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Pistolesi V, Morabito S, Pota V, Valente F, Di Mario F, Fiaccadori E, Grasselli G, Brienza N, Cantaluppi V, De Rosa S, Fanelli V, Fiorentino M, Marengo M, Romagnoli S. Regional citrate anticoagulation (RCA) in critically ill patients undergoing renal replacement therapy (RRT): expert opinion from the SIAARTI-SIN joint commission. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:7. [PMID: 37386664 DOI: 10.1186/s44158-023-00091-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/15/2023] [Indexed: 07/01/2023]
Abstract
Renal replacement therapies (RRT) are essential to support critically ill patients with severe acute kidney injury (AKI), providing control of solutes, fluid balance and acid-base status. To maintain the patency of the extracorporeal circuit, minimizing downtime periods and blood losses due to filter clotting, an effective anticoagulation strategy is required.Regional citrate anticoagulation (RCA) has been introduced in clinical practice for continuous RRT (CRRT) in the early 1990s and has had a progressively wider acceptance in parallel to the development of simplified systems and safe protocols. Main guidelines on AKI support the use of RCA as the first line anticoagulation strategy during CRRT in patients without contraindications to citrate and regardless of the patient's bleeding risk.Experts from the SIAARTI-SIN joint commission have prepared this position statement which discusses the use of RCA in different RRT modalities also in combination with other extracorporeal organ support systems. Furthermore, advise is provided on potential limitations to the use of RCA in high-risk patients with particular attention to the need for a rigorous monitoring in complex clinical settings. Finally, the main findings about the prospective of optimization of RRT solutions aimed at preventing electrolyte derangements during RCA are discussed in detail.
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Affiliation(s)
- Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy.
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Vincenzo Pota
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Fabrizio Valente
- Nephrology and Dialysis Unit, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Nicola Brienza
- Department of Interdisciplinary Medicine, ICU Section, University of Bari "Aldo Moro", Bari, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine (DIMET), University of Piemonte Orientale (UPO), AOU "Maggiore Della Carità", Novara, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Marco Fiorentino
- Nephrology Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
| | - Marita Marengo
- Department of Medical Specialist, Nephrology and Dialysis Unit, ASL CN1, Cuneo, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
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Worku E, Brodie D, Ling RR, Ramanathan K, Combes A, Shekar K. Venovenous extracorporeal CO 2 removal to support ultraprotective ventilation in moderate-severe acute respiratory distress syndrome: A systematic review and meta-analysis of the literature. Perfusion 2022:2676591221096225. [PMID: 35656595 DOI: 10.1177/02676591221096225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCO2R) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCO2R in supporting ultra-protective ventilation in moderate-to-severe ARDS. METHODS MEDLINE and EMBASE were interrogated for studies (2000-2021) reporting venovenous ECCO2R use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCO2R, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCO2R therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data. RESULTS Ten studies reporting 421 patients (PaO2:FiO2 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmH2O reduction (95%-CI: 3.22-3.91) in driving pressure from baseline (p < .001) and a 1.89 mL/kg (95%-CI: 1.75-2.02, p < .001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO2:FiO2 ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy. CONCLUSIONS Venovenous ECCO2R permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made.
