ECMO year in review: veno-venous ECMO

VV-ECMO: reasonable therapeutic option for patients with severe ARDS and major hypoxemia or excessive pressures; a review summarizing results of most recent trials and elaborating on the unmet needs: future trials should be designed to optimize patients management while on extracorporeal support.

Schmidt M, Franchineau G, Combes A. Recent advances in venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Curr Opin Crit Care. 2019 Feb;25(1):71-76. link

ECMO & ECCO2R for acute respiratory failure, a review: terminology, basics of ECLS, indications, potential indications and contraindications, goals & complications, regionalization at expert centers & mobile ECLS, historical perspective & future, current and future research priorities. Extracorporeal support evolved rapidly in recent years from niche technology to a mainstream strategy of respiratory & (right) heart support: as development of new ECLS technologies holds the promise of changing the approach respiratory failure, and role of ECLS will no doubt continue growing, the need for high-quality research to guide this evolution has never been greater.

Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA. 2019 Aug 13;322(6):557-568. link

A systematic literature review about animal models combining features of experimental ARDS with ECMO, developed to support translational research, to better understand this complex setting: significant heterogeneity in both design & reporting creates difficulty in assessing results and in generalizing findings to clinical settings. The introduction of a minimum data set for pre-clinical ECMO studies could achieved the standardization of reporting.

Millar JE, Bartnikowski N, von Bahr V, Malfertheiner MV, Obonyo NG, Belliato M, Suen JY, Combes A, McAuley DF, Lorusso R, Fraser JF; European Extracorporeal Life Support Organisation (EuroELSO) Innovations Workgroup; National Health Medical Research Council Australia Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving Organ Support (NHMRC CREACTIONS). Extracorporeal membrane oxygenation (ECMO) and the acute respiratory distress syndrome (ARDS): a systematic review of pre-clinical models. Intensive Care Med Exp. 2019 Mar 25;7(1):18. doi: 10.1186/s40635-019-0232-7 Open access link

Veno-venous extracorporeal support: from rescue high-flow VV ECMO, to low-flow or minimally invasive ECCO2R. In this open access review, options for VV ECLS, from cannulation to blood flow; rationale of the different settings, from rescue intervention for tissue hypoxia, primarily due to respiratory failure, to reduction of mechanical ventilation and related damages in ARDS, status asthmaticus, COPD exacerbation; timing: when to start and when to stop extracorporeal gas exchange.

Gattinoni L, Vassalli F, Romitti F, Vasques F, Pasticci I, Duscio E, Quintel M. Extracorporeal gas exchange: when to start and how to end? Crit Care. 2019 Jun 14;23(Suppl 1):203. Open access link

Mechanical ventilation on ECMO support

Should patients with ARDS on veno-venous ECMO have ventilatory support reduced to the lowest tolerable settings? here a debate…

How to manage MV in ARDS patients on VV ECMO? The lower, the better?? yes according to this perspective: as extracorporeal support facilitate protective ventilation, reducing ventilatory support to the lowest tolerable seems prudent, as best available evidence suggests no safe ventilatory limits exist, & lower settings associated with improved outcomes… waiting data from studies evaluating different ventilatory strategies in this population.

Zakhary B, Fan E, Slutsky A. Should Patients With Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation Have Ventilatory Support Reduced to the Lowest Tolerable Settings? Yes. Crit Care Med. 2019 Aug;47(8):1143-1146. link

Here a different viewpoint of extreme reduction in ventilatory settings in patients on VV #ECLS! Do not ignore potential risks of extreme reduction in MV settings on VV ECMO! No controversy on trying to limit the mechanical power delivered to the lungs, minimizing the risk of VILI. Achieving this, eg through proning, decreasing plateau & driving pressures, avoiding excessive PEEP, is paramount on extracorporeal support,… but risk-to-benefit ratio of maximal lung rest strategies warrant further consideration. In this paper, different viewpoint on how to manage mechanical ventilation in ARDS patients on veno-venous ECLS.

