ASAIO Journal 2022
Extracorporeal Membrane Oxygenation Circuits in Parallel
for Refractory Hypoxemia in COVID-19: A Case Series
Yatrik J. Patel ,* John W. Stokes ,* Whitney D. Gannon ,† Sean A. Francois,* Wei Kelly Wu,* Todd W. Rice ,†
and Matthew Bacchetta *‡
Refractory hypoxemia despite the use of extracorporeal mem-
brane oxygenation (ECMO) for coronavirus disease 2019
(COVID-19)–related acute respiratory distress syndrome
remains a challenging problem. A single ECMO circuit may
not provide adequate physiologic support in the setting of an
elevated cardiac output, physiologic demand, and impaired
gas exchange. In select patients with refractory hypoxemia,
addition of a second ECMO circuit in parallel can improve
oxygenation, facilitate lung protective ventilation, awakening,
and physical rehabilitation. We report the largest case series
to date of patients receiving ECMO circuits in parallel and
the first to report this approach in COVID-19. ASAIO Journal
2022; 00;00–00
Key Words: extracorporeal membrane oxygenation, acute
respiratory distress syndrome; ARDS, COVID-19, refractory
hypoxemia, parallel circuits
The use of extracorporeal membrane oxygenation (ECMO)
for coronavirus disease 2019 (COVID-19)–related acute
respiratory distress syndrome (ARDS) has introduced distinct
clinical challenges, and outcomes widely vary.1–3 One such
challenge includes persistent hypoxemia despite the use of
ECMO support, requiring concomitant use of therapies such
as prone positioning, neuromuscular blocking agents, inhaled
vasodilators, and ventilator settings that exceed criteria con-
sidered lung protective.1,3 Further strategies to temporize
refractory hypoxemia for patients receiving ECMO include
optimizing cannula positioning to reduce recirculation, reduc-
ing metabolic demand using antipyretics or beta-blocking
agents, blood transfusion, and placement of an additional
drainage cannula.4 However, these interventions may not be
safe in all clinical circumstances and have varying effects on
From the *Department of Thoracic Surgery, Vanderbilt University
Medical Center, Nashville, Tennessee; †Department of Pulmonary,
Allergy, and Critical Care Medicine, Vanderbilt University Medical
Center, Nashville, Tennessee; and ‡Department of Biomedical
Engineering, Vanderbilt University Medical Center, Nashville,
Tennessee.
Submitted for consideration October 2021; accepted for publication
in revised form January 2022.
Disclosure: The authors have no conflicts of interest to report.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text, and links to the digital files are
provided in the HTML and PDF versions of this article on the journal’s
Web site (www.asaiojournal.com).
Correspondence: Matthew Bacchetta, Departments of Thoracic and
Cardiac Surgery, Vanderbilt University Medical Center, 609 Oxford
House, 1313 21st Avenue South, Nashville, TN 10032. Email: mat-
thew.bacchetta@vumc.org.
Copyright © ASAIO 2022
DOI: 10.1097/MAT.0000000000001706
1
Copyright © ASAIO 2022
Management of COVID-19 Patients
hypoxemia. For example, the additional blood flow achieved
with a second drainage cannula remains limited by cannula
size and the maximum rated flow of an oxygenator. To address
severe, refractory hypoxemia despite maximum ECMO support
and other adjunct measures, we elected to introduce a second
ECMO circuit in parallel to substantially increase the blood
flow rate in select patients with COVID-19–related ARDS.
Additionally, we describe a novel technique for dual circuit
support using a single return cannula, obviating the need for
two return cannulas in two upper body central veins.5 This is
the largest case series of patients receiving ECMO circuits in
parallel and the first to report this approach in COVID-19.
Case 1
A 50 year old male with a body mass index (BMI) of 39.5 kg/
m2 (136 kg) and no known medical history was admitted to the
hospital for hypoxia secondary to COVID-19. He was endotra-
cheally intubated 2 days after admission for respiratory failure
and required high-pressure mechanical ventilation, deep seda-
tion, continuous neuromuscular blockade, and inhaled epo-
prostenol (Flolan, GlaxoSmithKline, Research Triangle Park,
NC). He remained hypoxemic despite these strategies and was
cannulated for venovenous (VV)-ECMO 3 days after intuba-
tion (Table 1). Ultrasound guidance was used to place a 25Fr
drainage cannula in the right common femoral vein and a 20Fr
return cannula in the right internal jugular (IJ) vein. An ECMO
blood flow rate of approximately 5.8 L/min was achieved. The
patient had an initial improvement in oxygenation yet contin-
ued to require 80–100% fraction of inspired oxygen (FiO2) on
the ventilator and continuous neuromuscular blockade. On
ECMO day 5, a second 21Fr drainage cannula was placed in
the left common femoral vein and a blood flow rate up to 6.6 L/
min was achieved. Despite maximum ECMO support and high-
pressure ventilation, arterial partial pressure of oxygen (PaO2)
fell to 49 mm Hg. Recirculation was ruled out. Hypotension
precluded the use of beta-blockers and diuresis. Adequate oxy-
genator function was confirmed. Given the presence of sepsis,
we suspected the patient’s cardiac output (CO) was substan-
tially higher than the flow we could achieve using a single
ECMO circuit. Therefore, we added a second ECMO circuit
in parallel to achieve a blood flow rate to better match the
patient’s metabolic demand. A 22Fr return cannula was placed
in the left IJ vein and the previously placed 21Fr left femoral
vein cannula was used as the drainage source for the second
circuit (Figure 1). Subsequently, a blood flow rate up to 8 L/min
was achieved and allowed reduction of ventilator pressures,
FiO2, sedation, and discontinuation of neuromuscular block-
ade (Table 2). Blood flow and sweep gas flow was partitioned
equally between the two circuits. As the lung injury, pulmo-
nary compliance and gas exchange improved, we were able
2 PATEL ET AL.

