Robert Arnaud, Honoré Patrick M, Bulpa Pierre, Michaux Isabelle
Department of ICU, Centre Hospitalier Universitaire Université Catholique de Louvain, Mont-Godinne, 5530 Yvoir, Belgium.
The Faculty of Medicine, Experimental Research Laboratory Institute of the Catholic Louvain Medical School, 1200 Brussels, Belgium.
J Clin Med. 2025 Feb 28;14(5):1653. doi: 10.3390/jcm14051653.
Veno-venous extracorporeal membrane oxygenation (vvECMO) is a life-saving intervention for severe respiratory failure unresponsive to conventional therapies. However, managing refractory hypoxemia in morbidly obese patients poses significant challenges due to the unique physiological characteristics of this population, including hyperdynamic circulation, elevated cardiac output, and increased oxygen consumption. These factors can limit the effectiveness of vvECMO by diluting arterial oxygen content and complicating oxygen delivery. Refractory hypoxemia in obese patients supported by vvECMO often stems from an imbalance between ECMO blood flow and cardiac output. Hyperdynamic circulation exacerbates the recirculation of oxygenated blood and impairs the efficiency of oxygen transfer. To address these challenges, a stepwise, individualized approach is essential. Strategies to reduce oxygen consumption include deep sedation, neuromuscular blockade, and temperature control. Cardiac output modulation can be achieved through beta-blockers and cautious therapeutic hypothermia. Optimizing oxygen delivery involves improving residual lung function; high positive end-expiratory pressure ventilation guided by esophageal pressure monitoring; prone positioning; and adjustments to the ECMO circuit, such as using dual oxygenators, larger membranes, or additional drainage cannulas. This review highlights the interplay of physiological adaptations and technical innovations required to overcome the challenges of managing refractory hypoxemia in obese patients during vvECMO. By addressing the complexities of high cardiac output and obesity, clinicians can enhance the effectiveness of vvECMO and improve outcomes for this high-risk population.
静脉-静脉体外膜肺氧合（vvECMO）是一种用于治疗对传统疗法无反应的严重呼吸衰竭的挽救生命的干预措施。然而，由于病态肥胖患者的独特生理特征，包括高动力循环、心输出量升高和氧消耗增加，管理这些患者的难治性低氧血症面临重大挑战。这些因素会通过稀释动脉血氧含量和使氧输送复杂化来限制vvECMO的有效性。接受vvECMO支持的肥胖患者的难治性低氧血症通常源于ECMO血流量与心输出量之间的失衡。高动力循环会加剧氧合血的再循环并损害氧转移效率。为应对这些挑战，采取逐步、个体化的方法至关重要。降低氧消耗的策略包括深度镇静、神经肌肉阻滞和体温控制。心输出量调节可通过β受体阻滞剂和谨慎的治疗性低温来实现。优化氧输送包括改善残余肺功能；在食管压力监测引导下进行高呼气末正压通气；俯卧位；以及对ECMO回路进行调整，例如使用双氧合器、更大的膜或额外的引流插管。本综述强调了在vvECMO期间克服肥胖患者难治性低氧血症管理挑战所需的生理适应与技术创新之间的相互作用。通过解决高心输出量和肥胖的复杂性，临床医生可以提高vvECMO的有效性并改善这一高危人群的预后。
