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ndings highlighted the advantages of delayed renal replacement therapy in critically ill patients [60], which does not promote early initiation of renal replacement therapy for uid removal. In continuous renal replacement therapy, a net
ultraltration between 1 and 1.75mL/kg/h is associated with a better prognosis
[33]. Targeting a net ultraltration of 2mL/kg/h provides a signicant decrease in
uid balance (if uid intake is restrictive) and seems safe, provided a strict hemodynamic monitoring [38]. In chronic intermittent hemodialysis, a net ultraltration over 10mL/kg/h is associated with increased mortality [61]; hence, it seems
reasonable to use lower net ultraltration rate in critically ill patients. To this
purpose, prolonged, more frequent sessions or isolated ultraltration may be carried out to induce a negative uid balance [62]. Regarding the control of uid
balance, experts have suggested to not wean renal replacement if the diuresis is
lower than 2L/day with diuretics [63]. To nish, recent data indicates to avoid
transition from continuous renal replacement therapy to intermittent hemodialysis if uid accumulation persists, as it has shown as a marker of poor hemodynamic tolerance of intermittent hemodialysis [64].
M. Ruste et al.
Deresuscitation: Do Not Forget Fluid Intake
If restrictive strategies to initial resuscitation is beyond the scope of this focus, a
tight control of uid intake remains an integral part of deresuscitation strategy. A
recent cohort emphasized that, in real-life, resuscitation uids only count for 6.6%
of the uid intake during the ICU stay, whereas maintenance uids count for 25%,
nutrition for 33% and uid creep (uids administrated as a vehicle for medication
or electrolytes) for 33%. Besides, resuscitation uids’ contribution to uid balance
decreases throughout the ICU stay, and the major determinants of the positive
cumulative uid balance, sodium and chloride burden are uids of maintenance and
uid creep [20]. In this regard, the prescription of maintenance uids and dilution
for medication needs special attention as they largely participate to sodium and
chloride load. As sodium-induced uid retention and chloride-related renal vasoconstriction could be responsible for uid accumulation themselves, maintenance
uids should preferably be orally administrated, hypotonic and for a total amount of
intake without exceeding 25–30mL/kg/day and 1mmol/kg/day of sodium [65]. To
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331
this purpose, dissolving as many medications as possible in glucose 5% is efcient
and probably safe [66].
Suggestions for daily clinical practice concerning deresuscitation are provided in
Figs.20.2 and 20.3.
Fig. 20.2 Deresuscitation and monitoring
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M. Ruste et al.
Fig. 20.3 Deresuscitation: suggestions for clinical practice. RRT Renal replacement therapy
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333
Deresuscitation: Evidence-Based Patient-Centered Impact
If uid overload was constantly associated with a worse prognosis, the causality
link is not well-established. Thus, as a patient–physician interaction, uid accumulation is probably in part inherent to pathological patient-related factors as capillary
leakage and organ failure, which obviously participate in this worse prognosis. In
this regard, interventional studies aiming to decrease uid overload have shown
relatively disappointing results. If restrictive strategies may help the mechanical
ventilation weaning without improving mortality [67, 68], high-quality trials are
scarce on deresuscitation strategy itself. They have shown difculties to elaborate
allowing a signicant decrease in cumulative uid balance and did not show any
signicant improvement in patients with sepsis outcomes [69]. A recent large randomized trial illustrates those difculties: a protocol targeting a progressive weight
decrease after day 2, using albumin, diuretics or ultraltration failed to decrease
cumulative uid balance compared to usual care [70]. Despite a complex dedicated
design, the trial suffered from contamination between groups. Suboptimal protocol
adherence was also reported and the strict safety criteria (suspension of the deresuscitation strategy if arterial hypotension, vasopressor requirement, renal function
deterioration) may have induced undertreatment in the interventional group.
