Abstract
Technological development of extracorporeal systems of the last 30 years led to extremely improved high-flow venoarterial or venovenous extracorporeal systems for cardiovascular support and refractory hypoxia and to less invasive low-flow systems for extracorporeal CO2 removal.
Oxygenation through modern polymethylpentene membrane lungs is nearly optimal: hemoglobin of blood exiting the membrane lungs is almost fully saturated, and oxygen partial pressure is close to the maximal theoretically achievable. On the contrary CO2 removal is less efficient, since only a small fraction of the total blood CO2 is present in the dissolved form, the only fraction which can be readily removed by the membrane lung. Promising technological developments, exploiting the bicarbonate ions, which represent almost 90 % of the total blood CO2 content, lead toward ultra low-flow CO2 removal systems.
Moreover, clinical and organizational improvements are foreseeable that might improve indications, management, and outcome for ECMO patients.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Gattinoni L, Pesenti A, Kolobow T, Damia G (1983) A new look at therapy of the adult respiratory distress syndrome: motionless lungs. Int Anesthesiol Clin 21:97–117
Hester RL, Ashcraft D, Curry E, Bower J (1992) Non-invasive determination of recirculation in the patient on dialysis. ASAIO J 38:M190–M193
Lindsay RM, Bradfield E, Rothera C, Kianfar C, Malek P, Blake PG (1998) A comparison of methods for the measurement of hemodialysis access recirculation and access blood flow rate. ASAIO J 44:62–67
Clements D, Primmer J, Ryman P, Marr B, Searles B, Darling E (2008) Measurements of recirculation during neonatal veno-venous extracorporeal membrane oxygenation: clinical application of the ultrasound dilution technique. J Extra Corpor Technol 40:184–187
Darling EM, Crowell T, Searles BE (2006) Use of dilutional ultrasound monitoring to detect changes in recirculation during venovenous extracorporeal membrane oxygenation in swine. ASAIO J 52:522–524
Körver EP, Ganushchak YM, Simons AP, Donker DW, Maessen JG, Weerwind PW (2012) Quantification of recirculation as an adjuvant to transthoracic echocardiography for optimization of dual-lumen extracorporeal life support. Intensive Care Med 38:906–909
Peek GJ, Killer HM, Reeves R, Sosnowski AW, Firmin RK (2002) Early experience with a polymethyl pentene oxygenator for adult extracorporeal life support. ASAIO J 48:480–482
Toomasian JM, Schreiner RJ, Meyer DE, Schmidt ME, Hagan SE, Griffith GW, Bartlett RH, Cook KE (2005) A polymethylpentene fiber gas exchanger for long-term extracorporeal life support. ASAIO J 51:390–397
Arlt M, Philipp A, Voelkel S, Camboni D, Rupprecht L, Graf BM, Schmid C, Hilker M (2011) Hand-held minimised extracorporeal membrane oxygenation: a new bridge to recovery in patients with out-of-centre cardiogenic shock. Eur J Cardiothorac Surg 40:689–694
The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308
Patroniti N, Bellani G, Cortinovis B, Foti G, Maggioni E, Manfio A, Pesenti A (2010) Role of absolute lung volume to assess alveolar recruitment in acute respiratory distress syndrome patients. Crit Care Med 38:1300–1307
Nuckton TJ, Alonso JA, Kallet RH, Daniel BM, Pittet JF, Eisner MD, Matthay MA (2002) Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med 346:1281–1286
Terragni PP, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, Gandini G, Herrmann P, Mascia L, Quintel M, Slutsky AS, Gattinoni L, Ranieri VM (2007) Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med 175:160–166
Terragni PP, Del Sorbo L, Mascia L, Urbino R, Martin EL, Birocco A, Faggiano C, Quintel M, Gattinoni L, Ranieri VM (2009) Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Anesthesiology 111:826–835
Livigni S, Maio M, Ferretti E, Longobardo A, Potenza R, Rivalta L, Selvaggi P, Vergano M, Bertolini G (2006) Efficacy and safety of a low-flow veno-venous carbon dioxide removal device: results of an experimental study in adult sheep. Crit Care 10:R151
