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Ferrer Gómez C, Gabaldón T, Hernández Laforet J. Ultraprotective Ventilation via ECCO2R in Three Patients Presenting an Air Leak: Is ECCO2R Effective? J Pers Med 2023; 13:1081. [PMID: 37511692 PMCID: PMC10381516 DOI: 10.3390/jpm13071081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 07/30/2023] Open
Abstract
Extracorporeal CO2 removal (ECCO2R) is a therapeutic approach that allows protective ventilation in acute respiratory failure by preventing hypercapnia and subsequent acidosis. The main indications for ECCO2R in acute respiratory failure are COPD (chronic obstructive pulmonary disease) exacerbation, acute respiratory distress syndrome (ARDS) and other situations of asthmatics status. However, CO2 removal procedure is not extended to those ARDS patients presenting an air leak. Here, we report three cases of air leaks in patients with an ARDS that were successfully treated using a new ECCO2R device. Case 1 is a polytrauma patient that developed pneumothorax during the hospital stay, case 2 is a patient with a post-surgical bronchial fistula after an Ivor-Lewis esophagectomy, and case 3 is a COVID-19 patient who developed a spontaneous pneumothorax after being hospitalized for a prolonged time. ECCO2R allowed for protective ventilation mitigating VILI (ventilation-induced lung injury) and significantly improved hypercapnia and respiratory acidemia, allowing time for the native lung to heal. Although further investigation is needed, our observations seem to suggest that CO2 removal can be a safe and effective procedure in patients connected to mechanical ventilation with ARDS-associated air leaks.
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Affiliation(s)
- Carolina Ferrer Gómez
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Tania Gabaldón
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Javier Hernández Laforet
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014 Valencia, Spain
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Zanella A, Pesenti A, Busana M, De Falco S, Di Girolamo L, Scotti E, Protti I, Colombo SM, Scaravilli V, Biancolilli O, Carlin A, Gori F, Battistin M, Dondossola D, Pirrone F, Salerno D, Gatti S, Grasselli G. A Minimally Invasive and Highly Effective Extracorporeal CO2 Removal Device Combined With a Continuous Renal Replacement Therapy. Crit Care Med 2022; 50:e468-e476. [PMID: 35044966 DOI: 10.1097/ccm.0000000000005428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Extracorporeal carbon dioxide removal is used to treat patients suffering from acute respiratory failure. However, the procedure is hampered by the high blood flow required to achieve a significant CO2 clearance. We aimed to develop an ultralow blood flow device to effectively remove CO2 combined with continuous renal replacement therapy (CRRT). DESIGN Preclinical, proof-of-concept study. SETTING An extracorporeal circuit where 200 mL/min of blood flowed through a hemofilter connected to a closed-loop dialysate circuit. An ion-exchange resin acidified the dialysate upstream, a membrane lung to increase Pco2 and promote CO2 removal. PATIENTS Six, 38.7 ± 2.0-kg female pigs. INTERVENTIONS Different levels of acidification were tested (from 0 to 5 mEq/min). Two l/hr of postdilution CRRT were performed continuously. The respiratory rate was modified at each step to maintain arterial Pco2 at 50 mm Hg. MEASUREMENTS AND MAIN RESULTS Increasing acidification enhanced CO2 removal efficiency of the membrane lung from 30 ± 5 (0 mEq/min) up to 145 ± 8 mL/min (5 mEq/min), with a 483% increase, representing the 73% ± 7% of the total body CO2 production. Minute ventilation decreased accordingly from 6.5 ± 0.7 to 1.7 ± 0.5 L/min. No major side effects occurred, except for transient tachycardia episodes. As expected from the alveolar gas equation, the natural lung Pao2 dropped at increasing acidification steps, given the high dissociation between the oxygenation and CO2 removal capability of the device, thus Pao2 decreased. CONCLUSIONS This new extracorporeal ion-exchange resin-based multiple-organ support device proved extremely high efficiency in CO2 removal and continuous renal support in a preclinical setting. Further studies are required before clinical implementation.
