Differential hypoxemia during venoarterial extracorporeal membrane oxygenation

Abstract

Venoarterial extracorporeal membrane oxygenation, indicated for severe cardio-respiratory failure, may result in anatomic regional differences in oxygen saturation. This depends on cannulation, hemodynamic state, and severity of respiratory failure. Differential hypoxemia, often discrete, may cause clinical problems in peripheral femoro-femoral venoarterial extracorporeal membrane oxygenation, when the upper body is perfused with low saturated blood from the heart and the lower body with well-oxygenated extracorporeal membrane oxygenation blood. The key is to diagnose and manage fulminant differential hypoxemia, that is, a state that may develop where the upper body is deprived of oxygen. We summarize physiology, assessment of diagnosis, and management of fulminant differential hypoxemia during venoarterial extracorporeal membrane oxygenation. A possible solution is implantation of an additional jugular venous return cannula. In this article, we propose an even better solution, to drain the venous blood from the superior vena cava. Drainage from the superior vena cava provides superiority to venovenoarterial configuration in terms of physiological rationale, efficiency, safety, and simplicity in clinical circuit design.

Predictors of brain infarction in adult patients on extracorporeal membrane oxygenation: an observational cohort study

“…Risk for differential hypoxemia on VA ECMO specifically may be an additional explanation 1 , where a high native cardiac output results in the hyper-oxygenated ECMO blood failing to reach the upper body's circulation leaving the upper body end organs to be perfused with blood oxygenated by lungs with limited or no gas exchange. Depending on cannulation configuration and infusion site 25 , the brain may be then be subject to increased oxidative stress, cerebral vasoconstriction 1 , and thus increased risk for BI 24,26 . This might explain the patients in our cohort with a BI caused by hypoperfusion.…”

Dynamic extracorporeal life support: A novel management modality in temporary cardio‐circulatory assistance

“…Thereby, the flow toward the arterial circulation may be dangerously reduced and, consequently, the circulatory support inadequate which also includes the flow to the cannulated leg which usually is provided by a single distal perfusion cannula. 19 Using a flowmeter on either the venous or arterial tubing, and one flowmeter on the distal perfusion line will indicate the need for controlled flow through a Hoffman clamp to facilitate the flow toward the arterial line (Figure 3). The importance of this management has to be underlined when ECLS flows are reduced during the weaning phase.…”

“…17 In septic shock patients with F I G U R E 1 Extracorporeal life support conversion of modality in support with single lumen and dual-lumen cannula [Color figure can be viewed at wiley onlin elibr ary.com] cardiopulmonary support peripheral jugular-femoral VA configuration has been employed with good results. [18][19][20][21] In this condition, the focus here is the drainage cannula position since most of the mixing of native and extracorporeal blood takes place on the venous side. 19,20 In the presence of two venous cannulae or DLC for drainage, a change in the flow to return oxygenated blood in one of the cannulae or the perfusion lumen of the DLC may represent a solution, provided that the oxygenated return flow to the venous side is controlled.…”

“…[18][19][20][21] In this condition, the focus here is the drainage cannula position since most of the mixing of native and extracorporeal blood takes place on the venous side. 19,20 In the presence of two venous cannulae or DLC for drainage, a change in the flow to return oxygenated blood in one of the cannulae or the perfusion lumen of the DLC may represent a solution, provided that the oxygenated return flow to the venous side is controlled. Based on the preferential direction of the reinfused flow toward the vessel with lower circuit pressure-drop, that is, flow resistance and opposing vascular pressure (venous system), the lack of flow control might induce a "steal" of oxygenated blood.…”

A review on extracorporeal membrane oxygenation and kidney injury

“…Hou reported a decrease in renal perfusion, major surgery, contrast nephropathy, use of aminoglycosides as the major factors associated with the occurrence of AKI. [ 11 ] Shusterman et al conducted a case‐control study in the *****USA, in 1981, they reported the major risk factor associated with AKI were hypovolemia, shock associated with septicemia, cardiac failure, and use of contrast media. Furthermore, a significant risk of AKI was seen in the patients who have been on ECMO, which is common among critically ill patients with cardiorespiratory failure, it is used in the Cath labs.…”