Measurements of Recirculation during Neonatal Veno-Venous Extracorporeal Membrane Oxygenation: Clinical Application of the Ultrasound Dilution Technique

Recirculation during dual lumen veno-venous (DLVV) extracorporeal membrane oxygenation (ECMO) is a dynamic event that results in a fraction of the oxygenated blood exiting the arterial lumen and immediately shunting back into the venous lumen. Excessive recirculation will result in suboptimal oxygen delivery to the patient. Ultrasound dilution is a technology that has been shown to rapidly quantify recirculation in veno-venous (VV) ECMO animal models. This manuscript reports the first clinical application of ultrasound dilution in quantifying recirculation during neonatal VV ECMO. A 2.8-kg neonate with congenital diaphragmatic hernia was placed on VV ECMO using a single DLVV cannula inserted into the right atrium through the internal jugular vein. Ultrasound sensors were clamped to the arterial and venous lines near the dual lumen cannula and 3- to 5-mL bolus injections of isotonic saline were used proximal to the circuit heat exchanger to make the recirculation measurements. Recirculation measurements were made after initiation and periodically thereafter. During the 12-day ECMO period, 86 recirculation measurements were performed. The average recirculation was 34.3% (range, 15-57%). Reproducibility of paired measurements was 5.6%. Changes in patient positioning resulted in significant changes in recirculation. Measurements using platelet injections were compared with those made with saline. The two were found to closely correlate (mean difference, .25% +/- 2.8%). Ultrasound dilution measurements of recirculation provided rapid monitoring data during a clinical VV ECMO procedure. Application of this technique could provide early data that will assist the clinician in guiding interventions to minimize recirculation.