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Gacitúa I, Frías A, Sanhueza ME, Bustamante S, Cornejo R, Salas A, Guajardo X, Torres K, Figueroa Canales E, Tobar E, Navarro R, Romero C. Extracorporeal CO 2 removal and renal replacement therapy in acute severe respiratory failure in COVID-19 pneumonia: Case report. Semin Dial 2021; 34:257-262. [PMID: 33969909 PMCID: PMC8206973 DOI: 10.1111/sdi.12980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/02/2021] [Indexed: 11/26/2022]
Abstract
The COVID‐19 pandemic significates an enormous number of patients with pneumonia that get complicated with severe acute respiratory distress syndrome (ARDS), some of them with refractory hypercapnia and hypoxemia that need mechanical ventilation (MV). Those patients who are not candidate to extracorporeal membrane oxygenation (ECMO), the extracorporeal removal of CO2 (ECCO2R) can allow ultra protective MV to limit the transpulmonary pressures and avoid ventilatory induced lung injury (VILI). We report a first case of prolonged ECCO2R support in 38 year male with severe COVID‐19 pneumonia refractory to conventional support. He was admitted tachypneic and oxygen saturation 71% without supplementary oxygen. The patient's clinical condition worsens with severe respiratory failure, increasing the oxygen requirement and initiating MV in the prone position. After 21 days of protective MV, PaCO2 rise to 96.8 mmHg, making it necessary to connect to an ECCO2R system coupled continuous veno‐venous hemodialysis (CVVHD). However, due to the lack of availability of equipment in the context of the pandemic, a pediatric gas exchange membrane adapted to CVVHD allowed to maintain the removal of CO2 until completing 27 days, being finally disconnected from the system without complications and with a satisfactory evolution.
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Affiliation(s)
- Ignacio Gacitúa
- Department of Nephrology, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Alondra Frías
- Department of Nephrology, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - María E Sanhueza
- Department of Nephrology, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Sergio Bustamante
- Department Cardiovascular, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Rodrigo Cornejo
- Department of Critical Care, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Andrea Salas
- Department Cardiovascular, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Ximena Guajardo
- Department of Nephrology, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Katherine Torres
- Department of Nephrology, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Enzo Figueroa Canales
- Anesthesia and Resuscitation Division, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Eduardo Tobar
- Department of Critical Care, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Rocío Navarro
- Physical Medicine and Rehabilitation Division, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Carlos Romero
- Department of Critical Care, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
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Redant S, De Bels D, Barbance O, Loulidi G, Honoré PM. Extracorporeal CO2 Removal Integrated within a Continuous Renal Replacement Circuit Offers Multiple Advantages. Blood Purif 2020; 50:9-16. [PMID: 32585671 DOI: 10.1159/000507875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/13/2020] [Indexed: 11/19/2022]
Abstract
Extracorporeal CO2 removal within a continuous renal replacement therapy circuit offers multiple advantages for the regulation of the CO2 extraction. The authors review the impact of the dialysate solution, the buffer, and the anticoagulation on CO2 removal. They propose a theoretical model of the ideal circuit for the optimization of CO2 extraction.
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Affiliation(s)
- Sébastien Redant
- ICU Department, Brugmann University Hospital, Brussels, Belgium,
| | - David De Bels
- ICU Department, Brugmann University Hospital, Brussels, Belgium
| | - Oceane Barbance
- ICU Department, Brugmann University Hospital, Brussels, Belgium
| | - Ghalil Loulidi
- ICU Department, Brugmann University Hospital, Brussels, Belgium
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López-Sánchez M, Rubio-López MI. Extracorporeal carbon dioxide removal with continuous renal replacement therapy. Case description and literature review. Rev Bras Ter Intensiva 2020; 32:143-148. [PMID: 32401973 PMCID: PMC7206950 DOI: 10.5935/0103-507x.20200020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 07/11/2019] [Indexed: 11/20/2022] Open
Abstract
In recent years and due, in part, to technological advances, the use of extracorporeal carbon dioxide removal systems paired with the use of extracorporeal membrane oxygenation has resurfaced. However, studies are lacking that establish its indications and evidence to support its use. These systems efficiently eliminate carbon dioxide in patients with hypercapnic respiratory failure using small-bore cannula, usually double-lumen cannula with a small membrane lung surface area. Currently, we have several systems with different types of membranes and sizes. Pump-driven veno-venous systems generate fewer complications than do arteriovenous systems. Both require systemic anticoagulation. The “lung-kidney” support system, by combining a removal system with hemofiltration, simultaneously eliminates carbon dioxide and performs continuous extrarenal replacement. We describe our initial experience with a combined system for extracorporeal carbon dioxide removal-continuous extrarenal replacement in a lung transplant patients with hypercapnic respiratory failure, barotrauma and associated acute renal failure. The most important technical aspects, the effectiveness of the system for the elimination of carbon dioxide and a review of the literature are described.
