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Ma X, Xu K, Gao B. Numerical Study of the Effect of the Port Angle of the Superior Vena Cava Supplying Cannula on Hemodynamics in the Right Atrium in VV-ECMO. Biomedicines 2024; 12:2198. [PMID: 39457510 PMCID: PMC11504959 DOI: 10.3390/biomedicines12102198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Revised: 09/20/2024] [Accepted: 09/25/2024] [Indexed: 10/28/2024] Open
Abstract
Objective: To elucidate the pattern of the influence of the port angle of the superior vena cava supplying cannula (SVCS) on hemodynamics within the right atrium in VV-ECMO. Methods: A three-dimensional model of the right atrium was established based on CT images of a real patient. The 3D models of the SVCS and inferior vena cava draining cannula (IVCD) were established based on the Edwards 18Fr and Medos 22Fr real intubation models, respectively. Based on these models, three-dimensional models of the SVCS ports with bending angles of -90°, -60°, -30°, 0°, 30°, 60°, and 90° in the plane formed by the centerline of the SVCS and the center point of the tricuspid valve (TV) were established. Transient-state computational fluid dynamics (CFD) was performed to clarify the right atrium blood flow pattern and hemodynamic states at different SVCS port orientation angles. The velocity clouds, wall pressure, wall shear stress (WSS), relative residence time (RRT), and recirculation fraction (RF) were calculated to assess hemodynamic changes in the right atrium at different angles of the port of the SVCS. Results: As the angle of the port of the superior chamber cannula changed, the location of the high-velocity blood impingement from the SVCS changed, and the pattern of blood flow within the right atrium was dramatically altered. The results for the maximum right atrial wall pressure were 13,472 pa, 13,424 pa, 10,915 pa, 7680.2 pa, 5890.3 pa, 5597.6 pa, and 7883.5 pa (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°), and the results for the mean right atrial wall pressure were 6788.9 pa, 8615.1 pa, 8684.9 pa, 6717.2 pa, 5429.2 pa, 5455.6 pa, and 7117.8 pa ( -90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°). The results of the maximum right atrial wall WSS in the seven cases were 63.572 pa, 55.839 pa, 31.705 pa, 39.531 pa, 40.11 pa, 28.474 pa, and 35.424 (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°), respectively, and the results of the mean right atrial wall WSS results were 3.8589 pa, 3.6706 pa, 3.3013 pa, 3.2487 pa, 2.3995 pa, 1.3304 pa, and 2.0747 pa (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°), respectively. The results for the area percentage of high RRT in the seven cases were 3.44%, 2.23%, 4.24%, 1.83%, 3.69%, 7.73%, and 3.68% (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°), and the results for the RF were 21.57%, 23.24%, 19.78%, 12.57%, 10.24%, 5.07%, and 8.05% (-90° vs. -60° vs. -30° vs. 0° vs. 30° vs. 60° vs. 90°). Conclusions: The more the port of the SVCS is oriented toward the TV, the more favorable it is for reducing RF and the impingement of blood flow in the right atrial wall, but there may be an increased risk of RRT. The opposite orientation of the SVCS port to the TV is not conducive to reducing flow impingement on the right atrial wall and RF.
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Affiliation(s)
| | | | - Bin Gao
- College of Chemistry and Life Science, Beijing University of Technology, Beijing 100124, China; (X.M.)
