Drainage From Superior Vena Cava Improves Upper Body Oxygenation in Patients on Femoral Veno-Arterial Extracorporeal Membrane Oxygenation

Abstract

ObjectiveTo investigate the feasibility of drainage from the superior vena cava (SVC) to improve upper body oxygenation in patients with cardiogenic shock undergoing femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO).MethodsSeventeen adult patients receiving peripheral femoral VA ECMO for circulatory support were enrolled. The femoral drainage cannula was shifted three times (from the inferior vena cava (IVC) level to the SVC level and then the IVC level again), all under ultrasound guidance, at an interval of 15 minutes. The blood gas levels of the right radial artery (RA) and SVC and cerebral oxygen saturation (ScO2) were measured and compared.ResultsFifteen patients (88.2%) were successfully weaned from ECMO, and 12 patients (70.6%) survived to discharge. The oxygen saturation (SO2) and oxygen partial pressure (PO2) of the RA (97.0 ± 3.5% to 98.3 ± 1.5%, P < 0.05, SO2; 127.4 ± 58.2 mmHg to 153.1 ± 67.8 mmHg, P < 0.05, PO2) and SVC (69.5 ± 9.0% to 75.7 ± 8.5%, P < 0.05, SO2; 38.5 ± 5.6 mmHg to 43.6 ± 6.4 mmHg, P < 0.05, PO2) were increased; ScO2 was also increased on both sides (left: 50.6 ± 8.6% to 55.0 ± 9.0%, P < 0.05; right: 48.7 ± 9.2% to 52.3 ± 9.8%, P < 0.05) when the femoral drainage cannula was shifted from the IVC level to the SVC level. When the femoral drainage cannula was shifted from SVC level to the IVC level again, the SO2 and PO2 of RA (98.3 ± 1.5% to 96.9 ± 3.2%, P <0.05, SO2; 153.1 ± 67.8 mmHg to 125.8 ± 63.3 mmHg, P <0.05, PO2) and SVC (75.7 ± 38.5% to 70.4 ± 7.6%, P <0.05, SO2; 43.6 ± 6.4 mmHg to 38.9 ± 4.5 mmHg, P <0.05, PO2) were decreased; ScO2 was also reduced on both sides (left: 55.0 ± 9.0% to 50.7 ± 8.2%, P < 0.05; right: 52.3 ± 9.8% to 48.7 ± 9.3%, P <0.05).ConclusionDrainage from the SVC by shifting the cannula upward could improve upper body oxygenation in patients with cardiogenic shock undergoing femoral VA ECMO. This cannulation strategy provides an alternative solution for differential hypoxia.

How to mange differential hypoxemia during veno-arterial extracorporeal membrane oxygenation

“…In our study, the efficiency of draining the blood from the SVC was comparable to V-AV or returning the blood to the axillary artery. In clinical practice, we also found drainage from the SVC by shifting the draining cannula from the IVC level to the SVC level could improve upper body oxygenation in patients undergoing peripheral VA-ECMO, 5 suggesting that the femoral drainage cannula can be inserted in the IVC before ECMO initiation to reduce the risk of differential oxygenation. Moreover, draining blood from the SVC and right atrium via a multistage cannula inserted in the right internal jugular vein (SVC-FA) is also an ideal alternative to avoid dual circulation.…”

Optimizing PO2 during peripheral veno-arterial ECMO: a narrative review

“…Then, S v O 2 will be determined mainly by oxygen saturation of the IVC blood (S IVC O 2 ). As returning from intra-abdominal organs oxygenated by VA-ECMO, it will be moderately deoxygenated, allowing an increased S v O 2 and finally increased S a O 2 [ 9 , 21 – 23 ]. In an experimental study on 15 patients supported by VA-ECMO but without Harlequin syndrome, shifting the drainage cannula tip from IVC to SVC increased right radial P a O 2 from 127 to 153 mmHg [ 23 ].…”

“…As returning from intra-abdominal organs oxygenated by VA-ECMO, it will be moderately deoxygenated, allowing an increased S v O 2 and finally increased S a O 2 [ 9 , 21 – 23 ]. In an experimental study on 15 patients supported by VA-ECMO but without Harlequin syndrome, shifting the drainage cannula tip from IVC to SVC increased right radial P a O 2 from 127 to 153 mmHg [ 23 ]. Then, clinical impact of this moderate oxygenation improvement in case of fulminant differential hypoxemia remains to be determined.…”

The effect of arterial cannula tip position on differential hypoxemia during venoarterial extracorporeal membrane oxygenation

“…In addition, they require meticulous surgical training and care to perform in the rst place, transport of the patient to an operating theatre, and cannot be used alongside simultaneous chest compressions [18,19]. Some studies have also suggested advancing the drainage cannula into the superior vena cava as a possible strategy [21][22][23]. This ensures drainage of poorly oxygenated blood from the upper body, thereby preventing its circulation to the arterial system.…”