Shekar K, Brodie D. Should Patients With Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation Have Ventilatory Support Reduced to the Lowest Tolerable Settings? No. Crit Care Med. 2019 Aug;47(8):1147-1149. link

Breathing & ventilation on ECMO support, how to find the balance between rest and load?? What creates the best conditions for the lungs, used to rhythmically expanding & relaxing, to heal, more rest or more movement?
How much unloading of the lungs is most beneficial for healing and repair in ARDS patients on ECLS, and what’s best ventilatory pattern on ECMO support? Some considerations about LIFEGARDS study, ventiLatIon management oF patients with Extracorporeal membrane oxyGenation for Acute Respiratory Distress Syndrome, an international prospective study about current practices regarding MV in patients on ECLS for severe ARDS.

Quintel M, Busana M, Gattinoni L. Breathing and Ventilation during Extracorporeal Membrane Oxygenation: How to Find the Balance between Rest and Load. Am J Respir Crit Care Med. 2019 Oct 15;200(8):954-956. Open access link

(this the link to the LIFEGARDS study by Schmidt et al.)

Mechanical ventilation on ECLS in ARDS: goal? decrease its intensity to reduce ventilator-induced lung injury, major contributor to morbidity & mortality, maximizing potential benefit of ECMO support, allowing for reducing the mechanical forces contributing to VILI. All conventional management strategies as lung-protective MV, prone positioning, PEEP titration, conservative fluid balance, and (perhaps) neuromuscular blockade should be optimized before consideration of extracorporeal support. MV strategies employed in the EOLIA trial represent a reasonable standard of care on ECMO, although authors suggest lower respiratory rates.

Abrams D, Schmidt M, Pham T, Beitler JR, Fan E, Goligher EC, McNamee JJ, Patroniti N, Wilcox ME, Combes A, Ferguson ND, McAuley DF, Pesenti A, Quintel M, Fraser J, Hodgson CL, Hough CL, Mercat A, Mueller T, Pellegrino V, Ranieri VM, Rowan K, Shekar K, Brochard L, Brodie D; International ECMO Network (ECMONet). Mechanical Ventilation for ARDS During Extracorporeal Life Support: Research and Practice. Am J Respir Crit Care Med. 2019 Nov 14. link

Lung recruitability in severe ARDS on ECMO support: may greater potential for lung recruitment be associated with more favorable outcome? wide range of recruitability observed in this study in patients with severe acute respiratory distress syndrome requiring ECLS; high potential for lung recruitment associated with shorter ICU stay & shorter ECMO run.

Camporota L, Caricola EV, Bartolomeo N, Di Mussi R, Wyncoll DLA, Meadows CIS, Amado-Rodriguez L, Vasques F, Sanderson B, Glover GW, Barrett NA, Shankar-Hari M, Grasso S. Lung Recruitability in Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation. Crit Care Med. 2019 Sep;47(9):1177-1183. link

Resting the lungs with ultra-protective MV on ECMO? According to the results of this single center RCT studying mechanical ventilation strategies to limit injuries & protecting the lung of patients with severe ARDS on veno-venous ECMO, an ultra-protective ventilation strategy, based on significantly decreased plateau pressure, driving pressure and Vt (markedly lowered from 5.7 mL/kg PBW to 3.3 mL/kg PBW), led to significantly reduced pulmonary biotrauma vs standard protective-lung ventilation, once on ECLS. However, plasma cytokine and bronchoalveolar lavage sRAGE levels did not differ among the different MV settings tested during the run.

Rozencwajg S, Guihot A, Franchineau G, Lescroat M, Bréchot N, Hékimian G, Lebreton G, Autran B, Luyt CE, Combes A, Schmidt M. Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. Crit Care Med. 2019 Nov;47(11):1505-1512. link

Integrating MV & ECMO in severe ARDS open access commentary…
Shekar K, Schmidt M. Integrating Mechanical Ventilation and Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2019;200(2):265–266. Open access link

to this study testing the old concept of near apneic ventilation and its effects on lung injury/fibroproliferation in an experimental model of severe ARDS on veno-venous ECLS
Araos J, Alegria L, Garcia P, Cruces P, Soto D, Erranz B, Amthauer M, Salomon T, Medina T, Rodriguez F, Ayala P, Borzone GR, Meneses M, Damiani F, Retamal J, Cornejo R, Bugedo G, Bruhn A. Near-Apneic Ventilation Decreases Lung Injury and Fibroproliferation in an Acute Respiratory Distress Syndrome Model with Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med. 2019 Mar 1;199(5):603-612. link

… and the authors’ reply Araos J, Bruhn A. Reply to Shekar and Schmidt: Integrating Mechanical Ventilation and Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2019;200(2):266. Open access link

Current practices regarding MV in patients treated with ECMO support for severe ARDS in this international, multi-center, prospective cohort study: ultra-protective lung ventilation on ECMO largely adopted across medium to high case-volume centers; vs previous observations, no association with prognosis.