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Antonsen LP, Espinoza A, Halvorsen PS, Schalit I, Bergan H, Lilja D, Landsverk SA. The impact of hypovolemia and PEEP on recirculation in venovenous ECMO: an experimental porcine model. Intensive Care Med Exp 2024; 12:51. [PMID: 38822111 PMCID: PMC11143165 DOI: 10.1186/s40635-024-00636-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/24/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Recirculation is a common problem in venovenous extracorporeal membrane oxygenation (VV ECMO) and may limit the effect of ECMO treatment due to less efficient blood oxygenation or unfavorable ECMO and ventilator settings. The impact of hypovolemia and positive end expiratory pressure (PEEP) on recirculation is unclear and poorly described in guidelines, despite clinical importance. The aim of this study was to investigate how hypovolemia, autotransfusion and PEEP affect recirculation in comparison to ECMO cannula distance and circuit flow. METHODS In anesthetized and mechanically ventilated pigs (n = 6) on VV ECMO, we measured recirculation fraction (RF), changes in recirculation fraction (∆RF), hemodynamics and ECMO circuit pressures during alterations in PEEP (5 cmH2O vs 15 cmH2O), ECMO flow (3.5 L/min vs 5.0 L/min), cannula distance (10-14 cm vs 20-26 cm intravascular distance), hypovolemia (1000 mL blood loss) and autotransfusion (1000 mL blood transfusion). RESULTS Recirculation increased during hypovolemia (median ∆RF 43%), high PEEP (∆RF 28% and 12% with long and short cannula distance, respectively), high ECMO flow (∆RF 49% and 28% with long and short cannula distance, respectively) and with short cannula distance (∆RF 16%). Recirculation decreased after autotransfusion (∆RF - 45%). CONCLUSIONS In the present animal study, hypovolemia, PEEP and autotransfusion were important determinants of recirculation. The alterations were comparable to other well-known factors, such as ECMO circuit flow and intravascular cannula distance. Interestingly, hypovolemia increased recirculation without significant change in ECMO drainage pressure, whereas high PEEP increased recirculation with less negative ECMO drainage pressure. Autotransfusion decreased recirculation. The findings are interesting for clinical studies.
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Affiliation(s)
- Lars Prag Antonsen
- Department of Anesthesia and Intensive Care, Rikshospitalet, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway.
- Department of Anesthesia and Intensive Care, Østfold Hospital Trust, Kalnesveien 300, 1714, Grålum, Norway.
- Department of Research, Østfold Hospital Trust, Kalnesveien 300, 1714, Grålum, Norway.
- The Intervention Centre, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway.
- Faculty of Medicine, University of Oslo, Problemveien 11, 0313, Oslo, Norway.
| | - Andreas Espinoza
- Department of Anesthesia and Intensive Care, Rikshospitalet, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
- The Intervention Centre, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Per Steinar Halvorsen
- Department of Anesthesia and Intensive Care, Rikshospitalet, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
- The Intervention Centre, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
- Faculty of Medicine, University of Oslo, Problemveien 11, 0313, Oslo, Norway
| | - Itai Schalit
- Department of Anesthesia and Intensive Care, Radiumhospitalet, Oslo University Hospital, Ullernchausseen 70, 0379, Oslo, Norway
| | - Harald Bergan
- Department of Anesthesia and Intensive Care, Rikshospitalet, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Didrik Lilja
- The Intervention Centre, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Svein Aslak Landsverk
- Department of Anesthesia and Intensive Care, Ullevaal Hospital, Oslo University Hospital, Kirkeveien 166, 0450, Oslo, Norway
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Cha S, Kostibas MP. Echocardiographic and Point-of-Care Ultrasonography (POCUS) Guidance in the Management of the ECMO Patient. J Clin Med 2024; 13:2630. [PMID: 38731160 PMCID: PMC11084171 DOI: 10.3390/jcm13092630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/13/2024] Open
Abstract
Veno-arterial (V-A) and Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) support is increasingly utilized for acute cardiogenic shock and/or respiratory failure. Echocardiography and point-of-care ultrasonography (POCUS) play a critical role in the selection and management of these critically ill patients, however, there are limited guidelines regarding their application. This comprehensive review describes current and potential application of echocardiography and POCUS for pre-ECMO assessment and patient selection, cannulation guidance with emphasis on dual-lumen configurations, diagnosis of ECMO complications and trouble-shooting of cannula malposition, diagnosis of common cardiac or pulmonary pathologies, and assessment of ECMO weaning appropriateness including identification of the aortic mixing point in V-A ECMO.