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Extracorporeal CO 2 removal in a case of respiratory distress syndrome by sepsis. ACTA ACUST UNITED AC 2019; 67:35-38. [PMID: 31780048 DOI: 10.1016/j.redar.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 11/22/2022]
Abstract
Multiorgan dysfunction syndrome is the most common cause of mortality in intensive care units. The lungs and kidneys are frequently affected, so up to 60% of patients require simultaneous respiratory support and renal replacement therapy. Extracorporeal CO2 elimination systems have now been developed with the aim of reducing the incidence of acute lung injury. These systems can be combined with renal support therapies in patients with dysfunction of both organs. We present a case of respiratory septic shock with renal failure and respiratory distress syndrome, in which extracorporeal elimination of CO2 therapy facilitated the use of protective ventilation, with a low tidal volume of 4ml/kg, plateau pressure below 30cmH2O, and PaCO2 values of less than 60mmHg.
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Abstract
Acute kidney injury (AKI) is defined by a rapid increase in serum creatinine, decrease in urine output, or both. AKI occurs in approximately 10-15% of patients admitted to hospital, while its incidence in intensive care has been reported in more than 50% of patients. Kidney dysfunction or damage can occur over a longer period or follow AKI in a continuum with acute and chronic kidney disease. Biomarkers of kidney injury or stress are new tools for risk assessment and could possibly guide therapy. AKI is not a single disease but rather a loose collection of syndromes as diverse as sepsis, cardiorenal syndrome, and urinary tract obstruction. The approach to a patient with AKI depends on the clinical context and can also vary by resource availability. Although the effectiveness of several widely applied treatments is still controversial, evidence for several interventions, especially when used together, has increased over the past decade.
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Affiliation(s)
- Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy; International Renal Research Institute of Vicenza, Vicenza, Italy; Department of Nephrology, San Bortolo Hospital, Vicenza, Italy.
| | - Rinaldo Bellomo
- Critical Care Department, Austin Hospital, Melbourne, VIC, Australia
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Hamzagic N, Nikolic T, Jovicic BP, Canovic P, Jacovic S, Petrovic D. Acute Kidney Damage: Definition, Classification and Optimal Time of Hemodialysis. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.1515/sjecr-2017-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Acute damage to the kidney is a serious complication in patients in intensive care units. The causes of acute kidney damage in these patients may be prerenal, renal and postrenal. Sepsis is the most common cause of the development of acute kidney damage in intensive care units. For the definition and classification of acute kidney damage in clinical practice, the RIFLE, AKIN and KDIGO classifications are used. There is a complex link between acute kidney damage and other organs. Acute kidney damage is induced by complex pathophysiological mechanisms that cause acute damage and functional disorders of the heart (acute heart failure, acute coronary syndrome and cardiac arrhythmias), brain (whole body cramps, ischaemic stroke and coma), lung (acute damage to the lung and acute respiratory distress syndrome) and liver (hypoxic hepatitis and acute hepatic insufficiency). New biomarkers, colour Doppler ultrasound diagnosis and kidney biopsy have significant roles in the diagnosis of acute kidney damage. Prevention of the development of acute kidney damage in intensive care units includes maintaining an adequate haemodynamic status in patients and avoiding nephrotoxic drugs and agents (radiocontrast agents). The complications of acute kidney damage (hyperkalaemia, metabolic acidosis, hypervolaemia and azotaemia) are treated with medications, intravenous solutions, and therapies for renal function replacement. Absolute indications for acute haemodialysis include resistant hyperkalaemia, severe metabolic acidosis, resistant hypervolaemia and complications of high azotaemia. In the absence of an absolute indication, dialysis is indicated for patients in intensive care units at stage 3 of the AKIN/KDIGO classification and in some patients with stage 2. Intermittent haemodialysis is applied for haemodynamically stable patients with severe hyperkalaemia and hypervolaemia. In patients who are haemodynamically unstable and have liver insufficiency or brain damage, continuous modalities of treatment for renal replacement are indicated.
