Case Report Open Access
EtCO2 in VA ECMO Management: Recognition of Increased Cardiac Output During ECMO and IABP Support
Cusmà Piccione R1, Spaini G2, Cazzani C3 and Alberio G4
1MSN, RN at Cardiac Surgery Intensive Care Unit, Department of Cardiological Anesthesia, ASST Sette Laghi – University of Insubria – Varese. Professor at Master I level in Operating Room Nurse – Department of Medicine and Surgery – University of Insubria, Italy
2RN at Department Abdominal Surgery, Sarcomas and rare cancers, European Institute of Oncology, Milan, Italy
3RN at Cardiac Surgery Intensive Care Unit, Department of Cardiological Anesthesia, ASST Sette Laghi – University of Insubria – Varese, Italy
4MSN, RN, Nurse Coordinator at Cardiac Surgery Intensive Care Unit, Department of Cardiological Anesthesia, ASST Sette Laghi – University of Insubria – Varese, Italy
*Corresponding author: Cusmà Piccione R, Cardiac Surgery Intensive Care Unit, Department of Cardiological Anesthesia, ASST Sette Laghi – University of Insubria – Varese. Professor at Master I level in Operating Room Nurse – Department of Medicine and Surgery – University of Insubria, Italy;Email: @
Received: August 30, 2018; Accepted: Novermber 25, 2018; Published: January 07, 2019
Citation: Cusmà Piccione R, Spaini G, Cazzani C, Alberio G (2019) EtCO2 in VA ECMO Management: Recognition of Increased Cardiac Output During ECMO and IABP Support J Emerg Crit Care Diagn Manag 2(1): 1-5.
Introduction: A 60 yo male was under ECMO and Intra Aortic Baloon Pump (IABP) support due to cardiogenic shock. When IAPB was

suspended for few seconds, myocardial contractility decreased with an EtCO2 around 14 mmHg and an arterial blood flat line. Despite the IAPB suspension, an ABP tracing was observed and EtCO2 increased to 25 mmHg.

ECMO is a lifesaving treatment in some specific cases of cardiac arrest [8] and EtCO2 represents a non-invasive measurement of the quality in cardiopulmonary resuscitation, which also gives a good probability of ROSC with levels above 10-15mmHg [20].

Materials and methods: A case report and literature review were applied to study a correlation between EtCO2 and cardiac output during ECMO support and identify the EtCO2 measurement like a non-invasive parameter about recovery of cardiac contractility during ECMO and IABP support.

Results: Different studies confirm EtCO2, cardiac arrest and ROSC correlation: in a meta-analysis and systematic review emerged that EtCO2 values are lower in ROSC obtained by a superficial CPR with differences between 10 to 20 mmHg. [13] Another survey deals an EtCO2 higher in people with ROSC than others without a pulse restored (34.5 ± 4.5 vs 23.1 ± 12.9 mmHg, p < .001) [23]. However, there are less references about ECMO and EtCO2.

Discussion: A literature review and case report, about EtCO2 and cardiac output during ECMO – IABP support, revealed that EtCO2 can be a non-invasive indicator of heart contractility in patients with low ejection fraction and non-pulmonary circulation, and It shows a contractility increasing with a consequent recovery of pulmonary circulation, without suspending the IABP activity, during ECMO VA support.

Keywords: ECMO: extracorporeal membrane oxygenation; VA ECMO: veno-arterial membrane oxygenation; CPA: cardiopulmonary arrest; EtCO2: endtidal CO2; ROSC: return of spontaneous circulation; CO: cardiac output
From European Guidelines of Resuscitation (2015), the outof- hospital cardiac arrest (OHCA) has an incidence of 38 per 100 000 people: cardiac aetiology is around 40% in a population under 75 years old, whereas traumatic or non-cardiac aetiologies concerned, principally, patient under 35 years old [10]. According to ELSO and AHA Guidelines, ECMO should be considered the lifesaving treatment in some specific cases of patient who had an excellent CPR [8] or in adults with cardiogenic shock and low cardiac output, in persisting shock despite volume, drugs administration and intraortic balloon pump (IABP), in septic shock, or in many cardiac diagnosys (i.e. acute myocardial infarction, myocarditis, post cardiotomy shock) [9].

