Supplementary Appendix

This appendix has been provided by the authors to give readers additional information
about their work.

Using Cardiohelp, Quadrox, and Nautilus Extracorporeal Membrane Oxygenators

as Vascular Access for Hemodialysis, Continuous Renal Replacement Therapy,
and Plasmapheresis: A Brief Technical Report

Mazen Odish, MD1; Pranav Garimella, MD2; Crisostomo, Hermogenes, RN3; Cassia Yi,
RN, MSN3; Robert L. Owens, MD1; Travis Pollema, DO4
1UC San Diego Department of Medicine, Division of Pulmonary, Critical Care,
Sleep Medicine, and Physiology
9300 Campus Point Drive, Mail Code #7381, La Jolla, CA 92037-7381
2UC San Diego Department of Medicine, Division of Nephrology-Hypertension

9300 Campus Point Dr, La Jolla, CA 92037, United States

3UC San Diego Health Department of Nursing

9300 Campus Point Dr, La Jolla, CA 92037, United States

4UC San Diego Department of Surgery, Division of Cardiovascular and Thoracic

Surgery
9300 Campus Point Dr, La Jolla, CA 92037, United States

Corresponding Author
Cassia Yi, RN, MSN
University of California, San Diego
Sulpizio Cardiovascular Center
9434 Medical Center Drive
La Jolla, CA 92037
T: 858- 657-6727
cyi@health.ucsd.edu
sTable 1: Required supplies to connect dialysis modalities to ECMO circuits
Part Name Number Brand Part/Reference
Required Number
Y-Pigtail 2 Centurion Parallel Y- EXW012
Extension Set
3 way stop-cock 2 Smith Medical MX43660
10 cc sterile 0.9% 2 Excelsior Medical 306546
saline flushes

Blood volume in circuits

 ECMO Circuit: 700 mls
 Prismaflex: 170 mls
Spectra Optia (TPE) circuits: 185 mls
Technique for running TPE and CRRT concurrently with ECMO (utilizing citrate as
anticoagulation)

Equipment
 Spectra Optia Machine
 Spectra Optia Exchange tubing set (for TPE)
 1 liter bag of Anticoagulant Citrate Dextrose Solution USP (ACD) Formula A
(institutions may use heparin for anticoagulation).

Protocol
1. All oxygenators (HLS – Cardiohelp oxygenator, Quadrox oxygenator, and Nautilus
oxygenator) have dual port Y-pigtails connected (see Figure 2 and 3)
a. Y-pigtails are placed if circuit lacks them or are replaced if clotted.
b. Prior to connection to CRRT/TPE the Y-pigtails are tested to ensure easy
blood removal and return.
2. Attach 3-way stopcocks to the Y-pigtails pre and post oxygenator.
a. At our institution, the CRRT draw (red line) has two stopcocks at it’s take-off
after the oxygenator. The proximal stopcock is used for normal saline (NS)
flushes as needed and distal stopcock is used to provide citrate
anticoagulation. A “third stopcock” proximal to ECMO unit and before NS
stopcock is added which serves as the take-off point for the draw-line for TPE
(see supplemental sFigure 1).
b. The CRRT return (blue line) has one stopcock used for replacement fluid.
Add “second stopcock” proximal to ECMO unit to which the return limb of the
TPE is connected.
3. Attaching the CRRT/TPE parallel to ECMO unit in tandem.
a. The dialysis RN will hand combined CRRT/TPE in parallel lines to the ECMO
specialist and it will be connected to the ECMO device as indicated below:
b. The CRRT RETURN line should be connected to the ECMO venous pigtail
(Y-connector) on the pre-oxygenator side (see Figures 1, 2, 3).
c. The CRRT ACCESS (draw) line should be connected to the ECMO arterial
pigtail (Y-connector) on the post-oxygenator side (see Figures 1, 2, 3).
4. Initiation of combined parallel procedure
a. Flush CRRT circuit with 0.9% Sodium Chloride prior to procedure to check
CRRT circuit patency. Notify primary RN to account fluid for accurate I & O.
b. Open both draw and return Spectra Optia stopcocks.
c. Initiate Spectra Optia TPE treatment as ordered.
d. Citrate of CRRT is ON at current rate and TPE anticoagulant citrate dextrose
(ACD-A) solution is utilized as ordered.
e. Calcium of CRRT is utilized for combined therapy procedure. Increase rate by
1.5 time the current rate for CRRT alone. Draw patient ionized calcium 30
mins after treatment started and notify Nephrologist of the results.
f. Set CRRT and TPE machine flow rates as ordered.
5. CRRT/TPE in parallel circuit monitoring and management will be done by the ICU
RN and Dialysis RN per institutional policy.
6. Lines from ECMO are to be disconnected by ECMO specialist.
7. Termination of TPE treatment.
a. After completion of the TPE treatment, rinse back arterial line of Spectra
Optia. Close Spectra Optia draw and return line stopcocks. Disconnect
Spectra Optia draw and return lines including the stopcocks they are
connected to.
b. Reset calcium and citrate to rate at start of dual therapy procedure.
c. Flush CRRT circuit with 0.9% Sodium Chloride as needed after the
procedure.
8. Termination of CRRT treatment
a. ECMO specialist claps the side of the pigtail that is connected to CRRT
b. The dialysis modality lines are disconnected
c. ECMO specialist flushes ECMO pigtails, ensuring no air entrainment
 Dialysis
Modality
(iHD, SLED, Stopcocks:
CRRT)
Na Citrate
NS flush Replacement
TPE Fluid
Do not recommend adding 3/8th
Do not recommend adding 3/8th inch connector with Leur-lock to
Return to inch connection with Leur-lock to ECMO drainage lines due to risk
Drainage from Pre-Oxygenator ECMO return lines due to risk of of air entrainment into pump
A Pigtail blood loss
C
Post-Oxygenator
Pigtail B
ECMO ECMO
Oxygenator Pump ECMO
Drainage