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Affiliation(s)
- Nedim Hamzagic
- Center of Hemodialysis , Medical Center Tutin , Tutin , Serbia
| | - Tomislav Nikolic
- Clinic of Urology, Nephrology and Dialysis , Clinical center Kragujevac , Kragujevac , Serbia
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Biljana Popovska Jovicic
- Clinic of Infectious Diseases , Clinical center Kragujevac , Kragujevac , Serbia
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Petar Canovic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Sasa Jacovic
- Medicines and Medical Devices Agency of Serbia , Belgrade , Serbia
| | - Dejan Petrovic
- Clinic of Urology, Nephrology and Dialysis , Clinical center Kragujevac , Kragujevac , Serbia
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
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Extracorporeal CO 2 Removal in Combination with Continuous Renal Replacement Therapy. Arch Bronconeumol 2019; 55:665-666. [PMID: 31255369 DOI: 10.1016/j.arbres.2019.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/08/2019] [Accepted: 05/10/2019] [Indexed: 11/20/2022]
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Karagiannidis C, Strassmann S, Brodie D, Ritter P, Larsson A, Borchardt R, Windisch W. Impact of membrane lung surface area and blood flow on extracorporeal CO 2 removal during severe respiratory acidosis. Intensive Care Med Exp 2017; 5:34. [PMID: 28766276 PMCID: PMC5539069 DOI: 10.1186/s40635-017-0147-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 07/18/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Veno-venous extracorporeal CO2 removal (vv-ECCO2R) is increasingly being used in the setting of acute respiratory failure. Blood flow rates through the device range from 200 ml/min to more than 1500 ml/min, and the membrane surface areas range from 0.35 to 1.3 m2. The present study in an animal model with similar CO2 production as an adult patient was aimed at determining the optimal membrane lung surface area and technical requirements for successful vv-ECCO2R. METHODS Four different membrane lungs, with varying lung surface areas of 0.4, 0.8, 1.0, and 1.3m2 were used to perform vv-ECCO2R in seven anesthetized, mechanically ventilated, pigs with experimentally induced severe respiratory acidosis (pH 7.0-7.1) using a 20Fr double-lumen catheter with a sweep gas flow rate of 8 L/min. During each experiment, the blood flow was increased stepwise from 250 to 1000 ml/min. RESULTS Amelioration of severe respiratory acidosis was only feasible when blood flow rates from 750 to 1000 ml/min were used with a membrane lung surface area of at least 0.8 m2. Maximal CO2 elimination was 150.8 ml/min, with pH increasing from 7.01 to 7.30 (blood flow 1000 ml/min; membrane lung 1.3 m2). The membrane lung with a surface of 0.4 m2 allowed a maximum CO2 elimination rate of 71.7 mL/min, which did not result in the normalization of pH, even with a blood flow rate of 1000 ml/min. Also of note, an increase of the surface area above 1.0 m2 did not result in substantially higher CO2 elimination rates. The pressure drop across the oxygenator was considerably lower (<10 mmHg) in the largest membrane lung, whereas the smallest revealed a pressure drop of more than 50 mmHg with 1000 ml blood flow/min. CONCLUSIONS In this porcine model, vv-ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 ml/min, with a membrane lung surface of at least 0.8 m2. In contrast, low blood flow rates (250-500 ml/min) were not sufficient to completely correct severe respiratory acidosis, irrespective of the surface area of the membrane lung being used. The converse was also true, low surface membrane lungs (0.4 m2) were not capable of completely correcting severe respiratory acidosis across the range of blood flows used in this study.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Stephan Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York City, NY, USA
| | | | - Anders Larsson
- Hedenstierna Laboratory, Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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