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Stommel AM, Herkner H, Kienbacher CL, Wildner B, Hermann A, Staudinger T. Effects of extracorporeal CO 2 removal on gas exchange and ventilator settings: a systematic review and meta-analysis. Crit Care 2024; 28:146. [PMID: 38693569 PMCID: PMC11061932 DOI: 10.1186/s13054-024-04927-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/21/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE A systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO2R) on gas exchange and respiratory settings in critically ill adults with respiratory failure. METHODS We conducted a comprehensive database search, including observational studies and randomized controlled trials (RCTs) from January 2000 to March 2022, targeting adult ICU patients undergoing ECCO2R. Primary outcomes were changes in gas exchange and ventilator settings 24 h after ECCO2R initiation, estimated as mean of differences, or proportions for adverse events (AEs); with subgroup analyses for disease indication and technology. Across RCTs, we assessed mortality, length of stay, ventilation days, and AEs as mean differences or odds ratios. RESULTS A total of 49 studies encompassing 1672 patients were included. ECCO2R was associated with a significant decrease in PaCO2, plateau pressure, and tidal volume and an increase in pH across all patient groups, at an overall 19% adverse event rate. In ARDS and lung transplant patients, the PaO2/FiO2 ratio increased significantly while ventilator settings were variable. "Higher extraction" systems reduced PaCO2 and respiratory rate more efficiently. The three available RCTs did not demonstrate an effect on mortality, but a significantly longer ICU and hospital stay associated with ECCO2R. CONCLUSIONS ECCO2R effectively reduces PaCO2 and acidosis allowing for less invasive ventilation. "Higher extraction" systems may be more efficient to achieve this goal. However, as RCTs have not shown a mortality benefit but increase AEs, ECCO2R's effects on clinical outcome remain unclear. Future studies should target patient groups that may benefit from ECCO2R. PROSPERO Registration No: CRD 42020154110 (on January 24, 2021).
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Affiliation(s)
- Alexandra-Maria Stommel
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Calvin Lukas Kienbacher
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Brigitte Wildner
- University Library, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Hermann
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Pasero D, Pistidda L, Piredda D, Liperi C, Cossu A, Esposito R, Muroni A, Mereu C, Rum C, Branca GP, Mulas F, Puci M, Sotgiu G, Terragni P. Lung (extracorporeal CO 2 removal) and renal (continuous renal replacement therapy) support: the role of ultraprotective strategy in Covid 19 and non-Covid 19 ARDS. A case-control study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:27. [PMID: 38671540 PMCID: PMC11055375 DOI: 10.1186/s44158-024-00164-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Preliminary studies suggest that moderate ARDS and acute renal failure might benefit from extracorporeal CO2 removal (ECCO2R) coupled with CRRT. However, evidence is limited and potential for this coupled treatment may need to be explored. The aim of the present study was to evaluate whether a protective driving pressure was obtained applying low-flow ECCO2-R plus CRRT in patients affected by moderate ARDS with COVID-19 compared to an historical group without COVID-19. METHODS A case-control study has been conducted comparing a group of consecutive moderate ARDS patients presenting AKI and affected by COVID-19, who needed low-flow ECCO2-R plus CRRT to achieve an ultra-protective ventilatory strategy, with historical group without COVID-19 that matched for clinical presentation and underwent the same ultra-protective treatment. VT was set at 6 mL/kg predicted body weight then ECCO2R was assessed to facilitate ultra-protective low VT ventilation to preserve safe Pplat and low driving pressure. RESULTS ECCO2R+CRRT reduced the driving pressure from 17 (14-18) to 11.5 (10-15) cmH2O (p<0.0004) in the fourteen ARDS patients by decreasing VT from 6.7 ml/kg PBW (6.1-6.9) to 5.1 (4.2-5.6) after 1 hour (p <0.0001). In the ARDS patients with COVID-19, the driving pressure reduction was more effective from baseline 18 (14-24) cmH2O to 11 (10-15) cmH2O (p<0.004), compared to the control group from 15 (13-17) to 12(10-16) cmH2O (p< 0.03), after one hour. ECCO2R+CRRT did not affected 28 days mortality in the two groups, while we observed a shorter duration of mechanical ventilation (19 {7-29} vs 24 {22-38} days; p=0.24) and ICU length of stay (19 {7-29} vs 24 {22-78} days; p=0.25) in moderate ARDS patients with COVID-19 compared to control group. CONCLUSIONS In moderate ARDS patients with or without COVID-19 disease, ECCO2R+CRRT may be and effective supportive treatment to reach protective values of driving pressure unless severe oxygenation defects arise requiring ECMO therapy initiation.
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Affiliation(s)
- Daniela Pasero
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy.
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Laura Pistidda
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Davide Piredda
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Corrado Liperi
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Andrea Cossu
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | | | - Angela Muroni
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Cristiano Mereu
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Carlino Rum
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | | | - Franco Mulas
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Mariangela Puci
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
- Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
- Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Pierpaolo Terragni
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
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Mekontso Dessap A, Bagate F, Repesse X, Blayau C, Fartoukh M, Canoui-Poitrine F, de Prost N, Vieillard-Baron A. Low-flow ECCO 2R conjoined with renal replacement therapy platform to manage pulmonary vascular dysfunction with refractory hypercapnia in ARDS. Heliyon 2024; 10:e23878. [PMID: 38226285 PMCID: PMC10788508 DOI: 10.1016/j.heliyon.2023.e23878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/17/2024] Open
Abstract
Background Hypercapnia worsens lung vascular dysfunction during acute respiratory distress syndrome (ARDS). We tested whether an extracorporeal carbon dioxide removal (ECCO2R) device based on a renal replacement therapy platform (Prismalung®) may reduce PaCO2 and alleviate lung vascular dysfunction in ARDS patients with refractory hypercapnia. Methods We planned to prospectively include 20 patients with moderate-to-severe ARDS, pulmonary vascular dysfunction on echocardiography, and PaCO2 ≥ 48 mmHg despite instrumental dead space reduction and the increase in respiratory rate. Hemodynamics, echocardiography, respiratory mechanics, and arterial blood gases were recorded at 2 (H2), 6 (H6) and 24 (H24) hours as ECCO2R treatment was continued for at least 24 h. Results Only eight patients were included, and the study was stopped due to worldwide shortage of ECCO2R membranes and the pandemic. Only one patient fulfilled the primary endpoint criterion (decrease in PaCO2 of more than 20 %) at H2, but this objective was achieved in half of patients (n = 4) at H6. The percentage of patients with a PaCO2 value < 48 mmHg increased with time, from 0/8 (0 %) at H0, to 3/8 (37.5 %) at H2 and 4/8 (50 %) at H6 (p = 0.04). There was no major change in hemodynamic and echocardiographic variables with ECCO2R, except for a significant decrease in heart rate. ECCO2R was prematurely discontinued before H24 in five (62.5 %) patients, due to membrane clotting in all cases. Conclusions This pilot study testing showed a narrow efficacy and high rate of membrane thrombosis with the first version of the system. Improved versions should be tested in future trials. Trial registration Registered at clinicaltrials.gov, identifier: NCT03303807, Registered: October 6, 2017, https://clinicaltrials.gov/ct2/show/NCT03303807.
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Affiliation(s)
- Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - François Bagate
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - Xavier Repesse
- AP-HP, Hôpital Ambroise Paré, Service de Médecine Intensive Réanimation, Boulogne Billancourt, Créteil, France
| | - Clarisse Blayau
- AP-HP, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France
| | - Muriel Fartoukh
- AP-HP, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France
| | - Florence Canoui-Poitrine
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Santé Publique, F-94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - Antoine Vieillard-Baron
- AP-HP, Hôpital Ambroise Paré, Service de Médecine Intensive Réanimation, Boulogne Billancourt, Créteil, France
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Zhou Z, Li Z, Liu C, Wang F, Zhang L, Fu P. Extracorporeal carbon dioxide removal for patients with acute respiratory failure: a systematic review and meta-analysis. Ann Med 2023; 55:746-759. [PMID: 36856550 PMCID: PMC9980035 DOI: 10.1080/07853890.2023.2172606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Acute respiratory failure (ARF) is a common clinical critical syndrome with substantial mortality. Extracorporeal carbon dioxide removal (ECCO2R) has been proposed for the treatment of ARF. However, whether ECCO2R could provide a survival advantage for patients with ARF is still controversial. METHODS Electronic databases (PubMed, Embase, Web of Science, and the Cochrane database) were searched from inception to 30 April 2022. Randomized controlled trials (RCTs) and observational studies that examined the following outcomes were included: mortality, length of hospital and ICU stay, intubation and tracheotomy rate, mechanical ventilation days, ventilator-free days (VFDs), respiratory parameters, and reported adverse events. RESULTS Four RCTs and five observational studies including 1173 participants with ARF due to COPD or ARDS were included in this meta-analysis. Pooled analyses of related studies showed no significant difference in overall mortality between ECCO2R and control group, neither in RCTs targeted ARDS or acute hypoxic respiratory failure patients (RR 1.05, 95% CI 0.83 to 1.32, p = 0.70, I2 =0.0%), nor in studies targeted patients with ARF secondary to COPD (RR 0.80, 95% CI 0.58 to 1.11, p = 0.19, I2 =0.0%). A shorter duration of ICU stay in the ECCO2R group was only obtained in observational studies (WMD -4.25, p < 0.01), and ECCO2R was associated with a longer length of hospital stay (p = 0.02). ECCO2R was associated with lower intubation rate (p < 0.01) and tracheotomy rate (p = 0.01), and shorter mechanical ventilation days (p < 0.01) in comparison to control group in ARF patients with COPD. In addition, an improvement in pH (p = 0.01), PaO2 (p = 0.01), respiratory rate (p < 0.01), and PaCO2 (p = 0.04) was also observed in patients with COPD exacerbations by ECCO2R therapy. However, the ECCO2R-related complication rate was high in six of the included studies. CONCLUSIONS Our findings from both RCTs and observational studies did not confirm a significant beneficial effect of ECCO2R therapy on mortality. A shorter length of ICU stay in the ECCO2R group was only obtained in observational studies, and ECCO2R was associated with a longer length of hospital stay. ECCO2R was associated with lower intubation rate and tracheotomy rate, and shorter mechanical ventilation days in ARF patients with COPD. And an improvement in pH, PaO2, respiratory rate and PaCO2 was observed in the ECCO2R group. However, outcomes largely relied on data from observational studies targeted patients with ARF secondary to COPD, thus further larger high-quality RCTs are desirable to strengthen the evidence on the efficacy and benefits of ECCO2R for patients with ARF.Key messagesECCO2R therapy did not confirm a significant beneficial effect on mortality.ECCO2R was associated with lower intubation and tracheotomy rate, and shorter mechanical ventilation days in patients with ARF secondary to COPD.An improvement in pH, PaO2, respiratory rate, and PaCO2 was observed in ECCO2R group in patients with COPD exacerbations.Evidence for the future application of ECCO2R therapy for patients with ARF. The protocol of this meta-analysis was registered on PROSPERO (CRD42022295174).
