Parallel circuits for refractory hypoxemia on venovenous extracorporeal membrane oxygenation

Parallel circuits for refractory hypoxemia on venovenous extracorporeal membrane oxygenation

Accepted Manuscript Paralell Circuits for Refractory Hypoxemia on Veno-Venous Extracorporeal Membrane Oxygenation Adnan Malik, MD, Larry L. Shears, MD...

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Accepted Manuscript Paralell Circuits for Refractory Hypoxemia on Veno-Venous Extracorporeal Membrane Oxygenation Adnan Malik, MD, Larry L. Shears, MD, Dmitriy Zubkus, MD, David J. Kaczorowski, MD PII:

S0022-5223(16)31467-2

DOI:

10.1016/j.jtcvs.2016.10.067

Reference:

YMTC 11021

To appear in:

The Journal of Thoracic and Cardiovascular Surgery

Received Date: 28 July 2016 Revised Date:

28 September 2016

Accepted Date: 16 October 2016

Please cite this article as: Malik A, Shears LL, Zubkus D, Kaczorowski DJ, Paralell Circuits for Refractory Hypoxemia on Veno-Venous Extracorporeal Membrane Oxygenation, The Journal of Thoracic and Cardiovascular Surgery (2016), doi: 10.1016/j.jtcvs.2016.10.067. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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PARALELL CIRCUITS FOR REFRACTORY HYPOXEMIA ON VENO-VENOUS EXTRACORPOREAL MEMBRANE OXYGENATION

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Adnan Malik MD1, Larry L. Shears MD2, Dmitriy Zubkus MD3, David J. Kaczorowski MD2

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1 Cardiology, 2 Cardiothoracic Surgery, 3 Pulmonary and Critical Care Medicine

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WellSpan Health, York, PA

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Conflicts: none

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Funding: none

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Running title: Parallel circuits for refractory hypoxemia

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Keywords: extracorporeal membrane oxygenation

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Word Count: 1558

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Corresponding author:

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David J. Kaczorowski, MD Director of Mechanical Circulatory Support Cardiothoracic Surgery WellSpan Health 25 Monument Road Suite 190 York, PA 17403 Phone: 717-851-6454 Fax: 717-851-1665 Email: [email protected]

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CENTRAL MESSAGE

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Parallel ECMO circuits can ameliorate refractory hypoxemia in patients with acute pulmonary failure and high cardiac output.

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Refractory hypoxemia during support on veno-venous extracorporeal membrane

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oxygenation (V-V ECMO) is a challenging clinical problem. Manipulating ventilator

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settings, prone positioning, optimizing cannula position and ECMO flows, and the use of

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beta-blockers have been advocated as methods to improve oxygenation during V-V

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ECMO.1,2 Cannulation strategies designed to prevent mixing have also been reported.3

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In patients with extremely high cardiac output, including those with trauma, sepsis, or

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other systemic inflammatory responses, these strategies may be inadequate or

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ineffective as the patient’s cardiac output may be substantially greater than the

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maximum flow achievable with an ECMO circuit. Here we report a novel strategy that

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was used to overcome refractory hypoxemia in a patient with high cardiac output.

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Specifically, a second ECMO circuit was used in parallel with the first to achieve

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adequate oxygenation.

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CLINICAL SUMMARY

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A 39 year-old woman developed severe hypoxemia due to ARDS as complication of

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intra-abdominal sepsis. She was placed on V-V ECMO using standard techniques.

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Venous drainage was accomplished using a 25-French long, multi-holed cannula in the

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right common femoral vein with its tip at the junction of the inferior vena cava (IVC) and

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right atrium (RA). An 18-French cannula was placed via the right internal jugular vein

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with its tip located in the RA. ECMO flows of approximately 5.5 liters/minute were

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achieved and were considered adequate since the patient’s weight was 55 kg and her

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body surface area was 1.6 m2. The patient improved and adequate oxygenation was

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achieved.

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However, the patient’s condition deteriorated over the next several days. She was

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tachycardic and had a cardiac output ranging between 8-10 liters/min. Despite

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optimizing ventilator settings and maximizing ECMO flows, the patient’s hypoxemia

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worsened with an arterial partial pressure of oxygen as low as 40 mm Hg. The position

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of the cannulas was confirmed with both chest x-ray and echocardiography.

