Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.
Highlights
Acute respiratory distress syndrome (ARDS) is characterized by an acute and diffuse inflammatory lung injury of different etiologies which is associated to hypoxemic and, sometimes, hypercapnic respiratory failure [1]
In a recent prospective observational study by our research group, we found a poor correlation between TEG reaction time and activated partial thromboplastin time (aPTT), whereas a moderate correlation was found between rotational thromboelastometry (ROTEM) CT and aPTT
Regional citrate anticoagulation has become the standard of care in CRRT circuits: citrate prevents clotting by chelation of ionized calcium, a fundamental cofactor of coagulation [117]
Summary
Acute respiratory distress syndrome (ARDS) is characterized by an acute and diffuse inflammatory lung injury of different etiologies which is associated to hypoxemic and, sometimes, hypercapnic respiratory failure [1]. Modern protective ventilation strategies contributed to ameliorate outcomes [10,11,12] by preventing the ventilator-induced lung injury (VILI) [13]. They became the cornerstone of ARDS treatment [14,15,16]. VILI is not always avoidable, in case of very low respiratory system compliance [17] In such circumstances, V-V ECMO remains an appealing approach, because it makes protective ventilation feasible.
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