Schmidt M, Pham T, Arcadipane A, Agerstrand C, Ohshimo S, Pellegrino V, Vuylsteke A, Guervilly C, McGuinness S, Pierard S, Breeding J, Stewart C, Ching SSW, Camuso JM, Stephens RS, King B, Herr D, Schultz MJ, Neuville M, Zogheib E, Mira JP, Rozé H, Pierrot M, Tobin A, Hodgson C, Chevret S, Brodie D, Combes A. Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. Am J Respir Crit Care Med. 2019 Oct 15;200(8):1002-1012. link

Tracheostomy on ECMO support

Investigating the safety of tracheostomy placement on ECMO support, and its impact on fluid intake & on the use of sedative, analgesic, vasoactive drugs: in this single-center experience, TT may result in a reduction in vasopressor and inotropic requirement, and analgesic usage, with no increase in major bleedings, and can be safely performed in selected ECLS patients in whom benefits outweigh the risks.

Grewal J, Sutt AL, Cornmell G, Shekar K, Fraser J. Safety and Putative Benefits of Tracheostomy Tube Placement in Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience. J Intensive Care Med. 2019 Mar 21:885066619837939. link

here a comment: Lother A, Bode C, Staudacher DL. Tracheostomy in Patients on Extracorporeal Membrane Oxygenation: Is it Really Safe? J Intensive Care Med. 2019 May 23:885066619851067. link

and, in the authors’ reply, steps to enhance procedure safety. Grewal J, Sutt AL, Shekar K, Fraser JF. Steps to Enhance Safety of Tracheostomy on ECMO. J Intensive Care Med. 2019 May 19:885066619851074. link

Tracheostomy on ECMO support: in this experience with open & percutaneous tracheostomies in 127 ECLS patients (largest series to date), the procedure appears safe as performed by an experienced team at an experienced center; excellent outcome reported, with no procedural mortality or significant morbidity. Periprocedural maintenance, or short suspension, of systemic anticoagulation seems not to be associated with significant bleeding or thrombotic events.

Salna M, Tipograf Y, Liou P, Chicotka S, Biscotti M 3rd, Agerstrand C, Abrams D, Brodie D, Bacchetta M. Tracheostomy Is Safe During Extracorporeal Membrane Oxygenation Support. ASAIO J. 2019 Aug 16. link

RV & hemodynamics on VV-ECMO

RV hypertrophy: common in patients with acute respiratory distress syndrome on VV ECMO; this finding could be related to persistent increased right ventricular afterload (a well-known contributor for the development of hypertrophy), but mechanism(s) involved in its genesis are still to be elucidated. RV hypertrophy may predispose to RV ischemia or infarction, worsening outcome, and this condition may influence clinical management. Here findings from a case series, suggesting that RV hypertrophy is common in #ARDS pts before extracorporeal support, and that it could increase after #ECLS implementation; also, some, but not all, the normal RVs become hypertrophied on ECMO support, maybe indicating other factors beyond increased afterload likely contribute to RV hypertrophy.

Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Chiostri M, Fulceri G, Peris A. Right Ventricular Hypertrophy in Refractory Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation Support. J Cardiothorac Vasc Anesth. 2019 Aug 27. link

Routine echocardiographic assessment of RV size & function in patients with severe acute respiratory distress syndrome requiring veno-venous ECMO? it would be advisable, given the importance of right ventricular dysfunction and acute cor pulmonale for managing this population & prognosticating outcomes. Here, ultrasound data from a large cohort.

