Venovenous Extracorporeal Membrane Oxygenation in Intractable Pulmonary Insufficiency: Practical Issues and Future Directions

Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.

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Bleomycin-induced lung injury treated with venovenous extracorporeal membrane oxygenation (ECMO) and ultra-protective ventilator settings

BMJ Case Reports ◽

10.1136/bcr-2020-236474 ◽

2020 ◽

Vol 13 (11) ◽

pp. e236474

Author(s):

Mazen Faris Odish ◽

William Cameron McGuire ◽

Patricia Thistlethwaite ◽

Laura E Crotty Alexander

Keyword(s):

Lung Injury ◽

Extracorporeal Membrane Oxygenation ◽

Case Reports ◽

Rapid Onset ◽

High Dose ◽

Drug Induced ◽

Membrane Oxygenation ◽

Hypoxic Respiratory Failure ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Vv Ecmo

Bleomycin treats malignancies, such as germ cell tumours and Hodgkin lymphoma. While efficacious, it can cause severe drug-induced lung injury. We present a 42-year-old patient with stage IIB seminoma treated with radical orchiectomy followed by adjuvant chemotherapy with bleomycin, etoposide and cisplatin. His postbleomycin course was complicated by the rapid onset of hypoxic respiratory failure, progressing to acute respiratory distress syndrome and requiring venovenous extracorporeal membrane oxygenation (VV-ECMO) support. Although the patient was treated with high dose systemic steroids and ultra-protective ventilator strategies to minimise ventilator-induced lung injury while on VV-ECMO, his lung injury failed to improve. Care was withdrawn 29 days later. Lung autopsy revealed diffuse organising pneumonia. We found six case reports (including this one) of bleomycin-induced lung injury requiring VV-ECMO with a cumulative survival of 33% (2/6). While VV-ECMO may be used to bridge patients to recovery or lung transplant, the mortality is high.

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Comparison of atrio-femoral and femoro-atrial venovenous extracorporeal membrane oxygenation in adult

Perfusion ◽

10.1177/0267659120969020 ◽

2020 ◽

pp. 026765912096902

Author(s):

Steven Kin-ho Ling

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Case Control Study ◽

Case Control ◽

Single Centre ◽

Retrospective Case ◽

Membrane Oxygenation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Control Study ◽

Ecmo Flow ◽

Vv Ecmo

Introduction: Different cannulation approaches existed for veno-venous extracorporeal membrane oxygenation (VV ECMO). We aimed to compare the atrio-femoral (AF) and femoro-atrial (FA) configuration in terms of their flow efficiency and influence on patient outcome. Method: This was a single-centre, retrospective case control study. Adult patients admitted to the Intensive Care Unit and required VV ECMO service at Tuen Mun Hospital, Hong Kong, from June 2015 to January 2020 were included. Data were collected from our ECMO database for comparison. Results: Between June 2015 and January 2020, eight patients received AF configuration and 19 patients received FA configuration. The maximum achieved flow in the AF group was significantly higher than that in the FA group (4.08 ± 0.57 L/min vs. 3.52 ± 0.58 L/min, p = 0.03). The fluid balance in first 3 days of ECMO was significantly lower in the AF group compared to that in the FA group (1.16 ± 2.71 L vs. 3.46 ± 1.97 L, p = 0.02). As well, the chance for successful awake ECMO was statistically higher in the AF group (p = 0.048). Conclusion: Atrio-femoral configuration in VV ECMO was associated with a higher maximum achieved ECMO flow, less fluid gain in first 3 days of ECMO and more successful awake ECMO.

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CRITICAL CARE ECHO ROUNDS: Extracorporeal membrane oxygenation

Echo Research and Practice ◽

10.1530/erp-14-0111 ◽

2015 ◽

Vol 2 (2) ◽

pp. D1-D11 ◽

Cited By ~ 7

Author(s):

Kelly Victor ◽

Nicholas A Barrett ◽

Stuart Gillon ◽

Abigail Gowland ◽

Christopher I S Meadows ◽

...

