A respiratory gas exchange catheter: In vitro and in vivo tests in large animals

Pasta for all: Abiomed Breethe extracorporeal membrane oxygenation system

Mathematical simulation of pulmonary O 2 and CO 2 exchange.

Essential Topics in the Management of Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Acute Respiratory Distress Syndrome

Chapter 16 - EXTRACORPOREAL MEMBRANE OXYGENATION

Extracorporeal Carbon Dioxide Removal (ECCO2R): A Potential Perioperative Tool in End-Stage Lung Disease

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Extracorporeal membrane oxygenation for respiratory failure: past, present and future

Carbon dioxide output in laparoscopic cholecystectomy

Extracorporeal membrane oxygenation is a technique for providing temporary extracorporeal respiratory circulation support in patients with respiratory failure who are difficult to treat with conventional therapy (mechanical ventilation). During extracorporeal membrane oxygenation, blood exits from the patient′s venous system, and then enters the artificial membrane lung for oxygenation and carbon dioxide removal, and finally returned to the patient.In order to avoid the loss of normal lung function, mechanical ventilation is still necessary in the process of extracorporeal membrane oxygenation, but there is no clear guidance on how to set mechanical ventilation parameters during extracorporeal membrane oxygenation.Therefore, this article will briefly describe the pathophysiological mechanisms of gas exchange during extracorporeal membrane oxygenation, and summarize the mechanical ventilation strategies in the extracorporeal membrane oxygenation process with available evidence and literature. Key words: Respiration, artificial; Tidal volume; Positive-Pressure Respiration; Extracorporeal membrane oxygenation; Driving pressure

Dual circulation is a common but underrecognized physiological occurrence associated with peripheral venoarterial extracorporeal membrane oxygenation (ECMO). Competitive flow will develop between blood ejected from the heart and blood travelling retrograde within the aorta from the ECMO reinfusion cannula. The intersection of these two competitive flows is referred to as the “mixing point”. The location of this mixing point, which depends upon the relative strengths of the native and extracorporeal pumps, will determine which regions of the body are perfused with blood ejected from the left ventricle and which regions are perfused by reinfused blood from the ECMO circuit, effectively establishing dual circulations. Because gas exchange within these circulations is dictated by the native lungs and membrane lung, respectively, oxygenation and carbon dioxide removal may differ between regions—depending on how well gas exchange is preserved within each circulation—potentially leading to differential oxygenation or differential carbon dioxide, each of which may have important clinical implications. In this perspective, we address the identification and management of dual circulation and differential gas exchange through various clinical scenarios of venoarterial ECMO. Recognition of dual circulation, proper monitoring for differential gas exchange, and understanding the various strategies to resolve differential oxygenation and carbon dioxide may allow for more optimal patient management and improved clinical outcomes.

During extracorporeal membrane oxygenation (ECMO), oxygen (O2) transfer (V'O2) and carbon dioxide (CO2) removal (V'CO2) are partitioned between the native lung (NL) and the membrane lung (ML), related to the patient's metabolic-hemodynamic pattern. The ML could be assimilated to a NL both in a physiological and a pathological way. ML O2 transfer (V'O2ML) is proportional to extracorporeal blood flow and the difference in O2 content between each ML side, while ML CO2 removal (V'CO2ML) can be calculated from ML gas flow and CO2 concentration at sweep gas outlet. Therefore, it is possible to calculate the ML gas exchange efficiency. Due to the ML aging process, pseudomembranous deposits on the ML fibers may completely impede gas exchange, causing a "shunt effect", significantly correlated to V'O2ML decay. Clot formation around fibers determines a ventilated but not perfused compartment, with a "dead space effect", negatively influencing V'CO2ML. Monitoring both shunt and dead space effects might be helpful to recognise ML function decline. Since ML failure is a common mechanical complication, its monitoring is critical for right ML replacement timing and it also important to understand the ECMO system performance level and for guiding the weaning procedure. ML and NL gas exchange data are usually obtained by non-continuous measurements that may fail to be timely detected in critical situations. A real-time ECMO circuit monitoring system therefore might have a significant clinical impact to improve safety, adding relevant clinical information. In our clinical practise, the integration of a real-time monitoring system with a set of standard measurements and samplings contributes to improve the safety of the procedure with a more timely and precise analysis of ECMO functioning. Moreover, an accurate analysis of NL status is fundamental in clinical setting, in order to understand the complex ECMO-patient interaction, with a multi-dimensional approach.