However, to decrease cumulative uid balance with deresuscitation strategy is not a
quixotic goal as shown by two recent interventional or quasi-experimental studies
[38, 71]. It must be noted that besides acute kidney injury and restrictive strategies
in the peri-operative setting [72, 73] or cognitive dysfunction and restrictive strategy
in acute respiratory distress syndrome [74], no sign of harm were suggested by studies on deresuscitation. It has to be modulated by the fact that data are scarce and
originate from deresuscitation protocols with restrictive safety criteria applied to
stabilized patients.
To conclude, if several experts support the concept of deresuscitation or deescalation [40, 75], the lack of solid evidence-based demonstration of its clinical
interest highlights the gap between physician practices and scientic knowledge. It
may explain the heterogeneity in diagnosis and therapeutic interventions observed
worldwide in several surveys on uid overload and uid removal [19, 76–78]. In
this context, trials are urgently needed to determine the eligible population, the
safety criteria, the targets and the means to “deresuscitate.”
Acknowledgment Authors thank Lucie Bernigaud for help in manuscript preparation.
Conict of Interest Statement The authors have no conicts of interest related to the manuscript
to declare.
Funding Sources
Author Contributions Drafting of manuscript: MR.
Critical revision of the manuscript for important intellectual content: MR, MJL, JLF.
No funding source.
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M. Ruste et al.
References
1. Messmer AS, Zingg C, Müller M, Gerber JL, Schefold JC, Pfortmueller CA.Fluid overload
and mortality in adult critical care patients—a systematic review and meta-analysis of observational studies*. Crit Care Med. 2020;48(12):1862–70.
2. Zhang L, Chen Z, Diao Y, Yang Y, Fu P. Associations of uid overload with mortality and
kidney recovery in patients with acute kidney injury: a systematic review and meta-analysis. J
Crit Care. 2015;30(4):860.e7–13.
3. Woodward CW, Lambert J, Ortiz-Soriano V, Li Y, Ruiz-Conejo M, Bissell BD, et al. Fluid
overload associates with Major adverse kidney events in critically ill patients with acute kidney
injury requiring continuous renal replacement therapy. Crit Care Med. 2019;47(9):e753–60.
4. Mele A, Cerminara E, Häbel H, Rodriguez-Galvez B, Oldner A, Nelson D, etal. Fluid accumulation and major adverse kidney events in sepsis: a multicenter observational study. Ann
Intensive Care. 2022;12(1):62.
5. Garzotto F, Ostermann M, Martín-Langerwerf D, Sánchez-Sánchez M, Teng J, Robert R, etal.
The Dose Response Multicentre Investigation on Fluid Assessment (DoReMIFA) in critically
ill patients. Crit Care Lond Engl. 2016;20(1):196.
6. Schneider AG, Thorpe C, Dellbridge K, Matalanis G, Bellomo R.Electronic bed weighing vs
daily uid balance changes after cardiac surgery. J Crit Care. 2013;28(6):1113.e1–5.
7. Perren A, Markmann M, Merlani G, Marone C, Merlani P. Fluid balance in critically ill
patients. Should we really rely on it? Minerva Anestesiol. 2011;77(8):802–11.
8. Davies H, Leslie G, Jacob E, Morgan D.Estimation of body uid status by uid balance and
body weight in critically ill adult patients: a systematic review. Worldviews Evid Based Nurs.
2019;16(6):470–7.
9. Vincent JL, Pinsky MR.We should avoid the term « uid overload ». Crit Care Lond Engl.
2018;22(1):214.
10. Malbrain MLNG, Martin G, Ostermann M.Everything you need to know about deresuscitation. Intensive Care Med. 2022;48:1781.
11. Vincent JL, De Backer D.Circulatory shock. N Engl J Med. 2013;369(18):1726–34.
12. O’Connor ME, Prowle JR.Fluid overload. Crit Care Clin. 2015;31(4):803–21.
13. Hahn RG.Understanding volume kinetics. Acta Anaesthesiol Scand. 2020;64(5):570–8.
14. Tatara T.Context-sensitive uid therapy in critical illness. J Intensive Care. 2016;4(1):20.
15. Collins SR, Blank RS, Deatherage LS, Dull RO.The endothelial glycocalyx: emerging concepts in pulmonary edema and acute lung injury. Anesth Analg. 2013;117(3):664–74.