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Echocardiography also showed no evidence of intracardiac shunt. Visual inspection of

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the arterial and venous lines suggested minimal recirculation and this was supported by

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blood gas data. Further, the venous drainage cannula was manipulated in an attempt to

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reduce any potential recirculation without any significant change in oxygenation or

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circuit flows. Oxygenator problems were also excluded. Visual inspection revealed no

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evidence of thrombus in the oxygenator. An oxygenator gas revealed a Pa02 of 464

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mm Hg. Beta-blockade was not possible due to hypotension. The ability to diurese the

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patient was limited by the patient’s septic state. In order to better match the patient’s

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high cardiac output, we sought to provide considerably more ECMO flow, beyond what

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might be achieved by insertion of an additional venous drainage cannula.

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A second ECMO circuit was placed in parallel with the first circuit. A 21-French long,

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multi-holed venous cannula was placed via the left femoral vein with its tip located more

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peripherally in the IVC. Another 18-French cannula was placed in the left subclavian

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vein with its tip near the superior vena cava. ECMO was initiated and the patient’s

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oxygenation improved. After adding the second circuit flows of 4.75 liters/minute and

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3.5 liters/minute were achieved with the first and second circuits respectively.

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Approximately 8-9 liters/minute of combined flow could be delivered at a given moment

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in this patient. The first arterial blood gas after insertion of the second circuit revealed a

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PaO2 of 92 mm Hg . Within 12 hours the PaO2 reached 187 mm Hg. This increase in

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oxygenation allowed the fraction of inspired oxygen on the ventilator to be weaned from

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100% to 30% within 24 hours. No other interventions were performed during that period

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of time that could account for the observed improvement in oxygenation.

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The patient was maintained on dual circuits for 14 days. At that time, the left femoral

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venous cannula was removed. The left subclavian cannula was then connected to the

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venous limb of the first circuit and used as an additional site of venous drainage. Later,

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a single site cannulation strategy using a dual-lumen bicaval cannula was used to allow

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mobility as she improved. The patient was weaned from ECMO after 60 days of

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support. She had a prolonged intensive care unit stay notable for acute renal failure

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requiring temporary hemodialysis. She was later discharged from the hospital

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decannulated of her tracheostomy and with normal renal function.

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DISCUSSION

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The use of ECMO for the management of patients with acute cardiac or pulmonary

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failure has grown substantially in recent years.4 While ECMO can be life saving for

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appropriately selected patients, those with high cardiac output can be challenging to

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manage with ECMO and outcomes may be suboptimal, particularly in the setting of

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sepsis.5 This report demonstrates that parallel V-V ECMO circuits can be successfully

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used to treat refractory hypoxemia in the setting of elevated cardiac output in a patient

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with acute pulmonary failure.

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One alternative to the approach utilized here is conversion to veno-arterial (VA) ECMO.

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VA ECMO can be useful to ameliorate both hypotension and ongoing hypoxemia in

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many cases. This is particularly true if myocardial function is impaired. However, in

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the setting of extremely high cardiac output and vasodilatation, VA ECMO may be

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ineffective and potentially deleterious. Since the cardiac output is already high, VA

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ECMO does not address the underlying pathophysiology and blood pressure may

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remain low under these circumstances due to lack of vascular tone. Further, when

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native cardiac output is very high and femoral cannulation is employed, mixing may

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occur very distally in the aorta resulting in delivery of deoxygenated blood to the upper

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body. These may be contributing factors to the poor outcomes observed with the use of

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VA ECMO in the management of septic shock.5

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While VA ECMO may be ineffective in patients with hypoxemia and high cardiac output,

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several other maneuvers should be considered to remedy the situation. Cannula

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position should be optimized. The venous cannula was pulled back in this case,

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however we did not manipulate the infusion cannula. It is possible that doing so would

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have reduced potential recirculation and improved oxygenation. Insertion of a drainage

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cannula in the superior vena cava (SVC) is also a viable alternative to consider prior to

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utilizing parallel circuits. Since insertion of an SVC cannula may allow additional ECMO

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flow and reduce mixing, this intervention should be considered prior to inserting a

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second circuit. In this case, we sought to provide more flow than what might be

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expected by the insertion of an additional cannula. Furthermore, the Extracorporeal Life

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Support Organization (ELSO) provides guidelines on the management of patients on

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ECMO.6 Given the important role of hemoglobin in oxygen delivery, these guidelines

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state that the hematocrit should be targeted as high as greater than 40%.6 Utilizing a

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higher goal hematocrit prior to inserting the second circuit may have allowed for

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improved oxygen delivery in this case. Another potential alternative to placing a second

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circuit is prone positioning. While this is certainly a possibility, we do not routinely place

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patients on ECMO in prone position due to concern for potential complications including

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cannula malposition and cannula dislodgement.

