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Immohr MB, Hettlich VH, Kindgen-Milles D, Brandenburger T, Feldt T, Aubin H, Tudorache I, Akhyari P, Lichtenberg A, Dalyanoglu H, Boeken U. Changes in Therapy and Outcome of Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation for COVID-19. Thorac Cardiovasc Surg 2024; 72:311-319. [PMID: 37146634 DOI: 10.1055/s-0043-57032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation (vv-ECMO) is related with poor outcome, especially in Germany. We aimed to analyze whether changes in vv-ECMO therapy during the pandemic were observed and lead to changes in the outcome of vv-ECMO patients. METHODS All patients undergoing vv-ECMO support for COVID-19 between 2020 and 2021 in a single center (n = 75) were retrospectively analyzed. Weaning from vv-ECMO and in-hospital mortality were defined as primary and peri-interventional adverse events as secondary endpoints of the study. RESULTS During the study period, four infective waves were observed in Germany. Patients were assigned correspondingly to four study groups: ECMO implantation between March 2020 and September 2020: first wave (n = 11); October 2020 to February 2021: second wave (n = 23); March 2021 to July 2021: third wave (n = 25); and August 2021 to December 2021: fourth wave (n = 20). Preferred cannulation technique changed within the second wave from femoro-femoral to femoro-jugular access (p < 0.01) and awake ECMO was implemented. Mean ECMO run time increased by more than 300% from 10.9 ± 9.6 (first wave) to 44.9 ± 47.0 days (fourth wave). Weaning of patients was achieved in less than 20% in the first wave but increased to approximately 40% since the second one. Furthermore, we observed a continuous numerically decrease of in-hospital mortality from 81.8 to 57.9% (p = 0.61). CONCLUSION Preference for femoro-jugular cannulation and awake ECMO combined with preexisting expertise and patient selection are considered to be associated with increased duration of ECMO support and numerically improved ECMO weaning and in-hospital mortality.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | | | - Detlef Kindgen-Milles
- Department of Anesthesiology, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Timo Brandenburger
- Department of Anesthesiology, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Torsten Feldt
- Department of Hepatology and Infectiology, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
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Parker LP, Svensson Marcial A, Brismar TB, Broman LM, Prahl Wittberg L. In silico parametric analysis of femoro-jugular venovenous ECMO and return cannula dynamics: In silico analysis of femoro-jugular VV ECMO. Med Eng Phys 2024; 125:104126. [PMID: 38508803 DOI: 10.1016/j.medengphy.2024.104126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 02/05/2024] [Accepted: 02/16/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Increasingly, computational fluid dynamics (CFD) is helping explore the impact of variables like: cannula design/size/position/flow rate and patient physiology on venovenous (VV) extracorporeal membrane oxygenation (ECMO). Here we use a CFD model to determine what role cardiac output (CO) plays and to analyse return cannula dynamics. METHODS Using a patient-averaged model of the right atrium and venae cava, we virtually inserted a 19Fr return cannula and a 25Fr drainage cannula. Running large eddy simulations, we assessed cardiac output at: 3.5-6.5 L/min and ECMO flow rate at: 2-6 L/min. We analysed recirculation fraction (Rf), time-averaged wall shear stress (TAWSS), pressure, velocity, and turbulent kinetic energy (TKE) and extracorporeal flow fraction (EFF = ECMO flow rate/CO). RESULTS Increased ECMO flow rate and decreased CO (high EFF) led to increased Rf (R = 0.98, log fit). Negative pressures developed in the venae cavae at low CO and high ECMO flow (high CR). Mean return cannula TAWSS was >10 Pa for all ECMO flow rates, with majority of the flow exiting the tip (94.0-95.8 %). CONCLUSIONS Our results underpin the strong impact of CO on VV ECMO. A simple metric like EFF, once supported by clinical data, might help predict Rf for a patient at a given ECMO flow rate. The return cannula imparts high shear stresses on the blood, largely a result of the internal diameter.
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Affiliation(s)
- Louis P Parker
- FLOW, Department of Engineering Mechanics, Royal Institute of Technology, KTH, Stockholm, Sweden
| | - Anders Svensson Marcial
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Division of Medical Imaging and Technology, Stockholm, Sweden; Department of Radiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Torkel B Brismar
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Division of Medical Imaging and Technology, Stockholm, Sweden; Department of Radiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lisa Prahl Wittberg
- FLOW, Department of Engineering Mechanics, Royal Institute of Technology, KTH, Stockholm, Sweden.
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Abstract
Extracorporeal membrane oxygenation (ECMO) can be delivered in veno-arterial (VA) and veno-venous (VV) configurations based on the cannulation strategy. VA and VV ECMO are delivered primarily for haemodynamic and respiratory support in patients with severe heart and lung failure, respectively. The Fick principle describes the relationship between blood flow and oxygen consumption - key parameters in the physiological management of extracorporeal support. This review will discuss the application of the Fick principle in: (i) recirculation in VV ECMO; (ii) the quantification of oxygen delivery (DO2) in VV ECMO and (iii) the quantification of transpulmonary blood flow and systemic arterial oxygen saturation in VA ECMO.
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Affiliation(s)
- Hoong Lim
- 156807Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
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4
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Sommer P, Nunnally M. Mechanical circulatory support in the intensive care unit. Int Anesthesiol Clin 2022; 60:46-54. [PMID: 35993668 DOI: 10.1097/aia.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Philip Sommer
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Mark Nunnally
- Departments of Anesthesiology, Perioperative Care and Pain Medicine, Medicine, Surgery, Neurology, NYU Langone Medical Center, New York, New York
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Parker LP, Marcial AS, Brismar TB, Broman LM, Prahl Wittberg L. Cannulation configuration and recirculation in venovenous extracorporeal membrane oxygenation. Sci Rep 2022; 12:16379. [PMID: 36180496 PMCID: PMC9523655 DOI: 10.1038/s41598-022-20690-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/16/2022] [Indexed: 11/29/2022] Open
Abstract
Venovenous extracorporeal membrane oxygenation is a treatment for acute respiratory distress syndrome. Femoro-atrial cannulation means blood is drained from the inferior vena cava and returned to the superior vena cava; the opposite is termed atrio-femoral. Clinical data comparing these two methods is scarce and conflicting. Using computational fluid dynamics, we aim to compare atrio-femoral and femoro-atrial cannulation to assess the impact on recirculation fraction, under ideal conditions and several clinical scenarios. Using a patient-averaged model of the venae cavae and right atrium, commercially-available cannulae were positioned in each configuration. Additionally, occlusion of the femoro-atrial drainage cannula side-holes with/without reduced inferior vena cava inflow (0-75%) and retraction of the atrio-femoral drainage cannula were modelled. Large-eddy simulations were run for 2-6L/min circuit flow, obtaining time-averaged flow data. The model showed good agreement with clinical atrio-femoral recirculation data. Under ideal conditions, atrio-femoral yielded 13.5% higher recirculation than femoro-atrial across all circuit flow rates. Atrio-femoral right atrium flow patterns resembled normal physiology with a single large vortex. Femoro-atrial cannulation resulted in multiple vortices and increased turbulent kinetic energy at > 3L/min circuit flow. Occluding femoro-atrial drainage cannula side-holes and reducing inferior vena cava inflow increased mean recirculation by 11% and 32%, respectively. Retracting the atrio-femoral drainage cannula did not affect recirculation. These results suggest that, depending on drainage issues, either atrio-femoral or femoro-atrial cannulation may be preferrable. Rather than cannula tip proximity, the supply of available venous blood at the drainage site appears to be the strongest factor affecting recirculation.