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Affiliation(s)
- Stephanie Cha
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street Suite 6216, Baltimore, MD 21287, USA;
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The Impact of Recirculation on Extracorporeal Gas Exchange and Patient Oxygenation during Veno-Venous Extracorporeal Membrane Oxygenation-Results of an Observational Clinical Trial. J Clin Med 2023; 12:jcm12020416. [PMID: 36675344 PMCID: PMC9866780 DOI: 10.3390/jcm12020416] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/17/2022] [Accepted: 12/27/2022] [Indexed: 01/07/2023] Open
Abstract
Background: Recirculation during veno-venous extracorporeal membrane oxygenation reduces extracorporeal oxygen exchange and patient oxygenation. To minimize recirculation and maximize oxygen delivery (DO2) the interaction of cannulation, ECMO flow and cardiac output requires careful consideration. We investigated this interaction in an observational trial. Methods: In 19 patients with acute respiratory distress syndrome and ECMO, we measured recirculation with the ultrasound dilution technique and calculated extracorporeal oxygen transfer (VO2), extracorporeal oxygen delivery (DO2) and patient oxygenation. To assess the impact of cardiac output (CO), we included CO measurement through pulse contour analysis. Results: In all patients, there was a median recirculation rate of approximately 14−16%, with a maximum rate of 58%. Recirculation rates >35% occurred in 13−14% of all cases. In contrast to decreasing extracorporeal gas exchange with increasing ECMO flow and recirculation, patient oxygenation increased with greater ECMO flows. High CO diminished recirculation by between 5−20%. Conclusions: Extracorporeal gas exchange masks the importance of DO2 and its effects on patients. We assume that increasing DO2 is more important than reduced VO2. A negative correlation of recirculation to CO adds to the complexity of this phenomenon. Patient oxygenation may be optimized with the direct measurement of recirculation.
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How to Do It: A Safe Bedside Protocol for Dual-Lumen Right Internal Jugular Cannulation for Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Patients With Severe Acute Respiratory Distress Syndrome. ASAIO J 2023; 69:31-35. [PMID: 35938953 PMCID: PMC9797117 DOI: 10.1097/mat.0000000000001795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
In appropriately selected patients with COVID-19 acute respiratory distress syndrome, venovenous extracorporeal membrane oxygenation (VV ECMO) may offer a promising bridge to lung recovery or lung transplantation if lung recovery fails. Although the cannulation technique for VV ECMO via a right internal jugular (RIJ) dual-lumen catheter (DLC) requires expertise and guidance by either fluoroscopy or transesophageal echocardiography (TEE), it offers theoretical circulatory support advantages by using bicaval venous drainage to deliver oxygenated blood systemically with minimal recirculation as compared with the femoral vein and RIJ dual-site cannula configuration. In addition, patients are often too unstable to transport safely to an operating room or catheterization laboratory, and fluoroscopy is not always readily available to guide RIJ DLC placement. Here, we provide a comprehensive description of a safe, bedside protocol for VV ECMO cannulation via a RIJ DLC under TEE guidance. We will report our center's experience (March 30, 2020 to November 21, 2021) and discuss important hemodynamic, safety, and infection control considerations.
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How to Do It: A Safe Bedside Protocol for Dual-Lumen Right Internal Jugular Cannulation for Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Patients With Severe Acute Respiratory Distress Syndrome. ASAIO J 2023. [PMID: 35938953 PMCID: PMC9797117 DOI: 10.1097/mat.0000000000001795 10.1097/-mat.0000000000001795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
In appropriately selected patients with COVID-19 acute respiratory distress syndrome, venovenous extracorporeal membrane oxygenation (VV ECMO) may offer a promising bridge to lung recovery or lung transplantation if lung recovery fails. Although the cannulation technique for VV ECMO via a right internal jugular (RIJ) dual-lumen catheter (DLC) requires expertise and guidance by either fluoroscopy or transesophageal echocardiography (TEE), it offers theoretical circulatory support advantages by using bicaval venous drainage to deliver oxygenated blood systemically with minimal recirculation as compared with the femoral vein and RIJ dual-site cannula configuration. In addition, patients are often too unstable to transport safely to an operating room or catheterization laboratory, and fluoroscopy is not always readily available to guide RIJ DLC placement. Here, we provide a comprehensive description of a safe, bedside protocol for VV ECMO cannulation via a RIJ DLC under TEE guidance. We will report our center's experience (March 30, 2020 to November 21, 2021) and discuss important hemodynamic, safety, and infection control considerations.