ECMO
Do not recommend adding 3/8th
inch connection with Leur-lock to
D Return

ECMO return lines due to risk of

Patient
air embolism and/or blood loss

sFigure 1: Diagram of CRRT/TPE in parallel and ECMO Circuit in Tandem. Optia:

Spectra Optia system for therapeutic plasma exchange (TPE). Of note, the TPE return
can be directly to the patient (instead of the oxygenator) through any intravenous
access (central venous catheter or peripheral IV). CRRT, continuous renal replacement
therapy. ECMO, extracorporeal membrane oxygenation.
sTable 2: Patient characteristics and outcomes.
ECMO with CRRT (n = 68)
Male (%) 49 (72.1)
Age, mean  SD 49.7  15.5
BMI, mean SD 30.1  7.1
Race, total (%)
- White 27 (39.7)
- Asian Or Indian/South Asian 9 (13.2)
- Middle Eastern 1 (1.5%)
- Native Pacific Islander 1 (1.5%)
- More than 1 race 10 (14.7)
- Other 9 (13.2)
- Unknown 5 (7.4)
Ethnicity, total (%)
- Hispanic 27 (39.7)
- Non-Hispanic 41 (60.3)
SOFA score at ICU admission, mean  SD 8.1  4.6
SOFA score at ECMO initiation, mean  SD 9.8  4.2
V-V ECMO for COVID-19 ARDS, total (% of total V-V 23 (total 38 V-V ECMO,
ECMO) 60.1%)
Configuration, total (%)
- V-A ECMO 28 (41.1)
- V-V ECMO 38 (55.8)
- V-AV ECMO 2 (2.9)
Other concurrent mechanical circulatory support 14 (50%)
(Impella, IABP) during V-A ECMO (% of total V-A
ECMO)
ECMO blood flow at 24 hours (liters/min), mean  SD 4.14  0.8
Hospital and ECMO complications, total (%)
- Intubated during ECMO 66 (97%)
- Tracheostomy 27 (39.7)
- Infection during hospitalization 53 (77.9)
- Required pressors or inotropes at 24 hours 62 (91.2)
post-ECMO initiation
- Any neurologic complication (seizures, stroke, 6 (8.8)
intracerebral hemorrhage)
- Deep vein thrombosis 12 (17.6)
- Bleeding complication, requiring ≥3 units of 68 (100%)
pRBC
Required dedicated vascular catheter, total (%) 5 (7.4)
- Oxygenator clot 2
- Oxygenator pressures 3
Total ECMO days, median (IQR) 10 (4-29)
Survival to hospital discharge (%)
 - V-A 9/28 (32.1)
- V-V 12/38 (31.5)
- V-AV (1 currently on) 0/1 (0), 1 currently on ECMO
- Total 21/67 (31.3), 1 patient
currently on ECMO
Patient characteristics who were on ECMO and CRRT concurrently from 9/2020 to
3/31/2023. Of note, the survival to hospital discharge in patient requiring ECMO without
CRRT was 58% during the same period. CRRT, continuous renal replacement therapy.
BMI, body mass index. V-A, veno-arterial. V-V, veno-venous. V-AV, veno-venous
arterial. ECMO, extracorporeal membrane oxygenation. SOFA, Sequential Organ
Failure Assessment. IABP, intra-aortic balloon pump. pRBC, pack of red blood cells.
sTable 3: Advantages and disadvantages of different vascular access configurations
for dialysis.
Configurations Advantages Disadvantages
Vascular access via - No issues with high - May have flow issues
dedicated central venous pressures depending on vascular
catheter. catheter location and size
- Increases difficulty
mobilizing
- Risk of accidental
removal of catheter
- Increased infectious risk
Vascular access via - ECMO rarely has flow - High ECMO pressures
ECMO circuit, see issues may be incompatible with
sFigure 1 - Depending on dialysis machine
configuration protects - Slightly decreased ECMO
patients from air embolus efficiency

