Prone and ECMO – a contradiction per se?

Abstract

Acute respiratory distress syndrome (ARDS) still represents a serious problem in clinical routine and is associated with a high mortality. Several concepts are known for special treatment, but, in some instances, the application of an extracorporeal membrane oxygenation (ECMO) is necessary for both the improvement of oxygenation and the elimination of carbon dioxide (CO(2)). One basic aspect in lung protective ventilation in this context is alveolar recruitment, which can be achieved by different approaches, such as "the open lung concept", according to Lachmann, or by additional kinetic therapy. The most exposed feature of this entity is 'prone', which may be quite challenging in patients requiring extracorporeal support or organ replacement therapy under ongoing critical illness. We report two outstanding cases of prone under conditions of a veno-venous ECMO therapy which improved significantly under this position. Furthermore, we reflect critically possible risk factors and adverse events of such procedures and afford a current view from the literature.

Complications of Prone Positioning During Extracorporeal Membrane Oxygenation for Respiratory Failure: A Systematic Review

“…The majority of the subjects experienced no complications from concurrent ECMO and prone positioning therapy. 2,3,6,7,[9][10][11] However, the most common complications included bleeding from the ECMO cannula site. One study reported 11 prone positioning maneuvers, of a total of 74 maneuvers among 12 subjects, resulted in bleeding from the cannula site.…”

“…No central venous or arterial catheters were reported dislodged among all studies. 2,3,6,7,[9][10][11] In the study with one of the largest sample sizes, bleeding from the central catheter was noted in 10.8% of a total of 74 prone position maneuvers among 12 subjects. 2 …”

“…None of the studies in this review reported cutaneous pressure sores. 2,3,6,7,[9][10][11] Facial edema was reported in 66.7% of subjects in 1 study but was reversible. 11 Also, this study reported complications related to ECMO (entrance of air in the circuit and pump failure), but these were deemed unrelated to the prone positioning.…”

“…Among the remainder of the studies that reported on the type of prone positioning maneuver used, all studies utilized manual prone positioning techniques. 2,6,7,9 …”

“…2,5 However, severe complications can potentially result from prone positioning ECMO patients. 2,3,[6][7][8][9][10][11] Prone positioning alone can pose serious risks. Among a study examining prone positioning in subjects without ECMO, a high incidence, 10.7%, of unintended extubations was reported.…”