Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients. Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia (e.g., lower PaO2 in the upper than in the lower body) in case of veno-arterial cannulation (VA-ECMO) and severe impairment of pulmonary function associated with cardiac recovery. The treatment of such complications remains challenging. We report the early effects of the use of veno-arterial-venous (V-AV) ECMO in this setting. Methods: Retrospective analysis including patients from five different European ECMO centers (January 2013 to December 2016) who required V-AV ECMO. We collected demographic data as well as comorbidities and ECMO characteristics, hemodynamics, and arterial blood gas values before and immediately after (i.e., within 2 h) V-AV implementation. Results: A total of 32 patients (age 53 (interquartiles, IQRs: 31–59) years) were identified: 16 were initially supported with VA-ECMO and 16 with VV-ECMO. The median time to V-AV conversion was 2 (1–5) days. After V-AV implantation, heart rate and norepinephrine dose significantly decreased, while PaO2 and SaO2 significantly increased compared to baseline values. Lactate levels significantly decreased from 3.9 (2.3–7.1) to 2.8 (1.4–4.4) mmol/L (p = 0.048). A significant increase in the overall ECMO blood flow (from 4.5 (3.8–5.0) to 4.9 (4.3–5.9) L/min; p < 0.01) was observed, with 3.0 (2.5–3.2) L/min for the arterial and 2.8 (2.1–3.6) L/min for the venous return flows. Conclusions: In ECMO patients with differential hypoxia or persistently low cardiac output syndrome, V-AV conversion was associated with improvement in some hemodynamic and respiratory parameters. A significant increase in the overall ECMO blood flow was also observed, with similar flow distributed into the arterial and venous return cannulas.
Highlights
Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients with promising results [1]
Peripheral cannulation may be complicated by a persistent low cardiac output in case of veno-venous cannulation (VV-ECMO) or by differential hypoxia in case of veno-arterial cannulation (VA-ECMO)
The veno-arteriovenous configuration (V-AV), where the return outflow is divided in two flows, one toward the aorta to provide circulatory support and the second toward the right atrium to provide respiratory support, has been shown to effectively control these complications related to the initial ECMO configuration [7]; no data have been reported on the early effects of V-AV ECMO on patients’ physiology in this setting
Summary
Extracorporeal membrane oxygenation (ECMO) is increasingly used to treat cardiopulmonary failure in critically ill patients with promising results [1]. Severe impairment of pulmonary function associated with cardiac recovery [5] The treatment of such complications remains challenging, but the hybrid ECMO modes, using a third or fourth cannula, may provide additional support when traditional VV or VA configurations fail to ensure adequate tissue perfusion and oxygenation [6]. In this setting, the veno-arteriovenous configuration (V-AV), where the return outflow (return cannula) is divided in two flows, one toward the aorta to provide circulatory support and the second toward the right atrium to provide respiratory support, has been shown to effectively control these complications related to the initial ECMO configuration [7]; no data have been reported on the early effects of V-AV ECMO on patients’ physiology in this setting
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