Extracorporeal life support devices and strategies for management of acute cardiorespiratory failure in adult patients: a comprehensive review

Abstract

Evolution of extracorporeal life support (ECLS) technology has added a new dimension to the intensive care management of acute cardiac and/or respiratory failure in adult patients who fail conventional treatment. ECLS also complements cardiac surgical and cardiology procedures, implantation of long-term mechanical cardiac assist devices, heart and lung transplantation and cardiopulmonary resuscitation. Available ECLS therapies provide a range of options to the multidisciplinary teams who are involved in the time-critical care of these complex patients. While venovenous extracorporeal membrane oxygenation (ECMO) can provide complete respiratory support, extracorporeal carbon dioxide removal facilitates protective lung ventilation and provides only partial respiratory support. Mechanical circulatory support with venoarterial (VA) ECMO employed in a traditional central/peripheral fashion or in a temporary ventricular assist device configuration may stabilise patients with decompensated cardiac failure who have evidence of end-organ dysfunction, allowing time for recovery, decision-making, and bridging to implantation of a long-term mechanical circulatory support device and occasionally heart transplantation. In highly selected patients with combined severe cardiac and respiratory failure, advanced ECLS can be provided with central VA ECMO, peripheral VA ECMO with timely transition to venovenous ECMO or VA-venous ECMO upon myocardial recovery to avoid upper body hypoxia or by addition of an oxygenator to the temporary ventricular assist device circuit. This article summarises the available ECLS options and provides insights into the principles and practice of these techniques. One should emphasise that, as is common with many emerging therapies, their optimal use is currently not backed by quality evidence. This deficiency needs to be addressed to ensure that the full potential of ECLS can be achieved.

Extracorporeal Membrane Oxygenation in Adults

“…Over the following decades, it became an universally accepted method in the treatment of severe forms of heart and respiratory failure in childhood; only in recent years has it become a common treatment modality in adult critical patients [3][4][5] .Thanks to the technical developments and growing experience, the results of ECMO treatment have been increasingly improving, and the indications were gradually extended [6][7][8][9][10] . Consequently, the number of patients treated with ECMO has been growing significantly every year.…”

Veno-arterial extracorporeal membrane oxygenation: an overview of different cannulation techniques

“…However, this configuration requires sternotomy and cannulation of the LV (or left atrium) and aorta. A reoperation (sternotomy or thoracotomy) is then required for explantation of the cannulae upon cardiac recovery or for implantation of a long-term mechanical assist device (42). …”

Look before leaping into combining extracorporeal techniques to improve oxygenation!

“…No data on cardiac function were provided. According to the Extracorporeal Life Support Organization guidelines, VA-ECMO should be applied exclusively in cardiac failure, whereas venovenous ECMO is first-line therapy for refractory or life-threatening hypoxemia in patients with preserved or drug-sustained cardiac function [2,3]. Venoarterial venous (VAV) ECMO is most appropriate to secure upper body oxygenation in case of severe myocardial dysfunction.…”

“…Venoarterial venous (VAV) ECMO is most appropriate to secure upper body oxygenation in case of severe myocardial dysfunction. Peripheral arterial cannulation for VAV-ECMO is feasible, yet a central approach better ''synchronizes'' perfusion to oxygenation needs by more closely regulating oxygenated blood return to the coronary and cerebral circulation [2,3]. Second, the high metabolic oxygen demands of ARDS patients can only be met by providing a high (i.e., between 3 and 7 L/min) ECMO blood flow rate.…”

“…In addition, increased shear stress, physical properties of the bypass circuit, the roller pump, and the hemofilter enhance red blood cell damage and lysis [5]. A hemolysisinduced rise of plasma-free hemoglobin and subsequent hemoglobinuria adversely affect renal tubular function and may cause acute kidney injury or delay renal recovery [2,5].…”