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Affiliation(s)
- Louis P Parker
- FLOW & BioMEx, Department of Engineering Mechanics, Royal Institute of Technology, KTH, Osquars backe 18, 100 44, Stockholm, Sweden
| | - Anders Svensson Marcial
- Department of Clinical Science, Intervention and Technology at Karolinska Institute, Division of Medical Imaging and Technology, Stockholm, Sweden
- Department of Radiology, ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital and Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Torkel B Brismar
- Department of Clinical Science, Intervention and Technology at Karolinska Institute, Division of Medical Imaging and Technology, Stockholm, Sweden
- Department of Radiology, ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital and Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Lisa Prahl Wittberg
- FLOW & BioMEx, Department of Engineering Mechanics, Royal Institute of Technology, KTH, Osquars backe 18, 100 44, Stockholm, Sweden.
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Fisser C, Palmér O, Sallisalmi M, Paulus M, Foltan M, Philipp A, Malfertheiner MV, Lubnow M, Müller T, Broman LM. Recirculation in single lumen cannula venovenous extracorporeal membrane oxygenation: A non-randomized bi-centric trial. Front Med (Lausanne) 2022; 9:973240. [PMID: 36117961 PMCID: PMC9470851 DOI: 10.3389/fmed.2022.973240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRecirculation is a common problem in venovenous (VV) extracorporeal membrane oxygenation (ECMO). The aims of this study were to compare recirculation fraction (Rf) between femoro-jugular and jugulo-femoral VV ECMO configurations, to identify risk factors for recirculation and to assess the impact on hemolysis.MethodsPatients in the medical intensive care unit (ICU) at the University Medical Center Regensburg, Germany receiving VV ECMO with femoro-jugular, and jugulo-femoral configuration at the ECMO Center Karolinska, Sweden, were included in this non-randomized prospective study. Total ECMO flow (QEC), recirculated flow (QREC), and recirculation fraction Rf = QREC/QEC were determined using ultrasound dilution technology. Effective ECMO flow (QEFF) was defined as QEFF = QEC * (1–Rf). Demographics, cannula specifics, and markers of hemolysis were assessed. Survival was evaluated at discharge from ICU.ResultsThirty-seven patients with femoro-jugular configuration underwent 595 single-point measurements and 18 patients with jugulo-femoral configuration 231 measurements. Rf was lower with femoro-jugular compared to jugulo-femoral configuration [5 (0, 11) vs. 19 (13, 28) %, respectively (p < 0.001)], resulting in similar QEFF [2.80 (2.21, 3.39) vs. 2.79 (2.39, 3.08) L/min (p = 0.225)] despite lower QEC with femoro-jugular configuration compared to jugulo-femoral [3.01 (2.40, 3.70) vs. 3.57 (3.05, 4.06) L/min, respectively (p < 0.001)]. In multivariate regression analysis, the type of configuration, distance between the two cannula tips, ECMO flow, and heart rate were significantly associated with Rf [B (95% CI): 25.8 (17.6, 33.8), p < 0.001; 960.4 (960.7, 960.1), p = 0.009; 4.2 (2.5, 5.9), p < 0.001; 960.1 (960.2, 0.0), p = 0.027]. Hemolysis was similar in subjects with Rf > 8 vs. ≤ 8%. Explorative data on survival showed comparable results in the femoro-jugular and the jugulo-femoral group (81 vs. 72%, p = 0.455).ConclusionVV ECMO with femoro-jugular configuration caused less recirculation. Further risk factors for higher Rf were shorter distance between the two cannula tips, higher ECMO flow, and lower heart rate. Rf did not affect hemolysis.
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Affiliation(s)
- Christoph Fisser
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
- *Correspondence: Christoph Fisser
| | - Oscar Palmér
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Marko Sallisalmi
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Paulus
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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7
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Charbit J, Courvalin E, Dagod G, Deras P, Laumon T, Girard M, Maury C, Weber H, Capdevila X. Mathematical modelling of oxygenation under veno-venous ECMO configuration using either a femoral or a bicaval drainage. Intensive Care Med Exp 2022; 10:10. [PMID: 35347456 PMCID: PMC8960524 DOI: 10.1186/s40635-022-00434-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The bicaval drainage under veno-venous extracorporeal membrane oxygenation (VV ECMO) was compared in present experimental study to the inferior caval drainage in terms of systemic oxygenation. METHOD Two mathematical models were built to simulate the inferior vena cava-to-right atrium (IVC → RA) route and the bicaval drainage-to-right atrium return (IVC + SVC → RA) route using the following parameters: cardiac output (QC), IVC flow/QC ratio, venous oxygen saturation, extracorporeal pump flow (QEC), and pulmonary shunt (PULM-Shunt) to obtain pulmonary artery oxygen saturation (SPAO2) and systemic blood oxygen saturation (SaO2). RESULTS With the IVC → RA route, SPAO2 and SaO2 increased linearly with QEC/QC until the threshold of the IVC flow/QC ratio, beyond which the increase in SPAO2 reached a plateau. With the IVC + SVC → RA route, SPAO2 and SaO2 increased linearly with QEC/QC until 100% with QEC/QC = 1. The difference in required QEC/QC between the two routes was all the higher as SaO2 target or PULM-Shunt were high, and occurred all the earlier as PULM-Shunt were high. The required QEC between the two routes could differ from 1.0 L/min (QC = 5 L/min) to 1.5 L/min (QC = 8 L/min) for SaO2 target = 90%. Corresponding differences of QEC for SaO2 target = 94% were 4.7 L/min and 7.9 L/min, respectively. CONCLUSION Bicaval drainage under ECMO via the IVC + SVC → RA route gave a superior systemic oxygenation performance when both QEC/QC and pulmonary shunt were high. The VV-V ECMO configuration (IVC + SVC → RA route) might be an attractive rescue strategy in case of refractory hypoxaemia under VV ECMO.
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Affiliation(s)
- Jonathan Charbit
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France. .,Critical Care Unit, Lapeyronie University Hospital, 34295, Montpellier Cedex 5, France.
| | - Elie Courvalin
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France
| | - Geoffrey Dagod
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France
| | - Pauline Deras
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France
| | - Thomas Laumon
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France
| | - Mehdi Girard
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France
| | - Camille Maury
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France
| | - Hugues Weber
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France
| | - Xavier Capdevila
- Département d'Anesthésie Réanimation Lapeyronie, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295, Montpellier, France
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MacLaren G, Barbaro R, Peek G. Expanding Extracorporeal Membrane Oxygenation Cannulation Strategies in Neonatal Respiratory Failure. Pediatr Crit Care Med 2021; 22:756-758. [PMID: 34397991 PMCID: PMC8371699 DOI: 10.1097/pcc.0000000000002770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Ryan Barbaro
- Division of Pediatric Critical Care, Department of Pediatrics, C.S. Mott Children's Hospital, Ann Arbor, MI
- Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, MI
| | - Giles Peek
- Congenital Heart Center, University of Florida, Gainesville, FL
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Conrad SA, Wang D. Evaluation of Recirculation During Venovenous Extracorporeal Membrane Oxygenation Using Computational Fluid Dynamics Incorporating Fluid-Structure Interaction. ASAIO J 2021; 67:943-953. [PMID: 33315664 PMCID: PMC8318564 DOI: 10.1097/mat.0000000000001314] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Recirculation in venovenous extracorporeal membrane oxygenation (VV ECMO) leads to reduction in gas transfer efficiency. Studies of the factors contributing have been performed using in vivo studies and computational models. The fixed geometry of previous computational models limits the accuracy of results. We have developed a finite element computational fluid dynamics model incorporating fluid-structure interaction (FSI) that incorporates atrial deformation during atrial filling and emptying, with fluid flow solved using large eddy simulation. With this model, we have evaluated an extensive number of factors that could influence recirculation during two-site VV ECMO, and characterized their impact on recirculation, including cannula construction, insertion depth and orientation, VV ECMO configuration, circuit blood flow, and changes in volume, venous return, heart rate, and blood viscosity. Simulations revealed that extracorporeal blood flow relative to cardiac output, ratio of superior vena caval (SVC) to inferior vena caval (IVC) blood flow, position of the SVC cannula relative to the cavo-atrial junction, and orientation of the return cannula relative to the tricuspid valve had major influences (>20%) on recirculation fraction. Factors with a moderate influence on recirculation fraction (5%-20%) include heart rate, return cannula diameter, and direction of extracorporeal flow. Minimal influence on recirculation (<5%) was associated with atrial volume, position of the IVC cannula relative to the cavo-atrial junction, the number of side holes in the return cannula, and blood viscosity.
