Extracorporeal Membrane Oxygenation in Extreme Obesity: A Case Report and Review of the Literature
The use of extracorporeal membrane oxygenation (ECMO) in the treatment of acute respiratory distress syndrome (ARDS) has been described as early as 1972 [Hill 1972]. Though a subsequent randomized trial showed no survival benefit over conventional mechanical ventilation [Zapol 1979], protective ventilation strategies and evolving extracorporeal technology improvements have led to a resurgence in the use of ECMO for patients with ARDS. The most recent randomized clinical trial, Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR), showed a significant mortality reduction in ARDS patients who were treated with ECMO [Peek 2009]. The results of the trial have led some to believe that the widespread adoption of ECMO as a feasible treatment for severe respiratory failure is forthcoming [MacLaren 2012; Del Sorbo 2014]. As the use of ECMO continues to increase, clinicians must be aware of the extremes in patient characteristics for which therapy might be considered reasonable. For example, many studies focus on the limited benefit of advanced therapies, such as ECMO, in the elderly [Salna 2014]. However, there is a paucity of literature on using veno-venous extracorporeal membrane oxygenation (VV ECMO) to treat ARDS in patients with extremity obesity [Ull 2015; Belliato 2016; Kadakia 2017]—a population that is often inherently discriminated against with regards to advanced medical and surgical therapies because of the practical challenges of treating someone of great size as well as the inherent social (and professional) biases against such patients. This case demonstrates application of ECMO in a patient with an extreme body mass index (BMI) and confirms the successful use of ECMO in this BMI patient population.
Al-Soufi S, Buscher H, Nguyen ND, Rycus P, Nair P. 2013. Lack of association between body weight and mortality in patients on veno-venous extracorporeal membrane oxygenation. Intensive Care Med 39:1995-2002.
Belliato M, Cremascoli L, Aliberti A, Pagani M, Pellegrini C, Iotti GA. 2016. A case of veno-venous extracorporeal membrane oxygenation for severe respiratory failure in a superobese patient. Clin Case Rep 4:1147-50.
Camboni D, Philipp A, Lubnow M, et al. 2012. Extracorporeal membrane oxygenation by single-vessel access in adults: advantages and limitations. ASAIO J 58:616-21.
Del Sorbo L, Cypel M, Fan E. 2014. Extracorporeal life support for adults with severe acute respiratory failure. Lancet Respir Med 2:154-64.
Fischer AJ, Kaese S, Lebiedz P. 2016. Management of obese patients with respiratory failure – A practical approach to a health care issue of increasing significance. Respir Med 117:174-8.
Gong MN1, Bajwa EK, Thompson BT, Christiani DC. 2010. Body mass index is associated with the development of acute respiratory distress syndrome. Thorax 65:44-50.
Hill JD, O’Brien TG, Murray JJ, et al. 1972. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med. 286:629-34.
Javidfar J, Wang D, Zwischenberger JB, et al. 2011. Insertion of bicaval dual lumen extracorporeal membrane oxygenation catheter with image guidance. ASAIO J 57:203-5.
Kadakia S, Ambur V, Moore R, Toyoda Y, Shiose A. 2017. Venovenous extracorporeal membrane oxygenation in two morbidly obese patients. Gen Thorac Cardiovasc Surg 65(10):594-7.
Kon ZN, Dahi S, Evans CF, et al. 2015. Class III obesity is not a contraindication to venovenous extracorporeal membrane oxygenation support. Ann Thorac Surg 100:1855-60.
Kress JP, Pohlman AS, Alverdy J, Hall JB. 1999. The impact of morbid obesity on oxygen cost of breathing (V˙o 2RESP) at rest. Am J Respir Crit Care Med 160:883-6.
Lazzeri C, Bonizzoli M, Cianchi G, et al. 2017. Body mass index and echocardiography in refractory ARDS treated with veno-venous extracorporeal membrane oxygenation. J Artif Organs 20:50-6.
MacLaren G, Combes A, Bartlett RH. 2012. Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era. Intensive Care Med 38:210-20.
Mongero LB, Beck JR, Charette KA, Stewart A. 2006. Respiratory failure of two sp gastric bypass patients and subsequent rescue with extracorporeal membrane oxygenation. Perfusion 21:73-6.
Murray JF, Matthay MA, Luce JM, Flick MR. 1988. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 138:720-3.
Peek GJ, Mugford M, Tiruvoipati R, et al. 2009. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 374:1351-63.
Salna M, Takeda K, Kurlansky P, et al. 2018. The influence of advanced age on venous–arterial extracorporeal membrane oxygenation outcomes. Eur J Cardiothorac Surg 53:1151-7.
Schmidt M, Tachon G, Devilliers C, et al. 2013. Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive Care Med 39:838-46.
Shashaty MG, Stapleton RD. 2014. Physiological and management implications of obesity in critical illness. Ann Am Thorac Soc 11:1286-97.
Swol J, Buchwald D, Strauch JT, Schildhauer TA, Ull C. 2017. Effect of body mass index on the outcome of surgical patients receiving extracorporeal devices (VV ECMO, pECLA) for respiratory failure. Int J Artif Organs 40:102-8.
Ull C, Buchwald D, Strauch J, Schildhauer TA, Swol, J. 2015. Extremely obese patients treated with venovenous ECMO—an intensivist’s challenge. Am J Emerg Med 33:1720.e3-1720.e4.
Zapol WM, Snider MT, Hill JD, et al. 1979. Extracorporeal membrane oxygenation in severe acute respiratory failure: a randomized prospective study. JAMA 242:2193-6.
Yaegashi M, Jean R, Zuriqat M, Noack S, Homel P. 2005. Outcome of morbid obesity in the intensive care unit. J Intensive Care Med 20:147-54
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).