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Affiliation(s)
- Zhifeng Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Zhengyan Li
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Chen Liu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Fang Wang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China.,State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, First Medical Center of Chinese, PLA General Hospital, Beijing, China
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5
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Florio G, Valsecchi C, Vivona L, Battistin M, Colombo SM, Cattaneo E, Protti I, DI Feliciantonio M, Castelli G, Dondossola D, Biancolilli O, Carlin A, Gatti S, Pesenti AM, Zanella A, Grasselli G. Enhanced extracorporeal carbon dioxide removal by acidification and metabolic control. Minerva Anestesiol 2023; 89:773-782. [PMID: 36951601 DOI: 10.23736/s0375-9393.23.17142-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Extracorporeal carbon dioxide removal (ECCO2R) promotes protective ventilation in patients with acute respiratory failure, but devices with high CO2 extraction capacity are required for clinically relevant impact. This study evaluates three novel low-flow techniques based on dialysate acidification, also combined with renal replacement therapy, and metabolic control. METHODS Eight swine were connected to a low-flow (350 mL/min) extracorporeal circuit including a dialyzer with a closed-loop dialysate circuit, and two membrane lungs on blood (MLb) and dialysate (MLd), respectively. The following 2-hour steps were performed: 1) MLb-start (MLb ventilated); 2) MLbd-start (MLb and MLd ventilated); 3) HLac (lactic acid infusion before MLd); 4) HCl-NaLac (hydrochloric acid infusion before MLd combined with renal replacement therapy and reinfusion of sodium lactate); 5) HCl-βHB-NaLac (hydrochloric acid infusion before MLd combined with renal replacement therapy and reinfusion of sodium lactate and sodium 3-hydroxybutyrate). Caloric and fluid inputs, temperature, blood glucose and arterial carbon dioxide pressure were kept constant. RESULTS The total MLs CO2 removal in HLac (130±25 mL/min), HCl-NaLac (130±21 mL/min) and HCl-βHB-NaLac (124±18 mL/min) were higher compared with MLbd-start (81±15 mL/min, P<0.05) and MLb-start (55±7 mL/min, P<0.05). Minute ventilation in HLac (4.3±0.9 L/min), HCl-NaLac (3.6±0.8 L/min) and HCl-βHB-NaLac (3.6±0.8 L/min) were lower compared to MLb-start (6.2±1.1 L/min, P<0.05) and MLbd-start (5.8±2.1 L/min, P<0.05). Arterial pH was 7.40±0.03 at MLb-start and decreased only during HCl-βHB-NaLac (7.35±0.03, P<0.05). No relevant changes in electrolyte concentrations, hemodynamics and significant adverse events were detected. CONCLUSIONS The three techniques achieved a significant extracorporeal CO2 removal allowing a relevant reduction in minute ventilation with a sufficient safety profile.
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Affiliation(s)
- Gaetano Florio
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carlo Valsecchi
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Luigi Vivona
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Michele Battistin
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Sebastiano M Colombo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Cattaneo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Protti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Gloria Castelli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniele Dondossola
- Liver Transplant and General Surgery Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Osvaldo Biancolilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Carlin
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Gatti
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio M Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy -
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
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Extracorporeal Carbon Dioxide Removal: From Pathophysiology to Clinical Applications; Focus on Combined Continuous Renal Replacement Therapy. Biomedicines 2023; 11:biomedicines11010142. [PMID: 36672649 PMCID: PMC9855411 DOI: 10.3390/biomedicines11010142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 01/08/2023] Open
Abstract
Lung-protective ventilation (LPV) with low tidal volumes can significantly increase the survival of patients with acute respiratory distress syndrome (ARDS) by limiting ventilator-induced lung injuries. However, one of the main concerns regarding the use of LPV is the risk of developing hypercapnia and respiratory acidosis, which may limit the clinical application of this strategy. This is the reason why different extracorporeal CO2 removal (ECCO2R) techniques and devices have been developed. They include low-flow or high-flow systems that may be performed with dedicated platforms or, alternatively, combined with continuous renal replacement therapy (CRRT). ECCO2R has demonstrated effectiveness in controlling PaCO2 levels, thus allowing LPV in patients with ARDS from different causes, including those affected by Coronavirus disease 2019 (COVID-19). Similarly, the suitability and safety of combined ECCO2R and CRRT (ECCO2R-CRRT), which provides CO2 removal and kidney support simultaneously, have been reported in both retrospective and prospective studies. However, due to the complexity of ARDS patients and the limitations of current evidence, the actual impact of ECCO2R on patient outcome still remains to be defined. In this review, we discuss the main principles of ECCO2R and its clinical application in ARDS patients, in particular looking at clinical experiences of combined ECCO2R-CRRT treatments.
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Extracorporeal CO 2 Removal During Renal Replacement Therapy to Allow Lung-Protective Ventilation in Patients With COVID-19-Associated Acute Respiratory Distress Syndrome. ASAIO J 2023; 69:36-42. [PMID: 35998214 PMCID: PMC9797119 DOI: 10.1097/mat.0000000000001803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The aim of this retrospective multicenter observational study is to test the feasibility and safety of a combined extracorporeal CO 2 removal (ECCO 2 R) plus renal replacement therapy (RRT) system to use an ultraprotective ventilator setting while maintaining (1) an effective support of renal function and (2) values of pH within the physiologic limits in a cohort of coronavirus infectious disease 2019 (COVID-19) patients. Among COVID-19 patients admitted to the intensive care unit of 9 participating hospitals, 27 patients with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) requiring invasive mechanical ventilation undergoing ECCO 2 R-plus-RRT treatment were included in the analysis. The treatment allowed to reduce V T from 6.0 ± 0.6 mL/kg at baseline to 4.8 ± 0.8, 4.6 ± 1.0, and 4.3 ± 0.3 mL/kg, driving pressure (ΔP) from 19.8 ± 2.5 cm H 2 O to 14.8 ± 3.6, 14.38 ± 4.1 and 10.2 ± 1.6 cm H 2 O after 24 hours, 48 hours, and at discontinuation of ECCO 2 R-plus-RRT (T3), respectively ( p < 0.001). PaCO 2 and pH remained stable. Plasma creatinine decreased over the study period from 3.30 ± 1.27 to 1.90 ± 1.30 and 1.27 ± 0.90 mg/dL after 24 and 48 hours of treatment, respectively ( p < 0.01). No patient-related events associated with the extracorporeal system were reported. These data show that in patients with COVID-19-induced ARDS and AKI, ECCO 2 R-plus-RRT is effective in allowing ultraprotective ventilator settings while maintaining an effective support of renal function and values of pH within physiologic limits.
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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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Santos JA, Gimbel AA, Peppas A, Truslow JG, Lang DA, Sukavaneshvar S, Solt D, Mulhern TJ, Markoski A, Kim ES, Hsiao JCM, Lewis DJ, Harjes DI, DiBiasio C, Charest JL, Borenstein JT. Design and construction of three-dimensional physiologically-based vascular branching networks for respiratory assist devices. LAB ON A CHIP 2021; 21:4637-4651. [PMID: 34730597 DOI: 10.1039/d1lc00287b] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Microfluidic lab-on-a-chip devices are changing the way that in vitro diagnostics and drug development are conducted, based on the increased precision, miniaturization and efficiency of these systems relative to prior methods. However, the full potential of microfluidics as a platform for therapeutic medical devices such as extracorporeal organ support has not been realized, in part due to limitations in the ability to scale current designs and fabrication techniques toward clinically relevant rates of blood flow. Here we report on a method for designing and fabricating microfluidic devices supporting blood flow rates per layer greater than 10 mL min-1 for respiratory support applications, leveraging advances in precision machining to generate fully three-dimensional physiologically-based branching microchannel networks. The ability of precision machining to create molds with rounded features and smoothly varying channel widths and depths distinguishes the geometry of the microchannel networks described here from all previous reports of microfluidic respiratory assist devices, regarding the ability to mimic vascular blood flow patterns. These devices have been assembled and tested in the laboratory using whole bovine or porcine blood, and in a porcine model to demonstrate efficient gas transfer, blood flow and pressure stability over periods of several hours. This new approach to fabricating and scaling microfluidic devices has the potential to address wide applications in critical care for end-stage organ failure and acute illnesses stemming from respiratory viral infections, traumatic injuries and sepsis.
