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Superior vena cava drainage improves upper body oxygenation during veno-arterial extracorporeal membrane oxygenation in sheep.

Hou X, Yang X, Du Z, Xing J, Li H, Jiang C, Wang J, Xing Z, Li S, Li X, Yang F, Wang H, Zeng H - Crit Care (2015)

Bottom Line: SVC-FA achieved oxygen-rich blood return from the IVC to the RA without shifting the arterial cannulation.Subsequently, SO₂ of the SVC and the pulmonary artery increased (70.4 ± 1.0% and 73.4 ± 1.1%, respectively).With knowledge of this mechanism, we can apply better cannula configurations in clinical practice.

View Article: PubMed Central - PubMed

Affiliation: Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, P.R. China. xt.hou@ccmu.edu.cn.

ABSTRACT

Introduction: Differential hypoxia is a pivotal problem in patients with femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support. Despite recognition of differential hypoxia and attempts to deliver more oxygenated blood to the upper body, the mechanism of differential hypoxia as well as prevention strategies have not been well investigated.

Methods: We used a sheep model of acute respiratory failure that was supported with femoral VA ECMO from the inferior vena cava to the femoral artery (IVC-FA), ECMO from the superior vena cava to the FA (SVC-FA), ECMO from the IVC to the carotid artery (IVC-CA) and ECMO with an additional return cannula to the internal jugular vein based on the femoral VA ECMO (FA-IJV). Angiography and blood gas analyses were performed.

Results: With IVC-FA, blood oxygen saturation (SO₂) of the IVC (83.6 ± 0.8%) was higher than that of the SVC (40.3 ± 1.0%). Oxygen-rich blood was drained back to the ECMO circuit and poorly oxygenated blood in the SVC entered the right atrium (RA). SVC-FA achieved oxygen-rich blood return from the IVC to the RA without shifting the arterial cannulation. Subsequently, SO₂ of the SVC and the pulmonary artery increased (70.4 ± 1.0% and 73.4 ± 1.1%, respectively). Compared with IVC-FA, a lesser difference in venous oxygen return and attenuated differential hypoxia were observed with IVC-CA and FA-IJV.

Conclusions: Differential venous oxygen return is a key factor in the etiology of differential hypoxia in VA ECMO. With knowledge of this mechanism, we can apply better cannula configurations in clinical practice.

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Related in: MedlinePlus

Vena cava angiography in IVC-FA and SVC-FA. The diagram (a, e and i) and representative photos in the early (b, f and j), intermediate (c, g and k) and late (d, h and l) stages of angiography are shown. (A) IVC angiography: contrast medium from the IVC. (a-d) IVC angiography in sheep without ECMO. (e-h) IVC angiography in sheep with IVC-FA. (i-l) IVC angiography in sheep with SVC-FA. Without ECMO, the contrast medium from the IVC entered the RA. In IVC-FA, the contrast medium from the IVC could not enter the RA. After shifting IVC-FA to SVC-FA, the contrast medium infused from the IVC could enter the RA again. (B) SVC angiography: contrast medium from the SVC. (a-d) SVC angiography in sheep without ECMO. (e-h) SVC angiography in sheep with IVC-FA. (i-l) SVC angiography in sheep with SVC-FA. Without ECMO or in IVC-FA, the contrast medium from the SVC entered the RA. After shifting IVC-FA to SVC-FA, the contrast medium infused from the SVC could barely enter the RA. The black arrow indicates the contrast medium. ECMO: extracorporeal membrane oxygenation; IVC-FA: a drainage cannula was placed into the inferior vena cava through the femoral vein and a return cannula was inserted into the femoral artery; RA: right atrium; RV: right ventricle; SVC-FA: a drainage cannula was placed into the superior vena cava through the femoral vein and a return cannula was placed into the femoral artery.
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Fig4: Vena cava angiography in IVC-FA and SVC-FA. The diagram (a, e and i) and representative photos in the early (b, f and j), intermediate (c, g and k) and late (d, h and l) stages of angiography are shown. (A) IVC angiography: contrast medium from the IVC. (a-d) IVC angiography in sheep without ECMO. (e-h) IVC angiography in sheep with IVC-FA. (i-l) IVC angiography in sheep with SVC-FA. Without ECMO, the contrast medium from the IVC entered the RA. In IVC-FA, the contrast medium from the IVC could not enter the RA. After shifting IVC-FA to SVC-FA, the contrast medium infused from the IVC could enter the RA again. (B) SVC angiography: contrast medium from the SVC. (a-d) SVC angiography in sheep without ECMO. (e-h) SVC angiography in sheep with IVC-FA. (i-l) SVC angiography in sheep with SVC-FA. Without ECMO or in IVC-FA, the contrast medium from the SVC entered the RA. After shifting IVC-FA to SVC-FA, the contrast medium infused from the SVC could barely enter the RA. The black arrow indicates the contrast medium. ECMO: extracorporeal membrane oxygenation; IVC-FA: a drainage cannula was placed into the inferior vena cava through the femoral vein and a return cannula was inserted into the femoral artery; RA: right atrium; RV: right ventricle; SVC-FA: a drainage cannula was placed into the superior vena cava through the femoral vein and a return cannula was placed into the femoral artery.