For an efficient resuscitation it’s foundamental an adequate blood flow and an optimal perfusion, relied to capnography parameter [22,11]. Related to EtCO2 concept, CO2 is a result of relation between volume ventilation and pulmonary perfusion (V/Q), directly linked to blood flow [15]. It depends on many factors like issues about ventilation system, placement of endotracheal tube, body temperature, hypoventilation or hyperventilation, blood perfusion and so forth [27].

EtCO2 swings are rapid indicator of systemic changes about CO2, like in cardiac arrest [4], where the EtCO2 trace crashes to zero [20]; during a cardiopulmonary arrest (CPA), it can recognize a ROSC, managing the resuscitation efforts. Therefore, an EtCO2 increasing is an index of myocardial contractility restoring and a successful reanimation [20].

Considering a pattern of intubated-patient in Intensive Care Unit with same conditions of ventilation system [18] and catecholamine administration [22], capnography is associated to cardiac output [1,5] and pulmonary flow [20].

In literature, there are many references about the EtCO2 role to manage the resuscitation effort, especially in ROSC. EtCO2 levels above 10-15mmHg give a high probability of ROSC, but at the same time low levels are indicator of negative prognosis [20].

EtCO2 has a key role in the chain of survival to advanced circulatory support, especially in extracorproeal life support (ECLS): the French Society of Intensive Care Medicine published a decision algorithm with ECLS inclusion criteria, like the “noflow” time <5 min and EtCO2 > 10 mmHg [12]. While the early cardiopulmonary resuscitation (CPR) by bystanders has been demonstrated to be fundamental to improve survival and neurological outcome in CPA victims [6]; the EtCO2 plays an important role in ECLS application, because several studies demonstrate that EtCO2 < 10 mmHg (before ECMO implantation) is relied to 100% of mortality rate [2]. Heart activity can be functional or not during ECMO support and this is recognizable by arterial blood pressure waveform. In fact, a numeric value of systolic and diastolic pressure is indicator of heart contractility and cardiac output; however, an absence of this value remarks cardiac inactivity and systemic pressure (represented by mean arterial pressure) is totally supported by VA ECMO.

Sometimes, in addition to ECMO, an implant of IABP support can prevent pulmonary edema due to inadeguate heart venting: in this case the suspenction of IABP activity for few seconds allows to evaluate the presence of flatline [16].
Case ReportTop
A 60 yo male was admitted from another hospital for cardiogenic shock due to anterior STEMI. After percutaneous coronary intervention and intraortic balloon pump (IABP) placement, the cardiogenic shock status remained with increasing of serum lactate, anuria, and VA ECMO was inserted. The cardiac output was highly depressed, and the blood flow was totally ensured by ECMO with the mean arterial pressure generated by ECMO output, when the IABP was suspended. During ECMO and IABP supports, EtCO2 had different values corresponding to changes of arterial blood pressure waveform.

Cause of the clinical case report, we can pose the following question: Can EtCO2 monitor functional cardiac recovery in patient supported by ECMO and IABP, without suspension of aortic counterpulsation?
Materials and MethodsTop
We performed a literature review and a rectrospective study on clinical case report.

The principal medical databases consulted were PubMed, Cinahl and Cochrane Library with a search strategy composed by two principal steps: firstly, correlation between EtCO2, CPA and ROSC was searched and, secondly, relation between EtCO2 in VA ECMO was applied.

The inclusion criteria were VA ECMO in adult’s population, whereas pediatric ECLS and VV ECMO were excluded. Relevant articles between 2008 and 2018 were considered for the first search strategy.

