Structural recirculation and refractory hypoxemia under femoro‐jugular veno‐venous extracorporeal membrane oxygenation

Charbit, Jonathan; Deras, Pauline; Courvalin, Elie; Laumon, Thomas; Dagod, Geoffrey; Martinez, Orianne; Capdevila, Xavier

doi:10.1111/aor.13916

Cited by 6 publications

(11 citation statements)

References 33 publications

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“…However, VV-ECMO may fail to restore a satisfactory level of oxygen saturation despite a significant extracorporeal blood flow. Direct determinants of systemic oxygenation are nowadays well known: pulmonary shunt, effective extracorporeal blood flow, cardiac output, and theoretical value of mixed venous oxygen saturation (“SvO 2 ”) [ 5 , 6 ]. Thus, effective extracorporeal blood flow, which is directly determined by the extracorporeal settings and recirculation phenomena, is the cornerstone of blood reoxygenation under VV-ECMO.…”

Section: Introductionmentioning

confidence: 99%

“…This IVC → RA route is reputed simple and efficient [ 9 ]. However, despite extensive use, the IVC → RA route has two main limitations: the structural recirculation and the superior cava shunt (i.e., deoxygenated venous blood from superior vena cava [SVC] directly heading to pulmonary artery) [ 6 – 8 ]. These structural limits in relation to the reinfusion of reoxygenated blood in the superior vena cava (SVC) are inevitable when extracorporeal blood flow is higher than the blood flow into the IVC and cannot be avoided by a simple modification of cannulas position [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

“…Using bicaval drainage and a proximal extracorporeal return, the IVC + SVC → RA route should be considered as a serial configuration, which should theoretically reduce structural recirculation. More important, the superior caval shunt, which is the main factor responsible for refractory hypoxaemia under V-V ECMO, would be also reduced; this is not possible with the IVC → RA route [ 6 ]. However, despite a strong physiological rational to limit the superior caval shunt, evidences on the superiority of the IVC + SVC → RA route to reoxygenate systemic blood is lacking.…”

Section: Introductionmentioning

confidence: 99%

“…However, despite a strong physiological rational to limit the superior caval shunt, evidences on the superiority of the IVC + SVC → RA route to reoxygenate systemic blood is lacking. Therefore, we wanted to compare the IVC → RA route with the IVC + SVC → RA route in terms of blood reoxygenation performance using a recently published ECMO mathematical model [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

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Mathematical modelling of oxygenation under veno-venous ECMO configuration using either a femoral or a bicaval drainage

Charbit

Courvalin

Dagod

et al. 2022

ICMx

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Background The bicaval drainage under veno-venous extracorporeal membrane oxygenation (VV ECMO) was compared in present experimental study to the inferior caval drainage in terms of systemic oxygenation. Method Two mathematical models were built to simulate the inferior vena cava-to-right atrium (IVC → RA) route and the bicaval drainage-to-right atrium return (IVC + SVC → RA) route using the following parameters: cardiac output (QC), IVC flow/QC ratio, venous oxygen saturation, extracorporeal pump flow (QEC), and pulmonary shunt (PULM-Shunt) to obtain pulmonary artery oxygen saturation (SPAO2) and systemic blood oxygen saturation (SaO2). Results With the IVC → RA route, SPAO2 and SaO2 increased linearly with QEC/QC until the threshold of the IVC flow/QC ratio, beyond which the increase in SPAO2 reached a plateau. With the IVC + SVC → RA route, SPAO2 and SaO2 increased linearly with QEC/QC until 100% with QEC/QC = 1. The difference in required QEC/QC between the two routes was all the higher as SaO2 target or PULM-Shunt were high, and occurred all the earlier as PULM-Shunt were high. The required QEC between the two routes could differ from 1.0 L/min (QC = 5 L/min) to 1.5 L/min (QC = 8 L/min) for SaO2 target = 90%. Corresponding differences of QEC for SaO2 target = 94% were 4.7 L/min and 7.9 L/min, respectively. Conclusion Bicaval drainage under ECMO via the IVC + SVC → RA route gave a superior systemic oxygenation performance when both QEC/QC and pulmonary shunt were high. The VV-V ECMO configuration (IVC + SVC → RA route) might be an attractive rescue strategy in case of refractory hypoxaemia under VV ECMO.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Mathematical modelling of oxygenation under veno-venous ECMO configuration using either a femoral or a bicaval drainage

Charbit

Courvalin

Dagod

et al. 2022

ICMx

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“…The main parameters of systemic oxygenation are the oxygen gas mix, BF/cardiac output ratio, extracorporeal blood ow recirculation and the importance of a pulmonary shunt. 4,5 Thus, maintaining systemic oxygenation may be challenging in extreme cases despite a high BF in the case of signi cant recirculation, high cardiac output and/or massive intrapulmonary shunt. In contrast, extracorporeal blood decarboxylation is reputed to be simpler to achieve using a lower BFs.…”

