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Parallel Veno-Venous Extracorporeal Membrane Oxygenation Circuits for Refractory Hypoxemia in a Super-Super-Obese Patient

Published:March 11, 2023DOI:
      Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) represents a rescue form of life support for refractory respiratory failure, shown to confer a mortality benefit.1, 2 Although relative contraindications to VV-ECMO have been evolving with technology and experience, they currently include mechanical ventilation for more than seven days [with plateau pressure (Pplat) > 30 cm H2O and/or fraction of inspired oxygen (FiO2) > 90%], intracranial hemorrhage or systemic bleeding, irreversible and incapacitating central nervous system pathology, immunosuppression, terminal malignancy, and advanced age.3 The latest ECMO guidelines do not list obesity as a contraindication.3 In fact, studies support the use of VV-ECMO in obese patients, in light of similar or even better survival outcomes compared to their non-obese counterparts.4-10 However, skepticism still exists, especially for those with extreme body mass index (BMI), defined as super-obese (BMI >50) or super-super obese (BMI > 60). Apart from practical challenges, like cannulation and proning difficulties, the complex pulmonary and cardiovascular pathophysiology associated with extreme obesity carries the risk of inadequate ECMO flows for the body surface area (BSA) with resultant hypoxemia, as well as hemolysis with secondary coagulopathy from required high flows. We report the successful implementation of two in-parallel VV-ECMO circuits to overcome the limitations encountered in a super-super obese patient undergoing conventional VV-ECMO for refractory respiratory failure.


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