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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Disclosure of funding: Institutional. No commercial or research funding to disclose.
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