Pettenuzzo T, Pichette M, Douflé G, Fan E, Right Ventricular Hypertrophy in Patients Undergoing Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. J Cardiothorac Vasc Anesth. 2019. link

Hemodynamic monitoring on VV ECMO, could be challenging! a couple of papers here…CO estimation? mandatory to assess cardiac function and to evaluate BF/CO ratio; authors of this study report good agreement/low percentage of error between an uncalibrated pulse-contour analysis and TTE measurements; a pulsewave-derived method can be provide continuous cardiac output monitoring, integrating echocardiography (with POCUS providing lot additional information, even if non-continuous!!).

Bond O, Pozzebon S, Franchi F, Zama Cavicchi F, Creteur J, Vincent JL, Taccone FS, Scolletta S. Comparison of estimation of cardiac output using an uncalibrated pulse contour method and echocardiography during veno-venous extracorporeal membrane oxygenation. Perfusion. 2019 Nov 10:267659119883204. link

Transpulmonary thermodilution? in this analysis a marked increases in global end-diastolic volume index, GEDVI, & extra-vascular lung water index, EVLWI, have been observed after ECMO implementation, more pronounced in case of femoral vs jugular indicator injection; these findings are consistent with the hypothesis of a potential loss of indicator into the extracorporeal circuit; CI & haemodynamic parameters not derived from TPTD seems not substantially affected.

Herner A, Lahmer T, Mayr U, Rasch S, Schneider J, Schmid RM, Huber W. Transpulmonary thermodilution before and during veno-venous extra-corporeal membrane oxygenation ECMO: an observational study on a potential loss of indicator into the extra-corporeal circuit. J Clin Monit Comput. 2019 Nov 5. link

Awake ECMO

ECMO support… it’s not just about the technique! this group describes an unconventional not-medication based successful intervention to manage anxiety in an awake patient on veno-venous ECLS.

Blair GJ, Kapil S, Cole SP, Rodriguez S. Virtual reality use in adult ICU to mitigate anxiety for a patient on V-V ECMO. J Clin Anesth. 2019 Aug;55:26-27. link

Awake neonatal ECMO support? may offer significant advantages over traditional management in certain scenarios! In this open assess report of cases appears safe, preventing MV induced lung/airway trauma, and could solve air leaks with no invasive drainage, enable de-sedation, and limit deconditioning, while improving family bonding. Awake neonatal ECMO is a practice requiring significant team preparation, commitment & readiness/capacity to manage evolution, and family support, along with careful balance of the potential risks versus benefits on individualized basis, considering anticipated duration of ECLS run.

Costa J, Dirnberger DR, Froehlich CD, Beaty CD, Priest MA, Ogino MT. Awake Neonatal Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Jul 12. link

Sedation & analgesia on ECMO support

An international survey to assess practices regarding the monitoring & management of pain, agitation, delirium in adults on VV ECMO for severe ARDS beyond initial cannulation. Most respondents reported use of validated scales to assess, along with protocols (although very few addressing this population) to help with management. Targeting a deep level of sedation, and propofol being used for any level of sedation were mostly referred. More than half of respondents, commonly from high-volume centers, reported extubation during the veno-venous ECLS run.

Dzierba AL, Abrams D, Madahar P, Muir J, Agerstrand C, Brodie D. Current practice and perceptions regarding pain, agitation and delirium management in patients receiving venovenous extracorporeal membrane oxygenation. J Crit Care. 2019 Oct;53:98-106. link

Sedation in neonates on ECMO support: not well described & no universal guidelines; this retrospective analysis examines types & median doses, describing practices for neonatal patients requiring ECLS. Opioids and benzodiazepine frequently administered, and some patients also required adjunct therapies to maintain desired level of sedation. Most commonly used continuous infusions included morphine, midazolam, hydromorphone, sometimes dexmedetomidine & ketamine; doses typically escalated over time. Pain scores did not correlate with sedation or analgesic administrations. According to the authors, an ECMO dedicated sedation assessment tool & RN driven algorithm may better determine sedation use in this population.