The principal keywords used in literature review were “EtCO2” OR “end-tidal carbon dioxide” OR “capnography” AND “cardiac arrest” OR “heart arrest” OR “cardiopulmonary arrest” AND “rosc” OR “return of spontaneous circulation” AND “postarrest” AND “cpr” OR “cardiopulmonary resuscitation” OR “cardiorespiratory resuscitation” OR “chest compressions” OR “cardiac arrest”.

A retrospective study was applied on the telemetry, as a continuous multiparameter registration. We focused on temporary stopping of IABP activity and hemodynamic signs, especially the correlation between EtCO2 and arterial blood pressure.
Case report
Observing hemodynamic sign registrations, during IAPB stopping, we have extracted the time we checked the pulsatility presence. In these time-lapse, we notice a correlation with EtCO2 and arterial blood pressure (ABP). When pulse is present, checking the arterial waveform with a systolic pressure around 90 mmHg and dyastolic around 40 mmHg, the EtCO2 increases to 24-26 mmHg, as represented in figure 2; when there is pulseless activity, EtCO2 values are around 13-15 mmHg, as represented in figure 1. During the recovery in ICU, many decreasing-increasing episodes about EtCO2 were identified, respectively, in depression and in recovery of cardiac output; this was confirmed by arterial pressure waveform during interruption of IABP activity.
Literature reviewTop
In the first search strategy many articles were consulted, while in the second one five relevant articles were identified. The literature review was extended to the Extracorporeal Life Support Organitation (ELSO), American Heart Association (AHA) and European Resuscitation Council Guidelines (ERC) and to principal books, especially about EtCO2 and ECMO correlation: in these references the keywords “EtCO2”, “CO2” and “capnography” were searched.

Different studies confirm a juction between EtCO2 and ROSC: from different reviews, like Paiva E. and Aminiahidashti H. studies in 2018, it’s emerged that EtCO2 is statistically higher in patients survived after CPR. In a meta-analysis and systematic review, participants in ROS with EtCO2 level about 25 mm Hg have higher values than people in ROSC with a superficial CPR with differences between 10 to 20 mmHg [13]. Another survey deals EtCO2 higher in people with ROSC than others without a pulse restored (34.5 ± 4.5 vs 23.1 ± 12.9 mmHg, p < .001) [23].
According to European Resuscitation Council most recent 2018 guidelines, EtCO2 is an early parameter of cardiac output variation; in fact, an increase of this waveform between 2,5 and 2,0 kPa [11] is an indicator of optimal CPR [5] and it can be used like a clinical tool during advanced cardiac life support [23,10].

The literature search revealed a lack of correlation studies between EtCO2 and ECMO. By the retrospective analysis of the clinical case, through the telemetries, it has been analyzed the relation between EtCO2 and ABP and identified an increase in CO2 at the resumption of myocardial contractility during ECMO support. This is physiologically permitted by cardiac contractility resumption, which allows a recovery of pulmonary circulation and alveolar-capillary exchange between oxygen and carbon dioxide. When contractility is depressed, the values of EtCO2 decrease, because of pulmonary circulation arrest, as reported by figure 1 and figure 2. The use of the EtCO2 could also reduce the IAPB suspension, considering that these interruptions still haven’t been declared capable of damage or not by literature.

Therefore, the respiratory CO2 can be a non-invasive, rapid and early parameter to find the re-establishment of the pulmonary circle and then the activity increasing of the left ventricle and right ventricle.

However, our hypothesis is based on clinical observation of the hemodynamic parameter recordings, determining the limit of the study between the respiratory and circulatory correlation during ECMO to a single case.

The intent of the authors is to continue, retrospectively and prospectively, to a correlation analysis between EtCO2 and cardiac output.
Figure 1:Correlation between EtCO2 – ABP in no cardiac output
Figure 2:Correlation between EtCO2 – ABP in return of cardiac output
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