Mentions: Vena cava angiography was performed in order to investigate whether the oxygenated blood entered the right atrium (RA). As shown in Figure 4 and the additional movie files (Additional files 6 and 7), under normal conditions without VA ECMO support, the contrast medium entered the RA from both the SVC and IVC. However, when the animals were supported with IVC-FA, the contrast medium failed to enter the RA from the IVC (Figure 4A; Additional file 8). In contrast, the SVC blood was conveyed to the RA (Figure 4B; Additional file 9). This observation indicates that high SO2 blood in the IVC was draining back into the drainage cannula instead of refluxing into the RA.Figure 4


Superior vena cava drainage improves upper body oxygenation during veno-arterial extracorporeal membrane oxygenation in sheep.

Hou X, Yang X, Du Z, Xing J, Li H, Jiang C, Wang J, Xing Z, Li S, Li X, Yang F, Wang H, Zeng H - Crit Care (2015)

Vena cava angiography in IVC-FA and SVC-FA. The diagram (a, e and i) and representative photos in the early (b, f and j), intermediate (c, g and k) and late (d, h and l) stages of angiography are shown. (A) IVC angiography: contrast medium from the IVC. (a-d) IVC angiography in sheep without ECMO. (e-h) IVC angiography in sheep with IVC-FA. (i-l) IVC angiography in sheep with SVC-FA. Without ECMO, the contrast medium from the IVC entered the RA. In IVC-FA, the contrast medium from the IVC could not enter the RA. After shifting IVC-FA to SVC-FA, the contrast medium infused from the IVC could enter the RA again. (B) SVC angiography: contrast medium from the SVC. (a-d) SVC angiography in sheep without ECMO. (e-h) SVC angiography in sheep with IVC-FA. (i-l) SVC angiography in sheep with SVC-FA. Without ECMO or in IVC-FA, the contrast medium from the SVC entered the RA. After shifting IVC-FA to SVC-FA, the contrast medium infused from the SVC could barely enter the RA. The black arrow indicates the contrast medium. ECMO: extracorporeal membrane oxygenation; IVC-FA: a drainage cannula was placed into the inferior vena cava through the femoral vein and a return cannula was inserted into the femoral artery; RA: right atrium; RV: right ventricle; SVC-FA: a drainage cannula was placed into the superior vena cava through the femoral vein and a return cannula was placed into the femoral artery.
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Related In: Results  -  Collection