Franciscovich CD, Monk HM, Brodecki D, Rogers R, Rintoul NE, Hedrick HL, Ely E. Sedation Practices of Neonates Receiving Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Aug 6. link

Individualizing Sedation in ARDS patients on ECMO support.
Shekar K, Grewal J, Lisa Sutt A, Fraser J. Individualizing Sedation in Acute Respiratory Distress Syndrome Patients on Extracorporeal Membrane Oxygenation. ASAIO J. 2019 May/Jun;65(4):e44-e45. Open access link

a comment to this (2018) study aiming to characterize sedation management in adults with severe respiratory distress syndrome treated with veno-venous ECLS
deBacker J, Tamberg E, Munshi L, Burry L, Fan E, Mehta S. Sedation Practice in Extracorporeal Membrane Oxygenation-Treated Patients with Acute Respiratory Distress Syndrome: A Retrospective Study. ASAIO J. 2018 Jul/Aug;64(4):544-551. Open access link

& the authors’ reply
deBacker J, Fan E, Mehta S. Individualizing and Minimizing Sedation on Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome Patients, a Reply. ASAIO J. 2019 May/Jun;65(4):e46.Open access link

Predicting and improving survival

Physiologic variables at the start and during the ECMO run to understand & describe clinical evolution in severe ARDS. Trend of specific parameters might provide prognostic indications along the course of extracorporeal support, and could be used to monitor the evolution of lung injury and differentiate survivors vs non survivors. In this retrospective observation, worsening extrapulmonary organ dysfunction seems associated with mortality, potentially prompting to reconsider the utility of ECLS.

Spinelli E, Mauri T, Carlesso E, Crotti S, Tubiolo D, Lissoni A, Bottino N, Panigada M, Tagliabue P1, Rossi N, Scotti E, Conigliaro F, Gattinoni L, Grasselli G, Pesenti A. Time-Course of Physiologic Variables During Extracorporeal Membrane Oxygenation and Outcome of Severe Acute Respiratory Distress Syndrome. ASAIO J. 2019 Jul 12. link

A network meta-analysis to compare & rank different therapeutic strategies, identifying the interventions associated with a reduction in mortality in adults with moderate to severe ARDS. Among 25 randomized clinical trials evaluating 9 interventions, prone positioning & veno-venous ECMO associated with significantly lower 28-day mortality, compared with lung protective MV alone. These 2 interventions had the highest ranking probabilities, although they were not significantly different from each other.

Assessment of Therapeutic Aoyama H, Uchida K, Aoyama K, Pechlivanoglou P, Englesakis M, Yamada Y, Fan E. Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis. JAMA Netw Open. 2019 Jul 3;2(7):e198116. Open access link

Veno-venous ECMO support for respiratory failure: Do we need to consider age? according to the results of this retrospective, single center study, including 182 pts, age is an independent predictor of survival to discharge, with in-hospital mortality increasing incrementally over 45 years of age. Patients <45 years have significantly greater survival (84.6%.) vs patients ≥45 years (67%;), as those ≥55 years (57.1%). Patients 65 years & older have very low rates of survival (16.7%), and authors suggest to carefully weight the decision to implement VV ECLS in this population.

Deatrick KB, Mazzeffi MA, Galvagno SM Jr, Tesoriero RB, Kaczoroswki DJ, Herr DL, Dolly K, Rabinowitz RP, Scalea TM, Menaker J. Outcomes of Venovenous Extracorporeal Membrane Oxygenation When Stratified by Age: How Old Is Too Old? ASAIO J. 2019 Nov 18. link

Does Weight Matter in ECLS? Outcomes of VV ECMO support for acute hypoxic or hypercarbic respiratory failure in adults: to in this single center observation, no differences in survival to discharge or length of stay were detected as patients are stratified by BMI; evidence for the “obesity paradox” in this population may be supported by these data. Authors suggest that obesity alone should not exclude candidacy for ECMO.

Galvagno SM Jr, Pelekhaty S, Cornachione CR, Deatrick KB, Mazzeffi MA, Scalea TM, Menaker J. Does Weight Matter? Outcomes in Adult Patients on Venovenous Extracorporeal Membrane Oxygenation When Stratified by Obesity Class. Anesth Analg. 2019 Oct 28. link

A review of the ELSO Registry data on prolonged extracorporeal support (≥14 days) in patients with respiratory failure, aiming to identify specific predictors of mortality, and including ECMO complications in a new predictive model, to improve discrimination, assisting in determination of which patients should continue the run. According to the Registry, prolonged support is required for ~1 in every 5 adult patients on ECMO for respiratory failure, and 51.3% will survive to discharge. Although survival in prolonged ECLS is 10% less than shorter runs patients, there has been a significant improvement in survival in recent years. Expansion of the ELSO registry for additional data collection in prolonged ECMO patients could furtherly advance understanding of factors potentially impacting on outcome.

