ICU-ECMO生理学.docx

ICU Physiology in 1,000 Words: Veno-Arterial Extra-Corporeal Membrane Oxygenation (VA-ECMO)Perhaps the most memorable patient of both my pulmonary and critical care fellowships was that of a very young woman who suffered from propofol-related infusion syndrome [PRIS]. As a consequence of PRIS, she endured multiple cardiac arrests and was placed on Veno-Arterial Extra-Corporeal Membrane Oxygenation [VA-ECMO] during cardiopulmonary resuscitation. Because of the rapid resuscitation she received from my colleagues, she survived to discharge – neuro-cognitively intact – despite spending an entire evening without cardiac activity. The details of her case may be reviewed here [1]. The aforementioned use of VA-ECMO highlights its life-preserving capability, and underscores the importance of its hemodynamic workings.Veno-Arterial versus Veno-Venous Extra-Corporeal Membrane OxygenationVA-ECMO is hemodynamically distinct from veno-venous extra-corporeal membrane oxygenation [VV-ECMO]. The latter is often used as a salvage therapy for severe ARDS in patients with preserved cardiac function as reviewed here [2]. VV-ECMO removes venous blood, performs gas exchange through an external circuit and then returns the blood back to the venous system. By contrast, VA-ECMO removes venous blood, performs gas exchange through an external circuit, and then returns the ‘revitalized’ blood to the arterial tree. VA-ECMO, therefore, bypasses the heart and the lungs completely and may be used in advanced cardiac-arrest algorithms as described in the case above. Importantly, should VA-ECMO be employed in advanced cardiac failure, the hemodynamic repercussions must be anticipated; this may be accomplished using the paradigm given to us by Arthur Guyton.A Guytonian PrimerA fantastic model – borne from the principles Arthur Guyton – was formed by Sunagawa et al [3]; very recently, this model was further developed by Sakamoto and colleagues as a framework for understanding VA-ECMO [4]. Before turning