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The Effects of Vasoconstriction And Volume Expansion on Veno-Arterial ECMO Flow

Journal article
Authors Per Werner Möller
Anisa Hana
Paul Philipp Heinisch
Shengchen Liu
Siamak Djafarzadeh
Matthias Haenggi
Andreas Bloch
Jukka Takala
Stephan M Jakob
David Berger
Published in Shock
Volume 51
Issue 5
Pages 650-658
ISSN 1073-2322
Publication year 2019
Published at Institute of Clinical Sciences, Department of Anesthesiology and Intensive care
Pages 650-658
Language en
Links https://doi.org/10.1097/SHK.0000000...
www.ncbi.nlm.nih.gov/entrez/query.f...
Keywords Crystalloid solutions, extracorporeal membrane oxygenation, hemodynamics, mean systemic filling pressure, norepinephrine, stressed volume, vasoconstrictor agents, venous return
Subject categories Cardiac and Cardiovascular Systems, Anesthesiology and Intensive Care, Clinical physiology, Physiology

Abstract

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is gaining widespread use in the treatment of severe cardiorespiratory failure. Blood volume expansion is commonly used to increase ECMO flow (QECMO), with risk of positive fluid balance and worsening prognosis. We studied the effects of vasoconstriction on recruitment of blood volume as an alternative for increasing QECMO, based on the concepts of venous return.In a closed chest, centrally cannulated porcine preparation (n = 9) in ventricular fibrillation and VA-ECMO with vented left atrium, mean systemic filling pressure (MSFP), and venous return driving pressure (VRdP) were determined in Euvolemia, during Vasoconstriction (norepinephrine 0.05, 0.125, and 0.2 μg/kg/min) and after Volume Expansion (3 boluses of 10 mL/kg Ringer's lactate). Maximum achievable QECMO was examined.Vasoconstriction and Volume Expansion both increased maximum achievable QECMO, delivery of oxygen (DO2), and MSFP, but right atrial pressure increased in parallel. VRdP did not change. The vascular elastance curve was shifted to the left by Vasoconstriction, with recruitment of stressed volume. It was shifted to the right by Volume Expansion with direct expansion of stressed volume. Volume Expansion decreased resistance to venous return and pump afterload.In a circulation completely dependent on ECMO support, maximum achievable flow directly depended on the vascular factors governing venous return-i.e., closing conditions, stressed vascular volume and the elastance and resistive properties of the vasculature. Both treatments increased maximum achievable ECMO flow at stable DO2, via increases in stressed volume by different mechanisms. Vascular resistance and pump afterload decreased with Volume Expansion.

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