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Ann Thorac Surg 2010;89:345-346. doi:10.1016/j.athoracsur.2009.08.022
© 2010 The Society of Thoracic Surgeons
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Correspondence

High Frequency of Organ Failures During Extracorporeal Membrane Oxygenation: Is the Microcirculation the Answer?

Christian Jung, MD, Hans R. Figulla, MD, Markus Ferrari, MD

Clinic of Internal Medicine I, Friedrich-Schiller-University, Erlanger Allee 101, Jena, 07740 Germany

(Email: christian.jung{at}med.uni-jena.de).

To the Editor:

We read with great interest the article by Thiagarajan and colleagues [1]. The authors presented important data regarding the use of extracorporeal membrane oxygenation (ECMO) to support cardiopulmonary resuscitation (CPR) by analyzing multiinstitutional data (295 patients) from the Extracorporeal Life Support Organization Registry. They showed that pre-ECMO factors (eg, arterial blood partial pressure of oxygen) are important for outcomes, but also the need for renal replacement therapy during ECMO. In addition, convincing data was presented regarding the complications that frequently occur during ECMO, including metabolic, cardiac, gastrointestinal, pulmonary, and renal complications.

During recent years microcirculation has attracted increased attention since imaging techniques began to noninvasively visualize the smallest vessels with new intra-vital microscopes, and the prognostic importance has been recognized for the prognosis of critically ill patients [2]. The microcirculation provides gas and nutrient exchange, and organ failures are strongly associated with microcirculatory changes.

Therefore we investigated the flow in the smallest vessel as microvascular flow index (MFI), which can monitor microflow changes during ECMO therapy [3]. Sublingual MFI was evaluated as previously described [4] using a side-stream dark field intra-vital microscope in 6 patients with emergently implanted ECMO (4 patients [Medtronic, Minneapolis, MN]; 2 patients [Lifebridge, Munich, Germany]; 4 men, 2 women; four resuscitations, with two during emergency cardiac intervention). The recorded video sequences were later analyzed in a semi-quantitative way (0 = no flow, 1 = intermittent flow, 2 = sluggish flow, 3 = continuous flow) separately for each vessel category (small, 10 to 25 µm; medium, 26 to 50 µm; large, 51 to 100 µm). Although mean arterial pressure was optimal (69.5 ± 5.5 mm Hg), the flow in the smallest vessels was not completely restored (MFI small, 2.61 ± 0.29; MFI medium, 2.53 ± 0.58; MFI large, 2.70 ± 0.44). Despite re-storing macrocirculation, the high frequency of organ failure may result from suboptimal microcirculation.

We believe that our therapeutic efforts should address the microcirculation. At first, we have to measure microcirculatory changes during ECMO. Second, we have to improve our treatment strategy by appropriate adaptation of ECMO or the infusion rates of catecholamines, fluids, or other drugs, or a combination of these, to restore physiologic conditions of microcirculation.


   References
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 References
 

  1. Thiagarajan RR, Brogan TV, Scheurer MA, Laussen PC, Rycus PT, Bratton SL. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in adults Ann Thorac Surg 2009;87:778-785.[Abstract/Free Full Text]
  2. Knotzer H, Hasibeder WR. Microcirculatory function monitoring at the bedside: a view from the intensive care Physiol Meas 2007;28:R65-R86.[Medline]
  3. Jung C, Ferrari M, Gradinger R, et al. Evaluation of the microcirculation during extracorporeal membrane-oxygenation Clin Hemorheol Microcirc 2008;40:311-314.[Medline]
  4. Jung C, Ferrari M, Roediger C, et al. Evaluation of the sublingual microcirculation in cardiogenic shock Clin Hemorheol Microcirc 2009;42:141-148.[Medline]

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Ravi R. Thiagarajan, Thomas V. Brogan, and Susan L. Bratton
Ann. Thorac. Surg. 2010 89: 346. [Extract] [Full Text] [PDF]



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Ann. Thorac. Surg., January 1, 2010; 89(1): 346 - 346.
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