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Russ M, Steiner E, Boemke W, Busch T, Melzer-Gartzke C, Taher M, Badulak J, Weber-Carstens S, Swenson ER, Francis RC, Pickerodt PA. Extracorporeal Membrane Oxygenation Blood Flow and Blood Recirculation Compromise Thermodilution-Based Measurements of Cardiac Output. ASAIO J 2022; 68:721-729. [PMID: 34860710 PMCID: PMC9067097 DOI: 10.1097/mat.0000000000001592] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The contribution of veno-venous (VV) extracorporeal membrane oxygenation (ECMO) to systemic oxygen delivery is determined by the ratio of total extracorporeal blood flow () to cardiac output (). Thermodilution-based measurements of may be compromised by blood recirculating through the ECMO (recirculation fraction; Rf). We measured the effects of and Rf on classic thermodilution-based measurements of in six anesthetized pigs. An ultrasound flow probe measured total aortic blood flow () at the aortic root. Rf was quantified with the ultrasound dilution technique. was set to 0-125% of and was measured using a pulmonary artery catheter (PAC) in healthy and lung injured animals. PAC overestimated () at all settings compared to . The mean bias between both methods was 2.1 L/min in healthy animals and 2.7 L/min after lung injury. The difference between and increased with an of 75-125%/ compared to QEC <50%/. Overestimation of was highest when resulted in a high Rf. Thus, thermodilution-based measurements can overestimate cardiac output during VV ECMO. The degree of overestimation of depends on the EC/ ratio and the recirculation fraction.
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Affiliation(s)
- Martin Russ
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Elvira Steiner
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Willehad Boemke
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thilo Busch
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christoph Melzer-Gartzke
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mahdi Taher
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jenelle Badulak
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Steffen Weber-Carstens
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Erik R. Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
- VA Puget Sound Health Care System, Seattle, Washington
| | - Roland C.E. Francis
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Philipp A. Pickerodt
- From the Department of Anesthesiology and Intensive Care Medicine (CCM, CVK); Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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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: 0.7] [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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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: 0.8] [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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Fujii Y, Sumikura H, Nagahama D. Establishment of a novel miniature veno-venous extracorporeal membrane oxygenation model in the rat. Artif Organs 2020; 45:63-67. [PMID: 32645762 DOI: 10.1111/aor.13769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
Recently, veno-venous extracorporeal membrane oxygenation (V-V ECMO) has been commonly used in the world to support patients with severe respiratory failure. However, V-V ECMO is a new technology compared to veno-arterial extracorporeal membrane oxygenation and cardiopulmonary bypass, and there are few reports of basic research. Although continuing research is desired, clinical research that standardizes conditions such as patients' background characteristics is difficult. The purpose of this study was to establish a simple and stably maintainable miniature V-V ECMO model to study the mechanisms of the biological reactions in circulation during V-V ECMO. The V-V ECMO system consisted of an original miniature membrane oxygenator, polyvinyl chloride tubing line, and roller pump. The priming volume of this system was only 8 mL. Polyethylene tubing was used to cannulate the right femoral vein as the venous return cannula for the V-V ECMO system. A 16-G cannula was passed through the right internal jugular vein and advanced into the right atrium as the conduit for venous uptake. The animals were divided into 2 groups: SHAM group and V-V ECMO group. V-V ECMO was initiated and maintained at 50-60 mL/kg/min, and oxygen was added into the oxygenator during V-V ECMO at a concentration of 100% (pump flow:oxygen = 1:10). Blood pressure was measured continuously, and blood cells were measured by blood collection. During V-V ECMO, the blood pressure and hemodilution rate were maintained around 80 mm Hg and 20%, respectively. Hb was kept at >10 g/dL, and V-V ECMO could be maintained without blood transfusion. It was possible to confirm oxygenation of and carbon dioxide removal from the blood. Likewise, the pH was adequately maintained. There were no problems with this miniature V-V ECMO system, and extracorporeal circulation progressed safely. In this study, a novel miniature V-V ECMO model was established in the rat. A miniature V-V ECMO model appears to be very useful for studying the mechanisms of the biological reactions during V-V ECMO and to perform basic studies of circulation assist devices.