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The use of femoral cannulation in this strategy precludes early mobilization and

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ambulation. However, it is unlikely that patients requiring parallel circuits would be

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suitable candidates for extubation or ambulation at that particular stage in their disease.

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A strategy involving parallel circuits does not preclude later conversion to a single-site,

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bicaval strategy, as was performed in this case. Of note, we did not find that the

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addition of a second circuit was overly cumbersome for the nursing staff and it did not

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impair daily nursing care.

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The cannulation strategy utilized in this case required positioning of two venous

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cannulas in the IVC, leading to concern over potential thrombotic complications

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involving the IVC. Adequate anticoagulation is likely an important factor to prevent

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these complications. In this case, the patient was systemically anticoagulated with a

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goal PTT of 60-80 seconds, but the ideal degree of anticoagulation is unknown.

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Greater experience with this technique will be required to evaluate the risk of this and

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other potential complications.

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Another potential concern is the cost of an additional ECMO circuit. In this case, the

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costs of the disposables used to establish the second circuit were minor. The majority

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of the cost of the care provided stems from the patient’s prolonged intensive care stay

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rather than the materials used for the ECMO circuit.

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Even when venous drainage is ideal and when little or no mixing of blood occurs, a

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standard ECMO circuit may not be able to provide enough flow to achieve adequate

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oxygenation in patients with very high cardiac output. Despite its potential limitations,

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the use of second circuit in parallel with the first should be considered when other

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methods of managing refractory hypoxemia during V-V ECMO are impossible to

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implement or unsuccessful.

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LEGENDS

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Figure 1. Parallel circuits for refractory hypoxemia despite V-V ECMO. A) Standard V-V ECMO with cannulation of the right common femoral vein and the right internal jugular vein. B) Parallel V-V ECMO circuits with a second circuit involving cannulation of the left common femoral vein and left subclavian vein. C) Conversion back to a single circuit with venous drainage from the both the left subclavian vein and right common femoral vein and return via cannulation of the right internal jugular vein.

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Video 1. Refractory hypoxemia during V-V ECMO and the case presented here are discussed.

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1. Montisci A, Maj G, Zangrillo A, Winterton D, Pappalardo F. Management of refractory hypoxemia during venovenous extracorporeal membrane oxygenation for ARDS. ASAIO J. 2015 May-Jun;61(3):227-36.

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2. Guarracino F, Zangrillo A, Ruggeri L, Pieri M, Calabrò MG, Landoni G, Stefani M, Doroni L, Pappalardo F. β-Blockers to optimize peripheral oxygenation during extracorporeal membrane oxygenation: a case series. J Cardiothorac Vasc Anesth. 2012 Feb;26(1):58-63.

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3. Bonacchi M, Harmelin G, Peris A, Sani G.A novel strategy to improve systemic oxygenation in venovenous extracorporeal membrane oxygenation: the "χconfiguration". J Thorac Cardiovasc Surg. 2011 Nov;142(5):1197-204.

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4. Squiers JJ, Lima B, DiMaio JM. Contemporary extracorporeal membrane oxygenation therapy in adults: Fundamental principles and systematic review of the evidence. J Thorac Cardiovasc Surg. 2016 Jul;152(1):20-32 5. Huang CT, Tsai YJ, Tsai PR, Ko WJ. Extracorporeal membrane oxygenation resuscitation in adult patients with refractory septic shock. J Thorac Cardiovasc Surg. 2013 Nov;146(5):1041-6.

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6. ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support. Extracorporeal Life Support Organization, Version 1.3 November 2013. Ann Arbor, MI, USA. www.elsonet.org. Accessed 9/17/2016.

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REFERENCES

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