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Affiliation(s)
- Elliott Worku
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, 12294Columbia University College of Physicians and Surgeons, NY, USA
- Center for Acute Respiratory Failure, 25065New York-Presbyterian Hospital, NY, USA
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Cardiothoracic Intensive Care Unit, 375583National University Heart Centre, National University Hospital, Singapore
| | - Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, 26933Pitié-Salpêtrière Hospital, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane and Bond University, Gold Coast, QLD, Australia
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Alkaline Liquid Ventilation of the Membrane Lung for Extracorporeal Carbon Dioxide Removal (ECCO 2R): In Vitro Study. MEMBRANES 2021; 11:membranes11070464. [PMID: 34206672 PMCID: PMC8306443 DOI: 10.3390/membranes11070464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 11/16/2022]
Abstract
Extracorporeal carbon dioxide removal (ECCO2R) is a promising strategy to manage acute respiratory failure. We hypothesized that ECCO2R could be enhanced by ventilating the membrane lung with a sodium hydroxide (NaOH) solution with high CO2 absorbing capacity. A computed mathematical model was implemented to assess NaOH–CO2 interactions. Subsequently, we compared NaOH infusion, named “alkaline liquid ventilation”, to conventional oxygen sweeping flows. We built an extracorporeal circuit with two polypropylene membrane lungs, one to remove CO2 and the other to maintain a constant PCO2 (60 ± 2 mmHg). The circuit was primed with swine blood. Blood flow was 500 mL × min−1. After testing the safety and feasibility of increasing concentrations of aqueous NaOH (up to 100 mmol × L−1), the CO2 removal capacity of sweeping oxygen was compared to that of 100 mmol × L−1 NaOH. We performed six experiments to randomly test four sweep flows (100, 250, 500, 1000 mL × min−1) for each fluid plus 10 L × min−1 oxygen. Alkaline liquid ventilation proved to be feasible and safe. No damages or hemolysis were detected. NaOH showed higher CO2 removal capacity compared to oxygen for flows up to 1 L × min−1. However, the highest CO2 extraction power exerted by NaOH was comparable to that of 10 L × min−1 oxygen. Further studies with dedicated devices are required to exploit potential clinical applications of alkaline liquid ventilation.
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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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d'Andrea A, Banfi C, Bendjelid K, Giraud R. The use of extracorporeal carbon dioxide removal in acute chronic obstructive pulmonary disease exacerbation: a narrative review. Can J Anaesth 2020; 67:462-474. [PMID: 31811514 DOI: 10.1007/s12630-019-01551-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 10/16/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) exacerbation induces hypercapnic respiratory acidosis. Extracorporeal carbon dioxide removal (ECCO2R) aims to eliminate blood carbon dioxide (CO2) in order to reduce adverse effects from hypercapnia and the related acidosis. Hypercapnia has deleterious extra-pulmonary consequences in increasing intracranial pressure and inducing and/or worsening right heart failure. During COPD exacerbation, the use of ECCO2R may improve the efficacy of non-invasive ventilation (NIV) in terms of CO2 removal, decrease respiratory rate and reduce dynamic hyperinflation and intrinsic positive end expiratory pressure, which all contribute to increasing dead space. Moreover, ECCO2R may prevent NIV failure while facilitating the weaning of intubated patients from mechanical ventilation. In this review of the literature, the authors will present the current knowledge on the pathophysiology related to COPD, the principles of the ECCO2R technique and its role in acute and severe decompensation of COPD. However, despite technical advances, there are only case series in the literature and few prospective studies to clearly establish the role of ECCO2R in acute and severe COPD decompensation.
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Affiliation(s)
- Alexia d'Andrea
- Service d'anesthésiologie, Hôpital Riviera-Chablais, Montreux, Switzerland
| | - Carlo Banfi
- Département de chirurgie cardio-thoracique, Istituto Clinico Sant'Ambrogio, Gruppo Ospedaliero San Donato, Milan, Italy
- Faculté de médecine, Université de Genève, Geneva, Switzerland
- Faculté de médecine, Groupe de recherche hémodynamique, Geneva, Switzerland
| | - Karim Bendjelid
- Service des soins intensifs, Hôpitaux Universitaires de Genève, 4, Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland
- Faculté de médecine, Université de Genève, Geneva, Switzerland
- Faculté de médecine, Groupe de recherche hémodynamique, Geneva, Switzerland
| | - Raphaël Giraud
- Service des soins intensifs, Hôpitaux Universitaires de Genève, 4, Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland.
- Faculté de médecine, Université de Genève, Geneva, Switzerland.
- Faculté de médecine, Groupe de recherche hémodynamique, Geneva, Switzerland.
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