16. Lee WL, Slutsky AS.Sepsis and endothelial permeability. N Engl J Med. 2010;363(7):689–91.
17. Prowle JR, Echeverri JE, Ligabo EV, Ronco C, Bellomo R. Fluid balance and acute kidney
injury. Nat Rev Nephrol. 2010;6(2):107–15.
18. Malbrain MLNG, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, etal.
Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic
review with suggestions for clinical practice. Anaesthesiol Intensive Ther. 2014;46(5):361–80.
19. Silversides JA, McAuley DF, Blackwood B, Fan E, Ferguson AJ, Marshall JC.Fluid management and deresuscitation practices: a survey of critical care physicians. J Intensive Care Soc.
2020;21(2):111–8.
20. Van Regenmortel N, Verbrugghe W, Roelant E, Van den Wyngaert T, Jorens PG.Maintenance
uid therapy and uid creep impose more signicant uid, sodium, and chloride burdens than
resuscitation uids in critically ill patients: a retrospective study in a tertiary mixed ICU population. Intensive Care Med. 2018;44(4):409–17.
21. For the ICON Investigators, Vincent JL, Ferguson A, Pickkers P, Jakob SM, Jaschinski U, etal.
The clinical relevance of oliguria in the critically ill patient: analysis of a large observational
database. Crit Care. 2020;24(1):171.
22. Sanlippo F, Corredor C, Fletcher N, Landesberg G, Benedetto U, Foex P, et al. Diastolic
dysfunction and mortality in septic patients: a systematic review and meta-analysis. Intensive
Care Med. 2015;41(6):1004–13.
20 The Surgical Critically Ill Patients: AFocus onDeresuscitation Strategy
https://t.me/med1917
23. Dugar S, Sato R, Chawla S, You JY, Wang X, Grimm R, etal. Is left ventricular systolic dysfunction associated with increased mortality among patients with sepsis and septic shock?
Chest. 2023:S0012369223001113.
24. Ruiz P, de Garibay A, Kortgen A, Leonhardt J, Zipprich A, Bauer M.Critical care hepatology:
denitions, incidence, prognosis and role of liver failure in critically ill patients. Crit Care.
2022;26(1):289.
25. Jacob M, Bruegger D, Rehm M, Stoeckelhuber M, Welsch U, Conzen P, etal. The endothelial
glycocalyx affords compatibility of Starling’s principle and high cardiac interstitial albumin
levels. Cardiovasc Res. 2007;73(3):575–86.
26. Prowle J, Mehta R.Fluid balance management during continuous renal replacement therapy.
Semin Dial. 2021;34(6):440–8.
27. Oh TK, Song IA, Do SH, Jheon S, Lim C.Association of perioperative weight-based uid
balance with 30-day mortality and acute kidney injury among patients in the surgical intensive
care unit. J Anesth. 2019;33(3):354–63.
28. Wollborn J, Hassenzahl LO, Reker D, Staehle HF, Omlor AM, Baar W, et al. Diagnosing
capillary leak in critically ill patients: development of an innovative scoring instrument for
non-invasive detection. Ann Intensive Care. 2021;11(1):175.
29. Stein A, de Souza LV, Belettini CR, Menegazzo WR, Viégas JR, Costa Pereira EM, etal. Fluid
overload and changes in serum creatinine after cardiac surgery: predictors of mortality and
longer intensive care stay. A prospective cohort study. Crit Care Lond Engl. 2012;16(3):R99.
30. Shen Y, Zhang W, Cheng X, Ying M.Association between postoperative uid balance and
acute kidney injury in patients after cardiac surgery: a retrospective cohort study. J Crit Care.