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Affiliation(s)
- Steven A. Conrad
- From the Departments of Medicine, Emergency Medicine, and Surgery Louisiana State University Health Sciences Center Shreveport, Shreveport, LA
| | - Dongfang Wang
- Department of Surgery, University of Kentucky, Lexington, KT
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Liang Y, Zhu J, Zheng X, Qiao Q, Guan Y, Zhang J, Chen E. Application of extracorporeal membrane oxygenation in the endoscopic treatment of severe benign airway stenosis: A case report and literature review. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Suk P, Šrámek V, Čundrle I. Extracorporeal Membrane Oxygenation Use in Thoracic Surgery. MEMBRANES 2021; 11:membranes11060416. [PMID: 34072713 PMCID: PMC8227574 DOI: 10.3390/membranes11060416] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022]
Abstract
This narrative review is focused on the application of extracorporeal membrane oxygenation (ECMO) in thoracic surgery, exclusive of lung transplantation. Although the use of ECMO in this indication is still rare, it allows surgery to be performed in patients where conventional ventilation is not feasible-especially in single lung patients, sleeve lobectomy or pneumonectomy and tracheal or carinal reconstructions. Comparisons with other techniques, various ECMO configurations, the management of anticoagulation, anesthesia, hypoxemia during surgery and the use of ECMO in case of postoperative respiratory failure are reviewed and supported by two cases of perioperative ECMO use, and an overview of published case series.
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Affiliation(s)
- Pavel Suk
- International Clinical Research Center, St. Anne’s University Hospital Brno, 65691 Brno, Czech Republic
- Department of Anesthesiology and Intensive Care, St. Anne’s University Hospital Brno, 65691 Brno, Czech Republic;
- Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
- Correspondence: (P.S.); (I.Č.J.)
| | - Vladimír Šrámek
- Department of Anesthesiology and Intensive Care, St. Anne’s University Hospital Brno, 65691 Brno, Czech Republic;
- Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
| | - Ivan Čundrle
- International Clinical Research Center, St. Anne’s University Hospital Brno, 65691 Brno, Czech Republic
- Department of Anesthesiology and Intensive Care, St. Anne’s University Hospital Brno, 65691 Brno, Czech Republic;
- Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
- Correspondence: (P.S.); (I.Č.J.)
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Charbit J, Deras P, Courvalin E, Laumon T, Dagod G, Martinez O, Capdevila X. Structural recirculation and refractory hypoxemia under femoro-jugular veno-venous extracorporeal membrane oxygenation. Artif Organs 2021; 45:893-902. [PMID: 33471364 DOI: 10.1111/aor.13916] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/05/2021] [Accepted: 01/16/2021] [Indexed: 12/01/2022]
Abstract
The performance of each veno-venous extracorporeal membrane oxygenation (vv-ECMO) configuration is determined by the anatomic context and cannula position. A mathematical model was built considering bicaval specificities to simulate femoro-jugular configuration. The main parameters to define were cardiac output (QC ), blood flow in the superior vena cava (QSVC ), extracorporeal pump flow (QEC ), and pulmonary shunt (kS-PULM ). The obtained variables were extracorporeal flow ratio in the superior vena cava (EFRSVC = QEC /[QEC + QSVC ]), recirculation coefficient (R), effective extracorporeal pump flow (Qeff-EC = [1 - R] × QEC ), Qeff-EC /QC ratio, and arterial blood oxygen saturation (SaO2 ). EFRSVC increased logarithmically when QEC increased. High QC or high QSVC /QC decreased EFRSVC (range, 68%-85% for QEC of 5 L/min). R also increased following a logarithmic shape when QEC increased. The R rise was earlier and higher for low QC and high QSVC /QC (range, 12%-49% for QEC of 5 L/min). The Qeff-EC /QC ratio (between 0 and 1) was equal to EFRSVC for moderate and high QEC . The Qeff-EC /QC ratio presented the same logarithmic profile when QEC increased, reaching a plateau (range, 0.67-0.91 for QEC /QC = 1; range, 0.75-0.94 for QEC /QC = 1.5). The Qeff-EC /QC ratio was linearly associated with SaO2 for a given pulmonary shunt. SaO2 < 90% was observed when the pulmonary shunt was high (Qeff-EC /QC ≤ 0.7 with kS-PULM = 0.7 or Qeff-EC /QC ≤ 0.8 with kS-PULM = 0.8). Femoro-jugular vv-ECMO generates a systematic structural recirculation that gradually increases with QEC . EFRSVC determines the Qeff-EC /QC ratio, and thereby oxygen delivery and the superior cava shunt. EFRSVC cannot exceed a limit value, explaining refractory hypoxemia in extreme situations.
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Affiliation(s)
- Jonathan Charbit
- Critical Care Unit, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Pauline Deras
- Critical Care Unit, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Elie Courvalin
- Critical Care Unit, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Thomas Laumon
- Critical Care Unit, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Geoffrey Dagod
- Critical Care Unit, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Orianne Martinez
- Critical Care Unit, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Xavier Capdevila
- Critical Care Unit, Lapeyronie University Hospital, Montpellier Cedex 5, France
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13
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Ling SKH. Comparison of atrio-femoral and femoro-atrial venovenous extracorporeal membrane oxygenation in adult. Perfusion 2020; 37:14-18. [PMID: 33126833 DOI: 10.1177/0267659120969020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Different cannulation approaches existed for veno-venous extracorporeal membrane oxygenation (VV ECMO). We aimed to compare the atrio-femoral (AF) and femoro-atrial (FA) configuration in terms of their flow efficiency and influence on patient outcome. METHOD This was a single-centre, retrospective case control study. Adult patients admitted to the Intensive Care Unit and required VV ECMO service at Tuen Mun Hospital, Hong Kong, from June 2015 to January 2020 were included. Data were collected from our ECMO database for comparison. RESULTS Between June 2015 and January 2020, eight patients received AF configuration and 19 patients received FA configuration. The maximum achieved flow in the AF group was significantly higher than that in the FA group (4.08 ± 0.57 L/min vs. 3.52 ± 0.58 L/min, p = 0.03). The fluid balance in first 3 days of ECMO was significantly lower in the AF group compared to that in the FA group (1.16 ± 2.71 L vs. 3.46 ± 1.97 L, p = 0.02). As well, the chance for successful awake ECMO was statistically higher in the AF group (p = 0.048). CONCLUSION Atrio-femoral configuration in VV ECMO was associated with a higher maximum achieved ECMO flow, less fluid gain in first 3 days of ECMO and more successful awake ECMO.