Posluszny J, Engoren M, Napolitano LM, Rycus PT, Bartlett RH; ELSO member centers. Predicting Survival of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Sep 30. link

Extended veno-venous ECMO for ARDS/ARF have similar survival rates vs short ECMO runs: time on extracorporeal support should not be the sole determining factor to stop ECLS, consider overall clinical conditions, including eventual MOF, & reversibility of the lung disease! Data from a high volume ECMO referral center.

Menaker J, Rabinowitz RP, Tabatabai A, Tesoriero RB, Dolly K, Cornachione C, Stene E, Buchner J, Kufera J, Kon ZN, Deatrick KB, Herr DL, O’Connor JV, Scalea TM. Veno-Venous Extracorporeal Membrane Oxygenation for Respiratory Failure: How Long Is Too Long? ASAIO J. 2019 Feb;65(2):192-196. link

Is muscle mass an important factor in the potential for recovery & outcome of patients requiring ECMO support for severe respiratory failure?? in this large retrospective observation, sarcopenia predicted worse 1 year mortality in pts who underwent veno-venous ECLS.

Cho WH, Choi YY, Byun KS, Lee SE, Jeon D, Kim YS, Han J, Yeo HJ. Prognostic Value of Sarcopenia for Long-Term Mortality in Extracorporeal Membrane Oxygenation for Acute Respiratory Failure. ASAIO J. 2019 Apr 18. link

Interesting case reports, series & experiences with selected indications

605 days (20 months!) on extracorporeal support for total acute lung failure & associated RV failure: read about the long journey to recovery of lung & heart function, 3 years after profound injury, through five different configuration of ECLS, from veno-arterial to veno-venous ECMO, then RVAD + membrane lung, & finally extracorporeal CO2 removal. A pediatric case report from the Johns Hopkins University School of Medicine.

Nelson-McMillan K, Vricella LA, Stewart FD, Young J, Shah AS, Hibino N, Coulson JD. Recovery from Total Acute Lung Failure After 20 Months of Extracorporeal Life Support. ASAIO J. 2020 Jan;66(1):e11-e14. Open access link

Extracorporeal support targeting for hypocapnia (25–30 mmHg) to reduce respiratory drive/effort in thoracic trauma, allowing for internal pneumatic stabilization and healing with synchronous positive pressure mechanical ventilation: open access case of an awake and cooperative patient with extensive bilateral flail chest (21 rib fractures) undergoing ECMO for bilateral pulmonary contusions & ARDS for 2 weeks and low-flow ECCO2R for the last 4 weeks with active rehabilitation. Extracorporeal carbon dioxide removal targeting hypocapnia is a potential adjunct in extensive flail chest injury undergoing nonsurgical management avoiding paradoxical movement and impairment of recovery.

Wells AH, Oswald TJ, Samra N, Scott LK, Conrad SA. Extracorporeal Carbon Dioxide Removal in the Management of Complex Bilateral Flail Chest Injury. ASAIO J. 2019 Sep/Oct;65(7):e75-e77. Open access link

Traumatic tracheo-bronchial injuries: potentially life-threatening conditions requiring early approach to provide adequate gas exchange. ECMO support represents a life-saving safe an effective additional arrow, when emergent intubation of the distal trachea and conventional MV is impossible, useful to both surgeon & anesthesiologist/intensivist to manage patients with severe airway lesions until/during repair. Report of a case of traumatic intrathoracic tracheal transection, with experts considerations about cannulation approach and configuration, intra & postoperative anticoagulation, cardio-pulmonary bypass CPB option.

Carretta A, Ciriaco P, Bandiera A, et al. Veno-venous extracorporeal membrane oxygenation in the surgical management of post-traumatic intrathoracic tracheal transection. J Thorac Dis. 2018;10(12):7045–7051. Open access link

& its comment. Aprile V, Korasidis S, Ambrogi MC, Lucchi M. Extracorporeal membrane oxygenation in traumatic tracheal injuries: a bold life-saving option. J Thorac Dis. 2019;11(7):2660–2663. link

ECMO assisted intratracheal tumor resection & carina reconstruction to support gas exchange without tracheal intubation, maintaining a clearly visible surgical field and improving the accuracy of anastomosis: simple & safe technique compared to traditional methods according to this case report!

