Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies

Tulman, David B.; Stawicki, Stanislaw P; Whitson, Bryan A.; Gupta, Saarik C; Tripathi, Ravi; Firstenberg, Michael S.; Hayes, Don; Xu, Xuzhong; Papadimos, Thomas J.

doi:10.1186/1471-2253-14-65

Cited by 46 publications

(59 citation statements)

References 80 publications

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“…Low plateau pressures and tidal volumes should be used to minimize iatrogenic trauma. Often a SpO 2 of 85% and PaO 2 of 40 mm Hg are acceptable [12]. While monitoring of the VV ECMO patient's oxygenation and perfusion may be similar to a non-ECMO patient, the treatment may be dramatically different.…”

Section: Discussionmentioning

confidence: 99%

“…Conversely, a SpO 2 of 90% may not be adequate for an anemic patient. While many clinicians are comfortable tolerating anemia during VV ECMO, some authors recommend maintaining the hematocrit is kept around 40% while others cite a goal of >5% above normal [12] [13]. When deciding to transfuse the anesthesiologist must weigh the benefits of improved oxygen delivery with the risks of the transfusion [12].…”

Section: Discussionmentioning

confidence: 99%

“…While many clinicians are comfortable tolerating anemia during VV ECMO, some authors recommend maintaining the hematocrit is kept around 40% while others cite a goal of >5% above normal [12] [13]. When deciding to transfuse the anesthesiologist must weigh the benefits of improved oxygen delivery with the risks of the transfusion [12]. While there is no universally accepted algorithm to determine the level of oxygen delivery that should be provided to these patients, it can be individualized to your specific patient based on parameters such as lactate, mixed venous oxygen saturation, and oxygen extraction.…”

Section: Discussionmentioning

confidence: 99%

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Veno-Venous Extracorporeal Membrane Oxygenation: Anesthetic Management for Massive Intracranial Hemorrhage in H1N1 Infection

Kraus¹,

Weis²,

Alwardt³

et al. 2015

OJAnes

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Background: Extracorporeal membrane oxygenator (ECMO) use is dramatically increasing in recent years. This case report describes a patient on veno-venous (VV) ECMO for H1N1 who underwent emergent craniotomy twice for intracranial hemorrhage. Case presentation: A 38-year-old male presented to a community hospital for worsening shortness of breath. He had experienced cough, malaise and fatigue for two weeks prior to presentation. On arrival, his arterial oxygen saturation was 64%. He was placed on oxygen via non-rebreather mask and started on Tamiflu plus antibiotics. He was intubated for worsening respiratory failure. Despite maximal ventilator settings, the arterial oxygen saturation was approximately 90%. He was placed in the prone position and nitric oxide was initiated. Severe acute respiratory distress syndrome (ARDS) secondary to influenza was diagnosed by viral PCR, clinical presentation, and diagnostic imaging. Within 24 hours of his intubation, a decision was made to initiate veno-venous (V-V) ECMO for respiratory support. Five days following the initiation of ECMO, asymmetric pupils and a nonreactive right pupil were noted. A massive right frontal intraparenchymal hemorrhage with midline shift and downward uncal herniation was found on computed tomography (CT). A decision was made to surgically intervene. He was taken to the operating room for immediate right frontal craniotomy and clot evacuation under general anesthesia. Conclusion: With the dramatic increase in ECMO use, anesthesiologists are encountering patients on ECMO in the operating room with more frequency. When the situation does arise, it is imperative that the anesthesiologist is knowledgeable about ECMO and how to appropriately administer anesthesia for these critically ill patients. Challenges M. Kraus et al. 252 confronting the anesthesiologist with ECMO patients include managing bleeding or coagulopathy, ventilation and oxygenation, volume status, transporting and positioning these patients, and altered pharmacokinetics of anesthetic drugs.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Veno-Venous Extracorporeal Membrane Oxygenation: Anesthetic Management for Massive Intracranial Hemorrhage in H1N1 Infection

Kraus¹,

Weis²,

Alwardt³

et al. 2015

OJAnes

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“…Patients with advanced and/or irreversible diseases, such as uncontrolled sepsis, non-pulmonary multi-organ failure, irreversible neurological injury, terminal illness or other life-limiting disease should not be candidates for VV-ECMO. Moreover, patients with chronic respiratory failure or ventilator-dependent respiratory failure who are not eligible to be bridged to lung transplantation should not be considered as candidates for VV-ECMO (8,9). Finally, patients with associated cardiac dysfunction and/ or cardiogenic shock should receive veno-arterial (VA) ECMO support (10).…”