Table 1. Baseline Patient Characteristics

Case Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

Age (years) 50 47 37 47 46
Sex Male Male Male Male Male
Body mass index (kg/m ) 2
39.5 32.6 38 36.9 39.7
Weight (kg) 136 99.7 127 133.8 132.9
Body surface area (m )2
2.56 2.15 2.46 2.59 2.51
Days from COVID-19 diagnosis to intubation 12 12 17 18 17
Days from intubation to ECMO initiation 3 2 1 3 1
Mechanical ventilation settings before ECMO initiation
Mode Pressure control Volume control Volume control Pressure control Pressure control
FiO2 (%) 100% 100% 100% 100% 100%
Driving pressure (cmH2O) 14 22 20
Tidal volume (ml) 350 450 400 430 350
Plateau pressure (cmH2O) 32 34
Respiratory rate (breaths per minute) 30 32 24 34 35
Positive end-expiratory pressure, (cmH2O) 14 15 15 15 16
Arterial blood gas before ECMO
pH 7.32 7.24 7.33 7.36 7.36
PaCO2 (mmHg) 68 75 64 61 65
PaO2 (mmHg) 62 63 61 63 53
SOFA score before ECMO initiation 5 4 4 4 4

COVID-19, coronavirus disease 2019; ECMO, extracorporeal membrane oxygenation; FiO2, fraction of inspired oxygen; PaCO2, partial
pressure of carbon dioxide; PaO2, partial pressure of oxygen; SOFA, sequential organ failure assessment.

to wean ECMO support on both circuits. During this period, Extracorporeal membrane oxygenation flow and sweep were
lung-protective mechanical ventilation was utilized and first weaned on both circuits to maintain appropriate oxygen
FiO2 was weaned to <60% before weaning ECMO support. saturation and normal pH. Once the patient was consistently

Figure 1. Venovenous-ECMO with parallel circuits with cannulation of bilateral femoral veins and bilateral internal jugular veins. ECMO,
extracorporeal membrane oxygenation.