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Affiliation(s)
- Jose A Santos
- Bioengineering Division, Draper, Cambridge, MA, USA.
| | - Alla A Gimbel
- Bioengineering Division, Draper, Cambridge, MA, USA.
| | | | | | - Daniel A Lang
- Bioengineering Division, Draper, Cambridge, MA, USA.
| | | | | | | | - Alex Markoski
- Bioengineering Division, Draper, Cambridge, MA, USA.
| | - Ernest S Kim
- Bioengineering Division, Draper, Cambridge, MA, USA.
| | | | - Diana J Lewis
- Bioengineering Division, Draper, Cambridge, MA, USA.
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10
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Consales G, Zamidei L, Turani F, Atzeni D, Isoni P, Boscolo G, Saggioro D, Resta MV, Ronco C. Combined Renal-Pulmonary Extracorporeal Support with Low Blood Flow Techniques: A Retrospective Observational Study (CICERO Study). Blood Purif 2021; 51:299-308. [PMID: 34237722 DOI: 10.1159/000517280] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 05/19/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critically ill patients with acute respiratory failure frequently present concomitant lung and kidney injury, within a multiorgan failure condition due to local and systemic mediators. To face this issue, extracorporeal carbon dioxide removal (ECCO2R) systems have been integrated into continuous renal replacement therapy (CRRT) platforms to provide a combined organ support, with efficient clearance of CO2 with very low extracorporeal blood flows (<400 mL/min). OBJECTIVES To evaluate efficacy and safety of combined ECCO2R-CRRT support with PrismaLung®-Prismaflex® in patients affected by hypercapnic respiratory acidosis associated with AKI in a second level intensive care unit. METHODS We carried out a retrospective observational study enrolling patients submitted to PrismaLung®-Prismaflex® due to mild to moderate acute respiratory distress syndrome (ARDS) or acute exacerbation of chronic obstructive pulmonary disease (aeCOPD). The primary endpoints were the shift to protective ventilation and extubation of mechanically ventilated patients and the shift to invasive mechanical ventilation of patients receiving noninvasive ventilation (NIV). Clinical-laboratoristic data and operational characteristics of ECCO2R-CRRT were recorded. RESULTS Overall, 12/17 patients on mechanical ventilation shifted to protective ventilation, CO2 clearance was satisfactorily maintained during the whole observational period, and pH was rapidly corrected. Treatment prevented NIV failure in 4 out of 5 patients. No treatment-related complications were recorded. CONCLUSION ECCO2R-CRRT was effective and safe in patients with aeCOPD and ARDS associated with AKI.
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Affiliation(s)
- Guglielmo Consales
- Emergency and Critical Care Department, S. Stefano Hospital, Prato, Italy
| | - Lucia Zamidei
- Emergency and Critical Care Department, S. Stefano Hospital, Prato, Italy
| | - Franco Turani
- Anaesthesia and Critical Care Department, Aurelia and European Hospital, Rome, Italy
| | - Diego Atzeni
- Cardioanaesthesia and Cardiosurgical Intensive Care Unit, Cardiovascular Department, San Michele Hospital, AO Brotzu, Cagliari, Italy
| | - Paolo Isoni
- Anaesthesia and Critical Care Unit, PO Santissima Trinità, ASSL Cagliari, Cagliari, Italy
| | - Gloria Boscolo
- Anaesthesia and Critical Care Department, dell'Angelo Hospital, Venice, Italy
| | - Debora Saggioro
- Anaesthesia and Critical Care Department, dell'Angelo Hospital, Venice, Italy
| | - Marco Vittorio Resta
- Anaesthesia and Critical Care Department, IRCCS San Donato Milanese Policlinic, San Donato Milanese, Milan, Italy
| | - Claudio Ronco
- DIMED, San Bortolo Hospital, University of Padova and International Renal Research Institute (IRRIV), Vicenza, Italy
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11
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Ding X, Chen H, Zhao H, Zhang H, He H, Cheng W, Wang C, Jiang W, Ma J, Qin Y, Liu Z, Wang J, Yan X, Li T, Zhou X, Long Y, Zhang S. ECCO 2R in 12 COVID-19 ARDS Patients With Extremely Low Compliance and Refractory Hypercapnia. Front Med (Lausanne) 2021; 8:654658. [PMID: 34307397 PMCID: PMC8295461 DOI: 10.3389/fmed.2021.654658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/02/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: A phenotype of COVID-19 ARDS patients with extremely low compliance and refractory hypercapnia was found in our ICU. In the context of limited number of ECMO machines, feasibility of a low-flow extracorporeal carbon dioxide removal (ECCO2R) based on the renal replacement therapy (RRT) platform in these patients was assessed. Methods: Single-center, prospective study. Refractory hypercapnia patients with COVID-19-associated ARDS were included and divided into the adjusted group and unadjusted group according to the level of PaCO2 after the application of the ECCO2R system. Ventilation parameters [tidal volume (VT), respiratory rate, and PEEP], platform pressure (Pplat) and driving pressure (DP), respiratory system compliance, arterial blood gases, and ECCO2R system characteristics were collected. Results: Twelve patients with refractory hypercapnia were enrolled, and the PaCO2 was 64.5 [56-88.75] mmHg. In the adjusted group, VT was significantly reduced from 5.90 ± 0.16 to 5.08 ± 0.43 ml/kg PBW; DP and Pplat were also significantly reduced from 23.5 ± 2.72 mmHg and 29.88 ± 3.04 mmHg to 18.5 ± 2.62 mmHg and 24.75 ± 3.41 mmHg, respectively. In the unadjusted group, PaCO2 decreased from 94 [86.25, 100.3] mmHg to 80 [67.50, 85.25] mmHg but with no significant difference, and the DP and Pplat were not decreased after weighing the pros and cons. Conclusions: A low-flow ECCO2R system based on the RRT platform enabled CO2 removal and could also decrease the DP and Pplat significantly, which provided a new way to treat these COVID-19 ARDS patients with refractory hypercapnia and extremely low compliance. Clinical Trial Registration: https://www.clinicaltrials.gov/, identifier NCT04340414.
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Affiliation(s)
- Xin Ding
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huan Chen
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hua Zhao
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Cheng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chunyao Wang
- Department of Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Jiang
- Department of Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jie Ma
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yan Qin
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhengyin Liu
- Department of Infectious Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jinglan Wang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaowei Yan
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Taisheng Li
- Department of Infectious Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiang Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shuyang Zhang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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12
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Leypoldt JK, Kurz J, Echeverri J, Storr M, Harenski K. Modeling acid-base balance for in-series extracorporeal carbon dioxide removal and continuous venovenous hemofiltration devices. Artif Organs 2021; 45:1036-1049. [PMID: 33909323 DOI: 10.1111/aor.13969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/10/2021] [Accepted: 04/02/2021] [Indexed: 01/03/2023]
Abstract
Patients with acute respiratory distress syndrome and acute kidney injury (AKI) treated by kidney replacement therapy may also require treatment with extracorporeal carbon dioxide removal (ECCO2 R) devices to permit protective or ultraprotective mechanical ventilation. We developed a mathematical model of acid-base balance during extracorporeal therapy using ECCO2 R and continuous venovenous hemofiltration (CVVH) devices applied in series for the treatment of mechanically ventilated AKI patients. Published data from clinical studies of mechanically ventilated AKI patients treated by CVVH at known infusion rates of substitution fluid without ECCO2 R were used to adjust the model parameters to fit plasma levels of arterial partial pressure of carbon dioxide (PaCO2 ), arterial plasma bicarbonate concentration ([HCO3 ]), and plasma pH (as well as certain other unmeasured physiological variables). The effects of applying ECCO2 R at an unchanged and a reduced tidal volume on PaCO2 , [HCO3 ] and plasma pH were then simulated assuming carbon dioxide removal rates from the ECCO2 R device measured in the clinical studies. Agreement of such model predictions with clinical data was good whether the ECCO2 R device was positioned proximal or distal to the CVVH device in the extracorporeal circuit. Although carbon dioxide removal rates from the ECCO2 R device measured in one previous clinical study were higher when it was placed proximal to the CVVH device, suggesting that such in-series positioning was optimal, the current mathematical model demonstrates that proximal positioning of the ECCO2 R device also results in lower bicarbonate (and, therefore, total carbon dioxide) removal from the distal CVVH device. Thus, the removal of total carbon dioxide by such extracorporeal circuits is relatively independent of the position of the in-series devices. It is concluded that the described mathematical model has quantitative accuracy; these results suggest that the overall acid-base balance when using ECCO2 R and CVVH devices in a single extracorporeal circuit will be similar, independent of their in-series position.
