TY - JOUR
T1 - Management of refractory hypoxemia during venovenous extracorporeal membrane oxygenation for ARDS
AU - Montisci, Andrea
AU - Maj, Giulia
AU - Zangrillo, Alberto
AU - Winterton, Dario
AU - Pappalardo, Federico
PY - 2015/7/20
Y1 - 2015/7/20
N2 - Venovenous extracorporeal membrane oxygenation (VV ECMO) in acute respiratory distress syndrome (ARDS) is currently a widely used therapeutic strategy. However, patients are often still hypoxemic despite complete ECMO support. The major determinants of peripheral oxygen saturation (SpO 2) during VV ECMO are pump flow, degree of recirculation, patient's systemic venous return and its oxygen saturation, hemoglobin concentration and residual lung function. Current guidelines state that the support can be considered adequate when the patient's SpO 2 is equal or greater than 80%, but a possible objection could be that such a value of O 2 -tension may be too low and may worsen the patient's prognosis. Moving from the pathophysiology of hypoxemia during VV ECMO, this review focuses on recirculation of blood and on the possible strategies to minimize it, on the pharmacologic modulation of intrapulmonary shunt and on the questions related to management of ECMO flow and the risks and benefits of permissive hypoxemic states. Transfusional strategy during VV ECMO, administration of neuromuscular blocking agents and sedatives, therapeutic hypothermia, and prone positioning is also reviewed. The potential advantages of β-blockers are discussed. Finally, transition from VV ECMO to venoarterial ECMO (VA ECMO) or a hybrid configuration is also examined.
AB - Venovenous extracorporeal membrane oxygenation (VV ECMO) in acute respiratory distress syndrome (ARDS) is currently a widely used therapeutic strategy. However, patients are often still hypoxemic despite complete ECMO support. The major determinants of peripheral oxygen saturation (SpO 2) during VV ECMO are pump flow, degree of recirculation, patient's systemic venous return and its oxygen saturation, hemoglobin concentration and residual lung function. Current guidelines state that the support can be considered adequate when the patient's SpO 2 is equal or greater than 80%, but a possible objection could be that such a value of O 2 -tension may be too low and may worsen the patient's prognosis. Moving from the pathophysiology of hypoxemia during VV ECMO, this review focuses on recirculation of blood and on the possible strategies to minimize it, on the pharmacologic modulation of intrapulmonary shunt and on the questions related to management of ECMO flow and the risks and benefits of permissive hypoxemic states. Transfusional strategy during VV ECMO, administration of neuromuscular blocking agents and sedatives, therapeutic hypothermia, and prone positioning is also reviewed. The potential advantages of β-blockers are discussed. Finally, transition from VV ECMO to venoarterial ECMO (VA ECMO) or a hybrid configuration is also examined.
KW - ARDS
KW - ECMO
KW - Hypoxemia
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U2 - 10.1097/MAT.0000000000000207
DO - 10.1097/MAT.0000000000000207
M3 - Article
C2 - 25923575
AN - SCOPUS:84937548861
VL - 61
SP - 227
EP - 236
JO - ASAIO Journal
JF - ASAIO Journal
SN - 0162-1432
IS - 3
ER -