Batchinsky AI, Jordan BS, Regn D, Necsoiu C, Federspiel WJ, Morris MJ, Cancio LC (2011) Respiratory dialysis: reduction in dependence on mechanical ventilation by venovenous extracorporeal CO2 removal. Crit Care Med 39:1382–1387
Kluge S, Braune SA, Engel M, Nierhaus A, Frings D, Ebelt H, Uhrig A, Metschke M, Wegscheider K, Suttorp N, Rousseau S (2012) Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilation. Intensive Care Med 38:1632–1639
Gille JP, Lautier A, Tousseul B (1992) EC CO2R: oxygenator or hemodialyzer? An in vitro study. Int J Artif Organs 15:229–233
Snider MT, Chaudhari SN, Richard RB, Whitcomb DR, Russell GB (1987) Augmentation of CO2 transfer in membrane lungs by the infusion of a metabolizable organic acid. ASAIO Trans 33:345–351
Nolte SH, Benfer RH, Grau J (1991) Extracorporeal CO2 removal with hemodialysis (ECBicCO2R): how to make up for the bicarbonate loss? Int J Artif Organs 14:759–764
Nolte SH, Jonitz WJ, Grau J, Roth H, Assenbaum ER (1989) Hemodialysis for extracorporeal bicarbonate/CO2 removal (ECBicCO2R) and apneic oxygenation for respiratory failure in the newborn. Theory and preliminary results in animal experiments. ASAIO Trans 35:30–34
Gille JP, Bauer P, Bollaert PE, Tousseul B, Kachani-Mansour R, Munsch L (1989) CO2 removal with hemodialysis and control of plasma oncotic pressure. ASAIO Trans 35:654–657
Gille JP, Saunier C, Schrijen F, Hartemann D, Tousseul B (1989) Metabolic CO2 removal by dialysis: THAM vs NaOH infusion. Int J Artif Organs 12:720–727
Cressoni M, Zanella A, Epp M, Corti I, Patroniti N, Kolobow T, Pesenti A (2009) Decreasing pulmonary ventilation through bicarbonate ultrafiltration: an experimental study. Crit Care Med 37:2612–2618
Zanella A, Patroniti N, Isgrò S, Albertini M, Costanzi M, Pirrone F, Scaravilli V, Vergnano B, Pesenti A (2009) Blood acidification enhances carbon dioxide removal of membrane lung: an experimental study. Intensive Care Med 35:1484–1487
Zanella A, Mangili P, Redaelli S, Scaravilli V, Giani M, Ferlicca D, Scaccabarozzi D, Pirrone F, Albertini M, Patroniti N, Pesenti A (2014) Regional blood acidification enhances extracorporeal carbon dioxide removal: a 48-hour animal study. Anesthesiology. 120(2):416–424
Zanella A, Giani M, Redaelli S, Mangili P, Scaravilli V, Ormas V, Costanzi M, Albertini M, Bellani G, Patroniti N, Pesenti A (2013) Infusion of 2.5 meq/min of lactic acid minimally increases CO2 production compared to an isocaloric glucose infusion in healthy anesthetized, mechanically ventilated pigs. Crit Care 11;17(6):R268. [Epub ahead of print]
Zanella A, Mangili P, Giani M, Redaelli S, Scaravilli V, Castagna L, Sosio S, Pirrone F, Albertini M, Patroniti N, Pesenti A (2013) Extracorporeal carbon dioxide removal through ventilation of acidified dialysate: An experimental study. J Heart Lung Transplant. pii: S1053-2498(13)01560-X. doi: 10.1016/j.healun.2013.12.006 [Epub ahead of print]
Wearden PD, Federspiel WJ, Morley SW, Rosenberg M, Bieniek PD, Lund LW, Ochs BD (2012) Respiratory dialysis with an active-mixing extracorporeal carbon dioxide removal system in a chronic sheep study. Intensive Care Med 38:1705–1711
Wang D, Lick SD, Campbell KM, Loran DB, Alpard SK, Zwischenberger JB, Chambers SD (2005) Development of ambulatory arterio-venous carbon dioxide removal (AVCO2R): the downsized gas exchanger prototype for ambulation removes enough CO2 with low blood resistance. ASAIO J 51:385–389
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2014 Springer-Verlag Italia
About this chapter
Cite this chapter
Giani, M., Zanella, A., Sangalli, F., Pesenti, A. (2014). Newer Indications and Challenges. In: Sangalli, F., Patroniti, N., Pesenti, A. (eds) ECMO-Extracorporeal Life Support in Adults. Springer, Milano. https://doi.org/10.1007/978-88-470-5427-1_40
Download citation
DOI: https://doi.org/10.1007/978-88-470-5427-1_40
Published:
Publisher Name: Springer, Milano
Print ISBN: 978-88-470-5426-4
Online ISBN: 978-88-470-5427-1
eBook Packages: MedicineMedicine (R0)