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Affiliation(s)
- John K Leypoldt
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Jörg Kurz
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Jorge Echeverri
- Medical Affairs, Baxter Healthcare Corporation, Deerfield, IL, USA
| | - Markus Storr
- Research and Development, Baxter International, Hechingen, Germany
| | - Kai Harenski
- Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
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13
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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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14
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See E, Ronco C, Bellomo R. The future of continuous renal replacement therapy. Semin Dial 2021; 34:576-585. [DOI: 10.1111/sdi.12961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/07/2021] [Accepted: 01/23/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Emily See
- Department of Intensive Care Austin Hospital Heidelberg Vic. Australia
- Department of Nephrology The Royal Melbourne Hospital Parkville Vic. Australia
- Centre for Integrated Critical Care School of Medicine University of Melbourne Parkville Vic. Australia
| | - Claudio Ronco
- Chair of Nephrology Department of Medicine University of Padova Padova Italy
- International Renal Research Institute of Vicenza (IRRIV) Vicenza Italy
- Department of Nephrology San Bortolo Hospital Vicenza Italy
| | - Rinaldo Bellomo
- Department of Intensive Care Austin Hospital Heidelberg Vic. Australia
- Centre for Integrated Critical Care School of Medicine University of Melbourne Parkville Vic. Australia
- Department of Intensive Care The Royal Melbourne Hospital Parkville Vic. Australia
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15
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Goursaud S, Valette X, Dupeyrat J, Daubin C, du Cheyron D. Ultraprotective ventilation allowed by extracorporeal CO 2 removal improves the right ventricular function in acute respiratory distress syndrome patients: a quasi-experimental pilot study. Ann Intensive Care 2021; 11:3. [PMID: 33411146 PMCID: PMC7788545 DOI: 10.1186/s13613-020-00784-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
Background Right ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS). RV failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. Veno-venous extracorporeal CO2 removal (ECCO2R) might allow ultraprotective ventilation with lower tidal volume (VT) and plateau pressure (Pplat). This study investigated whether ECCO2R therapy could affect RV function. Methods This was a quasi-experimental prospective observational pilot study performed in a French medical ICU. Patients with moderate-to-severe ARDS with PaO2/FiO2 ratio between 80 and 150 mmHg were enrolled. An ultraprotective ventilation strategy was used with VT at 4 mL/kg of predicted body weight during the 24 h following the start of a low-flow ECCO2R device. RV function was assessed by transthoracic echocardiography (TTE) during the study protocol. Results The efficacy of ECCO2R facilitated an ultraprotective strategy in all 18 patients included. We observed a significant improvement in RV systolic function parameters. Tricuspid annular plane systolic excursion (TAPSE) increased significantly under ultraprotective ventilation compared to baseline (from 22.8 to 25.4 mm; p < 0.05). Systolic excursion velocity (S’ wave) also increased after the 1-day protocol (from 13.8 m/s to 15.1 m/s; p < 0.05). A significant improvement in the aortic velocity time integral (VTIAo) under ultraprotective ventilation settings was observed (p = 0.05). There were no significant differences in the values of systolic pulmonary arterial pressure (sPAP) and RV preload. Conclusion Low-flow ECCO2R facilitates an ultraprotective ventilation strategy thatwould improve RV function in moderate-to-severe ARDS patients. Improvement in RV contractility appears to be mainly due to a decrease in intrathoracic pressure allowed by ultraprotective ventilation, rather than a reduction of PaCO2.
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Affiliation(s)
- Suzanne Goursaud
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France. .,Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000, Caen, France.
| | - Xavier Valette
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France
| | - Julien Dupeyrat
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France
| | - Cédric Daubin
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France
| | - Damien du Cheyron
- CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France
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16
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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17
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Combes A, Auzinger G, Capellier G, du Cheyron D, Clement I, Consales G, Dabrowski W, De Bels D, de Molina Ortiz FJG, Gottschalk A, Hilty MP, Pestaña D, Sousa E, Tully R, Goldstein J, Harenski K. ECCO 2R therapy in the ICU: consensus of a European round table meeting. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:490. [PMID: 32768001 PMCID: PMC7412288 DOI: 10.1186/s13054-020-03210-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/28/2020] [Indexed: 01/19/2023]
Abstract
Background With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO2 removal (ECCO2R). However, current evidence in these indications is limited. A European ECCO2R Expert Round Table Meeting was convened to further explore the potential for this treatment approach. Methods A modified Delphi-based method was used to collate European experts’ views to better understand how ECCO2R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus. Results Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO2R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO2R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO2R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO2 levels. Driving pressure (≥ 14 cmH2O) followed by plateau pressure (Pplat; ≥ 25 cmH2O) was considered the most important criteria for ECCO2R initiation. Key treatment targets for patients with ARDS undergoing ECCO2R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH2O) and Pplat (< 25 cmH2O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO2 and no decrease in respiratory rate were key criteria for initiating ECCO2R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30–7.35), respiratory rate (< 20–25 breaths/min), decrease of PaCO2 (by 10–20%), weaning from NIV, decrease in HCO3− and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group. Conclusions Insights from this group of experienced physicians suggest that ECCO2R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 47, Boulevard de l'Hôpital, F-75013, Paris, France. .,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, F-75013, Paris, France.
| | - Georg Auzinger
- Department of Critical Care, King's College Hospital, London, SE5 9RS, UK.,Department of Critical Care, Cleveland Clinic, London, SW1Y 7AW, UK
| | - Gilles Capellier
- Service de Médecine Intensive-Réanimation CHRU Besançon, EA 3920 University of Franche Comte, Besançon, France.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Damien du Cheyron
- Service de Médecine Intensive-Réanimation, Caen University Hospital, 14000, Caen, France
| | - Ian Clement
- Critical Care Unit, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - Guglielmo Consales
- Department Emergency and Critical Care, Prato Hospital, Azienda Toscana Centro, Prato, Italy
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Jaczewskiego Street 8, 20-954, Lublin, Poland
| | - David De Bels
- Service des Soins Intensifs Médico-chirurgicaux, CHU Brugmann, 4 Place A Van Gehuchten, 1020, Brussels, Belgium
| | - Francisco Javier González de Molina Ortiz
- Department of Critical Care, University Hospital Mútua Terrassa, Universitat de Barcelona, Terrassa, Barcelona, Spain.,Department of Critical Care, University Hospital Quirón Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antje Gottschalk
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - David Pestaña
- Department of Anesthesiology and Surgical Critical Care, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Viejo km 9, 28034, Madrid, Spain.,Universidad de Alcalá de Henares, Madrid, Spain
| | - Eduardo Sousa
- Serviço de Medicina Intensiva, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto, 3000-075, Coimbra, Portugal
| | - Redmond Tully
- Department of Intensive Care, Royal Oldham Hospital, Northern Care Alliance, Oldham, OL1 2JH, UK
| | - Jacques Goldstein
- Baxter World Trade SPRL, Acute Therapies Global, Braine-l'Alleud, Belgium
| | - Kai Harenski
- Baxter, Baxter Deutschland GmbH, Unterschleissheim, Germany
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18
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Ostermann M, Bellomo R, Burdmann EA, Doi K, Endre ZH, Goldstein SL, Kane-Gill SL, Liu KD, Prowle JR, Shaw AD, Srisawat N, Cheung M, Jadoul M, Winkelmayer WC, Kellum JA. Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int 2020; 98:294-309. [PMID: 32709292 PMCID: PMC8481001 DOI: 10.1016/j.kint.2020.04.020] [Citation(s) in RCA: 226] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 12/19/2022]
Abstract
In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, King's College London, London, UK.
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emmanuel A Burdmann
- Laboratório de Investigação Médica 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Zoltan H Endre
- Prince of Wales Hospital and Clinical School, University of New South Wales, Randwick, NSW, Australia
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kathleen D Liu
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA; Department of Anesthesia, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California, USA
| | - John R Prowle
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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19
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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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20
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Ronco C, Bagshaw SM, Bellomo R, Clark WR, Husain-Syed F, Kellum JA, Ricci Z, Rimmelé T, Reis T, Ostermann M. Extracorporeal Blood Purification and Organ Support in the Critically Ill Patient during COVID-19 Pandemic: Expert Review and Recommendation. Blood Purif 2020; 50:17-27. [PMID: 32454500 PMCID: PMC7270067 DOI: 10.1159/000508125] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 01/27/2023]
Abstract
Critically ill COVID-19 patients are generally admitted to the ICU for respiratory insufficiency which can evolve into a multiple-organ dysfunction syndrome requiring extracorporeal organ support. Ongoing advances in technology and science and progress in information technology support the development of integrated multi-organ support platforms for personalized treatment according to the changing needs of the patient. Based on pathophysiological derangements observed in COVID-19 patients, a rationale emerges for sequential extracorporeal therapies designed to remove inflammatory mediators and support different organ systems. In the absence of vaccines or direct therapy for COVID-19, extracorporeal therapies could represent an option to prevent organ failure and improve survival. The enormous demand in care for COVID-19 patients requires an immediate response from the scientific community. Thus, a detailed review of the available technology is provided by experts followed by a series of recommendation based on current experience and opinions, while waiting for generation of robust evidence from trials.
