Extracorporeal membrane oxygenation circuits in parallel for refractory hypoxemia in patients with COVID-19

Patel, Yatrik J; Gannon, Whitney D.; Francois, Sean A.; Stokes, John W.; Tipograf, Yuliya; Landsperger, Janna S.; Semler, Matthew W.; Casey, Jonathan D; Rice, Todd W.; Bacchetta, Matthew

doi:10.1016/j.jtcvs.2022.09.006

Cited by 7 publications

(13 citation statements)

References 35 publications

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“…Since the flow at this present oxygenator's maximum capacity, approximately 5L/min, and since there was an increased chance of recirculation phenomenon, we decided against this option. We also discussed using another separate circuit inserted in the left internal jugular for return and the left femoral to drain, as described by Patel et al [1]. We were concerned about issues with the two cannulas in the neck and also using up all venous access points.…”

Section: Discussionmentioning

confidence: 99%

Case Report: When Enough is not Enough… Treating Refractory Hypoxemia

Capatos¹,

Nihalani²,

Pratap³

2023

J Critical Care & Emerg Med

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Herein we report a case of a 43 year old immunocompromised male, post renal transplant, with Adult Respiratory Distress Syndrome (ARDS), secondary to Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), who required Veno-Venous Extra Corporeal Membrane Oxygenation (VV ECMO), with the unique configuration of double oxygenators. Despite invasive ventilatory support and maximum conventional VV ECMO support, he had persistent refractory hypoxemia. At this point, it was deemed necessary to attempt an adjuvant intervention to improve his oxygenation and hence the decision was made, to add another oxygenator to the existing ECMO circuit. His oxygenation parameters improved after the addition of the second oxygenator. The patient improved gradually and we continued to wean his ECMO settings. He was eventually DE cannulated after 34 days on ECMO. We believe that this is the first case where two oxygenators were placed in parallel, in a single circuit, for a SARS COV-2 patient with refractory hypoxemia. The addition of an oxygenator in parallel was successful in improving oxygenation and more importantly allowed us to continue with ultra-protective lung ventilation. The patient provided informed consent for scientific publication.

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Section: Discussionmentioning

confidence: 99%

Case Report: When Enough is not Enough… Treating Refractory Hypoxemia

Capatos¹,

Nihalani²,

Pratap³

2023

J Critical Care & Emerg Med

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“…4,5 Increasing ECMO RPM may risk suction events or hemolysis, while adding additional cannulas carries risks of line-related complications, procedural complications, or infections. 8,13 Initiation of esmolol risks worsening oxygen delivery in sepsis, anemia, or heart failure, all while improving the oxygen saturation and possibly delaying the diagnosis of critical events such as acute anemia. 2,4 The presented case highlights that refractory hypoxemia on VV-ECMO can be due to a myriad of etiologies-even in the same patient over short intervals of time.…”

Section: Discussionmentioning

confidence: 99%

“…In these situations, it may be useful to calculate DO 2 -ECMO to ensure an adequate DO 2 /VO 2 ratio or to consider the risks/benefits of different approaches to augment DO 2 -ECMO, such as by increasing ECMO flow by escalating RPM, elevating transfusion goals, or adding a drainage cannula. 7,9,13 For our patient, ECMO flow was clinically "maximal" at 2.6 L/ min with existing cannulas and clinical status, since RPM escalation resulted in rapid decreases in venous-limb pressure from approximately −50 to below −130 mm Hg. This was not responsive to reasonable volume resuscitation and concerning for an impending suction event.…”

Section: Case Descriptionmentioning

confidence: 95%

“…Consideration was given to adding an additional drainage cannula to improve ECMO flow; given the patient's small size and overall clinical improvement in ventilatory and other parameters, avoidance of the burden and risk of the procedure was paramount. 4,13 By calculation, transfusion from 7.9 to 9.9 g/dL would have increased DO 2 -ECMO from 419 to only 507 mL/min (Table 1, event 3). 14 This would maintain a DO 2 /VO 2 ratio of 2.9-still below goal.…”