Qiu Y, Chen Q, Wu W, Zhang S, Tang M, Chen Y, Zhang C, Zhou N, Jiang N, Feng J, Xia M, Wang H. Extracorporeal membrane oxygenation (ECMO)-assisted intratracheal tumor resection and carina reconstruction: A safer and more effective technique for resection and reconstruction. Thorac Cancer. 2019 May;10(5):1297-1302. Open access link

Emergency laparotomy to manage acute intrabdominal pathologies while on ECMO support for severe respiratory failure: prevalence, outcomes & complications of this high risk procedure in a high volume ECLS experienced center. Most patients presenting with acute abdomen signs, and found to have bowel ischemia requiring resection. Survival feasible but mortality higher vs patients not requiring laparotomy (supposed to be related to the severity of underlying organ failure). Authors suggest considering access to general surgery when planning to provide ECMO support.

McCann C, Adams K, Schizas A, George M, Barrett NA, Wyncoll DLA, Camporota L. Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study. J Crit Care. 2019 Oct;53:253-257. link

Drainage failure/lowering BF in severe #trauma patient on veno-venous ECMO support (TRALI + lung contusion) what would you do? consider measuring intra-abdominal pressure IAP & go for decompressive laparotomy if needed!

Matsumoto S, Morizane M, Matsuo K, Yamazaki M, Kitano M. Pitfalls when using extracorporeal life support in trauma patients. Trauma Surg Acute Care Open. 2019;4(1):e000298. Open access link

ECLS in respiratory failure for polytrauma patients: data collected from the 5 UK Respiratory ECMO centers suggest that does not exacerbate primary injury, even if anticoagulation administration is initiated, & may confer a survival benefit. Authors suggest not to consider neurological injury as an absolute contraindication to extracorporeal support in this population.

Kruit N, Prusak M, Miller M, Barrett N, Richardson C, Vuylsteke A. Assessment of safety and bleeding risk in the use of extracorporeal membrane oxygenation for multitrauma patients: A multicenter review. J Trauma Acute Care Surg. 2019 Jun;86(6):967-973. link

ECMO in foreign body aspiration: case series, review of the ELSO Registry, & systematic literature review; ECLS feasible and safe to stabilize children with life-threatening FBA before, during, after bronchoscopic removal, and the early use of extracorporeal support can improve the outcome increasing survival of these critically ill patients.

Anton-Martin P, Bhattarai P, Rycus P, Raman L, Potera R. The Use of Extracorporeal Membrane Oxygenation in Life-Threatening Foreign Body Aspiration: Case Series, Review of Extracorporeal Life Support Organization Registry Data, and Systematic Literature Review. J Emerg Med. 2019 May;56(5):523-529. link

Beta-blockers administration in refractory hypoxemia on VV ECMO, to decrease the Extracorporeal Blood Flow/Cardiac Output ratio, decrease the intra-pulmonary shunt & also provide myocardial protection. In this experience, BB therapy appears well tolerated and resulted in a significant increase in arterial oxygenation (but this may not increase DO2, due to the CO reduction).

Bunge JJH, Diaby S, Valle AL, Bakker J, Gommers D, Vincent JL, Creteur J, Taccone FS, Reis Miranda D. Safety and efficacy of beta-blockers to improve oxygenation in patients on veno-venous ECMO. J Crit Care. 2019 Oct;53:248-252. link

but maybe also consider advanced hemodynamic monitoring… a reply Giani M, Bronco A, Bosa L, Rona R, Foti G. Beta blockers during veno-venous ECMO to improve oxygenation: A case report. J Crit Care. 2019 Dec;54:269-270. link

Extended ECMO as bridge to lung transplantation: appropriate use of a precious resource? yes, according to this experience! Successful Tx after extracorporeal support could be achieved, with similar survival in high-risk recipients as in patients without ECMO, even in patients with prolonged runs: BTT time of less than 30 days seems crucial for success; the ECLS team experience and graft quality may be important factors for favorable outcome. Encouraging outcome in the (small) proportion of awake ECMO-BTT.

