiac ultrasonography to enhance patient care.
