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. 2021 Aug;45(8):893-902.
doi: 10.1111/aor.13916. Epub 2021 Mar 8.

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

Jonathan Charbit  1 , Pauline Deras  1 , Elie Courvalin  1 , Thomas Laumon  1 , Geoffrey Dagod  1 , Orianne Martinez  1 , Xavier Capdevila  1
Affiliations

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

Jonathan Charbit et al. Artif Organs. 2021 Aug.

Abstract

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 (QC ), blood flow in the superior vena cava (QSVC ), extracorporeal pump flow (QEC ), and pulmonary shunt (kS-PULM ). The obtained variables were extracorporeal flow ratio in the superior vena cava (EFRSVC = QEC /[QEC + QSVC ]), recirculation coefficient (R), effective extracorporeal pump flow (Qeff-EC = [1 - R] × QEC ), Qeff-EC /QC ratio, and arterial blood oxygen saturation (SaO2 ). EFRSVC increased logarithmically when QEC increased. High QC or high QSVC /QC decreased EFRSVC (range, 68%-85% for QEC of 5 L/min). R also increased following a logarithmic shape when QEC increased. The R rise was earlier and higher for low QC and high QSVC /QC (range, 12%-49% for QEC of 5 L/min). The Qeff-EC /QC ratio (between 0 and 1) was equal to EFRSVC for moderate and high QEC . The Qeff-EC /QC ratio presented the same logarithmic profile when QEC increased, reaching a plateau (range, 0.67-0.91 for QEC /QC = 1; range, 0.75-0.94 for QEC /QC = 1.5). The Qeff-EC /QC ratio was linearly associated with SaO2 for a given pulmonary shunt. SaO2 < 90% was observed when the pulmonary shunt was high (Qeff-EC /QC ≤ 0.7 with kS-PULM = 0.7 or Qeff-EC /QC ≤ 0.8 with kS-PULM = 0.8). Femoro-jugular vv-ECMO generates a systematic structural recirculation that gradually increases with QEC . EFRSVC determines the Qeff-EC /QC ratio, and thereby oxygen delivery and the superior cava shunt. EFRSVC cannot exceed a limit value, explaining refractory hypoxemia in extreme situations.

Keywords: acute respiratory distress syndrome; extracorporeal life support; oxygenation determinant; respiratory failure; respiratory support; structural recirculation.

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References

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