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14
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Lim SY, Ahn S, Hong SB, Chung CR, Jeon K, Lee SM, Cho WH, Park S, Cho YJ. Clinical outcomes according to cannula configurations in patients with acute respiratory distress syndrome under veno-venous extracorporeal membrane oxygenation: a Korean multicenter study. Ann Intensive Care 2020; 10:86. [PMID: 32572593 PMCID: PMC7306930 DOI: 10.1186/s13613-020-00700-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/11/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Recirculation during veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a known drawback that limits sufficient oxygenation. This study aimed to compare the short-term oxygenation and long-term mortality based on cannula configuration in patients with acute respiratory distress syndrome (ARDS) who receive VV-ECMO, especially in the absence of newly developed dual-lumen, single cannula. METHODS Data of patients with severe ARDS who received VV-ECMO from 2012 to 2015 at six hospitals were retrospectively analyzed. Primary outcomes were the partial pressure of oxygen (PaO2) at 1, 4, and 12 h after ECMO initiation and 180-day mortality. RESULTS Patients (n = 335) were divided into two groups based on the return cannula site: femoral vein (n = 178) or internal jugular vein (n = 157). The propensity score matching analysis generated 90 pairs, and baseline characteristics at admission, including PaO2, were similar between the groups. PaO2 at 1, 4 and 12 h after ECMO initiation were not different according to cannula configuration. Moreover, the increment in oxygenation from the baseline values was not different between the femoral and jugular group. PaCO2 level at 1, 4 and 12 h were significantly lower in the jugular group. The two groups did not differ in terms of mortality at 180 days after ECMO, however more cannula-related complications occurred in the jugular group. CONCLUSION Regardless of the cannula configuration, patients with ARDS managed with VV-ECMO showed comparable clinical outcomes in terms of short-term oxygenation and long-term mortality. Nevertheless, further well-designed randomized control trials are warranted.
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Affiliation(s)
- Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Soyeon Ahn
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Woo Hyun Cho
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-Si, Gyeongsangnam-do, Republic of Korea
| | - Sunghoon Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Anyang-Si, Gyeonggi-do, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do, Republic of Korea.
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15
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Abstract
Extracorporeal membrane oxygenation (ECMO) has become a key tool in the management of cardiac and/or respiratory failure refractory to conventional management. Although ECMO has multiple indications, it has been widely studied for the management of acute respiratory distress syndrome in adults. ECMO provides rest and support while the damaged lungs heal. It is an invasive modality with risks of serious complications; therefore, clinicians should be vigilant during patient selection. Furthermore, users should be familiar with different components of the ECMO machinery and the management of different organ systems while patients are on the circuit. ECMO is a relatively new modality that has shown good results when used in certain circumstance, and its use is becoming more popular across the United States.
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16
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Sieg A, Pandya K, Winstead R, Evans R. Overview of Pharmacological Considerations in Extracorporeal Membrane Oxygenation. Crit Care Nurse 2019; 39:29-43. [PMID: 30936129 DOI: 10.4037/ccn2019236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation has become more widely used in recent years. Although this technology has proven to be lifesaving, it is not devoid of complications contributing to significant morbidity and mortality. Nurses who care for patients receiving extracorporeal membrane oxygenation should further their understanding of changes in medication profiles due to complex interactions with the extracorporeal membrane oxygenation circuitry. The aim of this comprehensive review is to give nurses a better understanding of analgesic, sedative, anti-infective, and anticoagulation medications that are frequently used to treat patients receiving extracorporeal membrane oxygenation.
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Affiliation(s)
- Adam Sieg
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support. .,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy. .,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia. .,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina.
| | - Komal Pandya
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
| | - Ryan Winstead
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
| | - Rickey Evans
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
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17
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Chaves RCDF, Rabello Filho R, Timenetsky KT, Moreira FT, Vilanova LCDS, Bravim BDA, Serpa Neto A, Corrêa TD. Extracorporeal membrane oxygenation: a literature review. Rev Bras Ter Intensiva 2019; 31:410-424. [PMID: 31618362 PMCID: PMC7005959 DOI: 10.5935/0103-507x.20190063] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/18/2019] [Indexed: 12/19/2022] Open
Abstract
Extracorporeal membrane oxygenation is a modality of extracorporeal life support that allows for temporary support in pulmonary and/or cardiac failure refractory to conventional therapy. Since the first descriptions of extracorporeal membrane oxygenation, significant improvements have occurred in the device and the management of patients and, consequently, in the outcomes of critically ill patients during extracorporeal membrane oxygenation. Many important studies about the use of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome refractory to conventional clinical support, under in-hospital cardiac arrest and with cardiogenic refractory shock have been published in recent years. The objective of this literature review is to present the theoretical and practical aspects of extracorporeal membrane oxygenation support for respiratory and/or cardiac functions in critically ill patients.
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Affiliation(s)
- Renato Carneiro de Freitas Chaves
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Anestesiologia, Irmandade da Santa Casa de Misericórdia de Santos - Santos (SP), Brasil
| | - Roberto Rabello Filho
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Fabio Tanzillo Moreira
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
| | | | - Bruno de Arruda Bravim
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Ary Serpa Neto
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Departamento de Medicina Intensiva, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Medicina Intensiva, Hospital Municipal Dr. Moysés Deutsch - São Paulo (SP), Brasil
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18
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Frenckner B, Broman M, Broomé M. Position of draining venous cannula in extracorporeal membrane oxygenation for respiratory and respiratory/circulatory support in adult patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:163. [PMID: 29907121 PMCID: PMC6003129 DOI: 10.1186/s13054-018-2083-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/24/2018] [Indexed: 11/12/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with severe pulmonary and/or cardiac failure. Blood is drained from the venous system and pumped through a membrane oxygenator where it is oxygenated. For pulmonary support, the blood is returned to the patient via a vein (veno-venous ECMO) and for pulmonary/circulatory support it is returned via an artery (veno-arterial ECMO). Veno-venous ECMO can be performed either with a single dual-lumen cannula or with two separate single-lumen cannulas. If the latter is chosen, flow direction can either be from the inferior caval vein (IVC) to the right atrium or the opposite. Earlier research has shown that drainage from the IVC yields less recirculation and therefore the IVC to right atrium route has become the standard in most centers for veno-venous ECMO with two cannulas. However, recent research has shown that recirculation can be minimized using a multistage draining cannula in the optimal position inserted via the right internal jugular vein and with blood return to the femoral vein. The clinical results with this route are excellent. In veno-arterial ECMO the most common site for blood infusion is the femoral artery. If venous blood is drained from the IVC, the patient is at risk of developing a dual circulation (Harlequin syndrome, North-South syndrome, differential oxygenation) meaning a poor oxygenation of the upper part of the body, while the lower part has excellent oxygenation. By instead draining from the superior caval vein (SVC) via a multistage cannula inserted in the right internal jugular vein this risk is neutralized. In conclusion, the authors argue that draining blood from the SVC and right atrium via a multistage cannula inserted in the right internal jugular vein is equal or better than IVC drainage both in veno-venous two cannula ECMO and in veno-arterial ECMO with blood return to the femoral artery.