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Affiliation(s)
- Yutaka Fujii
- Department of Clinical Engineering and Medical Technology, Niigata University of Health and Welfare, Niigata, Japan
| | - Hirohito Sumikura
- Department of Science and Engineering, Tokyo Denki University, Hatoyama, Japan
| | - Daisuke Nagahama
- Department of Clinical Engineering and Medical Technology, Niigata University of Health and Welfare, Niigata, Japan
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Bautista-Rodriguez C, Sanchez-de-Toledo J, Da Cruz EM. The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation. Front Pediatr 2018; 6:297. [PMID: 30416991 PMCID: PMC6212474 DOI: 10.3389/fped.2018.00297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledge that the utility of echocardiography in ECMO patients is not limited to the evaluation of cardiac function, and that clinical decisions should not be made exclusively upon echocardiographic findings. Though echocardiography has specific indications and applications, it also has limitations, characterized as: prior to and during cannulation, throughout the ECMO run, upon separation and after separation from the circuit. The use of specific and consistent echocardiographic protocols for patients on ECMO is recommended.
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Affiliation(s)
- Carles Bautista-Rodriguez
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Joan Sanchez-de-Toledo
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Division of Cardiac Intensive Care, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eduardo M. Da Cruz
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, School of Medicine, University of Colorado Denver, Aurora, CO, United States
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12
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Togo K, Takewa Y, Katagiri N, Fujii Y, Yamashita AC, Tastumi E. Optimal drainage cannula position in dual cannulation for veno-venous extracorporeal membrane oxygenation. Int J Artif Organs 2018; 41:867-871. [DOI: 10.1177/0391398818795357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Recently, the use of veno-venous extracorporeal membrane oxygenation for adult patients with severe acute respiratory failure has increased. We previously investigated the optimal return cannula position; however, the optimal drainage cannula position has not yet been fully clarified. The aim of this study was to investigate the optimal drainage cannula position. Methods: Veno-venous extracorporeal membrane oxygenation was performed in four adult goats (mean body weight 59.6 ± 0.6 kg). The position of the drainage cannula was varied among the right atrium, the upper inferior vena cava, and the lower inferior vena cava, whereas the position of the return cannula was fixed in the superior vena cava. The recirculation fraction and arterial oxygen saturation and pressure (SaO2, PaO2) were measured in all drainage cannula positions. Results: In the lower inferior vena cava drainage cannula position, the recirculation fraction was the lowest. In the lower inferior vena cava, upper inferior vena cava, and right atrium drainage cannula positions at 3 L/min, SaO2 and PaO2 after 20 min were 92.9% ± 4.9% and 75.1 ± 26.0 mm Hg, 99.5% ± 0.5% and 113.8 ± 20.9 mm Hg, and 93.8% ± 6.2% and 91.9 ± 17.7 mm Hg, respectively. Conclusion: With respect to blood oxygenation, the optimal position for the drainage cannula was the upper inferior vena cava. These findings suggested that blood from the superior vena cava, inferior vena cava, and hepatic vein was most efficiently drained in the upper inferior vena cava cannula position.