Copyright © ASAIO 2022

 PARALLEL ECMO CIRCUITS FOR HYPOXEMIA 3

Table 2. ECMO Characteristics

Case Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

Initial configuration (drainage-reinfusion) RFV-RIJ RFV-RIJ RFV-RIJ RFV-RIJ RFV-RIJ

Initial cannula sizes (Fr) 25–20 25–22 27–22 27–25 27–25
ECMO settings 24 hours after cannulation
Blood flow rate (LPM) 5.3 4.2 4.5 4.4 5.4
FdO2 (%) 100 100 100 100 100
Sweep gas flow (LPM) 2 3 2 5 4
ECMO settings before second circuit
Blood flow rate (LPM) 6.6 6 5.9 5.5 5
FdO2 (%) 100 100 100 100 100
Sweep gas flow (LPM) 8 7 9 7 5
ECMO days before second circuit support 11 23 10 4 8
Mechanical ventilation settings before
second circuit
Mode Volume Pressure Pressure Pressure Pressure
Controlled Controlled Controlled Controlled Controlled
FiO2 (%) 100 100 100 100 100
Driving pressure (cmH2O) 18 16 16 14
Tidal volume (ml) 140 120 80 250 240
Respiratory rate (breaths per minute) 20 18 15 14 22
Positive end-expiratory pressure (cmH2O) 18 14 14 14 12
Arterial blood gas before second circuit
pH 7.32 7.45 7.43 7.39 7.32
PaCO2 (mmHg) 55 59 62 66 75
PaO2 (mmHg) 58 67 65 65 65
Neuromuscular blockade before second circuit Yes Yes Yes No No
support
Inhaled pulmonary vasodilators before Yes Yes Yes Yes No
second circuit support
ECMO settings 24 hours after second circuit
Flow 8 7.1 7.4 7.8 6.8
FdO2 (%) 100 100 100 100 100
Sweep gas flow (LPM) 7 4 6 6 8
Mechanical ventilation settings 24 hours
after second circuit
Mode Pressure control Pressure control Pressure control Pressure control Pressure control
FiO2 (%) 50 50 50 50 50
Driving pressure (cmH2O) 12 16 16 16 14
Tidal volume (ml) 160 140 150 150 270
Respiratory rate (breaths per minute) 12 18 15 14 22
Positive end-expiratory pressure (cmH2O) 14 12 14 14 14
Arterial blood gas 24 hours after second circuit
pH 7.35 7.46 7.41 7.45 7.37
PaCO2 (mmHg) 48 51 49 51 43
PaO2 (mmHg) 71 117 104 116 122

ECMO, extracorporeal membrane oxygenation; FdO2, fraction of delivered oxygen via ECMO; FiO2, fraction of inspired oxygen; LPM, liters
per minute; RFV, right femoral vein; RIJ, right internal jugular; PaCO2, partial pressure of arterial carbon dioxide; PaO2, partial pressure of
arterial oxygen.