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Affiliation(s)
- B Frenckner
- ECMO Centre Karolinska, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.
| | - M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden
| | - M Broomé
- ECMO Centre Karolinska, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden
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19
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Crivellari M, Pappalardo F. Femoro-jugular cannulation in veno-venous extracorporeal membrane oxygenation PRO/CON. J Thorac Dis 2018; 10:S613-S615. [PMID: 29732178 DOI: 10.21037/jtd.2018.02.89] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is the most efficient technique for respiratory support. It is based on a patient adequate circulation and cardiac function and it is indicated for isolated lung failure after optimization of the ventilatory support and the medical treatment. We describe PRO and CONs of the Femoro-jugular (F>J) approach, as an ideal setting for patients which require high flow (>5 L/min), such as those with extreme hypoxemia and/or septic shock. This technique can be accomplished very quickly at the bedside also in an unstable patient.
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20
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Burrell AJC, Ihle JF, Pellegrino VA, Sheldrake J, Nixon PT. Cannulation technique: femoro-femoral. J Thorac Dis 2018; 10:S616-S623. [PMID: 29732179 DOI: 10.21037/jtd.2018.03.83] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The cannulation technique used during veno-venous extracorporeal membrane oxygenation (VV ECMO) insertion can have a major impact on a patients' overall outcome. We have developed a technique that aims to combine speed and effectiveness, with minimal risk. The steps include: (I) percutaneous cannulation using the Seldinger technique; (II) ultrasound guided access and positioning of cannulas; (III) femoro-femoral circuit configuration with a later option of high flow; (IV) a no skin cut serial dilation technique; (V) non-suturing securing of cannulas and (VI) a non-surgical manual pressure technique of explantation. The following is a discussion around these techniques and their various advantages and disadvantages.
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Affiliation(s)
- Aidan J C Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joshua F Ihle
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Vincent A Pellegrino
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jayne Sheldrake
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul T Nixon
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
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21
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Yunoki K, Miyawaki I, Yamazaki K, Mima H. Extracorporeal Membrane Oxygenation-Assisted Airway Management for Difficult Airways. J Cardiothorac Vasc Anesth 2018; 32:2721-2725. [PMID: 29429929 DOI: 10.1053/j.jvca.2018.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Kazuma Yunoki
- The Department of Anesthesiology and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan.
| | - Ikuko Miyawaki
- The Department of Anesthesiology and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Kazuo Yamazaki
- The Department of Anesthesiology and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiroyuki Mima
- The Department of Anesthesiology and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
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22
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Clinical Pearls in Venovenous Extracorporeal Life Support for Adult Respiratory Failure. ASAIO J 2018; 64:1-9. [DOI: 10.1097/mat.0000000000000657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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23
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Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery. Anesthesiology 2018; 128:181-201. [DOI: 10.1097/aln.0000000000001887] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Abstract
The use of venovenous extracorporeal membrane oxygenation is increasing worldwide. These patients often require noncardiac surgery. In the perioperative period, preoperative assessment, patient transport, choice of anesthetic type, drug dosing, patient monitoring, and intraoperative and postoperative management of common patient problems will be impacted. Furthermore, common monitoring techniques will have unique limitations. Importantly, patients on venovenous extracorporeal membrane oxygenation remain subject to hypoxemia, hypercarbia, and acidemia in the perioperative setting despite extracorporeal support. Treatments of these conditions often require both manipulation of extracorporeal membrane oxygenation settings and physiologic interventions. Perioperative management of anticoagulation, as well as thresholds to transfuse blood products, remain highly controversial and must take into account the specific procedure, extracorporeal membrane oxygenation circuit function, and patient comorbidities. We will review the physiologic management of the patient requiring surgery while on venovenous extracorporeal membrane oxygenation.
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24
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Abstract
Extracorporeal membrane oxygenation (ECMO) is used as a lifesaving rescue treatment in refractory respiratory or cardiac failure. During venovenous (VV) ECMO, the presence of recirculation is known, but quantification and actions to minimize recirculation after measurement are to date not routinely practiced. In the current study, we investigated the effect of draining cannula design on recirculation fraction (Rf) during VV ECMO; conventional mesh cannula was compared with a multistage cannula. The effect of adjusting cannula position was also studied. Recirculation was measured with ultrasound dilution technique at different ECMO flows and after cannula repositioning. All patients who were admitted to our unit between October 2014 and July 2015 catheterized by the atrio-femoral single lumen method were included. A total of 108 measurements were conducted in 14 patients. The multistage cannula showed significantly less recirculation (19.0 ± 12.2%) compared with the conventional design (38.0 ± 13.7). Pooled data in cases improved from adjustment showing reduced Rf by 7%. In conclusion, the choice of cannula matters, as does adjustment of the draining cannula position during atrio-femoral VV ECMO. By utilizing the ultrasound dilution technique to measure Rf before and after repositioning, effective ECMO flow can be improved for a more effective ECMO treatment.
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25
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Reeb J, Olland A, Renaud S, Kindo M, Santelmo N, Massard G, Falcoz PE. Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica. EMC - TECNICHE CHIRURGICHE - CHIRURGIA GENERALE 2017. [PMCID: PMC7164803 DOI: 10.1016/s1636-5577(17)82113-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In origine, l’extracorporeal membrane oxygenation (ECMO) era una tecnica di assistenza respiratoria che utilizzava uno scambiatore gassoso a membrana. Per estensione, l’ECMO è diventata una tecnica respiratoria e cardiopolmonare utilizzata in caso di deficit respiratorio e/o cardiaco nell’attesa della restaurazione della funzione deficitaria o di un eventuale trapianto. Il supporto emodinamico può essere parziale o totale. Gli accessi vascolari possono essere periferici o centrali. Questo tipo di assistenza utilizza il concetto di circolazione extracorporea (CEC) sanguigna che in epoca moderna si è estesa con l’utilizzo di polmoni artificiali a membrana. Il circuito di base è semplice e comprende una pompa, un ossigenatore (che permette al sangue di caricarsi di O2 e di eliminare CO2) e delle vie d’accesso (una di drenaggio e una di reinfusione). La sua attuazione è facile, veloce e può essere avviata al letto del malato. Il miglioramento delle attrezzature, una migliore conoscenza delle tecniche e delle indicazioni, e le politiche di salute pubblica hanno reso popolare questa tecnica. Alcuni centri di chirurgia toracica la utilizzano di routine come assistenza alla realizzazione di un intervento terapeutico (soprattutto trapianto) assieme a team di rianimazione per il trattamento della sindrome da distress respiratorio acuto. Nel quadro della malattia polmonare dell’adulto, l’idea principale è quella di sviluppare il concetto di strategia minimalista con l’uso di una CEC adiuvante parziale – più che sostitutiva totale – che permetterebbe il recupero metabolico ad integrum del paziente. Nei prossimi anni, i progressi della tecnologia e dell’ingegneria così come le conoscenze approfondite permetteranno il miglioramento della prognosi dei pazienti colpiti da deficit respiratorio sotto assistenza meccanica.
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Affiliation(s)
- J. Reeb
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
- The Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, 200, Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - A. Olland
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - S. Renaud
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - M. Kindo
- Service de chirurgie cardiovasculaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - N. Santelmo
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - G. Massard
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - P.-E. Falcoz
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
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26
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Romano TG, Mendes PV, Park M, Costa ELV. Extracorporeal respiratory support in adult patients. J Bras Pneumol 2017; 43:60-70. [PMID: 28380189 PMCID: PMC5790677 DOI: 10.1590/s1806-37562016000000299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/05/2017] [Indexed: 01/19/2023] Open
Abstract
In patients with severe respiratory failure, either hypoxemic or hypercapnic, life support with mechanical ventilation alone can be insufficient to meet their needs, especially if one tries to avoid ventilator settings that can cause injury to the lungs. In those patients, extracorporeal membrane oxygenation (ECMO), which is also very effective in removing carbon dioxide from the blood, can provide life support, allowing the application of protective lung ventilation. In this review article, we aim to explore some of the most relevant aspects of using ECMO for respiratory support. We discuss the history of respiratory support using ECMO in adults, as well as the clinical evidence; costs; indications; installation of the equipment; ventilator settings; daily care of the patient and the system; common troubleshooting; weaning; and discontinuation.