2018;44:273–7.
31. Miller TE, Mythen M, Shaw AD, Hwang S, Shenoy AV, Bershad M, etal. Association between
perioperative uid management and patient outcomes: a multicentre retrospective study. Br J
Anaesth. 2021;126(3):720–9.
32. Silva JM, de Oliveira AMRR, Nogueira FAM, Vianna PMM, Pereira Filho MC, Dias LF, etal.
The effect of excess uid balance on the mortality rate of surgical patients: a multicenter prospective study. Crit Care Lond Engl. 2013;17(6):R288.
33. Murugan R, Bellomo R, Palevsky P, Kellum JA.Ultraltration in critically ill patients treated
with kidney replacement therapy. Nat Rev Nephrol. 2020;17:262.
34. Marik PE.Iatrogenic salt water drowning and the hazards of a high central venous pressure.
Ann Intensive Care. 2014;4(1):21.
35. Monnet X, Cipriani F, Camous L, Sentenac P, Dres M, Krastinova E, etal. The passive leg
raising test to guide uid removal in critically ill patients. Ann Intensive Care [Internet].
2016;6(1):46. [cité 10 oct 2018] Disponible sur: http://annalsontensivecare.springeropen.
com/articles/10.1186/s13613- 016- 0149- 1
36. Klijn E, Groeneveld ABJ, van Genderen ME, Betjes M, Bakker J, van Bommel J.Peripheral
perfusion index predicts hypotension during uid withdrawal by continuous Veno-venous
hemoltration in critically ill patients. Blood Purif. 2015;40(1):92–8.
37. Legrand M, Soussi S, Depret F.Cardiac output and CVP monitoring… to guide uid removal.
Crit Care Lond Engl. 2018;22(1):89.
38. Ruste M, Sghaier R, Chesnel D, Didier L, Fellahi JL, Jacquet-Lagrèze M.Perfusion-based
deresuscitation during continuous renal replacement therapy: a before-after pilot study (the
early dry cohort). J Crit Care. 2022;72:154169.
39. Rosner MH, Ostermann M, Murugan R, Prowle JR, Ronco C, Kellum JA, etal. Indications and
management of mechanical uid removal in critical illness. Br J Anaesth. 2014;113(5):764–71.
40. De Backer D, Cecconi M, Chew MS, Hajjar L, Monnet X, Ospina-Tascón GA, etal. A plea for
personalization of the hemodynamic management of septic shock. Crit Care. 2022;26(1):372.
41. Samoni S, Vigo V, Bonilla Reséndiz LI, Villa G, De Rosa S, Nalesso F, etal. Impact of hyperhydration on the mortality risk in critically ill patients admitted in intensive care units: comparison between bioelectrical impedance vector analysis and cumulative uid balance recording.
Crit Care. 2016;20(1):95.
335
336
https://t.me/med1917
42. Rhee H, Jang KS, Shin MJ, Lee JW, Kim IY, Song SH, etal. Use of multifrequency bioimpedance analysis in male patients with acute kidney injury who are undergoing continuous Venovenous Hemodialtration. PLoS One. 2015;10(7):e0133199.
43. Moonen HPFX, Van Zanten ARH. Bioelectric impedance analysis for body composition
measurement and other potential clinical applications in critical illness. Curr Opin Crit Care.
2021;27(4):344–53.
44. Cleymaet R, Scheinok T, Maes H, Stas A, Malbrain L, De Laet I, etal. Prognostic value of
bioelectrical impedance analysis for assessment of uid overload in ICU patients: a pilot study.
Anaesthesiol Intensive Ther. 2021;53(1):10–7.
45. Madsen JM, Wichmann S, Bestle MH, Itenov TS.Bioimpedance as a measure of uid status
in critically ill patients: a systematic review. Acta Anaesthesiol Scand. 2021;65(9):1155–67.
