ECMO with vasopressor use during early endotoxic shock: Can it improve circulatory support and regional microcirculatory blood flow?

Autoři: Thornton S. Mu aff001;  Amy M. Becker aff002;  Aaron J. Clark aff002;  Sherreen G. Batts aff002;  Lee-Ann M. Murata aff003;  Catherine F. T. Uyehara aff003
Působiště autorů: Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas, United States of America aff001;  Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America aff002;  Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, United States of America aff003
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article



While extracorporeal membrane oxygenation (ECMO) is effective in preventing further hypoxemia and maintains blood flow in endotoxin-induced shock, ECMO alone does not reverse the hypotension. In this study, we tested whether concurrent vasopressor use with ECMO would provide increased circulatory support and blood flow, and characterized regional blood flow distribution to vital organs.


Endotoxic shock was induced in piglets to achieve a 30% decrease in mean arterial pressure (MAP). Measurements of untreated pigs were compared to pigs treated with ECMO alone or ECMO and vasopressors.


ECMO provided cardiac support during vasodilatory endotoxic shock and improved oxygen delivery, but vasopressor therapy was required to return MAP to normotensive levels. Increased blood pressure with vasopressors did not alter oxygen consumption or extraction compared to ECMO alone. Regional microcirculatory blood flow (RBF) to the brain, kidney, and liver were maintained or increased during ECMO with and without vasopressors.


ECMO support and concurrent vasopressor use improve regional blood flow and oxygen delivery even in the absence of full blood pressure restoration. Vasopressor-induced selective distribution of blood flow to vital organs is retained when vasopressors are administered with ECMO.

Klíčová slova:

Blood flow – Blood pressure – Hypotension – Oxygen – Sepsis – Swine – Endotoxins – Vasopressin


1. Wooley T, Thompson P, Kirkman E, Reed R, Ausset S, Beckett A, et al. Trauma Hemostasis and Oxygenation Research Network Position Paper on the Role of Hypotension Resuscitation as Part of Remote Damage Control Resuscitation. J Trauma Acute Care Surg 2018;84: S3–S13. doi: 10.1097/TA.0000000000001856 29799823

2. Barbee RW, Reynolds PS, Ward KR. Assessing shock resuscitation strategies by oxygen debt repayment. Shock 2010; 33: 113–122. doi: 10.1097/SHK.0b013e3181b8569d 20081495

3. DeBacker D, Creteur J, Preiser JC, Dubois MJ, Vincent JL. Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med 2002;166: 98–104. 12091178

4. Trzeciak S, Dellinger RP, Parrillo JE, Guglielmi M, Bajaj J, Abate NL, et al. Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: Relationship to hemodynamics, oxygen transport, and survival. Annals of Emergency Medicine 2007;49: 88–98. doi: 10.1016/j.annemergmed.2006.08.021 17095120

5. Sakr Y, Dubois MJ, De Backer D, Creuter J, Vincent JL. Persistent microcirculatory alterations are associated with organ failue and death in patients with septic shock. Crit Care Med 2004;32: 1825–1831. doi: 10.1097/01.ccm.0000138558.16257.3f 15343008

6. Beca J, Butt W. Extracorporeal membrane oxygenation for refractory septic shock in children. Pediatrics 1994;93: 726–729. 8165069

7. Fortenberry JD, Paden ML. Extracorporeal therapies in the treatment of sepsis: experience and promise. Semin Pediatr Infect Dis 2006;17: 72–79. doi: 10.1053/j.spid.2006.04.005 16822469

8. MacLaren G, Butt W. Extracorporeal membrane oxygenation and sepsis. Critical Care and Resuscitation 2007;9: 76–80. 17352671

9. Meyer DM, Jessen ME, ELSO. Results of extracorporeal membrane oxygenation in neonates with sepsis. J Thoracic and Cardiovascular Surgery 1995;109: 419–427.

10. Smith HG, Whittlesey GC, Kundu SK, Salley SO, Kuhns LR, Chang CH, et al. Regional blood flow during extracorporeal membrane oxygenation in lambs. ASAIO Trans 1989;35: 657–660. 2597557

11. Brunauer A. Kokofer A, Bataar O, Gradwohl-Matis I, Dankl D, Dunser MW. The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients: a retrospective cohort study. Crit Care 2014; 18: 719–726. doi: 10.1186/s13054-014-0719-2 25524592

12. Dunser MW, Takal J, Brunauer A, Bakker J, Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach. Crit Care 2013;17: 326–332. doi: 10.1186/cc12727 24103466

13. Hylands M, Toma A, Beaudoin N, Frenette AJ, D’Aragon F, Belley-Cote E, et al. Early vasopressor use following traumatic injury: a systematic review. BMJ Open 2017;7: 1–11.

14. Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Loupot P, Akech SO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011; 364: 2483–2495. doi: 10.1056/NEJMoa1101549 21615299

15. Hughes NT, Burd RS, Teach SJ. Damage control resuscitation: Permissive hypotension and massive transfusion protocols. Pediatr Emer Care 2014;30: 651–659.

16. MacDonald SP, Taylor DM, Keijzers G, Arendts G, Fatovich DM, Kinnear FB, et al. Restricted fluid resuscitation in sepsis-associated hypotension (REFRESH): study protocol for a pilot randomized controlled trial. Trials 2017; 18: 399–413. doi: 10.1186/s13063-017-2137-7 28851407

17. Parker MM, Suffredini AF, Natnason D. Responses of left ventricular function in survivors and nonsurvivors of septic shock. J Critical Care 1989;4: 19–25.

18. Vincent JL, Gis P, Coffernils M. Myocardial depression and decreased vascular tone characterized fatal course from septic shock. Surgery 1992;111: 660–667. 1595062

19. Batts SG, Mu TS, Uyehara-Lock JH, Murata LA, and Uyehara CFT. ECMO Maintains Cerebral Blood Flow During Endotoxic Shock in Piglets. ASAIO Journal 2016;62: 732–736. doi: 10.1097/MAT.0000000000000413 27442858

20. De Oliviera CF, de Oliviera DS, Gottschald AF, Moura JD, Costa GA, Ventura AC, et al. ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation. Intensive Care Medicine 2008; 34: 1065–1075. doi: 10.1007/s00134-008-1085-9 18369591

21. Sarkar J, Golden PJ, Kajiura LN, Murata LM, Uyehara CFT. Vasopressin decreases pulmonary-to-systemic vascular resistance ratio in a porcine model of severe hemorrhagic shock. Shock 2015; 43(5): 475–482. doi: 10.1097/SHK.0000000000000325 25565637

22. Kinsella JP, Gerstmann DR, Rosenberg AA. The effect of extracorporeal membrane oxgyenation on coronary perfusion and regional blood flow distribution. Pediatr Res 1992;31: 80–84. doi: 10.1203/00006450-199201000-00015 1594336

23. Holt DB, Delaney RR, Uyehara CFT. Effects of combination dobutamine and vasopressin therapy on microcirculatory blood flow in a porcine model of severe endotoxic shock. J Surg Res 2011;171: 191–198. doi: 10.1016/j.jss.2009.11.739 20338585

24. Smith HG, Whittlesey GC, Kundu SK, Salley SO, Kuhns LR, Chang CH, et al. Regional blood flow during extracorporeal membrane oxygenation in lambs. ASAIO Trans 1989:35: 657–660. 2597557

Článek vyšel v časopise


2019 Číslo 10
Nejčtenější tento týden