Keyword(s):

Respiratory Failure ◽

Extracorporeal Membrane Oxygenation ◽

Ventilatory Support ◽

Ecmo Support ◽

Respiratory Physiology ◽

Organ Support ◽

Septic Cardiomyopathy ◽

Significant Past Medical History ◽

Membrane Oxygenation ◽

Vv Ecmo

Extracorporeal membrane oxygenation (ECMO) is an advanced form of organ support indicated in selected cases of severe cardiovascular and respiratory failure. Echocardiography is an invaluable diagnostic and monitoring tool in all aspects of ECMO support. The unique nature of ECMO, and its distinct effects upon cardio-respiratory physiology, requires the echocardiographer to have a sound understanding of the technology and its interaction with the patient. In this article, we introduce the key concepts underpinning commonly used modes of ECMO and discuss the role of echocardiography.CaseA 38-year-old lady, with no significant past medical history, was admitted to her local hospital with group A Streptococcal pneumonia. Rapidly progressive respiratory failure ensued and, despite intubation and maximal ventilatory support, adequate oxygenation proved impossible. She was attended by the regional severe respiratory failure service who established her on veno-venous (VV)-ECMO for respiratory support. Systemic oxygenation improved; however, significant cardiovascular compromise was encountered and echocardiography demonstrated a severe septic cardiomyopathy (ejection fraction <15%, aortic velocity time integral 5.9 cm and mitral regurgitation dP/dt 672 mmHg/s). Her ECMO support was consequently converted to a veno-veno-arterial configuration, thus providing additional haemodynamic support. As the sepsis resolved, arterial ECMO support was weaned under echocardiographic guidance; subsequent resolution of intrinsic respiratory function allowed the weaning of VV-ECMO support. The patient was liberated from ECMO 7 days after hospital admission.

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Continuous Renal Replacement Therapy (CRRT) Attenuates Myocardial Inflammation and Mitochondrial Injury Induced by Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) in a Healthy Piglet Model

Inflammation ◽

10.1007/s10753-013-9654-7 ◽

2013 ◽

Vol 36 (5) ◽

pp. 1186-1193 ◽

Cited By ~ 11

Author(s):

Juanhong Shen ◽

Wenkui Yu ◽

Qiyi Chen ◽

Jialiang Shi ◽

Yimin Hu ◽

...

Keyword(s):

Renal Replacement Therapy ◽

Extracorporeal Membrane Oxygenation ◽

Continuous Renal Replacement Therapy ◽

Replacement Therapy ◽

Myocardial Inflammation ◽

Mitochondrial Injury ◽

Membrane Oxygenation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Healthy Piglet ◽

Vv Ecmo

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A descriptive evaluation of causes of death in venovenous extracorporeal membrane oxygenation

Perfusion ◽

10.1177/02676591211035938 ◽

2021 ◽

pp. 026765912110359

Author(s):

Sagar B Dave ◽

Kristopher B Deatrick ◽

Samuel M Galvagno ◽

Michael A Mazzeffi ◽

David J Kaczorowski ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Cause Of Death ◽

Lung Transplant ◽

Acute Hemorrhage ◽

Ventilator Support ◽

Common Cause ◽

Membrane Oxygenation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Vv Ecmo

Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become an important support modality for patients with acute respiratory failure refractory to optimal medical therapy, such as low tidal volume mechanical ventilator support, early paralytic infusion, and early prone positioning. The objective of this cohort study was to investigate the causes and timing of in-hospital mortality in patients on VV ECMO. All patients, excluding trauma and bridge to lung transplant, admitted 8/2014–6/2019 to a specialty ICU for VV ECMO were reviewed. Two hundred twenty-five patients were included. In-hospital mortality was 24.4% ( n = 55). Most non-survivors (46/55, 84%) died prior to lung recovery and decannulation from VV ECMO. Most common cause of death (COD) for patients who died on VV ECMO was removal of life sustaining therapy (LST) in setting of multisystem organ failure (MSOF) ( n = 24). Nine patients died a median of 9 days [6, 11] after decannulation. Most common COD in these patients was palliative withdrawal of LST due to poor prognosis ( n = 3). Non-survivors were older and had worse predictive mortality scores than survivors. We found that death in patients supported with VV ECMO in our study most often occurs prior to decannulation and lung recovery. This study demonstrated that the most common cause of death in patients supported with VV ECMO was removal of LST due MSOF. Acute hemorrhage (systemic or intracranial) was not found to be a common cause of death in our patient population.