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Affiliation(s)
- Claudio Ronco
- Department of Nephrology, University of Padova, Padova, Italy
- International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - William R Clark
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Faeq Husain-Syed
- Department of Internal Medicine II, Division of Nephrology, Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, Giessen, Germany
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Thomas Rimmelé
- Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- EA 7426 "Pathophysiology of Injury-induced Immunosuppression", Pi3, Hospices Civils de Lyon - BioMérieux - Claude Bernard University Lyon, Lyon, France
| | - Thiago Reis
- Department of Nephrology, Clinica de Doenças Renais de Brasilia, Brasilia, Brazil
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom,
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21
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Hospach I, Goldstein J, Harenski K, Laffey JG, Pouchoulin D, Raible M, Votteler S, Storr M. In vitro characterization of PrismaLung+: a novel ECCO 2R device. Intensive Care Med Exp 2020; 8:14. [PMID: 32405714 PMCID: PMC7221037 DOI: 10.1186/s40635-020-00301-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Invasive mechanical ventilation is lifesaving in the setting of severe acute respiratory failure but can cause ventilation-induced lung injury. Advances in extracorporeal CO2 removal (ECCO2R) technologies may facilitate more protective lung ventilation in acute respiratory distress syndrome, and enable earlier weaning and/or avoid invasive mechanical ventilation entirely in chronic obstructive pulmonary disease exacerbations. We evaluated the in vitro CO2 removal capacity of the novel PrismaLung+ ECCO2R device compared with two existing gas exchangers. METHODS The in vitro CO2 removal capacity of the PrismaLung+ (surface area 0.8 m2, Baxter) was compared with the PrismaLung (surface area 0.35 m2, Baxter) and A.L.ONE (surface area 1.35 m2, Eurosets) devices, using a closed-loop bovine blood-perfused extracorporeal circuit. The efficacy of each device was measured at varying pCO2 inlet (pinCO2) levels (45, 60, and 80 mmHg) and blood flow rates (QB) of 200-450 mL/min; the PrismaLung+ and A.L.ONE devices were also tested at a QB of 600 mL/min. The amount of CO2 removed by each device was assessed by measurement of the CO2 infused to maintain circuit equilibrium (CO2 infusion method) and compared with measured CO2 concentrations in the inlet and outlet of the CO2 removal device (blood gas analysis method). RESULTS The PrismaLung+ device performed similarly to the A.L.ONE device, with both devices demonstrating CO2 removal rates ~ 50% greater than the PrismaLung device. CO2 removal rates were 73 ± 4.0, 44 ± 2.5, and 72 ± 1.9 mL/min, for PrismaLung+, PrismaLung, and A.L.ONE, respectively, at QB 300 mL/min and pinCO2 45 mmHg. A Bland-Altman plot demonstrated that the CO2 infusion method was comparable to the blood gas analysis method for calculating CO2 removal. The resistance to blood flow across the test device, as measured by pressure drop, varied as a function of blood flow rate, and was greatest for PrismaLung and lowest for the A.L.ONE device. CONCLUSIONS The newly developed PrismaLung+ performed more effectively than PrismaLung, with performance of CO2 removal comparable to A.L.ONE at the flow rates tested, despite the smaller membrane surface area of PrismaLung+ versus A.L.ONE. Clinical testing of PrismaLung+ is warranted to further characterize its performance.
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Affiliation(s)
- Ingeborg Hospach
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Jacques Goldstein
- Baxter World Trade SPRL, Acute Therapies Global, Braine-l'Alleud, Belgium
| | - Kai Harenski
- Baxter, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Galway, Ireland
| | | | - Manuela Raible
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Stefanie Votteler
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany
| | - Markus Storr
- Baxter International, Research and Development, Holger-Crafoord-Str. 26, 72379, Hechingen, Germany.
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22
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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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23
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Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion 2020; 35:492-508. [PMID: 32156179 DOI: 10.1177/0267659120906048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
TECHNOLOGY Extracorporeal carbon dioxide removal means the removal of carbon dioxide from the blood across a gas exchange membrane without substantially improving oxygenation. Carbon dioxide removal is possible with substantially less extracorporeal blood flow than needed for oxygenation. Techniques for extracorporeal carbon dioxide removal include (1) pumpless arterio-venous circuits, (2) low-flow venovenous circuits based on the technology of continuous renal replacement therapy, and (3) venovenous circuits based on extracorporeal membrane oxygenation technology. INDICATIONS Extracorporeal carbon dioxide removal has been shown to enable more protective ventilation in acute respiratory distress syndrome patients, even beyond the so-called "protective" level. Although experimental data suggest a benefit on ventilator induced lung injury, no hard clinical evidence with respect to improved outcome exists. In addition, extracorporeal carbon dioxide removal is a tool to avoid intubation and mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease failing non-invasive ventilation. This concept has been shown to be effective in 56-90% of patients. Extracorporeal carbon dioxide removal has also been used in ventilated patients with hypercapnic respiratory failure to correct acidosis, unload respiratory muscle burden, and facilitate weaning. In patients suffering from terminal fibrosis awaiting lung transplantation, extracorporeal carbon dioxide removal is able to correct acidosis and enable spontaneous breathing during bridging. Keeping these patients awake, ambulatory, and breathing spontaneously is associated with favorable outcome. COMPLICATIONS Complications of extracorporeal carbon dioxide removal are mostly associated with vascular access and deranged hemostasis leading to bleeding. Although the spectrum of complications may differ, no technology offers advantages with respect to rate and severity of complications. So called "high-extraction systems" working with higher blood flows and larger membranes may be more effective with respect to clinical goals.
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Affiliation(s)
- Thomas Staudinger
- Department of Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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24
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Joannidis M, Forni LG, Klein SJ, Honore PM, Kashani K, Ostermann M, Prowle J, Bagshaw SM, Cantaluppi V, Darmon M, Ding X, Fuhrmann V, Hoste E, Husain-Syed F, Lubnow M, Maggiorini M, Meersch M, Murray PT, Ricci Z, Singbartl K, Staudinger T, Welte T, Ronco C, Kellum JA. Lung-kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup. Intensive Care Med 2019; 46:654-672. [PMID: 31820034 PMCID: PMC7103017 DOI: 10.1007/s00134-019-05869-7] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Multi-organ dysfunction in critical illness is common and frequently involves the lungs and kidneys, often requiring organ support such as invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and/or extracorporeal membrane oxygenation (ECMO). METHODS A consensus conference on the spectrum of lung-kidney interactions in critical illness was held under the auspices of the Acute Disease Quality Initiative (ADQI) in Innsbruck, Austria, in June 2018. Through review and critical appraisal of the available evidence, the current state of research, and both clinical and research recommendations were described on the following topics: epidemiology, pathophysiology and strategies to mitigate pulmonary dysfunction among patients with acute kidney injury and/or kidney dysfunction among patients with acute respiratory failure/acute respiratory distress syndrome. Furthermore, emphasis was put on patients receiving organ support (RRT, IMV and/or ECMO) and its impact on lung and kidney function. CONCLUSION The ADQI 21 conference found significant knowledge gaps about organ crosstalk between lung and kidney and its relevance for critically ill patients. Lung protective ventilation, conservative fluid management and early recognition and treatment of pulmonary infections were the only clinical recommendations with higher quality of evidence. Recommendations for research were formulated, targeting lung-kidney interactions to improve care processes and outcomes in critical illness.
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Affiliation(s)
- Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK.,Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sebastian J Klein
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Doctoral College Medical Law and Healthcare, Faculty of Law, University Innsbruck, Innsbruck, Austria
| | - Patrick M Honore
- Department of Intensive Care Medicine, CHU Brugmann University Hospital, Brussels, Belgium
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - John Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, Department of Translational Medicine, University of Eastern Piedmont "A. Avogadro", Maggiore della Carità University Hospital, Novara, Italy
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai Key Laboratory of Kidney and Blood Purification, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine B, University Muenster, Muenster, Germany
| | - Eric Hoste
- ICU, Ghent University Hospital, Ghent, Belgium.,Research Fund-Flanders (FWO), Brussels, Belgium
| | - Faeq Husain-Syed
- Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Giessen, Germany
| | - Matthias Lubnow
- Department of Cardiology, Pulmonary and Critical Care Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Marco Maggiorini
- Medical Intensive Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Patrick T Murray
- School of Medicine, University College Dublin, Dublin, Ireland.,UCD Catherine McAuley Education and Research Centre, Dublin, Ireland
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Paediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy.,International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
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25
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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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26
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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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27
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Gross-Hardt S, Hesselmann F, Arens J, Steinseifer U, Vercaemst L, Windisch W, Brodie D, Karagiannidis C. Low-flow assessment of current ECMO/ECCO 2R rotary blood pumps and the potential effect on hemocompatibility. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:348. [PMID: 31694688 PMCID: PMC6836552 DOI: 10.1186/s13054-019-2622-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/23/2019] [Indexed: 01/10/2023]
Abstract
Background Extracorporeal carbon dioxide removal (ECCO2R) uses an extracorporeal circuit to directly remove carbon dioxide from the blood either in lieu of mechanical ventilation or in combination with it. While the potential benefits of the technology are leading to increasing use, there are very real risks associated with it. Several studies demonstrated major bleeding and clotting complications, often associated with hemolysis and poorer outcomes in patients receiving ECCO2R. A better understanding of the risks originating specifically from the rotary blood pump component of the circuit is urgently needed. Methods High-resolution computational fluid dynamics was used to calculate the hemodynamics and hemocompatibility of three current rotary blood pumps for various pump flow rates. Results The hydraulic efficiency dramatically decreases to 5–10% if operating at blood flow rates below 1 L/min, the pump internal flow recirculation rate increases 6–12-fold in these flow ranges, and adverse effects are increased due to multiple exposures to high shear stress. The deleterious consequences include a steep increase in hemolysis and destruction of platelets. Conclusions The role of blood pumps in contributing to adverse effects at the lower blood flow rates used during ECCO2R is shown here to be significant. Current rotary blood pumps should be used with caution if operated at blood flow rates below 2 L/min, because of significant and high recirculation, shear stress, and hemolysis. There is a clear and urgent need to design dedicated blood pumps which are optimized for blood flow rates in the range of 0.5–1.5 L/min.
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Affiliation(s)
- Sascha Gross-Hardt
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Felix Hesselmann
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Jutta Arens
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Leen Vercaemst
- Department of Perfusion, University Hospital Gasthuisberg, Leuven, Belgium
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Center, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Daniel Brodie
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Center, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany.