supported with a total ECMO flow of <5 L/min, the left IJ return
cannula was removed and the left femoral drainage cannula
served as an additional drainage cannula for the single circuit.
The patient remained on parallel circuits for 9 days. The patient
was decannulated from ECMO after 25 days. Mechanical ven-
tilation was ultimately weaned and the patient was discharged
from the hospital on 2 L of supplemental oxygen after 65 days.
Case 2
A 47 year old male (BMI 32.5 kg/m2, 99.7 kg) with no
known medical history was admitted with respiratory failure
from COVID-19 requiring endotracheal intubation. His gas
exchange remained poor despite maximized ventilator set-
tings, deep sedation, neuromuscular blockade, and prone
positioning. He was cannulated for VV-ECMO 2 days after intu-
bation using a 25Fr right femoral vein drainage cannula and a
22Fr right IJ vein return cannula. His oxygenation improved
with approximately 5 L/min of ECMO blood flow. Over the
next several days, the patient’s pulmonary compliance wors-
ened. Despite 5.8 L/min of ECMO flow, the patient continued
to require 70–100% FiO2, deep sedation, and neuromuscular
blockade. He had refractory hypoxemia with PaO2 decreasing
to 52 mmHg despite maximum ECMO support and ventilator
pressures exceeding those considered lung protective.6 There
was no evidence of meaningful recirculation and beta block-
ade was deferred due to hypotension and septic shock. To better
match the patient’s elevated metabolic demand, we inserted a
second ECMO circuit in parallel using a 23Fr left femoral vein
drainage cannula and a 20Fr left IJ vein return cannula. With
two circuits, we were able to achieve up to 10 L/min of total
ECMO blood flow. His arterial PaO2 improved to 124 mmHg,
which allowed the ventilator FiO2 to be weaned to 40% and
driving pressure to be reduced. Neuromuscular blockade was
stopped. His lung compliance continued to slowly improve.
The patient underwent tracheostomy placement on ECMO day
37 in an effort to reduce sedation requirements and improve
pulmonary toilet. His hospital course was complicated by a

