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Structural recirculation and refractory hypoxemia under femoro‐jugular veno‐venous extracorporeal membrane oxygenation
Author(s) -
Charbit Jonathan,
Deras Pauline,
Courvalin Elie,
Laumon Thomas,
Dagod Geoffrey,
Martinez Orianne,
Capdevila Xavier
Publication year - 2021
Publication title -
artificial organs
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.684
H-Index - 76
eISSN - 1525-1594
pISSN - 0160-564X
DOI - 10.1111/aor.13916
Subject(s) - shunt (medical) , extracorporeal membrane oxygenation , hypoxemia , superior vena cava , medicine , jugular vein , extracorporeal , nuclear medicine , anesthesia , surgery
The performance of each veno‐venous extracorporeal membrane oxygenation (vv‐ECMO) configuration is determined by the anatomic context and cannula position. A mathematical model was built considering bicaval specificities to simulate femoro‐jugular configuration. The main parameters to define were cardiac output (Q C ), blood flow in the superior vena cava (Q SVC ), extracorporeal pump flow (Q EC ), and pulmonary shunt (k S‐PULM ). The obtained variables were extracorporeal flow ratio in the superior vena cava (EFR SVC = Q EC /[Q EC + Q SVC ]), recirculation coefficient (R), effective extracorporeal pump flow (Q eff‐EC = [1 – R] × Q EC ), Q eff‐EC /Q C ratio, and arterial blood oxygen saturation (SaO 2 ). EFR SVC increased logarithmically when Q EC increased. High Q C or high Q SVC /Q C decreased EFR SVC (range, 68%‐85% for Q EC of 5 L/min). R also increased following a logarithmic shape when Q EC increased. The R rise was earlier and higher for low Q C and high Q SVC /Q C (range, 12%‐49% for Q EC of 5 L/min). The Q eff‐EC /Q C ratio (between 0 and 1) was equal to EFR SVC for moderate and high Q EC . The Q eff‐EC /Q C ratio presented the same logarithmic profile when Q EC increased, reaching a plateau (range, 0.67‐0.91 for Q EC /Q C = 1; range, 0.75‐0.94 for Q EC /Q C = 1.5). The Q eff‐EC /Q C ratio was linearly associated with Sa O 2 for a given pulmonary shunt. SaO 2 < 90% was observed when the pulmonary shunt was high (Q eff‐EC /Q C ≤ 0.7 with k S‐PULM = 0.7 or Q eff‐EC /Q C ≤ 0.8 with k S‐PULM = 0.8). Femoro‐jugular vv‐ECMO generates a systematic structural recirculation that gradually increases with Q EC . EFR SVC determines the Q eff‐EC /Q C ratio, and thereby oxygen delivery and the superior cava shunt. EFR SVC cannot exceed a limit value, explaining refractory hypoxemia in extreme situations.