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Extracorporeal carbon dioxide removal for lowering the risk of mechanical ventilation: research questions and clinical potential for the future. THE LANCET RESPIRATORY MEDICINE 2019; 6:874-884. [PMID: 30484429 DOI: 10.1016/s2213-2600(18)30326-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/28/2018] [Accepted: 07/19/2018] [Indexed: 12/30/2022]
Abstract
As a result of technical improvements, extracorporeal carbon dioxide removal (ECCO2R) now has the potential to play an important role in the management of adults with acute respiratory failure. There is growing interest in the use of ECCO2R for the management of both hypoxaemic and hypercapnic respiratory failure. However, evidence to support its use is scarce and several questions remain about the best way to implement this therapy, which can be associated with serious side-effects. This Review reflects the consensus opinion of an international group of clinician scientists with expertise in managing acute respiratory failure and in using ECCO2R therapies in this setting. We concisely review clinically relevant aspects of ECCO2R, and provide a series of recommendations for clinical practice and future research, covering topics that include the practicalities of ECCO2R delivery, indications for use, and service delivery.
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Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, Forel JM, Guérin C, Jaber S, Mekontso-Dessap A, Mercat A, Richard JC, Roux D, Vieillard-Baron A, Faure H. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019. [PMID: 31197492 DOI: 10.1186/s13613-019-0540-9.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 -); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 -); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
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Affiliation(s)
- Laurent Papazian
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Cécile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Daniel Chiche
- Service de Médecine Intensive - Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris-Centre, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié- Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri-Mondor, AP-HP, DHU A-TVB, 94010, Créteil, France
| | - Alain Mercat
- Medical Intensive Care Department, Angers University Hospital, 4, rue Larrey, 49933, Angers Cedex, France
| | | | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | | | - Henri Faure
- Service de Médecine Intensive - Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, 93602, Aulnay-sous-Bois, France
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Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, Forel JM, Guérin C, Jaber S, Mekontso-Dessap A, Mercat A, Richard JC, Roux D, Vieillard-Baron A, Faure H. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019; 9:69. [PMID: 31197492 PMCID: PMC6565761 DOI: 10.1186/s13613-019-0540-9] [Citation(s) in RCA: 410] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/27/2019] [Indexed: 12/16/2022] Open
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 −); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 −); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
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Affiliation(s)
- Laurent Papazian
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Cécile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Daniel Chiche
- Service de Médecine Intensive - Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris-Centre, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié- Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri-Mondor, AP-HP, DHU A-TVB, 94010, Créteil, France
| | - Alain Mercat
- Medical Intensive Care Department, Angers University Hospital, 4, rue Larrey, 49933, Angers Cedex, France
| | | | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | | | - Henri Faure
- Service de Médecine Intensive - Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, 93602, Aulnay-sous-Bois, France
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[Current techniques for extracorporeal decarboxylation]. Med Klin Intensivmed Notfmed 2019; 114:733-740. [PMID: 31020339 DOI: 10.1007/s00063-019-0567-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/13/2019] [Indexed: 02/06/2023]
Abstract
The widespread use of extracorporeal lung assist (ECLA) in recent years has led to the introduction of different decarboxylation systems into clinical practice. Due to the large CO2 transport capacity of the blood such systems require considerably lower extracorporeal blood flows and therefore allow for effective decarboxylation with reduced invasiveness and complexity. While systems derived from classical lung assist are mainly used to control severe acute hypercapnic respiratory failure, recently a growing number of therapies based on renal replacement platforms have become available ("respiratory dialysis"). Such low-flow systems still allow for effective partial CO2 elimination and can control respiratory acidosis as well as facilitate or even enable protective and ultraprotective ventilation strategies in acute lung failure (ARDS). While the use of extracorporeal CO2 elimination (ECCO2R) has been shown to decrease ventilator-induced lung injury (VILI), positive effects on hard clinical endpoints such as mortality or duration of mechanical ventilation are still unproven. In light of limited evidence, ECCO2R must be regarded as an experimental procedure. Its use should therefore at present be restricted to centers with appropriate experience.
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Strassmann S, Merten M, Schäfer S, de Moll J, Brodie D, Larsson A, Windisch W, Karagiannidis C. Impact of sweep gas flow on extracorporeal CO 2 removal (ECCO 2R). Intensive Care Med Exp 2019; 7:17. [PMID: 30911910 PMCID: PMC6434004 DOI: 10.1186/s40635-019-0244-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/14/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Veno-venous extracorporeal carbon dioxide (CO2) removal (vv-ECCO2R) is increasingly being used in the setting of acute respiratory failure. Blood flow rates range in clinical practice from 200 mL/min to more than 1500 mL/min, and sweep gas flow rates range from less than 1 to more than 10 L/min. The present porcine model study was aimed at determining the impact of varying sweep gas flow rates on CO2 removal under different blood flow conditions and membrane lung surface areas. METHODS Two different membrane lungs, with surface areas of 0.4 and 0.8m2, were used in nine pigs with experimentally-induced hypercapnia. During each experiment, the blood flow was increased stepwise from 300 to 900 mL/min, with further increases up to 1800 mL/min with the larger membrane lung in steps of 300 mL/min. Sweep gas was titrated under each condition from 2 to 8 L/min in steps of 2 L/min. Extracorporeal CO2 elimination was normalized to a PaCO2 of 45 mmHg before the membrane lung. RESULTS Reversal of hypercapnia was only feasible when blood flow rates above 900 mL/min were used with a membrane lung surface area of at least 0.8m2. The membrane lung with a surface of 0.4m2 allowed a maximum normalized CO2 elimination rate of 41 ± 6 mL/min with 8 L/min sweep gas flow and 900 mL blood flow/min. The increase in sweep gas flow from 2 to 8 L/min increased normalized CO2 elimination from 35 ± 5 to 41 ± 6 with 900 mL blood flow/min, whereas with lower blood flow rates, any increase was less effective, levelling out at 4 L sweep gas flow/min. The membrane lung with a surface area of 0.8m2 allowed a maximum normalized CO2 elimination rate of 101 ± 12 mL/min with increasing influence of sweep gas flow. The delta of normalized CO2 elimination increased from 4 ± 2 to 26 ± 7 mL/min with blood flow rates being increased from 300 to 1800 mL/min, respectively. CONCLUSIONS The influence of sweep gas flow on the CO2 removal capacity of ECCO2R systems depends predominantly on blood flow rate and membrane lung surface area. In this model, considerable CO2 removal occurred only with the larger membrane lung surface of 0.8m2 and when blood flow rates of ≥ 900 mL/min were used.
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Affiliation(s)
- 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
| | - Michaela Merten
- 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
| | - Simone Schäfer
- 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
| | - Jonas de Moll
- 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, 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
| | - 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.
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Karagiannidis C, Hesselmann F, Fan E. Physiological and Technical Considerations of Extracorporeal CO 2 Removal. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:75. [PMID: 30849995 PMCID: PMC6408850 DOI: 10.1186/s13054-019-2367-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Felix Hesselmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute Aachen, RWTH Aachen University, Aachen, Germany
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto and the Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
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Nentwich J, Wichmann D, Kluge S, Lindau S, Mutlak H, John S. Low-flow CO 2 removal in combination with renal replacement therapy effectively reduces ventilation requirements in hypercapnic patients: a pilot study. Ann Intensive Care 2019; 9:3. [PMID: 30617611 PMCID: PMC6323065 DOI: 10.1186/s13613-019-0480-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/02/2019] [Indexed: 01/21/2023] Open
Abstract
Background Lung-protective strategies are the cornerstone of mechanical ventilation in critically ill patients with both ARDS and other disorders. Extracorporeal CO2 removal (ECCO2R) may enhance lung protection by allowing even further reductions in tidal volumes and is effective in low-flow settings commonly used for renal replacement therapy. In this study, we describe for the first time the effects of a labeled and certified system combining ECCO2R and renal replacement therapy on pulmonary stress and strain in hypercapnic patients with renal failure. Methods Twenty patients were treated with the combined system which incorporates a membrane lung (0.32 m2) in a conventional renal replacement circuit. After changes in blood gases under ECCO2R were recorded, baseline hypercapnia was reestablished and the impact on ventilation parameters such as tidal volume and driving pressure was recorded. Results The system delivered ECCO2R at rate of 43.4 ± 14.1 ml/min, PaCO2 decreased from 68.3 ± 11.8 to 61.8 ± 11.5 mmHg (p < 0.05) and pH increased from 7.18 ± 0.09 to 7.22 ± 0.08 (p < 0.05). There was a significant reduction in ventilation requirements with a decrease in tidal volume from 6.2 ± 0.9 to 5.4 ± 1.1 ml/kg PBW (p < 0.05) corresponding to a decrease in plateau pressure from 30.6 ± 4.6 to 27.7 ± 4.1 cmH2O (p < 0.05) and a decrease in driving pressure from 18.3 ± 4.3 to 15.6 ± 3.9 cmH2O (p < 0.05), indicating reduced pulmonary stress and strain. No complications related to the procedure were observed. Conclusions The investigated low-flow ECCO2R and renal replacement system can ameliorate respiratory acidosis and decrease ventilation requirements in hypercapnic patients with concomitant renal failure. Trial registration NCT02590575, registered 10/23/2015.
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Affiliation(s)
- Jens Nentwich
- Medical Intensive Care, Department of Cardiology, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Dominic Wichmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Lindau
- Department of Anesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Haitham Mutlak
- Department of Anesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Stefan John
- Medical Intensive Care, Department of Cardiology, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany.