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Sedation and analgesia requirements during venovenous extracorporeal membrane oxygenation in acute respiratory distress syndrome patients

Perfusion ◽

10.1177/02676591211052160 ◽

2021 ◽

pp. 026765912110521

Author(s):

Xingshu Ren ◽

Yuhang Ai ◽

Lina Zhang ◽

Chunguang Zhao ◽

Li Li ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Linear Correlation ◽

Distress Syndrome ◽

Membrane Oxygenation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Sedation And Analgesia ◽

Vv Ecmo

Introduction: The purpose of this study is to describe sedation and analgesia management, and identify the factors associated with increased demand for medication in acute respiratory distress syndrome (ARDS) patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). Methods: This retrospective, single-center study included consecutive adult ARDS patients who received VV-ECMO for at least 24 hours from January 2018 to December 2020 in a comprehensive intensive care unit. The electronic medical records were retrospectively reviewed to collect data. Results: Forty-two adult patients meeting the inclusion criteria were included in the study. Midazolam, sufentanil, and remifentanil were main sedatives and analgesics used in the patient population. The morphine equivalents, representative of the demand for opioids, was 512.9 (IQR, 294.5, 798.2) mg/day. The midazolam equivalents, representative of benzodiazepine requirement, was 279.6 (IQR, 208.8, 384.5) mg/day. The levels of serum creatinine, total bilirubin, lactic acid, SOFA score, and APACHE Ⅱ score at cannulation were found to be associated with opiate or benzodiazepine requirements. Multiple linear regression analysis revealed a linear correlation between midazolam equivalents and morphine equivalents (p < 0.001). In addition, there was a negative linear correlation between Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score and midazolam equivalents (p = 0.024). Conclusions: The sedation and analgesia requirements of ARDS patients receiving VV-ECMO often increase simultaneously. More large-scale studies are needed to confirm the risk factors for increased sedation and analgesia needs in patients supported on VV-ECMO.

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Venovenous Extracorporeal Membrane Oxygenation as a Treatment for Obesity Hypoventilation Syndrome

Case Reports in Critical Care ◽

10.1155/2017/9437452 ◽

2017 ◽

Vol 2017 ◽

pp. 1-3

Author(s):

Nao Umei ◽

Shingo Ichiba

Keyword(s):

Weight Loss ◽

Respiratory Failure ◽

Extracorporeal Membrane Oxygenation ◽

Morbidly Obese ◽

Obesity Hypoventilation Syndrome ◽

Membrane Oxygenation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Hypoventilation Syndrome ◽

Obesity Hypoventilation ◽

Vv Ecmo

The mortality rate for respiratory failure resulting from obesity hypoventilation syndrome is high if it requires ventilator management. We describe a case of severe acute respiratory failure resulting from obesity hypoventilation syndrome (BMI, 60.2 kg/m2) successfully treated with venovenous extracorporeal membrane oxygenation (VV-ECMO). During ECMO management, a mucus plug was removed by bronchoscopy daily and 18 L of water was removed using diuretics, resulting in weight loss of 24 kg. The patient was weaned from ECMO on day 5, extubated on day 16, and discharged on day 21. The fundamental treatment for obesity hypoventilation syndrome in morbidly obese patients is weight loss. VV-ECMO can be used for respiratory support until weight loss has been achieved.

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The potential of accurate SVO2 monitoring during venovenous extracorporeal membrane oxygenation: an in vitro model using ultrasound dilution

Perfusion ◽

10.1177/0267659107083656 ◽

2007 ◽

Vol 22 (4) ◽

pp. 239-244 ◽

Cited By ~ 8

Author(s):

Joshua Walker ◽

Johanna Primmer ◽

Bruce E. Searles ◽

Edward M. Darling

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Oxygen Saturation ◽

Ecmo Circuit ◽

Ultrasound Dilution ◽

Membrane Oxygenation ◽

Mixed Venous Saturation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Line Oxygen ◽