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Affiliation(s)
- Thiago Gomes Romano
- . Disciplina de Nefrologia, Faculdade de Medicina do ABC, Santo André (SP) Brasil.,. Hospital Sírio-Libanês, São Paulo (SP) Brasil
| | - Pedro Vitale Mendes
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.,. Hospital Sírio-Libanês, São Paulo (SP) Brasil
| | - Marcelo Park
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Eduardo Leite Vieira Costa
- . Hospital Sírio-Libanês, São Paulo (SP) Brasil.,. UTI Respiratória, Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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27
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[Extracorporeal life support in thoracic surgery: What are the indications and the pertinence?]. Rev Mal Respir 2017; 34:802-819. [PMID: 28502521 DOI: 10.1016/j.rmr.2016.10.879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 10/31/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In thoracic surgery, extracorporeal life support (ECLS) technologies are used in cases of severe and refractory respiratory failure or as intraoperative cardiorespiratory support. The objectives of this review are to describe the rationale of ECLS techniques, to review the pulmonary diseases potentially treated by ECLS, and finally to demonstrate the efficacy of ECLS, using recently published data from the literature, in order to practice evidence based medicine. STATE OF THE ART ECLS technologies should only be undertaken in expert centers. ECLS allows a protective ventilatory strategy in severe ARDS. In the field of lung transplantation, ECLS may be used successfully as a bridge to transplantation, as intraoperative cardiorespiratory support or as a bridge to recovery in cases of severe primary graft dysfunction. In general thoracic surgery, ECLS technology seems to be safe and efficient as intraoperative respiratory support for tracheobronchial surgery or for severe respiratory insufficiency, without significant increase in perioperative risk. PERSPECTIVE The indications for ECLS are going to increase. Future improvements both in scientific knowledge and bioengineering will improve the prognosis of patients treated with ECLS for respiratory failure. Multicenter randomized controlled trials will refine the indications for ECLS and improve the global care strategies for these patients. CONCLUSION ECLS is an efficient therapeutic strategy that will improve the prognosis of patients suffering from, or exposed to, the risks of severe respiratory failure.
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Xie A, Yan TD, Forrest P. Recirculation in venovenous extracorporeal membrane oxygenation. J Crit Care 2016; 36:107-110. [DOI: 10.1016/j.jcrc.2016.05.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 05/26/2016] [Accepted: 05/30/2016] [Indexed: 11/27/2022]
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Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica. EMC - TECNICHE CHIRURGICHE TORACE 2016. [PMCID: PMC7159017 DOI: 10.1016/s1288-3336(16)79382-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
In origine, l’extracorporeal membrane oxygenation (ECMO) era una tecnica di assistenza respiratoria che utilizzava uno scambiatore gassoso a membrana. Per estensione, l’ECMO è diventata una tecnica respiratoria e cardiopolmonare utilizzata in caso di deficit respiratorio e/o cardiaco nell’attesa della restaurazione della funzione deficitaria o di un eventuale trapianto. Il supporto emodinamico può essere parziale o totale. Gli accessi vascolari possono essere periferici o centrali. Questo tipo di assistenza utilizza il concetto di circolazione extracorporea (CEC) sanguigna che in epoca moderna si è estesa con l’utilizzo di polmoni artificiali a membrana. Il circuito di base è semplice e comprende una pompa, un ossigenatore (che permette al sangue di caricarsi di O2 e di eliminare CO2) e delle vie d’accesso (una di drenaggio e una di reinfusione). La sua attuazione è facile, veloce e può essere avviata al letto del malato. Il miglioramento delle attrezzature, una migliore conoscenza delle tecniche e delle indicazioni, e le politiche di salute pubblica hanno reso popolare questa tecnica. Alcuni centri di chirurgia toracica la utilizzano di routine come assistenza alla realizzazione di un intervento terapeutico (soprattutto trapianto) assieme a team di rianimazione per il trattamento della sindrome da distress respiratorio acuto. Nel quadro della malattia polmonare dell’adulto, l’idea principale è quella di sviluppare il concetto di strategia minimalista con l’uso di una CEC adiuvante parziale – più che sostitutiva totale – che permetterebbe il recupero metabolico ad integrum del paziente. Nei prossimi anni, i progressi della tecnologia e dell’ingegneria così come le conoscenze approfondite permetteranno il miglioramento della prognosi dei pazienti colpiti da deficit respiratorio sotto assistenza meccanica.
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Squiers JJ, Lima B, DiMaio JM. Contemporary extracorporeal membrane oxygenation therapy in adults: Fundamental principles and systematic review of the evidence. J Thorac Cardiovasc Surg 2016; 152:20-32. [DOI: 10.1016/j.jtcvs.2016.02.067] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 01/30/2016] [Accepted: 02/28/2016] [Indexed: 12/15/2022]
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Lequier L. Extracorporeal Life Support in Pediatric and Neonatal Critical Care: A Review. J Intensive Care Med 2016; 19:243-58. [PMID: 15358943 DOI: 10.1177/0885066604267650] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Extracorporeal life support (ECLS) is a modified form of cardiopulmonary bypass used to provide prolonged tissue oxygen delivery in patients with respiratory and/or cardiac failure. The first large-scale success of ECLS was achieved in the management of term newborns with respiratory failure. ECLS has become an accepted therapeutic modality for neonates, children, and adults who have failed conventional therapy and in whom cardiac and/or respiratory insufficiency is potentially reversible. The use of ECLS allows one to reduce other cardiopulmonary supports and apply a gentle ventilation strategy in a population of severely compromised critical care patients. ECLS has now been employed in more than 26,000 neonatal and pediatric patients with an overall survival rate of 68%. ECLS has evolved significantly over 25 years of clinical practice; patient selection for this complex and highly invasive therapy, as well as how ECLS is employed in different patient groups, is constantly changing. Generally, ECLS is used more liberally now than in the past. The number of patients requiring this support, however, is declining yearly, and those patients who receive ECLS compose a more severe subset of an intensive care population. This review provides an overview of the development of ECLS and the equipment and techniques employed. The use of ECLS for neonatal respiratory failure, pediatric respiratory failure, and cardiac support are outlined. Management of the ECLS patient is discussed in detail, and outcome of these patients is reviewed. Finally, current trends and future implications of ECLS in neonatal and pediatric critical care are addressed.
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Affiliation(s)
- Laurance Lequier
- Stollery Children's Hospital, Pediatric Critical Care, Edmonton, Alberta T6G 2B7, Canada.