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Extracorporeal Carbon Dioxide Removal. CRITICAL CARE NEPHROLOGY 2019. [PMCID: PMC7969728 DOI: 10.1016/b978-0-323-44942-7.00124-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Mechanical ventilation (MV) represents a lifesaving treatment for patients with respiratory failure, but it could be harmful through the development of ventilator-induced lung injury (VILI). In patients with acute respiratory distress syndrome (ARDS), protective MV strategies with low tidal volume to minimize VILI have been demonstrated to reduce lung injury and mortality. However, they can be limited by the emergence of uncontrolled hypercapnia. Similarly, in COPD patients, noninvasive MV failure often is associated with a progressive rise in arterial CO2 and need for endotracheal intubation, with higher risk of hospital mortality. Minimally invasive extracorporeal CO2 removal systems (ECCO2R) theoretically can remove the entire amount of the CO2 produced in the body per minute. In ARDS patients, ECCO2R may further reduce the risk of VILI ensuring ultraprotective MV and avoiding hypercapnia. In patients with exacerbation of COPD, ECCO2R may help to avoid intubation or facilitate weaning from invasive MV. In intensive care unit, concomitant renal and respiratory failure with MV is one of the strongest risk factors for hospital mortality. Combining ECCO2R and renal replacement therapy may support respiratory and renal functions and limit the side effects of MV. However, the need for systemic anticoagulation and the related risk of bleeding still represent a concern for a wider application of ECCO2R devices. In conclusion, ECCO2R is an effective support therapy to MV to limit its invasiveness and side effects, but its efficacy and safety must be proven in well-designed clinical trials. This chapter will:Explain the physiology of CO2 removal during extracorporeal support. Describe potential clinical applications of extracorporeal CO2 removal systems (ECCO2R) support therapy in patients with acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD) as well as in those with acute kidney injury requiring renal replacement therapy.
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Grant AA, Hart VJ, Lineen EB, Forsberg BC, Klima A, Mirsaeidi M, Schulman IH, Badiye A, Vianna RM, Patel A, Loebe M, Ghodsizad A. Rescue therapy for hypercapnia due to high PEEP mechanical ventilation in patients with ARDS and renal failure. Artif Organs 2018; 43:599-604. [PMID: 30431163 DOI: 10.1111/aor.13393] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 11/30/2022]
Abstract
Extracorporeal removal of carbon dioxide in patients experiencing severe hypercapnia due to lung protective mechanical ventilation was first described over four decades ago. There have been many devices developed and described in the interim, many of which require additional training, resources, and staff. This manuscript describes a readily available and relatively simple adjunct that can provide partial lung support in patients with acute respiratory distress syndrome complicated by severe hypercapnia and acute kidney injury requiring dialysis.
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Affiliation(s)
- April A Grant
- Dewitt Daughtry Family Department of Surgery, Division of Trauma, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida.,Jackson Health System & Ryder Trauma Center, Miami, Florida
| | - Valerie J Hart
- Dewitt Daughtry Family Department of Surgery, Division of Trauma, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida.,Jackson Health System & Ryder Trauma Center, Miami, Florida
| | - Edward B Lineen
- Dewitt Daughtry Family Department of Surgery, Division of Trauma, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida.,Jackson Health System & Ryder Trauma Center, Miami, Florida
| | | | - Alan Klima
- Comprehensive Care Services, Inc, Livonia, Michigan
| | - Mehdi Mirsaeidi
- Department of Medicine, Division of Pulmonology and Sleep Medicine, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Ivonne H Schulman
- Department of Medicine, Division of Nephrology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Amit Badiye
- Department of Medicine, Division of Cardiology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Rodrigo M Vianna
- Miami Transplant Institute, Miami, Florida.,Dewitt Daughtry Family Department of Surgery, Liver, Intestinal and Multivisceral Transplant, University of Miami, Leonard M Miller School of Medicine, Miami, Florida
| | - Amit Patel
- Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, Florida
| | - Matthias Loebe
- Miami Transplant Institute, Miami, Florida.,Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, Florida
| | - Ali Ghodsizad
- Miami Transplant Institute, Miami, Florida.,Dewitt Daughtry Family Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Leonard M Miller School of Medicine, Miami, Florida
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Abstract
Extracorporeal gas exchange is increasingly used for various indications. Among these are refractory acute respiratory failure, including the acute respiratory distress syndrome (ARDS), and the avoidance of ventilator-induced lung injury (VILI) by enabling lung-protective ventilation. Additionally, extracorporeal gas exchange allows the treatment of hypercapnic respiratory failure while helping to unload the respiratory muscles and avoid intubation and invasive ventilation, as well as facilitating weaning from the ventilator. These indications are based on a reasonable physiologic rationale but must be weighed against the costs and complications associated with the technique. This article summarizes current evidence and indications for extracorporeal gas exchange.
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Fanelli V, Cantaluppi V, Alessandri F, Costamagna A, Cappello P, Brazzi L, Pugliese F, Biancone L, Terragni P, Ranieri VM. Extracorporeal CO2 Removal May Improve Renal Function of Patients with Acute Respiratory Distress Syndrome and Acute Kidney Injury: An Open-Label, Interventional Clinical Trial. Am J Respir Crit Care Med 2018; 198:687-690. [DOI: 10.1164/rccm.201712-2575le] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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39
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Extracorporeal organ support (ECOS) in critical illness and acute kidney injury: from native to artificial organ crosstalk. Intensive Care Med 2018; 44:1447-1459. [DOI: 10.1007/s00134-018-5329-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022]
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40
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Scaravilli V, Di Girolamo L, Scotti E, Busana M, Biancolilli O, Leonardi P, Carlin A, Lonati C, Panigada M, Pesenti A, Zanella A. Effects of sodium citrate, citric acid and lactic acid on human blood coagulation. Perfusion 2018; 33:577-583. [PMID: 29783879 DOI: 10.1177/0267659118777441] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Citric acid infusion in extracorporeal blood may allow concurrent regional anticoagulation and enhancement of extracorporeal CO2 removal. Effects of citric acid on human blood thromboelastography and aggregometry have never been tested before. METHODS In this in vitro study, citric acid, sodium citrate and lactic acid were added to venous blood from seven healthy donors, obtaining concentrations of 9 mEq/L, 12 mEq/L and 15 mEq/L. We measured gas analyses, ionized calcium (iCa++) concentration, activated clotting time (ACT), thromboelastography and multiplate aggregometry. Repeated measure analysis of variance was used to compare the acidifying and anticoagulant properties of the three compounds. RESULTS Sodium citrate did not affect the blood gas analysis. Increasing doses of citric and lactic acid progressively reduced pH and HCO3- and increased pCO2 (p<0.001). Sodium citrate and citric acid similarly reduced iCa++, from 0.39 (0.36-0.39) and 0.35 (0.33-0.36) mmol/L, respectively, at 9 mEq/L to 0.20 (0.20-0.21) and 0.21 (0.20-0.23) mmol/L at 15 mEq/L (p<0.001). Lactic acid did not affect iCa++ (p=0.07). Sodium citrate and citric acid similarly incremented the ACT, from 234 (208-296) and 202 (178-238) sec, respectively, at 9 mEq/L, to >600 sec at 15 mEq/L (p<0.001). Lactic acid did not affect the ACT values (p=0.486). Sodium citrate and citric acid similarly incremented R-time and reduced α-angle and maximum amplitude (MA) (p<0.001), leading to flat-line thromboelastograms at 15 mEq/L. Platelet aggregometry was not altered by any of the three compounds. CONCLUSIONS Citric acid infusions determine acidification and anticoagulation of blood similar to lactic acid and sodium citrate, respectively.
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Affiliation(s)
- Vittorio Scaravilli
- 1 Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
| | - Luca Di Girolamo
- 2 Department of Medical Physiopathology and Transplants, University of Milan, Milan (MI), Italy
| | - Eleonora Scotti
- 2 Department of Medical Physiopathology and Transplants, University of Milan, Milan (MI), Italy
| | - Mattia Busana
- 2 Department of Medical Physiopathology and Transplants, University of Milan, Milan (MI), Italy
| | - Osvaldo Biancolilli
- 3 School of Medicine and Surgery, University of Milan-Bicocca, Milan (MI), Italy
| | - Patrizia Leonardi
- 2 Department of Medical Physiopathology and Transplants, University of Milan, Milan (MI), Italy
| | - Andrea Carlin
- 2 Department of Medical Physiopathology and Transplants, University of Milan, Milan (MI), Italy
| | - Caterina Lonati
- 4 Center of Preclinical Research, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
| | - Mauro Panigada
- 1 Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
| | - Antonio Pesenti
- 1 Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
| | - Alberto Zanella
- 1 Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
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41
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Schmidt M, Jaber S, Zogheib E, Godet T, Capellier G, Combes A. Feasibility and safety of low-flow extracorporeal CO 2 removal managed with a renal replacement platform to enhance lung-protective ventilation of patients with mild-to-moderate ARDS. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:122. [PMID: 29743094 PMCID: PMC5944133 DOI: 10.1186/s13054-018-2038-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/13/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Extracorporeal carbon-dioxide removal (ECCO2R) might allow ultraprotective mechanical ventilation with lower tidal volume (VT) (< 6 ml/kg predicted body weight), plateau pressure (Pplat) (< 30 cmH2O), and driving pressure to limit ventilator-induced lung injury. This study was undertaken to assess the feasibility and safety of ECCO2R managed with a renal replacement therapy (RRT) platform to enable very low tidal volume ventilation of patients with mild-to-moderate acute respiratory distress syndrome (ARDS). METHODS Twenty patients with mild (n = 8) or moderate (n = 12) ARDS were included. VT was gradually lowered from 6 to 5, 4.5, and 4 ml/kg, and PEEP adjusted to reach 23 ≤ Pplat ≤ 25 cmH2O. Standalone ECCO2R (no hemofilter associated with the RRT platform) was initiated when arterial PaCO2 increased by > 20% from its initial value. Ventilation parameters (VT, respiratory rate, PEEP), respiratory system compliance, Pplat and driving pressure, arterial blood gases, and ECCO2R-system operational characteristics were collected during at least 24 h of very low tidal volume ventilation. Complications, day-28 mortality, need for adjuvant therapies, and data on weaning off ECCO2R and mechanical ventilation were also recorded. RESULTS While VT was reduced from 6 to 4 ml/kg and Pplat kept < 25 cmH2O, PEEP was significantly increased from 13.4 ± 3.6 cmH2O at baseline to 15.0 ± 3.4 cmH2O, and the driving pressure was significantly reduced from 13.0 ± 4.8 to 7.9 ± 3.2 cmH2O (both p < 0.05). The PaO2/FiO2 ratio and respiratory-system compliance were not modified after VT reduction. Mild respiratory acidosis occurred, with mean PaCO2 increasing from 43 ± 8 to 53 ± 9 mmHg and mean pH decreasing from 7.39 ± 0.1 to 7.32 ± 0.10 from baseline to 4 ml/kg VT, while the respiratory rate was not altered. Mean extracorporeal blood flow, sweep-gas flow, and CO2 removal were 421 ± 40 ml/min, 10 ± 0.3 L/min, and 51 ± 26 ml/min, respectively. Mean treatment duration was 31 ± 22 h. Day-28 mortality was 15%. CONCLUSIONS A low-flow ECCO2R device managed with an RRT platform easily and safely enabled very low tidal volume ventilation with moderate increase in PaCO2 in patients with mild-to-moderate ARDS. TRIAL REGISTRATION ClinicalTrials.gov, NCT02606240. Registered on 17 November 2015.