Section: Introductionmentioning

confidence: 99%

Performance of The Decarboxylation Index To Predict CO2 Removal And Mechanical Ventilation Reduction Under VV-ECMO Or High-Flow ECCO2R

Laumon

Courvalin

Dagod

et al. 2022

Preprint

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Background: Optimal decarboxylation dose under extracorporeal respiratory support to ensure sufficient reduction of mechanical ventilation stress remains unclear and understudied. The aim of this study was to assess the interdependence of blood flow (BF) and gas flow (GF) in predicting CO2 removal and mechanical ventilation reduction (MVR) under extracorporeal respiratory support. Methods: All patients who benefited from veno-venous ECMO (HLS-maquet 7.0, 1.8 m²) and high-flow ECCO2R (HLS-maquet 5.0, 1.3 m²) in our intensive care unit over a period of 18 months were included. CO2 removal was calculated from inlet/outlet blood gases performed in clinical practice during the first 7 days of oxygenator use. The relationship between the BF × GF product and CO2 removal or MVR was studied using linear regression models. Results: Eighteen patients were analysed, corresponding to 24 oxygenators and 261 datasets. CO2 removal was 393 mL/min (IQR, 310–526 mL/min) for 1.8 m2 oxygenators and 179 mL/min (IQR, 165–235 mL/min) for 1.3 m2 oxygenators. The decarboxylation index was associated linearly with CO2 removal (R2 = 0.62 and R2 = 0.77 for the two oxygenators, respectively) and MVR (R2 = 0.72 and R2 = 0.62, respectively). Values in the range 20−30L2/min2 were associated with an MVR ratio between 38% and 58% for 1.8 m2 oxygenators, and between 37% and 55% for 1.3 m2 oxygenators. Conclusion: The decarboxylation index is a simple parameter to predict CO2 removal and MVR under extracorporeal respiratory support. A BF of 2 L2/min2 or more may be necessary to obtain a significant reduction of mechanical convection.Trial Registration: Being a retrospective study, no trial registration was made.

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PCO2 Gradient Between Inlet and Outlet Blood of Extracorporeal Respiratory Support Is a Reliable Marker of CO2 Elimination

Charbit,

Courvalin,

Dagod

et al. 2023

ASAIO Journal

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Our objective was to assess the relationship between the pre-/post-oxygenator gradient of the partial pressure of carbon dioxide (∆EC PCO2; dissolved form) and CO2 elimination under extracorporeal respiratory support. All patients who were treated with veno-venous extracorporeal membrane oxygenation and high-flow extracorporeal CO2 removal in our intensive care unit over 18 months were included. Pre-/post-oxygenator blood gases were collected every 12 h and CO2 elimination was calculated for each pair of samples (pre-/post-oxygenator total carbon dioxide content in blood [ctCO2] × pump flow [extracorporeal pump flow {QEC}]). The relationship between ∆EC PCO2 and CO2 elimination, as well as the origin of CO2 removed. Eighteen patients were analyzed (24 oxygenators and 293 datasets). Each additional unit of ∆EC PCO2 × QEC was associated with an increase in CO2 elimination of 5.2 ml (95% confidence interval [CI], 4.7−5.6 ml; p < 0.001). Each reduction of 1 ml STPD/dl of CO2 across the oxygenator was associated with a reduction of 0.63 ml STPD/dl (95% CI, 0.60−0.66) of CO2 combined with water, 0.08 ml STPD/dl (95% CI, 0.07−0.09) of dissolved CO2, and 0.29 ml STPD/dl (95% CI, 0.27−0.31) of CO2 in erythrocytes. The pre-/post-oxygenator PCO2 gradient under extracorporeal respiratory support is thus linearly associated with CO2 elimination; however, most of the CO2 removed comes from combined CO2 in plasma, generating bicarbonate.

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Structural recirculation and refractory hypoxemia under femoro‐jugular veno‐venous extracorporeal membrane oxygenation

Cited by 6 publications

References 33 publications

Mathematical modelling of oxygenation under veno-venous ECMO configuration using either a femoral or a bicaval drainage

Mathematical modelling of oxygenation under veno-venous ECMO configuration using either a femoral or a bicaval drainage

Performance of The Decarboxylation Index To Predict CO2 Removal And Mechanical Ventilation Reduction Under VV-ECMO Or High-Flow ECCO2R

PCO2 Gradient Between Inlet and Outlet Blood of Extracorporeal Respiratory Support Is a Reliable Marker of CO2 Elimination

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