Copyright © ASAIO 2022

4 PATEL ET AL.
right pneumothorax requiring chest tube placement and he
died from uncontrolled bleeding after iatrogenic hepatic injury
on day 38 of ECMO support despite improving lung compli-
ance and function.
Case 3
A 37 year old male (BMI 38 kg/m , 127 kg) with no signifi-
2
cant medical history was cannulated for VV-ECMO the day
after intubation for refractory hypoxemia secondary to severe
COVID-19 ARDS. He was cannulated with a 27Fr right femoral
vein drainage cannula and a 22Fr right IJ vein return cannula.
His lung compliance continued to worsen; tidal volumes were
approximately 120 ml on pressure-control ventilation with a
driving pressure of 18 cmH2O. Despite 5.5 L/min of ECMO
blood flow, he continued to require 100% FiO2, deep seda-
tion, and continuous neuromuscular blockade. Septic shock
precluded the use of beta blockade to attenuate his tachycar-
dia and elevated CO. His arterial PaO2 was 56 mmHg despite
maximum ECMO support. We elected to add a second cir-
cuit in parallel to achieve increased ECMO flows to match
the patient’s elevated CO and to reduce excessive ventila-
tor support and avoid long-term neuromuscular blockade. A
23Fr left femoral vein drainage cannula and a 20Fr left IJ vein
return cannula were placed. With two circuits, we were able
to achieve flows up to 10 L/min. After improved oxygenation,
ventilator settings and neuromuscular blockade were weaned.
Over time, sedation was weaned. While receiving dual cir-
cuit support, he was able to participate in physical therapy
on a stationary bike while in bed. After 62 days on ECMO,
his lung compliance remained poor with little evidence of
improvement. He was evaluated and listed for lung transplant.
He continued to participate in physical therapy while on two
parallel circuits. After 72 days on parallel circuits and a total
of 96 days on ECMO, he underwent double lung transplanta-
tion. His postoperative course was unremarkable, and he was
discharged on room air oxygen after a 125 day hospitalization
and returned home.
Case 4
A 47 year old male (BMI 36.8 kg/m2, 133.8 kg) presented with
severe ARDS and hypoxia despite optimized mechanical ven-
tilation, deep sedation, inhaled vasodilators, and neuromus-
cular blockade. He was cannulated for VV-ECMO 3 days after
intubation using a 27Fr right femoral vein drainage cannula
and a 25Fr right IJ vein return cannula. He was initially sup-
ported with up to 6 L/min of blood flow allowing for weaning
of neuromuscular blockade and inhaled vasodilators. Six days
into his ECMO course, his pulmonary compliance and oxy-
genation worsened requiring 100% FiO2 and deep sedation.
The patient required more ECMO blood flow than what could
be achieved with the addition of a second drainage cannula.
Therefore, a circuit in parallel was added by inserting a 25Fr
drainage cannula into the left femoral vein and the return line
of the second circuit was joined with a Y connector to the exist-
ing 25Fr right IJ vein return line of the first circuit (Figure 2). The
25Fr return cannula was large enough to accommodate 10 L/
min of total flow with outflow pressures consistently less than
200 mmHg. He required dual circuit support for 47 days and
was weaned from total ECMO support after 98 days. After 154
Copyright © ASAIO 2022
hospital days, the patient was discharged to a long-term acute
care facility where he tolerated slow weaning of mechanical
ventilation.
Case 5
A 46 year old male (BMI 40.9 kg/m2, 132.9 kg) was can-
nulated for VV-ECMO 1 day after intubation for refractory
hypoxemia due to COVID-19 despite maximal medical man-
agement. He was cannulated with a 27Fr right femoral vein
drainage cannula and a 25Fr right IJ vein return cannula.
He continued to require 80–100% FiO2 and deep sedation
despite maximum ECMO support with up to 6 L/min of flow.
In an effort to achieve lung-protective ventilation6 and reduce
sedation, a second circuit was added for increased support. A
25Fr left femoral vein drainage cannula served as the inflow
of the second circuit and the outflow was connected to the
existing 25Fr right IJ cannula with a Y connection. With a sec-
ond circuit, we were able to achieve up to 10 L/min of ECMO
flow allowing us to maintain lung-protective ventilation6 and
dramatically reduce the patient’s sedation requirements. He
required dual circuit support for 13 days. His hospital course
was complicated by renal failure requiring renal replacement
therapy and numerous infections, including Candida albicans
fungemia. He was decannulated after 53 days on ECMO in an
attempt to clear the fungemia. He required recannulation after
48 hours for hypercapnic respiratory failure; a 28Fr single-site
dual-lumen cannula was placed. The patient was decannulated
after 71 total days on ECMO. After a prolonged hospitalization,
the patient was discharged from the hospital to a rehabilitation
facility with evidence of both renal and pulmonary recovery.
Mechanical ventilation was weaned and he returned home on
2 L of supplemental oxygen.
Discussion
Extracorporeal membrane oxygenation is a life-saving
therapy for select patients with COVID-19 ARDS. Refractory
hypoxemia despite ECMO support can occur requiring the use
of injurious ventilator settings and concomitant rescue thera-
pies. We demonstrate that refractory hypoxemia can be ame-
liorated with a second, parallel ECMO circuit allowing for lung
protective ventilation, awakening and physical rehabilitation.
Outcomes were excellent; four of five (80%) of patients sur-
vived to hospital discharge (Table 3). This is the first case series
reporting the use of two circuits for VV-ECMO to support a
single patient.
COVID-19–induced inflammatory syndrome driven by
hyperactivation of the immune system results in severe lung
injury7 leading to marked impairment of gas exchange by the
native lungs. On presentation, patients can have atypical hemo-
dynamic profiles and an inflammation-driven hyperdynamic
circulation contributing to lung stiffness creating a vicious
cycle between the heart and lungs.8 We did not obtain CO data
using a Swan-Ganz catheter as routine use of these catheters is
not part of our institution’s standard of care for ARDS patients.
However, to obtain an estimation of the CO in these patients,
we used the LiDCOrapid monitor (LiDCO Ltd, Cambridge,
United Kingdom). The LiDCOrapid uses the PulseCO (LiDCO
Ltd) algorithm to calculate continuous beat-to-beat CO by
analyzing the arterial blood pressure tracing from an existing
 PARALLEL ECMO CIRCUITS FOR HYPOXEMIA 5

Figure 2. Venovenous-ECMO with parallel circuits with cannulation of bilateral femoral veins and reinfusion via a 25Fr right internal jugular
vein return cannula. ECMO, extracorporeal membrane oxygenation.

