J Extra Corpor Technol. 2016;48:113–121 The Journal of ExtraCorporeal Technology

Esmolol Corrects Severe Hypoxemia in Patients with Femoro-Femoral Venoarterial Extracorporeal Life Support for Lung Transplantation Mohamed Ghalayini, MD;* Pierre-Yves Brun, MD;* Pascal Augustin, MD;* Elise Guivarch, MD;* Marie Pierre Dilly, MD;* Sophie Provenchere, MD;* Pierre Mordant, MD;† Yves Castier, MD, PhD;†‡ Philippe Montravers, MD, PhD;*§ Dan Longrois, MD, PhD*‡ *Département d’Anesthésie Réanimation, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, Paris, France; †Service de Chirurgie Vasculaire et Thoracique, Université Paris Diderot, APHP, CHU Bichat-Claude Bernard, Paris, France; ‡Unité ISERM UMR 1148, Hôpital Bichat Claude Bernard, Paris, France; and §Unité INSERM UMR 1152, UFR de Médecine Xavier Bichat, Paris, France

Abstract: Competitive flows syndrome result in severe regional hypoxemia when the deoxygenated flow from the native left ventricle (LV) competes with oxygenated flow from extracorporeal life support (ECLS) pump with potentially severe consequences for the cerebral and coronary circulations. Fast correction of hypoxemia could be obtained by decreasing native LV flow by infusion of a short-acting beta-blocker (esmolol). Our purpose was to retrospectively review the efficacy of esmolol in this situation and hypothesize on the potential mechanisms of action and the associated risks. This is a retrospective analysis of five clinical cases, who underwent lung transplantation and a femoro-femoral venoarterial (VA) ECLS. The patients presented severe hypoxemia (SpO2 < 85%) measured through photoplethysmography on a right hand finger. From the patients’ medical records and anesthesia flowcharts, hemodynamic, right heart catheterization, echocardiography variables, and arterial blood gas results were noted before and after injection of esmolol. Mechanical ventilation and VA ECLS function variables were optimized

and unchanged before and after esmolol injection. All patients had terminal respiratory failure with pulmonary hypertension and conserved LV systolic function. Immediately following esmolol injection (1.3 ± .7 mg/kg; mean ± 1 SD), SpO2 increased from 73% ± 12 to 95% ± 6; blood to arterial partial pressure in CO2 (PaCO2) decreased from 52 ± 18 to 35 ± 7 mmHg systolic pulmonary artery pressure decreased from 61 ± 8 to 50 ± 12 mmHg; the pulmonary artery oxygen saturation (SvO2); increased from 51% ± 24 to 77% ± 12; systemic arterial pressure or catecholamine requirements were unchanged. In conclusion, these results suggest that injection of esmolol allowed rapid correction of regional hypoxemia occurring during lung transplantation despite femoro-femoral VA ECLS. The mechanism is probably a decreased cardiac output of the native LV due to esmololinduced negative inotropic and chronotropic effects without significant adverse effects on systemic tissue perfusion. Keywords: esmolol, ECLS, competitive flow syndrome, lung transplantation. J Extra Corpor Technol. 2016;48:113–121

Lung transplantation constitutes a recognized therapeutic option for terminal chronic respiratory failure with survival rates at 3 and 5 years of 60% and 50%, respectively (1). The prerequisite is a rigorous selection of the potential recipients. Four pathologies share the main indications for lung transplantation: mucoviscidosis, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis (PF), and alpha-1

antitrypsin deficiency emphysema (2). Shortage of transplantable lungs from brain-dead donors has been an incentive to extend the donor lung selection criteria in 2003 (3) and allowed for the increase of the percentage of brain-death organ donors in whom lungs were harvested from 9.8% in 2000 to 15.8% in 2006 (1). Impaired lung function in marginal grafts is associated with an increased risk of shortand long-term graft dysfunction following transplantation (4) with hypoxemia being one of the first clinical/monitoring signs. Furthermore, marginal lung grafts are more prone to the deleterious effects of mechanical ventilation. One possible solution to prevent/correct both the potentially deleterious effects of mechanical ventilation and graft dysfunction during/after lung transplantation has been the use of extracorporeal life support (ECLS) devices (5–9). Veno-venous (VV) or veno-arterial (VA) ECLS can be used. Anticipation of

Received for publication December 18, 2015; accepted June 15, 2016. Address correspondence to: Mohamed Ghalayini, MD, Hôpital Bichat, Paris, Ile de France, France. E-mail: [email protected] The two first authors (Mohamed Ghalayini and Pierre-Yves Brun) have contributed equally to this manuscript. The senior author has stated that the authors have reported no material, financial, or other relationship with any healthcare-related business or other entity whose products or services are discussed in this paper.

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hemodynamic instability, mainly related to pre-transplantation pulmonary hypertension is an indication for VA ECLS (10,11). Implantation sites for VA ECLS during lung transplantation are mainly the femoral vessels. In some situations, femoro-femoral VA ECLS is not able to correct severe hypoxemia because of competitive flows between the anterograde left ventricular (LV) flow (which delivers profoundly desaturated arterial blood because of lung dysfunction) and the retrograde flow (which delivers highly oxygenated blood) from the VA ECLS (Figure 1). The competitive flows syndrome requires two conditions; an oxygenated retrograde flow from the femoral artery cannula of the ECLS and deoxygenated anterograde flow from the native LV due to severe defect in ventilatory function (12,13). The competitive flows syndrome is defined, in our study, by the presence of femoro-femoral VA ECLS; an alteration of the ventilatory function defined by the necessity of maintaining a fraction of delivered oxygen (FdO2) of 1 on the ECLS; ventilator settings characterized by a plateau pressure >30 cmH2O and inspired oxygen fraction (FiO2) of 1 with lung protective settings; preserved LV systolic function defined by left ventricle ejection fraction (LVEF) >40%; and upper body desaturation defined by SpO2 values

Esmolol Corrects Severe Hypoxemia in Patients with Femoro-Femoral Venoarterial Extracorporeal Life Support for Lung Transplantation.

Competitive flows syndrome result in severe regional hypoxemia when the deoxygenated flow from the native left ventricle (LV) competes with oxygenated...
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