A novel escalation from veno-venous bypass to veno-venous ECMO during orthotopic liver transplantation. A case report

Abstract

We describe the challenging perioperative course of a 55-year-old patient with hepatic failure requiring liver transplantation (LT). Different modalities of the extracorporeal device were successfully used, ranging from veno-veno bypass to partial and full veno-veno extracorporeal membrane oxygenation (ECMO) in order to optimize preload, reduce bleeding from the collateral circulation, optimize acid base balance and/or improve oxygenation. The case highlights the potential use of the device as a rescue method in challenging cases. Furthermore this is the first documented case that extracorporeal CO2 removal (ECCO2R) is used to optimize the biochemistry profile intraoperatively during a LT. The patient was weaned off the device at the end of the case and has been discharged home.

Extracorporeal Membrane Oxygenation use on Liver Transplantation: An Integrative Review

“…15 Other situations, such as occlusion of important veins in circulatory drainages, such as the brachycephalic, internal jugular, and subclavian veins, have also been evaluated for using ECMO. 5 As for cases of hemodynamic repercussion due to severe post-reperfusion syndrome, six articles reported the issue, with two papers about cardiac arrest, 15,16 while others showed arrhythmia, 17 intracardiac thrombosis, 18 severe pulmonary embolism, 19 and cardiogenic shock. 20 In four of them, cardiopulmonary resuscitation maneuvers with vasoactive drugs were performed, however, without success.…”

“…This oxygenation ensures assistance for situations of respiratory and cardiac failure, 3 becoming increasingly frequent in the treatment of diseases associated with liver transplantation. 4 The literature points to the use of ECMO during the intraoperative period, in cases of severe post-reperfusion syndrome, 5 and postoperatively in cases in cases such as respiratory distress syndrome from persistent or remnant hepatopulmonary syndrome. 6 However, its use is not yet well established, 4 with a controversial literature about its indications.…”

“…In this context, some studies show complications, such as sepsis and bleeding, that make it even more difficult to weigh the benefits against the risks of this clinical conduct. [5][6][7] Given this, this review aims to evaluate the indication of ECMO during the pre-, intra-, and postoperative periods of liver transplantation.…”

Uso de Oxigenação por Membrana Extracorpórea no Transplante Hepático: Uma Revisão Integrativa

“…Essa oxigenação assegura a assistência para situações de falência respiratória e cardíaca, 3 tornando-se cada vez mais frequente no tratamento de doenças associadas ao transplante hepático. 4 A literatura aponta o uso da ECMO durante os períodos intraoperatório, em casos de síndrome de pós-reperfusão grave, 5 e pós-operatório, em casos como síndrome da angústia respiratória por síndrome hepatopulmonar persistente ou resquicial. 6 No entanto seu uso ainda não é bem estabelecido, 4 havendo uma literatura controversa acerca de suas indicações.…”

“…Nesse contexto, alguns estudos mostram complicações, como sepse e sangramentos, que dificultam ainda mais na ponderação dos benefícios em detrimento dos riscos dessa conduta clínica. [5][6][7] Diante disso, essa revisão tem como objetivo avaliar a indicação da ECMO durante os períodos pré-, intra-e pós-operatórios do transplante hepático.…”