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Yamashita T, Uchiyama A, Enokidani Y, Yoshida T, Fujino Y. Combined Use of Alkaline Agents With Low-Flow Extracorporeal Carbon Dioxide Removal in Carbon Dioxide Inhalation Models Preserving Inspiratory Efforts. J Acute Med 2024; 14:28-38. [PMID: 38487759 PMCID: PMC10933589 DOI: 10.6705/j.jacme.202403_14(1).0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/23/2022] [Accepted: 01/03/2023] [Indexed: 03/17/2024]
Abstract
Background Low-flow extracorporeal CO 2 removal (ECCO 2 R), managed using a renal replacement platform, is useful in achieving lung-protective ventilation with low tidal volume. However, its capacity for CO 2 elimination is limited. Whether this system is valuable in reducing strong inspiratory efforts in respiratory failure is unclear. The combined use of alkaline agents with low-flow ECCO 2 R might be useful in hypercapnic subjects preserving inspiratory efforts. Methods This study examined the effects of low-flow ECCO 2 R on respiratory status and investigated the effects of NaHCO 3 , trometamol, and saline on respiratory status during low-flow ECCO 2 R in CO 2 inhalation models. Results Although low-flow ECCO 2 R did not significantly change the respiratory rate (92.2% ± 24.3% [mean ± standard deviation] of that before ECCO 2 R), it reduced minute ventilation (MV) (78.9% ± 13.5% of that before ECCO 2 R). The addition of NaHCO 3 improved acidemia but did not change MV compared with that of the saline group (0.451 ± 0.026 L/min/kg body weight [BW] vs. 0.556 ± 0.138 L/min/kg BW, respectively). The addition of trometamol improved acidemia and reduced MV compared with that of the saline group (0.381 ± 0.050 L/min/kg BW vs. 0.556 ± 0.138 L/min/kg BW, respectively). The total amounts of CO 2 removed during ECCO 2 R in the NaHCO 3 group were lower than those in the saline and trometamol groups. Conclusion The low-flow ECCO 2 R reduced MV in subjects preserving spontaneous breathing efforts with CO 2 overload. The addition of NaHCO 3 improved acidemia but did not change MV, whereas the addition of trometamol improved acidemia and reduced MV.
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Affiliation(s)
- Tomonori Yamashita
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
| | - Akinori Uchiyama
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
| | - Yusuke Enokidani
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
| | - Takeshi Yoshida
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
| | - Yuji Fujino
- Osaka University Graduate School of Medicine Department of Anesthesiology and Intensive Care Medicine Suita Japan
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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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3
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Wang XX, Guo Y. [Recent research on extracorporeal carbon dioxide removal]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:205-209. [PMID: 36854699 DOI: 10.7499/j.issn.1008-8830.2208187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Extracorporeal carbon dioxide removal is an artificial lung auxiliary technique based on extrapulmonary gas exchange and can effectively remove carbon dioxide and provide oxygenation to a certain extent, and it is one of the effective treatment techniques for hypercapnia developed after mechanical ventilation and extracorporeal membrane oxygenation in recent years and has wide application prospect. This article elaborates on the development, working principle, advantages, classification, complications, and clinical application of extracorporeal carbon dioxide removal, so as to provide a new choice for extracorporeal carbon dioxide removal in clinical practice.
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Affiliation(s)
- Xiao-Xin Wang
- Neonatal Medical Center, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Yan Guo
- Neonatal Medical Center, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
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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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Gendreau S, Geri G, Pham T, Vieillard-Baron A, Mekontso Dessap A. The role of acute hypercapnia on mortality and short-term physiology in patients mechanically ventilated for ARDS: a systematic review and meta-analysis. Intensive Care Med 2022; 48:517-534. [PMID: 35294565 PMCID: PMC8924945 DOI: 10.1007/s00134-022-06640-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/03/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE Hypercapnia is frequent during mechanical ventilation for acute respiratory distress syndrome (ARDS), but its effects on morbidity and mortality are still controversial. We conducted a systematic review and meta-analysis to explore clinical consequences of acute hypercapnia in adult patients ventilated for ARDS. METHODS We searched Medline, Embase, and the Cochrane Library via the OVID platform for studies published from 1946 to 2021. "Permissive hypercapnia" defined hypercapnia in studies where the group with hypercapnia was ventilated with a protective ventilation (PV) strategy (lower VT targeting 6 ml/kg predicted body weight) while the group without hypercapnia was managed with a non-protective ventilation (NPV); "imposed hypercapnia" defined hypercapnia in studies where hypercapnic and non-hypercapnic patients were managed with a similar ventilation strategy. RESULTS Twenty-nine studies (10,101 patients) were included. Permissive hypercapnia, imposed hypercapnia under PV, and imposed hypercapnia under NPV were reported in 8, 21 and 1 study, respectively. Studies testing permissive hypercapnia reported lower mortality in hypercapnic patients receiving PV as compared to non-hypercapnic patients receiving NPV: OR = 0.26, 95% CI [0.07-0.89]. By contrast, studies reporting imposed hypercapnia under PV reported increased mortality in hypercapnic patients receiving PV as compared to non-hypercapnic patients also receiving PV: OR = 1.54, 95% CI [1.15-2.07]. There was a significant interaction between the mechanism of hypercapnia and the effect on mortality. CONCLUSIONS Clinical effects of hypercapnia are conflicting depending on its mechanism. Permissive hypercapnia was associated with improved mortality contrary to imposed hypercapnia under PV, suggesting a major role of PV strategy on the outcome.