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Affiliation(s)
- Konomi Togo
- Department of Medical Course, Faculty of Health and Medical Science, Teikyo Heisei University, Tokyo, Japan
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Chemical Science and Technology, Faculty of Bioscience and Applied Chemistry, Hosei University, Tokyo, Japan
| | - Yoshiaki Takewa
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Nobumasa Katagiri
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yutaka Fujii
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Clinical Engineering and Medical Technology, Faculty of Medical Technology, Niigata University of Health and Welfare, Niigata, Japan
| | - Akihiro C Yamashita
- Department of Chemical Science and Technology, Faculty of Bioscience and Applied Chemistry, Hosei University, Tokyo, Japan
| | - Eisuke Tastumi
- Department of Artificial Organs, National Cerebral and Cardiovascular Center, Osaka, Japan
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13
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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: 29] [Impact Index Per Article: 3.2] [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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14
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Sawa Y, Matsuda K, Tatsumi E, Matsumiya G, Tsukiya T, Abe T, Fukunaga K, Kishida A, Kokubo K, Masuzawa T, Myoui A, Nishimura M, Nishimura T, Nishinaka T, Okamoto E, Tokunaga S, Tomo T, Yagi Y, Yamaoka T. Journal of Artificial Organs 2015: the year in review : Journal of Artificial Organs Editorial Committee. J Artif Organs 2016; 19:1-7. [PMID: 26896942 DOI: 10.1007/s10047-016-0886-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Y Sawa
- Division of Cardiovascular Surgery, Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - K Matsuda
- Emergency and Critical Care Medicine, University of Yamanashi Hospital, Yamanashi, Japan
| | - E Tatsumi
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - G Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - T Tsukiya
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - T Abe
- Department of Urology, Iwate Medical University School of Medicine, Iwate, Japan
| | - K Fukunaga
- Faculty of Health Sciences, Kyorin University, Tokyo, Japan
| | - A Kishida
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Tokyo, Japan
| | - K Kokubo
- Department of Medical Engineering and Technology, Kitasato University School of Allied Health Science, Kanagawa, Japan
| | - T Masuzawa
- Department of Mechanical Engineering, Ibaraki University, Ibaraki, Japan
| | - A Myoui
- Medical Center for Translational Research, Osaka University Hospital, Osaka, Japan
| | - M Nishimura
- Division of Organ Regeneration Surgery, Tottori University Faculty of Medicine, Tottori, Japan
| | - T Nishimura
- Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - T Nishinaka
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - E Okamoto
- Department of Human Science and Informatics, School of Bioscience and Engineering, Tokai University, Sapporo, Japan
| | - S Tokunaga
- The Department of Cardiovascular Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - T Tomo
- Second Department of Internal Medicine, Faculty of Medicine, Oita University, Oita, Japan
| | - Y Yagi
- Department of Clinical Engineering, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - T Yamaoka
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
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15
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Clinical significance of echocardiography in patients supported by venous-venous extracorporeal membrane oxygenation. J Artif Organs 2015; 18:99-105. [PMID: 25708044 DOI: 10.1007/s10047-015-0824-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 02/09/2015] [Indexed: 02/07/2023]
Abstract
Although there are extensive published data regarding venous-arterial (VA) ECMO, particularly in the pediatric population, there is a paucity of data (mainly including case reports and observational studies) delineating the role of echocardiography in the management of adult patients supported by venous-venous (VV) ECMO. The present review is aimed at specifically addressing the rationale for echocardiography use in patients supported by VV-ECMO and at summarizing the available evidence on this topic. Based on the available evidence and on the experience of our group, practical considerations on the use of echocardiography in adult patients on VV-ECMO support are reported. To date, echocardiography is mainly used for selecting the type of ECMO (VA vs VV), monitoring cannulation and the early detection of complications, but it is underused in patients supported by VV-ECMO. Nevertheless, in these patients, this methodology can provide useful information in monitoring cardiac function, cannula positioning, pericardial fluid (for early detection of tamponade) during ECMO support, and therefore it can contribute to the integrated assessment and management of these complex patients. There is a clinical need to elaborate shared protocols for echocardiography use during VV ECMO support, particularly at this time when advanced echocardiography is gaining interest among intensivists.
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