The ProtekDuo in ECMO configuration for ARDS secondary to COVID-19 - a systematic review

Objectives: Assessment of the literature on the ProtekDuo cannula when used as venopulmonary (V-P) extracorporeal membrane oxygenation (ECMO) in ARDS secondary to COVID-19. Method(s): Systematic literature search in EMBASE, Medline (Pubmed) and NHS library using appropriate keywords as well as PICOS and PRISMA approach. Result(s): We found 285 publications, of which 5 publications met the search criteria and were included in this review. A total of 194 patients with COVID-19 related ARDS had a ProtekDuo placed to establish venovenous (V-V) ECMO and right ventricular (RV) support. Patients treated with the ProtekDuo cannula had survival rates between between the studies of 59 and 89%, with a significant survival compared to an invasive ventilation group or when compared to dual site V-V ECMO or other double lumen ECMO cannulas. One of the studies focused on extubation and early discontinuation of ventilator support, which the authors achieved in 100% of ProtekDuo patients. The incidence of acute kidney injury (AKI) and use of continuous renal replacement therapy (CRRT) was significantly reduced in the ProtekDuo versus other groups. Conclusion(s): The ProtekDuo displayed lower mortality rates, AKI occurrence and CRRT need as compared to other respiratory support modalities and has shown to be a game changer for ECMO support in patients suffering from COVID-19 ARDS. Many authors suggested the ProtekDuo for first line use in these patients.

CARDIOSIM© cardiovascular software simulator for the study of ECMO support and mechanical ventilation interaction

The management of ventilated patients on extracorporeal membrane oxygenation (ECMO) support can be quite complex. This chapter will focus on the management of these patients based on the analysis of haemodynamic and energetic parameters using numerical simulations generated by a software package named CARDIOSIM©. New modules of the systemic circulation and ECMO were implemented in CARDIOSIM© software, a modular simulator of the cardiovascular system used in research, clinical and e-learning environment. The newstructure of the developed modules is based on the concept of lumped (0D) numerical modelling. Different ECMO configurations have been connected to the cardiovascular network to reproduce veno-arterial (VA) and veno-venous (VV) ECMO assistance. The advantages and limitations of different ECMO cannulation strategies have been considered. Literature data to validate the effects of a combined ventilation and ECMO support strategy were used. The outcome of the simulations has shown the typical effects induced during mechanical ventilation and ECMO assistance. We have focused our attention on ECMO with triple cannulation such as veno-ventricular-arterial (VV-A) and veno-atrial-arterial (VA-A) configurations to improve the haemodynamic and energetic conditions of a virtual patient. Simulations of VV-A and VA-A assistance with and without mechanical ventilation have generated specific effects on cardiac output, coupling of arterial and ventricular elastance for both ventricles, mean pulmonary artery pressure, external work and pressure volume area. The new modules used in this context have shown great potential for the purpose of this study. Based on our clinical experience during the COVID-19 pandemic, numerical simulations may help clinicians with data analysis and treatment optimisation of patients requiring both mechanical ventilation and circulatory support. © 2023 by Nova Science Publishers, Inc. All rights reserved.

Overview of extra-corporeal membrane oxygenation the role of simulation in relation to outcome prediction

Objectives: ECMO has become increasingly available to treat critically ill patients although overall survival rates remain unchanged. Traditional ECMO support includes veno-venous (VV) and veno-arterial (VA) configurations. Hybrid ECMO configurations have been considered recently to improve outcome. We sought to give an overview of the potential of a simulation approach in a clinical setting. Methods: CARDIOSIM © software has been used for this purpose based on pressure-volume (PV) loop analysis, modified time-varying elastance and lump-parameter modelling. Two new numerical models have been implemented to account for ECMO, IABP and Impella, which can interact according to the simulation settings. The software also simulates the effects of assisted ventilation in COVID-19 patients. Results: Hypothetical scenarios and true patients have been considered in relation to preoperative planning and clinical decision-making. Discussion: Increased left ventricular (LV) afterload leading to LV distension may affect the beneficial effects of VA-ECMO support. Experimental evidence confirms clinical findings and highlights reduced LV ejection fraction and stroke work as markers of LV dysfunction during VA-ECMO support. Optimal balance between LV unloading and systemic perfusion remains critical. LV unloading during VA-ECMO support depends on the absolute flow and the recruitable LV contractile reserve. A degree of LV ejection is highly desirable in a clinical setting. The impact of VA-ECMO on LV function can be accurately explained in terms of pressure- volume (PV) loops and Starling curves. Conclusion: ECMO support remains appropriate although potentially detrimental. A patient-specific modelling approach may help understand grey areas with a view to treatment optimisation and outcome prediction.