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Reeb J, Olland A, Renaud S, Lejay A, Santelmo N, Massard G, Falcoz PE. Vascular access for extracorporeal life support: tips and tricks. J Thorac Dis 2016; 8:S353-63. [PMID: 27195133 DOI: 10.21037/jtd.2016.04.42] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In thoracic surgery, extracorporeal life support (ECLS) techniques are performed to (I) provide a short to mid term extracorporeal mechanical support; (II) realize the gas exchanges; and (III)-depending the configuration of the circuit-substitute the failed heart function. The objective of this review is to describe the rational of the different ECLS techniques used in thoracic surgery and lung transplantation (LTx) with a specific attention to the vascular access. Venovenous extracorporeal membrane oxygenation (VV ECMO) is the most common ECLS technique used in thoracic surgery and represents the best strategy to support the lung function. VV ECMO needs peripheral vascular access. The selection between his double-site or single-site configuration should be decided according the level of O2 requirements, the nosological context, and the interest to perform an ECLS ambulatory strategy. Venoarterial (VA) ECMO uses peripheral and/or central cannulation sites. Central VA ECMO is mainly used in LTx instead a conventional cardiopulmonary bypass (CPB) to decrease the risk of hemorrhagic issues and the rate of primary graft dysfunction (PGD). Peripheral VA ECMO is traditionally realized in a femoro-femoral configuration. Femoro-femoral VA ECMO allows a cardiocirculatory support but does not provide an appropriate oxygenation of the brain and the heart. The isolated hypercapnic failure is currently supported by extracorporeal CO2 removal (ECCO2R) devices inserted in jugular or subclavian veins. The interest of the Novalung (Novalung GmbH, Hechingen, Germany) persists due to his central configuration indicated to bridge to LTx patients suffering from pulmonary hypertension. The increasing panel of ECLS technologies available in thoracic surgery is the results of a century of clinical practices, engineering progress, and improvements of physiological knowledges. The selection of the ECLS technique-and therefore the vascular access to implant the device-for a given nosological context trends to be defined according an evidence-based medicine.
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Affiliation(s)
- Jeremie Reeb
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Anne Olland
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Stephane Renaud
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Anne Lejay
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Nicola Santelmo
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Gilbert Massard
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Pierre-Emmanuel Falcoz
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
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Attia MY, Abdelbary AA, Khaled MM, Abdelfattah AH. Veno-venous Extracorporeal Membrane Oxygenation in a case of organophosphorus poisoning. THE EGYPTIAN JOURNAL OF CRITICAL CARE MEDICINE 2016. [DOI: 10.1016/j.ejccm.2016.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Venovenous extracorporeal membrane oxygenation for acute respiratory failure : A clinical review from an international group of experts. Intensive Care Med 2016; 42:712-724. [PMID: 27007108 DOI: 10.1007/s00134-016-4314-7] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/08/2016] [Indexed: 01/15/2023]
Abstract
Despite expensive life-sustaining interventions delivered in the ICU, mortality and morbidity in patients with acute respiratory failure (ARF) remain unacceptably high. Extracorporeal membrane oxygenation (ECMO) has emerged as a promising intervention that may provide more efficacious supportive care to these patients. Improvements in technology have made ECMO safer and easier to use, allowing for the potential of more widespread application in patients with ARF. A greater appreciation of the complications associated with the placement of an artificial airway and mechanical ventilation has led clinicians and researchers to seek viable alternatives to providing supportive care in these patients. Thus, this review will summarize the current knowledge regarding the use of venovenous (VV)-ECMO for ARF and describe some of the recent controversies in the field, such as mechanical ventilation, anticoagulation and transfusion therapy, and ethical concerns in patients supported with VV-ECMO.
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Management of refractory hypoxemia during venovenous extracorporeal membrane oxygenation for ARDS. ASAIO J 2016; 61:227-36. [PMID: 25923575 DOI: 10.1097/mat.0000000000000207] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Venovenous extracorporeal membrane oxygenation (VV ECMO) in acute respiratory distress syndrome (ARDS) is currently a widely used therapeutic strategy. However, patients are often still hypoxemic despite complete ECMO support. The major determinants of peripheral oxygen saturation (SpO2) during VV ECMO are pump flow, degree of recirculation, patient's systemic venous return and its oxygen saturation, hemoglobin concentration and residual lung function. Current guidelines state that the support can be considered adequate when the patient's SpO2 is equal or greater than 80%, but a possible objection could be that such a value of O2-tension may be too low and may worsen the patient's prognosis. Moving from the pathophysiology of hypoxemia during VV ECMO, this review focuses on recirculation of blood and on the possible strategies to minimize it, on the pharmacologic modulation of intrapulmonary shunt and on the questions related to management of ECMO flow and the risks and benefits of permissive hypoxemic states. Transfusional strategy during VV ECMO, administration of neuromuscular blocking agents and sedatives, therapeutic hypothermia, and prone positioning is also reviewed. The potential advantages of β-blockers are discussed. Finally, transition from VV ECMO to venoarterial ECMO (VA ECMO) or a hybrid configuration is also examined.
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Abstract
Extracorporeal membrane oxygenation (ECMO) is a method for providing long-term treatment of a patient in a modified heart-lung machine. Desaturated blood is drained from the patient, oxygenated and pumped back to a major vein or artery. ECMO supports heart and lung function and may be used in severe heart and/or lung failure when conventional intensive care fails. The Stockholm programme started in 1987 with treatment of neonates. In 1995, the first adult patient was accepted onto the programme. Interhospital transportation during ECMO was started in 1996, which enabled retrieval of extremely unstable patients during ECMO. Today, the programme has an annual volume of about 80 patients. It has been characterized by, amongst other things, minimal patient sedation. By 31 December 2014, over 900 patients had been treated, the vast majority for respiratory failure, and over 650 patients had been transported during ECMO. The median ECMO duration was 5.3, 5.7 and 7.1 days for neonatal, paediatric and adult patients, respectively. The survival to hospital discharge rate for respiratory ECMO was 81%, 70% and 63% in the different age groups, respectively, which is significantly higher than the overall international experience as reported to the Extracorporeal Life Support Organization (ELSO) Registry (74%, 57% and 57%, respectively). The survival rate was significantly higher in the Stockholm programme compared to ELSO for meconium aspiration syndrome, congenital diaphragmatic hernia in neonates and pneumocystis pneumonia in paediatric patients.
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Affiliation(s)
- B Frenckner
- ECMO Center Karolinska and the Department of Pediatric Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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A numerical model of blood oxygenation during veno-venous ECMO: analysis of the interplay between blood oxygenation and its delivery parameters. J Clin Monit Comput 2015; 30:327-32. [PMID: 26091774 DOI: 10.1007/s10877-015-9721-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 06/08/2015] [Indexed: 11/26/2022]
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Recirculation during Veno-Venous Extra-Corporeal Membrane Oxygenation – a Simulation Study. Int J Artif Organs 2014; 38:23-30. [DOI: 10.5301/ijao.5000373] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2014] [Indexed: 11/20/2022]
Abstract
Purpose Veno-venous ECMO is indicated in reversible life-threatening respiratory failure without life-threatening circulatory failure. Recirculation of oxygenated blood in the ECMO circuit decreases efficiency of patient oxygen delivery but is difficult to measure. We seek to identify and quantify some of the factors responsible for recirculation in a simulation model and compare with clinical data. Methods A closed-loop real-time simulation model of the cardiovascular system has been developed. ECMO is simulated with a fixed flow pump 0 to 5 l/min with various cannulation sites – 1) right atrium to inferior vena cava, 2) inferior vena cava to right atrium, and 3) superior+inferior vena cava to right atrium. Simulations are compared to data from a retrospective cohort of 11 consecutive adult veno-venous ECMO patients in our department. Results Recirculation increases with increasing ECMO-flow, decreases with increasing cardiac output, and is highly dependent on choice of cannulation sites. A more peripheral drainage site decreases recirculation substantially. Conclusions Simulations suggest that recirculation is a significant clinical problem in veno-venous ECMO in agreement with clinical data. Due to the difficulties in measuring recirculation and interpretation of the venous oxygen saturation in the ECMO drainage blood, flow settings and cannula positioning should rather be optimized with help of arterial oxygenation parameters. Simulation may be useful in quantification and understanding of recirculation in VV-ECMO.