Artificial lungs are commonly used in cardiopulmonary-bypass surgery (CPB), extracorporeal life support (ECLS), and extracorporeal carbon dioxide removal therapy (ECCO2R). In this study, a semi-empirical model for O2 and CO2 transfer in an oxygenator was formulated to evaluate the gas exchange performance at different blood/gas flow rates and various inlet conditions. The model uses experimentally obtained mass transfer coefficients together with blood-gas and acid-base inlet parameters to determine the corresponding outlet values by considering the mass transfer equations for both O2 and CO2. Increasing the blood flow rate (1–7 L/min) decreases pO2 at the outlet (from 376 to 120 mmHg), but linearly increases the total oxygen transfer rate (OTR) from 76 to 450 mL/min. CTR, the CO2 transfer rate (64–648 mL/min), depends primarily on the ratio of gas to blood flow rate (1:1–5:1). In addition, venous concentrations of O2–CO2 play a pivotal role in the overall gas exchange efficiency of the oxygenator. Conclusively, a good agreement (R2=0.99) could be observed between the experimental data and the model’s predictions for OTR and CTR alike at standard inlet conditions. The model's capabilities can be extended by modeling gas exchange during CPB, ECLS and ECCO2R therapies for different connection configurations.

Among the potential complications of extracorporeal membrane oxygenation, neurological dysfunctions, including brain death, are not negligible. In Brazil, the diagnostic process of brain death is regulated by Federal Council of Medicine resolution 2,173 of 2017. Diagnostic tests for brain death include the apnea test, which assesses the presence of a ventilatory response to hypercapnic stimulus. However, gas exchange, including carbon dioxide removal, is maintained under extracorporeal membrane oxygenation, making the test challenging. In addition to the fact that the aforementioned resolution does not consider the specificities of the diagnostic process under extracorporeal membrane oxygenation, studies on the subject are scarce. This review aims to identify case studies (and/or case series) published in the PubMed® and Cochrane databases describing the process of brain death diagnosis. A total of 17 publications (2011 - 2019) were identified. The practical strategies described were to provide pretest supplemental oxygenation via mechanical ventilation and extracorporeal membrane oxygenation (fraction of inspired oxygen = 1.0) and, at the beginning of the test, titrate the sweep flow (0.5 - 1.0L/minute) to minimize carbon dioxide removal. It is also recommended to increase blood flow and/or sweep flow in the presence of hypoxemia and/or hypotension, which may be combined with fluid infusion and/or the escalation of inotropic/vasoactive drugs. If the partial pressure of carbon dioxide threshold is not reached, repeating the test under supplementation of carbon dioxide exogenous to the circuit is an alternative. Last, in cases of venoarterial extracorporeal membrane oxygenation, to measure gas variation and exclude differential hypoxia, blood samples of the native and extracorporeal (post-oxygenator) circulations are recommended.