Mixed Venous ◽

Vv Ecmo

Introduction. Some degree of recirculation occurs during venovenous extracorporeal membrane oxygenation (VV ECMO) which, (1) reduces oxygen (O2) delivery, and (2) renders venous line oxygen saturation monitoring unreliable as an index of perfusion adequacy. Ultrasound dilution allows clinicians to rapidly monitor and quantify the percent of recirculation that is occurring during VV ECMO. The purpose of this paper is to test whether accurate patient mixed venous oxygen saturation (SVO2) can be calculated once recirculation is determined. It is hypothesized that it is possible to derive patient mixed venous saturations by integrating recirculation data with the ECMO circuit arterial and venous line oxygen saturation data. Methods. A test system containing sheep blood adjusted to three venous saturations (low-30%, med-60%, high-80%) was interfaced via a mixing chamber with a standard VV ECMO circuit. Recirculation, arterial line and venous line oxygen saturations were measured and entered into a derived equation to calculate the mixed venous saturation. The resulting value was compared to the actual mixed venous saturation. Results. Recirculation was held constant at 30.5 ± 2.0% for all tests. A linear regression comparison of “actual” versus “calculated” mixed venous saturations produced a correlation coefficient of R2 = 0.88. Direct comparison of actual versus calculated saturations for all three test groups respectively are as follows; Low: 31.8 ± 3.95% vs. 37.0 ± 6.7% (NS), Med: 61.7 ± 1.5% vs. 72.3 ± 1.8% (p < 0.05), High: 84.4 ± 0.9% vs. 91.2 ± 1.1% (p < 0.05). Discussion. There was a strong correlation between actual and calculated mixed venous saturations; however, significant differences between actual and calculated values where observed at the Med and High groups. While this data suggests that using quantified recirculation data to calculate SVO2 is promising, it appears that a straightforward derivative of the oxygen saturation-based equation may not be sufficient to produce clinically accurate calculations of actual mixed venous saturations. Perfusion (2007) 22, 239—244.

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Approach to Sedation and Analgesia in COVID-19 Patients on Venovenous Extracorporeal Membrane Oxygenation

Annals of Pharmacotherapy ◽

10.1177/10600280211010751 ◽

2021 ◽

pp. 106002802110107

Author(s):

Diane Dreucean ◽

Jesse E. Harris ◽

Prakruthi Voore ◽

Kevin R. Donahue

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Patient Population ◽

Data Extraction ◽

Ecmo Support ◽

Pharmacokinetic Studies ◽

Safety And Efficacy ◽

Membrane Oxygenation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Sedation And Analgesia ◽

Vv Ecmo

Objective: To describe clinically pertinent challenges of managing sedation in COVID-19 patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) and describe considerations for enhanced safety and efficacy of pharmacological agents used. Data Sources: A PubMed search was performed using the following search terms: ECMO, ARDS, sedation, COVID-19, coronavirus, opioids, analgesia, fentanyl, hydromorphone, morphine, oxycodone, methadone, ketamine, propofol, dexmedetomidine, clonidine, benzodiazepines, midazolam, lorazepam, and diazepam. Study Selection and Data Extraction: Relevant clinical and pharmacokinetic studies were considered. All studies included were published between January 1988 and March 2021. Data Synthesis: Patients with acute respiratory distress syndrome secondary to COVID-19 may progress to requiring VV-ECMO support. Agents frequently used for sedation and analgesia in these patients have been shown to have significant adsorption to ECMO circuitry, leading to possible diminished clinical efficacy. Use of hydromorphone-based analgesia has been associated with improved clinical outcomes in patients on VV-ECMO. However, safety and efficacy regarding use of other agents in this patient population remains an area of further research. Relevance to Patient Care and Clinical Practice: This review addresses clinical challenges associated with sedation management in COVID-19 patients requiring VV-ECMO support and provides potential strategies to overcome these challenges. Conclusions: Historically, sedation and analgesia management in patients requiring ECMO support have posed a challenge for bedside clinicians given the unique physiological and pharmacokinetic changes in this patient population. A multimodal strategy to managing analgesia and sedation should be used, and the use of enteral agents may play a role in reducing parenteral agent requirements.

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