46. De Laet I, Deeren D, Schoonheydt K, Van Regenmortel N, Dits H, Malbrain ML. Renal
replacement therapy with net uid removal lowers intra-abdominal pressure and volumetric
indices in critically ill patients. Ann Intensive Care. 2012;2(Suppl 1):S20.
47. Goudelin M, Champy P, Amiel JB, Evrard B, Fedou AL, Daix T, etal. Left ventricular overloading identied by critical care echocardiography is key in weaning-induced pulmonary
edema. Intensive Care Med. 2020;46(7):1371–81.
48. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS)
Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden
D, etal. Comparison of two uid-management strategies in acute lung injury. N Engl J Med.
2006;354(24):2564–75.
49. Wallbach M, Valentova M, Schroeter MR, Alkabariti A, Iraki I, Leha A, et al. Intrarenal
Doppler ultrasonography in patients with HFrEF and acute decompensated heart failure undergoing recompensation. Clin Res Cardiol [Internet]. 2023; [cité 22 mai 2023]; Disponible sur:
https://link.springer.com/10.1007/s00392- 023- 02184- 6
50. Aronson D, Abassi Z, Allon E, Burger AJ.Fluid loss, venous congestion, and worsening renal
function in acute decompensated heart failure. Eur J Heart Fail. 2013;15(6):637–43.
51. Uz Z, Ince C, Guerci P, Ince Y, Araujo RP, Ergin B, etal. Recruitment of sublingual microcirculation using handheld incident dark eld imaging as a routine measurement tool during the
postoperative de-escalation phase—a pilot study in post ICU cardiac surgery patients. Perioper
Med. 2018;7(1):18.
52. Deschamps J, Denault A, Galarza L, Rola P, Ledoux-Hutchinson L, Huard K, etal. Venous
Doppler to assess congestion: a comprehensive review of current evidence and nomenclature.
Ultrasound Med Biol. 2023;49(1):3–17.
53. Guinot PG, Bahr PA, Andrei S, Popescu BA, Caruso V, Mertes PM, etal. Doppler study of
portal vein and renal venous velocity predict the appropriate uid response to diuretic in ICU:
a prospective observational echocardiographic evaluation. Crit Care. 2022;26(1):305.
54. McCoy IE, Chertow GM, Chang TIH.Patterns of diuretic use in the intensive care unit. PLoS
One. 2019;14(5):e0217911.
55. Côté JM, Bouchard J, Murray PT, Beaubien-Souligny W.Diuretic strategies in patients with
resistance to loop-diuretics in the intensive care unit: a retrospective study from the MIMIC-III
database. J Crit Care. 2021;65:282–91.
56. Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore PM, Hoste E, etal. Prevention of
acute kidney injury and protection of renal function in the intensive care unit: update 2017:
expert opinion of the working group on prevention, AKI section, European Society of Intensive
Care Medicine. Intensive Care Med. 2017;43(6):730–49.
57. Shahn Z, Lehman LWH, Mark RG, Talmor D, Bose S. Delaying initiation of diuretics in
critically ill patients with recent vasopressor use and high positive uid balance. Br J Anaesth.
2021;127(4):569–76.
58. Douvris A, Zeid K, Hiremath S, Bagshaw SM, Wald R, Beaubien-Souligny W, et al.
Mechanisms for hemodynamic instability related to renal replacement therapy: a narrative
review. Intensive Care Med. 2019;45(10):1333–46.
59. Benichou N, Gaudry S, Dreyfuss D.The articial kidney induces acute kidney injury: yes.
Intensive Care Med. 2020;46(3):513–5.
60. Gaudry S, Hajage D, Benichou N, Chaïbi K, Barbar S, Zarbock A, et al. Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a system-
M. Ruste et al.
20 The Surgical Critically Ill Patients: AFocus onDeresuscitation Strategy
https://t.me/med1917
atic review and individual patient data meta-analysis of randomised clinical trials. Lancet.
2020;395(10235):1506–15.