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Fig4: Vena cava angiography in IVC-FA and SVC-FA. The diagram (a, e and i) and representative photos in the early (b, f and j), intermediate (c, g and k) and late (d, h and l) stages of angiography are shown. (A) IVC angiography: contrast medium from the IVC. (a-d) IVC angiography in sheep without ECMO. (e-h) IVC angiography in sheep with IVC-FA. (i-l) IVC angiography in sheep with SVC-FA. Without ECMO, the contrast medium from the IVC entered the RA. In IVC-FA, the contrast medium from the IVC could not enter the RA. After shifting IVC-FA to SVC-FA, the contrast medium infused from the IVC could enter the RA again. (B) SVC angiography: contrast medium from the SVC. (a-d) SVC angiography in sheep without ECMO. (e-h) SVC angiography in sheep with IVC-FA. (i-l) SVC angiography in sheep with SVC-FA. Without ECMO or in IVC-FA, the contrast medium from the SVC entered the RA. After shifting IVC-FA to SVC-FA, the contrast medium infused from the SVC could barely enter the RA. The black arrow indicates the contrast medium. ECMO: extracorporeal membrane oxygenation; IVC-FA: a drainage cannula was placed into the inferior vena cava through the femoral vein and a return cannula was inserted into the femoral artery; RA: right atrium; RV: right ventricle; SVC-FA: a drainage cannula was placed into the superior vena cava through the femoral vein and a return cannula was placed into the femoral artery.
Mentions: Vena cava angiography was performed in order to investigate whether the oxygenated blood entered the right atrium (RA). As shown in Figure 4 and the additional movie files (Additional files 6 and 7), under normal conditions without VA ECMO support, the contrast medium entered the RA from both the SVC and IVC. However, when the animals were supported with IVC-FA, the contrast medium failed to enter the RA from the IVC (Figure 4A; Additional file 8). In contrast, the SVC blood was conveyed to the RA (Figure 4B; Additional file 9). This observation indicates that high SO2 blood in the IVC was draining back into the drainage cannula instead of refluxing into the RA.Figure 4

Bottom Line: SVC-FA achieved oxygen-rich blood return from the IVC to the RA without shifting the arterial cannulation.Subsequently, SO₂ of the SVC and the pulmonary artery increased (70.4 ± 1.0% and 73.4 ± 1.1%, respectively).With knowledge of this mechanism, we can apply better cannula configurations in clinical practice.

View Article: PubMed Central - PubMed

Affiliation: Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, 100029, P.R. China. xt.hou@ccmu.edu.cn.

ABSTRACT

Introduction: Differential hypoxia is a pivotal problem in patients with femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support. Despite recognition of differential hypoxia and attempts to deliver more oxygenated blood to the upper body, the mechanism of differential hypoxia as well as prevention strategies have not been well investigated.

Methods: We used a sheep model of acute respiratory failure that was supported with femoral VA ECMO from the inferior vena cava to the femoral artery (IVC-FA), ECMO from the superior vena cava to the FA (SVC-FA), ECMO from the IVC to the carotid artery (IVC-CA) and ECMO with an additional return cannula to the internal jugular vein based on the femoral VA ECMO (FA-IJV). Angiography and blood gas analyses were performed.

Results: With IVC-FA, blood oxygen saturation (SO₂) of the IVC (83.6 ± 0.8%) was higher than that of the SVC (40.3 ± 1.0%). Oxygen-rich blood was drained back to the ECMO circuit and poorly oxygenated blood in the SVC entered the right atrium (RA). SVC-FA achieved oxygen-rich blood return from the IVC to the RA without shifting the arterial cannulation. Subsequently, SO₂ of the SVC and the pulmonary artery increased (70.4 ± 1.0% and 73.4 ± 1.1%, respectively). Compared with IVC-FA, a lesser difference in venous oxygen return and attenuated differential hypoxia were observed with IVC-CA and FA-IJV.

Conclusions: Differential venous oxygen return is a key factor in the etiology of differential hypoxia in VA ECMO. With knowledge of this mechanism, we can apply better cannula configurations in clinical practice.

Show MeSH
Related in: MedlinePlus