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Impact of bypass flow rate and catheter position in veno-venous extracorporeal membrane oxygenation on gas exchange in vivo. J Artif Organs 2014; 18:128-35. [DOI: 10.1007/s10047-014-0810-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 11/27/2014] [Indexed: 10/24/2022]
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Lafçı G, Budak AB, Yener AÜ, Cicek OF. Use of Extracorporeal Membrane Oxygenation in Adults. Heart Lung Circ 2014; 23:10-23. [DOI: 10.1016/j.hlc.2013.08.009] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
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Schmidt M, Tachon G, Devilliers C, Muller G, Hekimian G, Bréchot N, Merceron S, Luyt CE, Trouillet JL, Chastre J, Leprince P, Combes A. Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive Care Med 2013; 39:838-46. [DOI: 10.1007/s00134-012-2785-8] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 12/05/2012] [Indexed: 12/21/2022]
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Abstract
This paper reviews the basic fluid dynamics underlying extracorporeal membrane oxygenation (ECMO) cannula design. General cannula features and their effect on flow are discussed and the specific requirements of different ECMO circuits are explained. The current commercially available cannula options for veno-arterial and veno-venous circuits are reviewed and the main characteristics presented.
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Affiliation(s)
- K Kohler
- Department of Anaesthesia, West Suffolk Hospital, Bury St Edmunds, UK
| | - K Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
| | - G Nias
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
| | - A Vuylsteke
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
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Hodgson CL, Hayes K, Everard T, Nichol A, Davies AR, Bailey MJ, Tuxen DV, Cooper DJ, Pellegrino V. Long-term quality of life in patients with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation for refractory hypoxaemia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R202. [PMID: 23082772 PMCID: PMC3682304 DOI: 10.1186/cc11811] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 09/28/2012] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The purpose of the study was to assess the long term outcome and quality of life of patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia. METHODS A retrospective observational study with prospective health related quality of life (HRQoL) assessment was conducted in ARDS patients who had ECMO as a rescue therapy for reversible refractory hypoxemia from January 2009 until April 2011 in a tertiary Australian centre. Survival and long-term quality of life assessment, using the Short-Form 36 (SF-36) and the EuroQol health related quality of life questionnaire (EQ5D) were assessed and compared to international data from other research groups. RESULTS Twenty-one patients (mean age 36.3 years) with ARDS receiving ECMO for refractory hypoxemia were studied. Eighteen (86%) patients were retrieved from external intensive care units (ICUs) by a dedicated ECMO retrieval team. Eleven (55%) had H1N1 influenza A-associated pneumonitis. Eighteen (86%) patients survived to hospital discharge. Of the 18 survivors, ten (56%) were discharged to other hospitals and 8 (44%) were discharged directly home. Sequelae and health related quality of life were evaluated for 15 of the 18 (71%) long-term survivors (assessment at median 8 months). Mean SF-36 scores were significantly lower across all domains compared to age and sex matched Australian norms. Mean SF-36 scores were lower (minimum important difference at least 5 points) than previously described ARDS survivors in the domains of general health, mental health, vitality and social function. One patient had long-term disability as a result of ICU acquired weakness. Only 26% of survivors had returned to previous work levels at the time of follow-up. CONCLUSIONS This ARDS cohort had a high survival rate (86%) after use of ECMO support for reversible refractory hypoxemia. Long term survivors had similar physical health but decreased mental health, general health, vitality and social function compared to other ARDS survivors and an unexpectedly poor return to work.
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Lindstrom SJ, Mennen MT, Rosenfeldt FL, Salmonsen RF. Veno-right ventricular cannulation reduces recirculation in extracorporeal membrane oxygenation. Perfusion 2012; 27:464-9. [PMID: 22733979 DOI: 10.1177/0267659112450744] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation has several advantages over veno-arterial support for patients with severe reversible respiratory failure. However, recirculation can limit oxygen delivery as pump flow increases. This could be ameliorated by placing the return catheter in the right ventricle instead of the central veins. We compared recirculation in veno-right ventricular support with that in conventional veno-venous support and its relationship with pump flow. METHODS Five greyhound dogs were sequentially cannulated percutaneously for both veno-venous and veno-right ventricular support. Recirculation was measured by comparing oxygen levels in the circuit drainage and return lines before and immediately after a sudden increase in circuit oxygenation at pump flows between 0.5 L/min and 4 L/min for both modalities. RESULTS Recirculation was reduced in veno-right ventricular support compared with conventional veno-venous support at 4 L/min pump flow (8.4% versus 37.9%, p=0.0076) and increased less with increases in pump flow (2.9% per 1 L/min vs. 11.1% per 1 L/min, p<0.0001). CONCLUSIONS Recirculation can be dramatically reduced by returning blood into the right ventricle, which improves oxygen delivery to the lungs and the systemic circulation. The design of specialized catheters may facilitate percutaneous ventricular cannulation, improve safety and further reduce recirculation.
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Affiliation(s)
- S J Lindstrom
- Internal Medicine, The Alfred Hospital, Melbourne, Australia.
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Sidebotham D, Allen SJ, McGeorge A, Ibbott N, Willcox T. Venovenous extracorporeal membrane oxygenation in adults: practical aspects of circuits, cannulae, and procedures. J Cardiothorac Vasc Anesth 2012; 26:893-909. [PMID: 22503344 DOI: 10.1053/j.jvca.2012.02.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Indexed: 01/19/2023]
Affiliation(s)
- David Sidebotham
- Cardiothoracic Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.
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Sadahiro T, Oda S, Nakamura M, Hirayama Y, Watanabe E, Tateishi Y, Shinozaki K. Trends in and perspectives on extracorporeal membrane oxygenation for severe adult respiratory failure. Gen Thorac Cardiovasc Surg 2012; 60:192-201. [PMID: 22451141 DOI: 10.1007/s11748-011-0868-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Indexed: 10/28/2022]
Abstract
Various approaches such as ventilator management involving lung-protective ventilation, corticosteroids, prone positioning, and nitric oxide have failed to maintain sufficient lung oxygenation or appropriate ventilation competence in very severe acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) has been aggressively introduced for such patients, although in only a few institutions. The clinical usefulness of ECMO in a large-scale multicenter study (CESAR trial, 2009) and continued development/improvement of ECMO devices have facilitated performance of ECMO, with further increase in the number of institutions adopting ECMO therapy. Clinical usefulness of ECMO was documented in many cases of severe ARDS secondary to influenza A (H1N1) 2009 infection. ECMO requires establishment of an appropriate management system to minimize fatal complications (e.g., hemorrhage), which requires a multidisciplinary team. This, in combination with a new technique, interventional lung assist, will further extend the indications for ECMO. ECMO can be expected to gain importance as a respiratory support technique.
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Affiliation(s)
- Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuoku, Chiba, 260-8677, Japan.
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Chao CS, Chang YP, Chin HK, Chin J. A Patient with Abdominal Compartment Syndrome and Perforated Transverse Colon Successfully Managed with ECMO. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2011. [DOI: 10.47102/annals-acadmedsg.v40n12p554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Chia Sheng Chao
- Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, ROC
| | | | - Hsien Kuo Chin
- Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, ROC
| | - Jen Chin
- Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, ROC
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Bonacchi M, Harmelin G, Peris A, Sani G. A novel strategy to improve systemic oxygenation in venovenous extracorporeal membrane oxygenation: The “χ-configuration”. J Thorac Cardiovasc Surg 2011; 142:1197-204. [PMID: 21397257 DOI: 10.1016/j.jtcvs.2011.01.046] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 12/26/2010] [Accepted: 01/24/2011] [Indexed: 10/18/2022]
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