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Affiliation(s)
- Matthieu Schmidt
- Sorbonne Université, INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Pitié-Salpêtrière Hospital, F-75013, Paris, France.,Service de Médecine Intensive et Réanimation, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 47, boulevard de l'Hôpital, F-75013, Paris, France
| | - Samir Jaber
- Département d'Anesthésie et Réanimation B, CHU de Montpellier, Hôpital Saint-Eloi, INSERM Unité 1046, Université Montpellier 1, Montpellier, France
| | - Elie Zogheib
- Anesthesiology and Critical Care Medicine Department, Amiens University Hospital, INSERM U-1088, Université de Picardie Jules-Verne, 80054, Amiens Cedex, France
| | - Thomas Godet
- Département de Médecine Périopératoire (MPO), Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, France.,GReD, UMR/CNRS6293, Université Clermont-Auvergne, INSERM U1103, F-63003, Clermont-Ferrand, France
| | - Gilles Capellier
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besançon, France
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Pitié-Salpêtrière Hospital, F-75013, Paris, France. .,Service de Médecine Intensive et Réanimation, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 47, boulevard de l'Hôpital, F-75013, Paris, France.
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42
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Peperstraete H, Eloot S, Depuydt P, De Somer F, Roosens C, Hoste E. Low flow extracorporeal CO 2 removal in ARDS patients: a prospective short-term crossover pilot study. BMC Anesthesiol 2017; 17:155. [PMID: 29179681 PMCID: PMC5704518 DOI: 10.1186/s12871-017-0445-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/12/2017] [Indexed: 12/15/2022] Open
Abstract
Background Lung protective mechanical ventilation (MV) is the corner stone of therapy for ARDS. However, its use may be limited by respiratory acidosis. This study explored feasibility of, effectiveness and safety of low flow extracorporeal CO2 removal (ECCO2R). Methods This was a prospective pilot study, using the Abylcap® (Bellco) ECCO2R, with crossover off-on-off design (2-h blocks) under stable MV settings, and follow up till end of ECCO2R. Primary endpoint for effectiveness was a 20% reduction of PaCO2 after the first 2-h. Adverse events (AE) were recorded prospectively. We included 10 ARDS patients on MV, with PaO2/FiO2 < 150 mmHg, tidal volume ≤ 8 mL/kg with positive end-expiratory pressure ≥ 5 cmH2O, FiO2 titrated to SaO2 88–95%, plateau pressure ≥ 28 cmH2O, and respiratory acidosis (pH <7.25). Results After 2-h of ECCO2R, 6 patients had a ≥ 20% decrease in PaCO2 (60%); PaCO2 decreased 28.4% (from 58.4 to 48.7 mmHg, p = 0.005), and pH increased (1.59%, p = 0.005). ECCO2R was hemodynamically well tolerated. During the whole period of ECCO2R, 6 patients had an AE (60%); bleeding occurred in 5 patients (50%) and circuit thrombosis in 3 patients (30%), these were judged not to be life threatening. Conclusions In ARDS patients, low flow ECCO2R significantly reduced PaCO2 after 2 h, Follow up during the entire ECCO2R period revealed a high incidence of bleeding and circuit thrombosis. Trial registration https://clinicaltrials.gov identifier: NCT01911533, registered 23 July 2013. Electronic supplementary material The online version of this article (10.1186/s12871-017-0445-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harlinde Peperstraete
- Intensive Care Unit, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Sunny Eloot
- Renal Division, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.,Ghent University, Ghent, Belgium
| | - Pieter Depuydt
- Intensive Care Unit, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.,Ghent University, Ghent, Belgium
| | - Filip De Somer
- Ghent University, Ghent, Belgium.,Department of Cardiac Surgery, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Carl Roosens
- Intensive Care Unit, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Eric Hoste
- Intensive Care Unit, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.,Ghent University, Ghent, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
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43
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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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44
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Bein T, Aubron C, Papazian L. Focus on ECMO and ECCO 2R in ARDS patients. Intensive Care Med 2017; 43:1424-1426. [PMID: 28717835 DOI: 10.1007/s00134-017-4882-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Thomas Bein
- Department of Anesthesia and Operative Critical Care, University Hospital Regensburg, 93042, Regensburg, Germany
| | - Cécile Aubron
- Médecine Intensive Réanimation, Centre Hospitalier Régionale et Universitaire de Brest, Université de Bretagne occidentale, Brest, France
| | - Laurent Papazian
- Assistance Publique, Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Université, Faculté de médecine, Marseille, France.
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45
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Allardet-Servent J, Castanier M, Signouret T, Seghboyan JM, Morelli A. Comments on Morelli et al.: Extracorporeal carbon dioxide removal (ECCO 2R) in patients with acute respiratory failure. Intensive Care Med 2017; 43:1171-1172. [PMID: 28573390 DOI: 10.1007/s00134-017-4822-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Jérôme Allardet-Servent
- Service de Réanimation, Hôpital Européen Marseille, 6 Rue Désirée Clary, 13003, Marseille, France.
| | - Matthias Castanier
- Service de Réanimation, Hôpital Européen Marseille, 6 Rue Désirée Clary, 13003, Marseille, France
| | - Thomas Signouret
- Service de Réanimation, Hôpital Européen Marseille, 6 Rue Désirée Clary, 13003, Marseille, France
| | - Jean-Marie Seghboyan
- Service de Réanimation, Hôpital Européen Marseille, 6 Rue Désirée Clary, 13003, Marseille, France
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Viale del Policlinico 155, 00161, Rome, Italy
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Braune S, Sieweke A, Jarczak D, Kluge S. [Extracorporeal lung support]. Med Klin Intensivmed Notfmed 2017; 112:426-436. [PMID: 28555443 DOI: 10.1007/s00063-017-0304-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 01/28/2023]
Abstract
Systems for extracorporeal lung support have recently undergone significant technological improvements leading to more effective and safe treatment. Despite limited scientific evidence these systems are increasingly used in the intensive care unit for treatment of different types of acute respiratory failure. In general two types of systems can be differentiated: devices for extracorporeal carbon dioxide removal (ECCO2R) for ventilatory insufficiency and devices for extracorporeal membrane oxygenation (ECMO) for severe hypoxemic failure. Despite of all technological developments extracorporeal lung support remains an invasive and a potentially dangerous form of treatment with bleeding and vascular injury being the two main complications. For this reason indications and contraindications should always be critically considered and extracorporeal lung support should only be carried out in centers with appropriate experience and expertise.
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Affiliation(s)
- S Braune
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- IV. Medizinische Klinik, Internistische Intensivmedizin und Notaufnahme, St. Franziskus-Hospital, 48145, Münster, Deutschland
| | - A Sieweke
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - D Jarczak
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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[The role of extracorporeal removal of CO 2 (ECCO 2R) in the management of respiratory diseases]. Rev Mal Respir 2017; 34:598-606. [PMID: 28506729 DOI: 10.1016/j.rmr.2017.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 10/21/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The aim of extracorporeal removal of CO2 (ECCO2R) is to ensure the removal of CO2 without any significant effect on oxygenation. ECCO2R makes use of low to moderate extracorporeal blood flow rates, whereas extracorporeal membrane oxygenation (ECMO) requires high blood flows. STATE OF THE ART For each ECCO2R device it is important to consider not only performance in terms of CO2 removal, but also cost and safety, including the incidence of hemolysis and of hemorrhagic and thrombotic complications. In addition, it is possible that the benefits of such techniques may extend beyond simple removal of CO2. There have been preliminary reports of benefits in terms of reduced respiratory muscle workload. Mobilization of endothelial progenitor cells could also occur, in analogy to the data reported with ECMO, with a potential benefit in term of pulmonary repair. The most convincing clinical experience has been reported in the context of the acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (COPD), especially in patients at high risk of failure of non-invasive ventilation. PERSPECTIVES Preliminary results prompt the initiation of randomized controlled trials in these two main indications. Finally, the development of these technologies opens new perspectives in terms of long-term ventilatory support.
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Assessing Feasibility (and Increasing Simplicity) in Extracorporeal Rescue Therapy for Acute Respiratory Distress Syndrome: The Pulmonary and Renal Support in Acute Respiratory Distress Syndrome Study. Crit Care Med 2016; 43:2683-5. [PMID: 26575659 DOI: 10.1097/ccm.0000000000001364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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