title: Venous Cannula Positioning in Arterial Deoxygenation During Veno-Arterial Extracorporeal Membrane Oxygenation-A Simulation Study and Case Report.
abstract: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is indicated in reversible life-threatening circulatory failure with or without respiratory failure. Arterial desaturation in the upper body is frequently seen in patients with peripheral arterial cannulation and severe respiratory failure. The importance of venous cannula positioning was explored in a computer simulation model and a clinical case was described. A closed-loop real-time simulation model has been developed including vascular segments, the heart with valves and pericardium. ECMO was simulated with a fixed flow pump and a selection of clinically relevant venous cannulation sites. A clinical case with no tidal volumes due to pneumonia and an arterial saturation of below 60% in the right hand despite VA-ECMO flow of 4 L/min was described. The case was compared with simulation data. Changing the venous cannulation site from the inferior to the superior caval vein increased arterial saturation in the right arm from below 60% to above 80% in the patient and from 64 to 81% in the simulation model without changing ECMO flow. The patient survived, was extubated and showed no signs of hypoxic damage. We conclude that venous drainage from the superior caval vein improves upper body arterial saturation during veno-arterial ECMO as compared with drainage solely from the inferior caval vein in patients with respiratory failure. The results from the simulation model are in agreement with the clinical scenario.
authors.affiliation: ECMO Department, Karolinska University Hospital.|Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet.
authors.forename: Mattias
authors.initials: M
authors.lastname: Lindfors
authors.affiliation: ECMO Department, Karolinska University Hospital.|Division of Pediatric Surgery, Department of Women's and Children's Health, Karolinska Institutet.
authors.forename: Björn
authors.initials: B
authors.lastname: Frenckner
authors.affiliation: Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital.|Department of Molecular Medicine and Surgery, Karolinska Institutet.
authors.forename: Ulrik
authors.initials: U
authors.lastname: Sartipy
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet.|Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden.
authors.forename: Anna
authors.initials: A
authors.lastname: Bjällmark
authors.affiliation: ECMO Department, Karolinska University Hospital.|Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet.|Department of Medical Engineering, School of Technology and Health, KTH Royal Institute of Technology, Stockholm, Sweden.
authors.forename: Michael
authors.initials: M
authors.lastname: Broomé
mesh_terms: D000293:Adolescent; D001158:Arteries / Q000503:physiopathology; D001342:Autonomic Nervous System Diseases / Q000097:blood / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D002404:Catheterization / Q000379:methods*; D003198:Computer Simulation; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D005483:Flushing / Q000097:blood / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D006439:Hemodynamics; D006801:Humans; D007007:Hypohidrosis / Q000097:blood / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D008955:Models, Cardiovascular; D010100:Oxygen / Q000097:blood* / Q000378:metabolism; D010101:Oxygen Consumption; D012131:Respiratory Insufficiency / Q000097:blood / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D062666:Vascular Access Devices; D014680:Veins / Q000503:physiopathology
chemical_list: D010100:Oxygen
keywords: Cannulation; Differential hypoxia; Dual circulations; Extracorporeal membrane oxygenation; Harlequin syndrome; Modeling; Simulation; Venoarterial