------------- ------------- -------------

Vascular access via the - Minimize risk of
ECMO oxygenator (see entrainment of air into
sFigure 1, A) ECMO circuit
(recommended protocol - Any air entrainment
in this manuscript) would be caught in the
oxygenator
- No need to cut into the
3/8th inch tubing,
minimizing risk of clots or
dislodgement
- Oxygenator pigtails can
be easily replaced,
requiring minimal time off
ECMO
- Clots in the oxygenator
may limited use of
oxygenator pigtails
- If high pressures required
for ECMO blood flow, may
result in high access
pressures that are
incompatible with dialysis
machine

Vascular access via

ECMO cannulas (not
recommended):

- Pre-pump access with - Minimal issues with - Increased risk of

cut-in 3/8th inch tubing access pressures entraining air (pre-pump
Luer-locks (see sFigure 1, negative pressure),
C) resulting in a pump-lock,
causing drops or ceases in
ECMO blood flow
------------- ------------- -------------
- Post-ECMO pump (pre-
oxygenator) access with
cut-in 3/8th inch tubing
Luer-locks , (see sFigure
1, B)
-------------
- Post-Oxygenator (post-
pump) access with cut-in
3/8th inch tubing Luer-locks
(see sFigure 1, D)
- Decreased risk of air
entrainment since 3/8th
tubing is pressurized post-
pump
- any air entrainment would
be captured in the ECMO
oxygenator
-------------
- Decreased risk of air
entrainment since 3/8th
tubing is pressurized post-
pump.
- Increased risk of
accidental dislodgement
with loss of blood.
- If high pressures required
for ECMO blood flow, may
result in high access
pressures that are
incompatible with dialysis
machine
-------------
- Increased risk of
accidental dislodgement
with loss of blood.
- If high pressures required
for ECMO blood flow, may
result in high access
pressures that are
incompatible with dialysis
machine
- Any air entrainment
would go to patient
Other References:

1. International Complication Trend ELSO Report - 2021. Extracorporeal Life

Support Organization. Accessed: 7/30/2022. Website:

https://www.elso.org/Registry.

2. Nautilus ECMO Oxygenator. Medtronic. Accessed 7/30/2022. Website:

https://www.medtronic.com/nautilus.

3. Cardiohelp system. Getinge. Accessed 7/30/2022. Website:

https://www.getinge.com/int/products/cardiohelp-system/.

4. PLS Set. Getinge. Accessed 7/30/2022. Website:

https://www.getinge.com/int/products/pls-set/