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Affiliation(s)
- Ségolène Gendreau
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive-Réanimation, 94010, Créteil, France
- Université Paris Est Créteil, CARMAS, 94010, Créteil, France
- Université Paris Est Créteil, INSERM, IMRB, 94010, Créteil, France
| | - Guillaume Geri
- AP-HP, Hôpital Universitaire Ambroise-Paré, Service de Médecine Intensive Réanimation, 92100, Boulogne-Billancourt, France
- Université de Paris Saclay, INSERM UMR 1018, Clinical Epidemiology Team, CESP, Villejuif, France
| | - Tai Pham
- AP-HP, Hôpital de Bicêtre, DMU CORREVE, Service de Médecine Intensive-Réanimation, Université Paris-Saclay, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm U1018, Equipe d'Epidémiologie respiratoire intégrative, CESP, 94807, Villejuif, France
| | - Antoine Vieillard-Baron
- AP-HP, Hôpital Universitaire Ambroise-Paré, Service de Médecine Intensive Réanimation, 92100, Boulogne-Billancourt, France
- Université de Paris Saclay, INSERM UMR 1018, Clinical Epidemiology Team, CESP, Villejuif, France
| | - Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive-Réanimation, 94010, Créteil, France.
- Université Paris Est Créteil, CARMAS, 94010, Créteil, France.
- Université Paris Est Créteil, INSERM, IMRB, 94010, Créteil, France.
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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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Kryvenko V, Vadász I. Mechanisms of Hypercapnia-Induced Endoplasmic Reticulum Dysfunction. Front Physiol 2021; 12:735580. [PMID: 34867444 PMCID: PMC8640499 DOI: 10.3389/fphys.2021.735580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/27/2021] [Indexed: 01/16/2023] Open
Abstract
Protein transcription, translation, and folding occur continuously in every living cell and are essential for physiological functions. About one-third of all proteins of the cellular proteome interacts with the endoplasmic reticulum (ER). The ER is a large, dynamic cellular organelle that orchestrates synthesis, folding, and structural maturation of proteins, regulation of lipid metabolism and additionally functions as a calcium store. Recent evidence suggests that both acute and chronic hypercapnia (elevated levels of CO2) impair ER function by different mechanisms, leading to adaptive and maladaptive regulation of protein folding and maturation. In order to cope with ER stress, cells activate unfolded protein response (UPR) pathways. Initially, during the adaptive phase of ER stress, the UPR mainly functions to restore ER protein-folding homeostasis by decreasing protein synthesis and translation and by activation of ER-associated degradation (ERAD) and autophagy. However, if the initial UPR attempts for alleviating ER stress fail, a maladaptive response is triggered. In this review, we discuss the distinct mechanisms by which elevated CO2 levels affect these molecular pathways in the setting of acute and chronic pulmonary diseases associated with hypercapnia.
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Affiliation(s)
- Vitalii Kryvenko
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.,The Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - István Vadász
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.,The Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Institute for Lung Health (ILH), Giessen, Germany
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8
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Jafari D, Cohen AL, Monsieurs K, Becker LB. Changing resuscitation strategies during a pandemic: lessons from the consecutive surges in New York and global challenges. Curr Opin Crit Care 2021; 27:656-662. [PMID: 34581299 DOI: 10.1097/mcc.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW To provide a framework for resuscitation of COVID-19 critical illness for emergency and intensive care clinicians with the most up to date evidence and recommendations in the care of COVID-19 patients in cardiac arrest or in extremis. RECENT FINDINGS Performing cardiopulmonary resuscitation (CPR) on COVID-19 patients requires the clinicians to adopt infection mitigation strategies such as full personal protective equipment, mechanical chest compression devices, and restricting the number of people present during the resuscitation. The time of intubation is a subject of ongoing research and clinicians should use their best judgment for each patient. Clinicians should prepare for CPR in prone position. Particular attention should be given to the psychological well-being of the staff. Point of care ultrasound has proved to be an invaluable diagnostic tool in assessing ventricular dysfunction and parenchymal lung disease. Although novel therapies to supplant the function of diseased lungs have shown promise in select patients the evidence is still being collected. The end-of-life discussions have been negatively impacted by prognostic uncertainty as well as barriers to in person meetings with families. SUMMARY The resuscitation of critically ill COVID-19 patients poses new challenges, but the principles remain largely unchanged.
