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Case Reports
. 2020 Jun 18;23(4):255-263.
doi: 10.1002/ajum.12206. eCollection 2020.

Ultrasonographic assessment of aortic flow characteristics in a paediatric patient with sepsis treated with extracorporeal life support: defining the mixing zone

Tristan Reddan  1   2 , Prem S Venugopal  3   4 , Jennifer Powell  1   4   5 , Adrian C Mattke  4   6   7
Affiliations
Case Reports

Ultrasonographic assessment of aortic flow characteristics in a paediatric patient with sepsis treated with extracorporeal life support: defining the mixing zone

Tristan Reddan et al. Australas J Ultrasound Med. .

Abstract

We describe a case of severe sepsis in a 14-year-old boy who was treated with veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support. The haemodynamic challenges inherent to femoro-femoral VA ECMO are discussed, and the use of ultrasonography to define the location of the mixing zone in the abdominal aorta is demonstrated. We propose that the use of ultrasound is able to assist clinicians in understanding perfusion of abdominal organs in the presence of suspected differential oxygenation.

Keywords: extracorporeal membrane oxygenation; paediatrics; sepsis; ultrasonography.

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Conflict of interest statement

The authors have nothing to disclose in relation to the publication of this case report.

Figures

Figure 1
Figure 1
The interaction between deoxygenated blood from cardiac output and oxygenated blood from the femoral ECMO cannula can shift the mixing zone along the aorta. In this case, the zone was initially seen just cephalad to the CA origin with one circuit. CA, coeliac axis; SMA, superior mesenteric artery; CFA, common femoral artery.
Figure 2
Figure 2
Monophasic flow in the left femoral artery indicating a lack of cardiac output and pulsatility, with arterial perfusion supplied by the recently inserted right femoral arterial cannula.
Figure 3
Figure 3
Single ECMO circuit – oscillating blood flow in the abdominal aorta, the mixing point seen in the colour Doppler reversal superior to the coeliac axis origin.
Figure 4
Figure 4
Single ECMO circuit – increased velocity and turbulent flow observed within the coeliac artery.
Figure 5
Figure 5
The mixing zone is now seen slightly caudal to the SMA origin with a second circuit connected. CA, coeliac axis; SMA, superior mesenteric artery; CFA, common femoral artery.
Figure 6
Figure 6
Two ECMO circuits – increased velocity and reduced resistance in the coeliac artery.
Figure 7
Figure 7
Reduction in the femoral circuit flow rate saw the mixing point move distally to below the SMA origin.
Figure 8
Figure 8
Antegrade flow from the cervical circuit now constantly perfused the aorta above the SMA origin.
Figure 9
Figure 9
Arterial lactate levels (mmol/L) over time after PICU admission (hours). Arrows indicate the points at which ECMO circuits were inserted.
Figure 10
Figure 10
Coronal post‐contrast computed tomography image following left arm peripheral venous injection demonstrating right femoral venous ECMO catheter extending to the IVC/RA junction, near complete consolidation of both lungs with small aerated portion at the apices, regions of lung necrosis, abnormal myocardial enhancement, and marked body wall oedema. The right femoral arterial ECMO catheter can also be visualised with tip in the right common iliac artery.
Figure 11
Figure 11
Computational fluid dynamic modelling ECMO volume fractions for coronal (1) and sagittal (2) views and velocity streamlines (3) in the abdominal aorta for ECMO support levels of 70% (a), 55% (b), 40% (c), and 25% (d) (used with permission).10
See this image and copyright information in PMC

References

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