Recirculation in venovenous extracorporeal membrane oxygenation.

Despite the increasing use of venovenous extracorporeal membrane oxygenation (ECMO) to treat severe respiratory failure, recirculation remains a common complication that may result in severe hypoxemia and end-organ damage. The present review, therefore, examines updated evidence for the causes, measurement, and management of recirculation. Six electronic databases were searched from their dates of inception to January 2016, and 38 relevant studies were selected for analysis. This review revealed that, currently, recirculation is typically calculated from measurement of blood oxygen saturations, although limited evidence suggests that oxygen content may provide a more accurate measure. Dilutional ultrasound may play an additional role in dynamic quantitative monitoring of recirculation, but further human studies are required to validate its clinical use. Although cannula configuration appears to be a key contributor to recirculation in addition to factors such as ECMO flow rate, there are insufficient comparative clinical studies to recommend an optimal cannulation technique for minimizing recirculation. Existing evidence suggests that the dual-lumen cannula may have a low recirculation fraction, but only if correctly positioned. This review underscores the need for more robust clinical and laboratory studies to effectively evaluate and address the persistent problem of recirculation.