Management of Refractory Hypoxemia During Venovenous Extracorporeal Membrane Oxygenation for ARDS

Choosing the appropriate configuration and cannulation strategies for extracorporeal membrane oxygenation: the potential dynamic process of organ support and importance of hybrid modes

“…V‐V ECMO with a femoral‐jugular configuration is commonly used where dual‐lumen cannulas are not available or are deemed unsuitable. Outflow supported by a long multi‐stage femoral venous cannula combined with a short reinfusion cannula inserted through the internal jugular vein grants excellent flow with minimal recirculation. A reverse, atrio‐femoral strategy is used in some centers.…”

“…Patient physiology or clinical conditions and needs, may change over time (e.g. the heart may recover faster than the lungs) and modifications in ECMO configuration mat be occasionally necessary. The conversion from the initial ECMO strategy to a different modality should always be strongly considered if the patient's perfusion is inadequate or other goals of therapy are not being met, or if complications are arising as a result of the cannulation strategy, e.g.…”

“…differential hypoxemia. The need to convert to a different ECMO modality should not necessarily be considered as a planning failure, but rather as a response to a patient's dynamic condition.…”

Persistent hypoxemia on ECMO

“…A final option is to leverage the native lungs, such as through prone positioning, as long as lung protective strategies can be maintained. 4 …”

Respiratory ECMO

“…Adding more oxygen to either disease obstructed alveoli or the ECMO membrane will not solve the problem. 4 Carbon dioxide is a diffusion-limited gas: CO 2 does not have the same problem as oxygen. It can ride on the hemoglobin, the albumin, and can also swim in the CO 2 –HCO 3 buffer.…”