61. Assimon MM, Wenger JB, Wang L, Flythe JE.Ultraltration rate and mortality in maintenance hemodialysis patients. Am J Kidney Dis. 2016;68(6):911–22.
62. Gaudry S, Palevsky PM, Dreyfuss D.Extracorporeal kidney-replacement therapy for acute
kidney injury. Ingelnger JR, éditeur. N Engl J Med. 2022;386(10):964–75.
63. Wald R, Beaubien-Souligny W, Chanchlani R, Clark EG, Neyra JA, Ostermann M, et al.
Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury.
Intensive Care Med. 2022;48(10):1368–81.
64. Beaubien-Souligny W, Yang Y, Burns KEA, Friedrich JO, Meraz-Muñoz A, Clark EG, etal.
Intra-dialytic hypotension following the transition from continuous to intermittent renal
replacement therapy. Ann Intensive Care. 2021;11(1):96.
65. Van Regenmortel N, Moers L, Langer T, Roelant E, De Weerdt T, Caironi P, et al. Fluidinduced harm in the hospital: look beyond volume and start considering sodium. From physiology towards recommendations for daily practice in hospitalized adults. Ann Intensive Care.
2021;11(1):79.
66. Bihari S, Prakash S, Potts S, Matheson E, Bersten AD.Addressing the inadvertent sodium
and chloride burden in critically ill patients: a prospective before-and-after study in a tertiary mixed intensive care unit population. Crit Care Resusc J Australas Acad Crit Care Med.
2018;20(4):285–93.
67. Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC, etal. Conservative
uid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and metaanalysis. Intensive Care Med. 2017;43(2):155–70.
68. Reynolds PM, Stefanos S, MacLaren R.Restrictive resuscitation in patients with sepsis and
mortality: a systematic review and - with trial sequential analysis. Pharmacother
J Hum Pharmacol Drug Ther. 2023;43(2):104–14.
69. Messmer AS, Dill T, Müller M, Pfortmueller CA.Active uid de-resuscitation in critically
ill patients with septic shock: a systematic review and meta-analysis. Eur J Intern Med.
2023;109:89–96.
70. Bollaert PE, Monnier A, Schneider F, Argaud L, Badie J, Charpentier C, etal. Fluid balance
control in critically ill patients: results from POINCARE-2 stepped wedge cluster-randomized
trial. Crit Care. 2023;27(1):66.
71. Silversides JA, McMullan R, Emerson LM, Bradbury I, Bannard-Smith J, Szakmany T, etal.
Feasibility of conservative uid administration and deresuscitation compared with usual care
in critical illness: the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomised clinical trial. Intensive Care Med. 2022;48(2):190–200.
72. Chiu C, Fong N, Lazzareschi D, Mavrothalassitis O, Kothari R, Chen LL, etal. Fluids, vasopressors, and acute kidney injury after major abdominal surgery between 2015 and 2019: a
multicentre retrospective analysis. Br J Anaesth. 2022;129(3):317–26.
73. Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, etal. Restrictive versus liberal
uid therapy for major abdominal surgery. N Engl J Med. 2018;378(24):2263–74.
74. Mikkelsen ME, Christie JD, Lanken PN, Biester RC, Thompson BT, Bellamy SL, etal. The
adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological
function in survivors of acute lung injury. Am J Respir Crit Care Med. 2012;185(12):1307–15.
75. Malbrain MLNG, Langer T, Annane D, Gattinoni L, Elbers P, Hahn RG, etal. Intravenous uid
therapy in the perioperative and critical care setting: Executive summary of the International
Fluid Academy (IFA). Ann Intensive Care. 2020;10(1):64.
76. Murugan R, Ostermann M, Peng Z, Kitamura K, Fujitani S, Romagnoli S, etal. Net ultraltration prescription and practice among critically ill patients receiving renal replacement therapy:
a multinational survey of critical care practitioners. Crit Care Med. 2020;48(2):e87–97.