Section: Indications For Vv-ecmomentioning

confidence: 99%

Veno-venous extracorporeal membrane oxygenation: cannulation techniques

et al. 2016

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The development of extracorporeal membrane oxygenation (ECMO) technology allows a new approach for the intensive care management of acute cardiac and/or respiratory failure in adult patients who are not responsive to conventional treatment. Current ECMO therapies provide a variety of options for the multidisciplinary teams who are involved in the management of these critically ill patients. In this regard, veno-venous ECMO (VV-ECMO) can provide quite complete respiratory support, even if this highly complex technique presents substantial risks, such as bleeding, thromboembolic events and infection.While VV-ECMO circuits usually include the cannulation of two vessels (double cannulation) in its classic configuration, the use of a single cannula is now possible for VV-ECMO support. Recently, experienced centers have employed more advanced approaches by cannulating three vessels (triple cannulation) which follows veno-arterio-venous (VAV) or veno-arterio-pulmonary-arterial cannulation (VAPa). However, 'triple' cannulation expands the field of application but increases the complexity of ECMO systems. In the present review, the authors focus on the indications for VV-ECMO, patient assessment prior to cannulation, the role of ultrasound-guided vessel puncture, double lumen single bicaval cannulations, and finally triple cannulation in VV-ECMO.

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“…Despite advances in understanding of ARDS pathogenesis (10, 11), only three interventions have been shown to reduce mortality in Phase III RCTs: low tidal volume ventilation (12), NMB (13), and prone positioning (14) and mortality in moderate to severe ARDS remains >40% (15, 16). Other than NMB, pharmacologic therapies have been disappointing (17–20) and a role for extracorporeal membrane oxygenation (ECMO) in ARDS has not been well defined (21). …”

Section: Introductionmentioning

confidence: 99%

Pilot Feasibility Study of Therapeutic Hypothermia for Moderate to Severe Acute Respiratory Distress Syndrome*

Slack

Corwin

Shah

et al. 2017

Critical Care Medicine

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Objectives Prior studies suggest hypothermia may be beneficial in ARDS, but cooling causes shivering and increases metabolism. The objective of this study was to assess the feasibility of performing a randomized clinical trial (RCT) of hypothermia in patients with ARDS receiving treatment with neuromuscular blockade (NMB) because they cannot shiver. Design Retrospective study and pilot prospective open-label feasibility study. Setting Medical Intensive Care Unit. Patients Retrospective review of 58 patients with ARDS based on Berlin criteria and PaO2:FiO2 (P:F)<150 who received NMB. Prospective hypothermia treatment in 8 ARDS patients with (P:F)<150 receiving NMB. Intervention Cooling to 34°–36°C for 48h. Measurements and Main Results Core temperature, hemodynamics, serum glucose and electrolytes, and P:F, were sequentially measured and medians (interquartile ranges) presented, and 28-day ventilator-free days (VFDs), and hospital mortaltiy were calculated in historical controls and 8 cooled patients. Average patient core temperature was 36.7(36–37.3)°C and fever occurred during NMB in 30/58 retrospective patients. In the prospectively cooled patients core temperature reached target range ≤4h of initiating cooling, remained <36°C for 92% of the 48h cooling period without adverse events, and was lower than the controls (34.35(34–34.8)°C; p<0.0001). Compared with historical controls, the cooled patients tended to have lower hospital mortality (75% vs 53.4%; p=0.26), more VFDs (9(0–21.5) vs. 0(0–12); p=0.16) and higher day-3 P:F (255(160–270) vs. 171(120–214), p=0.024). Conclusions NMB alone does not cause hypothermia, but allowed ARDS patients to be effectively cooled. Results support conducting an RCT of hypothermia in ARDS and the feasibility of studying ARDS patients receiving NMB.

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Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies

Cited by 46 publications

References 80 publications

Veno-Venous Extracorporeal Membrane Oxygenation: Anesthetic Management for Massive Intracranial Hemorrhage in H1N1 Infection

Veno-Venous Extracorporeal Membrane Oxygenation: Anesthetic Management for Massive Intracranial Hemorrhage in H1N1 Infection

Veno-venous extracorporeal membrane oxygenation: cannulation techniques

Pilot Feasibility Study of Therapeutic Hypothermia for Moderate to Severe Acute Respiratory Distress Syndrome*

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