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Transpulmonary thermodilution before and during veno-venous extra-corporeal membrane oxygenation ECMO: an observational study on a potential loss of indicator into the extra-corporeal circuit

  • Alexander Herner
  • Tobias Lahmer
  • Ulrich Mayr
  • Sebastian Rasch
  • Jochen Schneider
  • Roland M. Schmid
  • Wolfgang HuberEmail author
Original Research

Abstract

Haemodynamic monitoring before extra-corporeal membrane oxygenation (ECMO) might help to optimize the effectiveness of ECMO. However, there are concerns that pulmonary arterial and trans-pulmonary thermodilution (TPTD) might be confounded by a loss of indicator into the ECMO-circuit, resulting in an overestimation of volumetric parameters. Since there is a lack of data on indicator dilution techniques during ECMO, we compared TPTD-measurements before and during ECMO. TPTD-derived parameters before and after initiation of ECMO were compared in 14 intensive care unit-patients with veno-venous ECMO and TPTD-monitoring (PiCCO®). Eight patients had a jugular and six patients a femoral central venous catheter (CVC). Cardiac index, global end-diastolic volume index (GEDVI) and extra-vascular lung water index (EVLWI) before ECMO as well as the ECMO-flow were comparable in patients with jugular and femoral CVC. Pre-ECMO, cardiac index (CI) was not significantly different compared to values during ECMO (4.5 ± 1.7 vs. 4.4 ± 2.1 L/min/m2; p = 0.43). By contrast, GEDVI (791 ± 179 vs. 974 ± 384 mL/m2; p = 0.04) and EVLWI (21 ± 9 vs. 28 ± 11 mL/kg; p < 0.01) were higher during ECMO than before. Increases in GEDVI (36 ± 210 vs. 378 ± 247 mL/m2; p = 0.02) and EVLWI (3 ± 2 vs. 11 ± 8 mL/kg; p = 0.06) were substantially more pronounced in patients with femoral compared to jugular indicator injection. In multivariate analysis, femoral indicator injection was independently associated with larger increases in GEDVI (p < 0.01) and EVLWI (p = 0.04) during ECMO. However, CI and haemodynamic parameters not derived from TPTD, but from pulse contour analysis (systolic and diastolic arterial pressure, stroke volume variation and pulse pressure variation) were not affected by the start of ECMO. Our study demonstrates marked increases in GEDVI and EVLWI after the onset of ECMO. These increases were more pronounced for femoral compared to jugular indicator injection. CI and haemodynamic parameters not derived from TPTD were not affected by the extra-corporeal circuit.

Keywords

Extra-corporeal membrane oxygenation Trans-pulmonary thermodilution Cardiac output Pulse contour analysis Global end-diastolic volume index Extra-vascular lung water index 

Abbreviations

AP

Arterial pressure

ARDS

Acute respiratory distress syndrome

PBV

Pulmonary blood volume

CI

Cardiac index

CO

Cardiac output

CPI

Cardiac power index

CV

Controlled ventilation

CVC

Central venous catheter

CVP

Central venous pressure

DST

Downslope time

Ea_dyn

Dynamic arterial elastance

ECMO

Extra-corporeal membrane oxygenation

EVLWI

Extra-vascular lung water index

GEDVI

Global end-diastolic volume index

HPS

Hepatopulmonary syndrome

ICU

Intensive care unit

LOI

Loss of indicator

MTT

Mean transit time

PAC

Pulmonary arterial catheter

PCA

Pulse contour analysis

PBV

Pulmonary blood volume

PPV

Pulse pressure variation

PTT

Partial thromboplastin time

PTV

Pulmonary thermal volume

PVPI

Pulmonary vascular permeability index

RCT

Randomized controlled trial

SR

Sinus rhythm

SVV

Stroke volume variation

TPTD

Trans-pulmonary thermodilution

ITTV

Intra-thoracic thermal volume

Vv

Veno-venous

Notes

Funding

The authors received no specific funding for this work.

Compliance with ethical standards

Conflict of interest

Wolfgang Huber collaborates with Pulsion Medical Systems SE, Feldkirchen, Germany as Member of the Medical Advisory Board. All other authors declare that they have no competing interests.

Ethical approval

The Institutional Review Board approved the study (Ethikkommission; Fakultät für Medizin; Technische Universität München 310/18S).

Informed consent

The need for informed consent was waived.

Supplementary material

10877_2019_398_MOESM1_ESM.docx (25 kb)
Supplementary material 1 (DOCX 24 kb)
10877_2019_398_MOESM2_ESM.docx (19 kb)
Supplementary material 2 (DOCX 19 kb)

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Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.Medizinische Klinik und Poliklinik II, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
  2. 2.II. Medizinische Klinik, Klinikum rechts der IsarMunichGermany

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