Background: Combined lung and kidney dysfunction are frequent in extracorporeal membrane oxygenation (ECMO) patients affecting up to 70% of them. Current treatment relies on the use of two separate circuits combining ECMO and renal replacement therapy, increasing infection risks and the use of artificial surfaces. Therefore, we aim to develop a novel artificial lung that integrates lung and kidney support in a single device combining oxygenation and hemodialysis fibers. Thus, we analyzed how many oxygenation fibers could be substituted by hemodialysis fibers while still maintaining 90% of the oxygenator’s gas exchange capacity and the effect fiber configuration has on oxygen (O2) and carbon dioxide (CO2) transfer. Methods: Fiber bundles were composed of oxygenation fiber mats (Oxyplus™ 90/200, 3M) stacked perpendicularly at a 90° angle and/or crossed at a 24° angle on top of each other. We manufactured bundles with all oxygenation fibers open and bundles with oxygenation fibers closed in a way that they could not contribute to gas exchange, simulating hemodialysis fibers. Bundles in perpendicular configuration had 100% of fibers open (Oxy100P), 50% of fibers closed (Oxy50P), or 25% of fibers closed (Oxy75P), Figure 1. Bundles in crossed configuration had all fibers open (Oxy100C) or 33% of fibers closed (Oxy67C). Bundles were tested for gas exchange performance following in-vitro blood tests according to ISO 7199:2016. Results: Our results show that bundles with 25% of oxygenation fibers closed in perpendicular configuration were able to still maintain 90% of the O2 exchange and 80% of the CO2 exchange capacity of our oxygenator. Bundles with 25% oxygenation fibers closed had no statistically significant difference in O2 or CO2 transfer compared to a fully open oxygenator with the same fiber configuration, Figure 2. Additionally, Oxy75P bundles were able to keep O2 delivery above 55 mL/LBlood flow and CO2 removal above 52 mL/LBlood flow up to 140 mL/min. Fiber configuration did not affect gas exchange for fully open bundles, however, configuration significantly influenced O2 and CO2 exchange for bundles with closed fiber layers. Closing fibers in perpendicular configuration resulted in a lower decrease in gas transfer. Below 140 mL/min, this was demonstrated by a similar decrease in O2 transfer of 20% when 50% of perpendicular fibers or 33% of crossed fibers were closed Conclusions: We analyzed the effect of replacing oxygenation fibers with hemodialysis fibers on gas exchange efficiency. Our results demonstrate that 25% of oxygenation fibers in a perpendicular configuration could be replaced by hemodialysis fibers while still maintaining 90% of the O2 exchange of our oxygenator. Moreover, this type of bundle kept O2 delivery above 55 mL/LBlood flow up to 140 mL/min. This shows that gas exchange can be preserved to a desirable extent when oxygenation fiber layers are replaced. This is a step towards combining lung and kidney support in a single device.Figure 1. Illustration of a device combining extracorporeal lung and kidney support. Oxygen flows through the lumen of oxygenation fibers and dialysate flows inside hemodialysis fibers. In this work, fiber bundles were manufactured with a perpendicular and/or crossed configuration having a varying number of oxygenation fiber layers closed, simulating hemodialysis fibers (open fibers in white and closed fibers in blue). Perpendicular bundles had 50% of fibers closed (Oxy50P), 25% of fibers closed (Oxy75P), or 100% of fibers open (Oxy100P), while crossed bundles had 33% of fibers closed (Oxy67C), or all fibers open (Oxy100C).Figure 2. Oxygen exchange performance mL/LBlood flow ± standard deviation from the mean (n = 10) for bundles with different fiber configurations. We found no statistically significant difference in mean oxygen exchange between Oxy75P and the fully open oxygenator Oxy100P (ANOVA p > 0.38).

Monitoring for thrombosis and hemolysis is crucial for patients under extracorporeal or mechanical circulatory support, but it can be costly. We investigated correlations between hemolysis index (HI) and plasma-free hemoglobin (PFH) levels on one hand, and between the HI and plasma lactate dehydrogenase (LDH) levels on the other, in critically ill patients with and without extracorporeal or mechanical circulatory support. Additionally, we calculated the cost reductions if monitoring through HI were to replace monitoring through PFH or plasma LDH. In a single-center study, HI was compared with PFH and plasma LDH levels in blood samples taken for routine purposes in critically ill patients with and without extracorporeal or mechanical circulatory support. A cost analysis, restricted to direct costs associated with each measurement, was made for an average 10-bed ICU. This study included 147 patients: 56 patients with extracorporeal or mechanical circulatory support (450 measurements) and 91 patients without extracorporeal or mechanical circulatory support (562 measurements). The HI correlated well with PFH levels (r = 0.96; p < 0.01) and poorly with plasma LDH levels (r = 0.07; p < 0.01) in patients with extracorporeal or mechanical circulatory support. Similarly, HI correlated well with PFH levels (r = 0.97; p < 0.01) and poorly with plasma LDH levels (r = -0.04; p = 0.39) in patients without extracorporeal or mechanical circulatory support. ROC analyses demonstrated a strong performance of HI, with the curve indicating excellent discrimination in the whole cohort (area under the ROC of 0.969) as well as in patients under ECMO or mechanical circulatory support (area under the ROC of 0.988). Although the negative predictive value of HI for predicting PFH levels > 10 mg/dL was high, its positive predictive value was found to be poor at various cutoffs. A simple cost analysis showed substantial cost reduction if HI were to replace PFH or plasma LDH for hemolysis monitoring. In conclusion, in this cohort of critically ill patients with and without extracorporeal or mechanical circulatory support, HI correlated well with PFH levels, but poorly with plasma LDH levels. Given the high correlation and substantial cost reductions, a strategy utilizing HI may be preferable for monitoring for hemolysis compared to monitoring strategies based on PFH or plasma LDH. The PPV of HI, however, is unacceptably low to be used as a diagnostic test.