arterial line.9 Figure 3A shows the CO data over a 24 hour
period immediately before reconfiguration to parallel circuits
for patients 2–5; Figure 3B shows the calculated CO of the
patients based on body surface area, ECMO flow with one cir-
cuit, and estimated CO based on the LiDCOrapid monitor. The
estimated CO ranged from 9.8 to 19.2 L/min. Anemia, hypoxia,
and sepsis further contribute to this hyperdynamic high CO
state. With an additional circuit in parallel, we were able to
significantly increase the total ECMO blood flow, thereby

Table 3. Outcomes

Case Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

Hospital length of stay (days) 64 37 124 154 95

ICU length of stay (days) 56 37 115 154 95
Total ECMO duration (days) 25 37 95 98 69
Duration of two circuit support 9 14 72 47 13
(days)
ECMO-associated bleeding None None Yes, LIJ cannula dislodgement None None
complications requiring replacement
Thromboembolic complications Cannula-associated DVT None None None None
Requirement of renal replacement Yes No No No Yes
therapy during ECMO
Evidence of renal recovery at time Yes N/A N/A Yes Yes
of discharge
Survival to decannulation Yes No Yes* Yes Yes
Survival to discharge Yes No Yes Yes Yes
Discharge disposition Skilled nursing facility N/A Rehabilitation hospital Long-term acute Long-term acute
care hospital care hospital

*Patient required double lung transplantation.

ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; LIJ, left internal jugular.

Copyright © ASAIO 2022

6 PATEL ET AL.

Figure 3. Cardiac output data obtained by LiDCO. A: Estimated cardiac output over a 24-hour period for patients 2–5 immediately prior
to addition of a second parallel ECMO circuit. B: Comparison of each patient’s calculated cardiac output with the estimated mean cardiac
output over a 24-hour period using the LiDCO device. ECMO, extracorporeal membrane oxygenation.

decreasing the total undrained systemic venous return and
increasing the ECMO flow:patient CO ratio.
Mechanisms of refractory hypoxemia during VV-ECMO
include a 1) high recirculation fraction, 2) high pulmonary
shunt fraction, 3) low ECMO blood flow to patient CO ratio,
and 4) oxygenator dysfunction.10 Chest radiography confirmed
proper positioning of drainage and reinfusion cannulas in all
patients, and there was no evidence of meaningful recircula-
tion. The drainage cannula was inserted deep enough to lie in
the intrahepatic portion of the inferior vena cava (IVC) close to
the right atrial-IVC junction. The intrahepatic portion of the IVC
is least collapsible because of the surrounding hepatic paren-
chyma and less likely to collapse with negative pressure from
the drainage cannula. The reinfusion cannula was inserted
with the tip in the superior vena cava (SVC) close to the right
atrial-SVC junction. Oxygenator dysfunction was ruled out in
all cases. In our cohort of patients, efforts to reduce the intra-
pulmonary shunt included increasing the ventilator FiO2, peak
end expiratory pressure, and initiating inhaled epoprostenol.
These interventions were marginally and transiently effective
and compromised lung-protective ventilation. Methods of
reducing the patient’s CO such as beta-blockers11 and hypo-
thermia were used to decrease native CO but improvement
in oxygenation was temporary, and use was limited due to
clinical circumstances. Extracorporeal membrane oxygenation
circuit temperature was maintained between 36°C and 37°C