77. Lumlertgul N, Murugan R, Seylanova N, McCready P, Ostermann M.Net ultraltration prescription survey in Europe. BMC Nephrol. 2020;21(1):522.
78. Zeuthen E, Wichmann S, Schønemann-Lund M, Järvisalo MJ, Rubenson-Wahlin R, Sigurðsson
MI, etal. Nordic survey on assessment and treatment of uid overload in intensive care. Front
Med. 2022;9:1067162.
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Extracorporeal Membrane Oxygenation
SasaRajsic, BenediktTreml, andRobertBreitkopf
Introduction
Extracorporeal membrane oxygenation (ECMO, extracorporeal life support
[ECLS]) presents a temporary life-saving technology used in patients with refractory cardiogenic shock or severe pulmonary failure. The main aim of ECMO is
providing cardiac or respiratory support until the patient’s heart or lungs recover.
Moreover, it can bridge the time to organ transplantation or permanent organ assistance, such as mechanical circulatory support devices, ventricular assist devices, or
total articial heart.
The rst reports on the use of a prolonged extracorporeal circuit and the beginning of ECMO support date from 1972 (Bramson-membrane heart-lung machine)
[1]. Over the last two decades, the use of ECMO has expanded beyond severe cardiorespiratory failure, comprising an assortment of clinical presentations. Refractory
cardiac arrest requiring prolonged resuscitation (i.e., refractory ventricular arrhythmias, local anesthetics intoxication, etc.) is an evolving indication for extracorporeal cardiopulmonary reanimation (eCPR). The successful use of ECMO support
for out-of-hospital cardiac arrest is gaining popularity [2–5]. Moreover, ECMO support is increasingly used as bridge to heart and/or lung transplantation, rewarming
of patients with deep hypothermia, or treating hypoxic respiratory failure triggered
by trauma [6–10] or COVID-19 [11].
However, the overall survival after ECMO depends on many intrinsic variables
of the patient, besides the interactions between extracorporeal circulation, circuit
S. Rajsic (*) · B. Treml · R. Breitkopf
Medical University Innsbruck, Innsbruck, Austria
e-mail: sasa.rajsic@i-med.ac.at; benedikt.treml@i-med.ac.at;
robert.breitkopf@tirol-kliniken.at
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_21
339© The Author(s), under exclusive license to Springer Nature
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S. Rajsic et al.
surface, hemostatic factors and blood components; generating complex coagulation
and inammatory reactions; and making the management of the critically ill more
complex [12].
ECMO Physiology andCircuit
Homeostasis in critically ill patients, particularly those receiving ECMO support, is
multifactorially compromised. Cardiac surgery or ECMO implantation (surgical
trauma) and exposure of the patient’s blood to the large surface of the circuit initiate
and propagate an immediate inammatory reaction and activation of the coagulation cascade [13]. Numerous cellular and humoral systems are involved in these
complex inammatory responses during ECMO support, resulting in a procoagulant state of the organism and the need for systemic anticoagulation. The balance
between procoagulant factors and the iatrogenic coagulopathy is crucial to avoid
severe adverse events (both hemorrhagic and/or thromboembolic), and for the
patency of the circuit and its components [13].
The ECMO circuit is a closed system with a membrane-type gas-exchange technology. The main distinction between ECMO and a cardiopulmonary bypass is in the
air–blood interface and the duration of support. In contrast to ECMO, venous reservoirs are integrated into cardiopulmonary bypass circuits for cardiotomy suction and
venting of blood. Moreover, while cardiopulmonary bypass is usually used only for
the surgery duration, ECMO support may be employed for weeks or even months [14].
The ECMO circuit comprises of inow and outow cannulas, a pump, an oxygenator, and heat exchanger (Fig.21.1). The system components are connected by
Fig. 21.1 Venovenous-ECMO circuit: cannulation of the internal jugular and femoral vein
(Courtesy Getinge AB, Rastatt, Germany)
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