Section: Case Descriptionmentioning

confidence: 99%

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Refractory Hypoxemia on VV-ECMO: Repetition of a Structured Approach Is Paramount: A Case Report

et al. 2023

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Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is increasingly used to manage severe respiratory failure. Unfortunately, refractory hypoxemia often complicates VV-ECMO support. Both circuit- and patient-related etiologies can drive this, and a structured approach is necessary to diagnose and treat the condition. We present the case of a patient on VV-ECMO for acute respiratory distress syndrome who suffered from several distinct etiologies of refractory hypoxemia over a short timeframe. Frequent recalculation of cardiac output and oxygen delivery enabled early diagnosis and treatment of these conditions. We highlight the need for a structured and oft-repeated approach to this complex problem.

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“…The recent paper describes an alternative approach based on using two parallel ECMO circuits 23 . The authors were able to increase blood flow through the ECLS up to 7.0 L/min and simultaneously decrease the intensity of mechanical ventilation, reducing FiO 2 from 1.0 to 0.6 while maintaining very good survival rate exceeding 70%.…”

Section: Discussionmentioning

confidence: 99%

Effects of adding the second drainage cannula in severely hypoxemic patients supported with VV ECMO due to COVID‐19‐associated ARDS

Szułdrzyński,

Kowalewski,

Jankowski

et al. 2023

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BackgroundExtracorporeal membrane oxygenation (ECMO) is a recognized method of support in patients with severe and refractory acute respiratory distress syndrome (ARDS) caused by SARS‐CoV‐2 infection. While veno‐venous (VV) ECMO is the most common type, some patients with severe hypoxemia may require modifications to the ECMO circuit. In this study, we aimed to investigate the effects of adding a second drainage cannula to the circuit in patients with refractory hypoxemia, on their gas exchange, mechanical ventilation, ECMO settings, and clinical outcomes.MethodsWe conducted an observational retrospective study based on a single‐center institutional registry including all consecutive cases of COVID‐19 patients requiring ECMO admitted to the Centre of Extracorporeal Therapies in Warsaw between March 1, 2020 and March 1, 2022. We selected patients who had an additional drainage cannula inserted. Changes in ECMO and ventilator settings, blood oxygenation, and hemodynamic parameters, as well as clinical outcomes were assessed.ResultsOf 138 VV ECMO patients, 12 (9%) patients met the inclusion criteria. Ten patients (83%) were men, and mean age was 42.2 ± 6.8. An addition of drainage cannula resulted in a significant raise in ECMO blood flow (4.77 ± 0.44 to 5.94 ± 0.81 [L/min]; p = 0.001), and the ratio of ECMO blood flow to ECMO pump rotations per minute (RPM), whereas the raise in ECMO RPM alone was not statistically significant (3432 ± 258 to 3673 ± 340 [1/min]; p = 0.064). We observed a significant drop in ventilator FiO2 and a raise in PaO2 to FiO2 ratio, while blood lactates did not change significantly. Nine patients died in hospital, one was referred to lung transplantation center, two were discharged uneventfully.ConclusionsThe use of an additional drainage cannula in severe ARDS associated with COVID‐19 allows for an increased ECMO blood flow and improved oxygenation. However, we observed no further improvement in lung‐protective ventilation and poor survival.

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Extracorporeal membrane oxygenation circuits in parallel for refractory hypoxemia in patients with COVID-19

Cited by 7 publications

References 35 publications

Case Report: When Enough is not Enough… Treating Refractory Hypoxemia

Case Report: When Enough is not Enough… Treating Refractory Hypoxemia

Refractory Hypoxemia on VV-ECMO: Repetition of a Structured Approach Is Paramount: A Case Report

Effects of adding the second drainage cannula in severely hypoxemic patients supported with VV ECMO due to COVID‐19‐associated ARDS

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