Copyright © ASAIO 2022

 PARALLEL ECMO CIRCUITS FOR HYPOXEMIA
in all patients. To optimize venous drainage, we used the larg-
est available femoral drainage cannula (27Fr) we have avail-
able at our institution. Despite using large drainage cannulas
and ensuring adequate patient preload, we found it difficult
to achieve ECMO flows greater than 6 L/min with a single cir-
cuit due to excessive negative drainage pressures. With the
addition of a second drainage cannula to a single circuit, the
maximum flow we were able to achieve was 6.5 L/min. Only
by increasing ECMO blood flow above the rated limits of avail-
able oxygenators with parallel circuits were we able to better
match the patients’ high CO state and consistently wean venti-
lator settings and discontinue rescue therapies.
The Extracorporeal Life Support Organization (ELSO)
guidelines advocate for transfusion to achieve a hemato-
crit level greater than 40% to improve oxygen delivery.12
Targeting higher hematocrit thresholds may have improved
oxygen delivery in our patients and could have been con-
sidered before providing dual circuit support although there
are no data that provide evidence for maintaining higher
hematocrit targets in adult patients. Furthermore, blood con-
servation protocols may reduce blood transfusions without
increasing end-organ dysfunction and mortality.13 Prone posi-
tioning during VV-ECMO could also have been considered
and may have led to improved oxygenation14 but we do not
routinely place patients on ECMO in the prone position at
our institution. Furthermore, benefits of prone positioning
remain uncertain in patients with the most severe form of
COVID ARDS requiring VV-ECMO15 and prone positioning of
patients on ECMO complicates nursing care and increases
risk for complications.
There were no complications associated with cannulation for
dual circuit support. There were no thrombotic complications
resulting from placing two large-bore drainage cannulas in the
IVC. All patients were anticoagulated for a target activated par-
tial thromboplastin time (aPTT) of 40–60 seconds unless indi-
cations for therapeutic anticoagulation were present. There was
one major ECMO-associated bleeding complication in patient
3 secondary to a left IJ return cannula dislodgement attributed
to skin breakdown surrounding the cannula entry site and com-
promised suture integrity due to long-term ECMO support. We
modified our cannulation strategy after the first three patients
to avoid cannulation of both IJ veins. For addition of a paral-
lel circuit, we placed a drainage cannula in the contralateral
femoral vein and the reinfusion line of the circuit no. 2 was con-
nected to the reinfusion line of circuit no. 1 using a Y connector.
Reinfusion from both circuits occurred through the single large
cannula placed in the right IJ vein (Figure 2). With the addition of
a second circuit in parallel, circuit pressures typically decreased
because we were able to achieve approximately 3.5–4 L/min of
flow through each circuit rather than 5–6 L/min through a single
circuit. There was no increase in postartificial lung membrane
pressures even when using a single reinfusion cannula for both
circuits. We saw no evidence of increased hemolysis from this
modified cannulation strategy. We began placing larger 23–25Fr
outflow cannulas at the time of initial cannulation for all COVID-
19 patients to obviate the requirement for a second reinfusion
cannula should the patient need parallel ECMO support later
in their course. We found no differences in the thrombotic risk
between the two configurations in our patients, but the risk of
thrombus formation with larger cannulas should be recognized.
Details regarding the types of ECMO devices and cannulas used
Copyright © ASAIO 2022
7
are provided in Table 1, Supplemental Digital Content, http://
links.lww.com/ASAIO/A800.
There are important factors to consider when selecting
patients for a second circuit in parallel. Extracorporeal mem-
brane oxygenation is a limited and resource-consuming ther-
apy. Triaging scarce resources during a pandemic has practical
and ethical implications. Choosing to offer dual circuit support
to a patient could potentially deprive another patient of a life-
saving therapy in the setting of resource limitations. Further,
while outcomes were promising, no conclusions can be made
about the safety or efficacy of this strategy. Other consider-
ations include the increased burden of care on bedside staff
and cost of disposables. We initiate ECMO for all patients
with the intent of managing the patient on a single circuit
and employ a second circuit based on physiologic need. Our
ECMO and critical care teams maintained daily communica-
tion with the patients’ family regarding the plan of care, and
risks and benefits of each therapy were extensively discussed
before any intervention.
Venovenous-ECMO management in patients with COVID-
19 ARDS is challenging given the severity of lung injury and
inflammatory and metabolic derangements. A single ECMO
circuit may not provide adequate support in the setting of an
elevated CO and severely impaired gas exchange. In select
patients, addition of a second ECMO circuit in parallel can
result in increased ECMO blood flow and improved oxygen-
ation in the setting of refractory hypoxemia.
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