Langer F, Aliyev P, Schäfers HJ, Trudzinski FC, Seiler F, Bals R, Wilkens H, Lepper PM. Improving Outcomes in Bridge-to-Transplant: Extended Extracorporeal Membrane Oxygenation Support to Obtain Optimal Donor Lungs for Marginal Recipients. ASAIO J. 2019 Jul;65(5):516-521. link

2 decades of experience with ECLS as bridge to lung #transplantation: #ECMO support from an acute rescue therapy to a semi-elective procedure; stratified outcome analysis of this large institutional database revealed that extracorporeal life support bridging yielded similar long-term survival compared with nonbridged patients.

Benazzo A, Schwarz S, Frommlet F, Schweiger T, Jaksch P, Schellongowski P, Staudinger T, Klepetko W, Lang G, Hoetzenecker K; Vienna ECLS Program. Twenty-year experience with extracorporeal life support as bridge to lung transplantation. J Thorac Cardiovasc Surg. 2019 Jun;157(6):2515-2525.e10. link

Extracorporeal Life Support for severe Legionella pneumonia: appears associated with a high rate of survival, permitting diagnostic evaluation & time for antibiotics to exert effect; early ECLS may improve outcomes in this subset of patients. ECMO support is a beneficial tool for appropriate candidates with rare disease and the ELSO registry may be a helpful depot for information about these experiences.

Dorfman MV, Clark JD, Brogan TV. ECLS for Legionella: All Ages Welcome in the ELSO Registry. ASAIO J. 2019 Mar 13. link

Extracorporeal CO2 removal

Physiology & technique of extracorporeal CO2 removal: physiology of carbon dioxide, control of respiratory drive, ECCO2R systems and cannulas, pump technology, membrane lung technology, blood flow rates/treatment goals.

Karagiannidis C, Hesselmann F, Fan E. Physiological and Technical Considerations of Extracorporeal CO2 Removal. Crit Care. 2019 Mar 9;23(1):75. Open access link

Feasibility & safety of extracorporeal carbon dioxide removal to facilitate ultraprotective ventilation, VT 4 mL/kg and PPLAT ≤ 25 cmH2O in patients with moderate acute respiratory distress syndrome ARDS: The SUPERNOVA (Strategy of Ultra-Protective lung ventilation with Extracorporeal CO2 Removal for New-Onset moderate to severe ARDS) study results demonstrating that ultra-protective ventilation supported by ECCO2R is feasible & mitigates respiratory acidosis.

Combes A, Fanelli V, Pham T, Ranieri VM; European Society of Intensive Care Medicine Trials Group and the “Strategy of Ultra-Protective lung ventilation with Extracorporeal CO2 Removal for New-Onset moderate to severe ARDS” (SUPERNOVA) investigators. Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med. 2019 May;45(5):592-600. Open access link

Here, the secondary analysis of SUPERNOVA study. Data suggest decreasing VT to 4 mL/ kg & PPLAT to ≤25 of cmH2O are consistently achievable only with higher extraction ECCO2R devices. According to the authors opinion, future RCTs assessing benefit/harm of ultraprotective MV should be carried out with larger membrane lungs & blood flows between 800 and 1000 mL/min.

Combes A, Tonetti T, Fanelli V, Pham T, Pesenti A, Mancebo J, Brodie D, Ranieri VM. Efficacy and safety of lower versus higher CO2 extraction devices to allow ultraprotective ventilation: secondary analysis of the SUPERNOVA study. Thorax. 2019 Dec;74(12):1179-1181. link

Continuous monitoring of membrane lung CO2 removal on ECMO: does it help in estimating the oxygenator performance, in terms of V’CO2ML & VDsML? Results of an experimental in-vivo model of veno-arterial ECLS testing a capnometer prototype.

Montalti A, Belliato M, Gelsomino S, Nalon S, Matteucci F, Parise O, de Jong M, Makhoul M, Johnson DM, Lorusso R. Continuous monitoring of membrane lung carbon dioxide removal during ECMO: experimental testing of a new volumetric capnometer. Perfusion. 2019 Oct;34(7):538-543. link

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