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Affiliation(s)
- Daniel Jafari
- Department of Emergency Medicine.,Department of Surgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Hofstra Northwell, Hempstead, New York, USA
| | | | - Koen Monsieurs
- Emergency Department, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
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Zhou Z, Kuang H, Ma Y, Zhang L. Application of extracorporeal therapies in critically ill COVID-19 patients. J Zhejiang Univ Sci B 2021; 22:701-717. [PMID: 34514751 PMCID: PMC8435342 DOI: 10.1631/jzus.b2100344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is a major public health event caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 has spread widely all over the world. A high proportion of patients become severely or critically ill, and suffer high mortality due to respiratory failure and multiple organ dysfunction. Therefore, providing timely and effective treatment for critically ill patients is essential to reduce overall mortality. Convalescent plasma therapy and pharmacological treatments, such as aerosol inhalation of interferon-α (IFN-α), corticosteroids, and tocilizumab, have all been applied in clinical practice; however, their effects remain controversial. Recent studies have shown that extracorporeal therapies might have a potential role in treating critically ill COVID-19 patients. In this review, we examine the application of continuous renal replacement therapy (CRRT), therapeutic plasma exchange (TPE), hemoadsorption (HA), extracorporeal membrane oxygenation (ECMO), and extracorporeal carbon dioxide removal (ECCO2R) in critically ill COVID-19 patients to provide support for the further diagnosis and treatment of COVID-19.
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Affiliation(s)
- Zhifeng Zhou
- Department of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu 610041, China.
| | - Huang Kuang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Yuexian Ma
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, China
| | - Ling Zhang
- Department of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu 610041, China.
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Allescher J, Rasch S, Wiessner JR, Perez Ruiz de Garibay A, Huberle C, Hesse F, Schulz D, Schmid RM, Huber W, Lahmer T. Extracorporeal carbon dioxide Removal (ECCO 2 R) with the Advanced Organ Support (ADVOS) system in critically ill COVID-19 patients. Artif Organs 2021; 45:1522-1532. [PMID: 34309036 PMCID: PMC8444686 DOI: 10.1111/aor.14044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/17/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022]
Abstract
Disturbed oxygenation is foremost the leading clinical presentation in COVID‐19 patients. However, a small proportion also develop carbon dioxide removal problems. The Advanced Organ Support (ADVOS) therapy (ADVITOS GmbH, Munich, Germany) uses a less invasive approach by combining extracorporeal CO2‐removal and multiple organ support for the liver and the kidneys in a single hemodialysis device. The aim of our study is to evaluate the ADVOS system as treatment option in‐COVID‐19 patients with multi‐organ failure and carbon dioxide removal problems. COVID‐19 patients suffering from severe respiratory insufficiency, receiving at least two treatments with the ADVOS multi system (ADVITOS GmbH, Munich, Germany), were eligible for study inclusion. Briefly, these included patients with acute kidney injury (AKI) according to KDIGO guidelines, and moderate or severe ARDS according to the Berlin definition, who were on invasive mechanical ventilation for more than 72 hours. In total, nine COVID‐19 patients (137 ADVOS treatment sessions with a median of 10 treatments per patient) with moderate to severe ARDS and carbon dioxide removal problems were analyzed. During the ADVOS treatments, a rapid correction of acid‐base balance and a continuous CO2 removal could be observed. We observed a median continuous CO2 removal of 49.2 mL/min (IQR: 26.9‐72.3 mL/min) with some treatments achieving up to 160 mL/min. The CO2 removal significantly correlated with blood flow (Pearson 0.421; P < .001), PaCO2 (0.341, P < .001) and HCO3‐ levels (0.568, P < .001) at the start of the treatment. The continuous treatment led to a significant reduction in PaCO2 from baseline to the last ADVOS treatment. In conclusion, it was feasible to remove CO2 using the ADVOS system in our cohort of COVID‐19 patients with acute respiratory distress syndrome and multiorgan failure. This efficient removal of CO2 was achieved at blood flows up to 300 mL/min using a conventional hemodialysis catheter and without a membrane lung or a gas phase.
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Affiliation(s)
- Julia Allescher
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Sebastian Rasch
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Johannes R Wiessner
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | | | - Christina Huberle
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Felix Hesse
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Dominik Schulz
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Wolfgang Huber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
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11
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Robba C, Ball L, Battaglini D, Cardim D, Moncalvo E, Brunetti I, Bassetti M, Giacobbe DR, Vena A, Patroniti N, Rocco PRM, Matta BF, Pelosi P. Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study. Crit Care 2021; 25:111. [PMID: 33741052 PMCID: PMC7978164 DOI: 10.1186/s13054-021-03537-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics. METHODS This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients. RESULTS Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57-69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51-54]% vs. 49 [47-50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56-71] to 82 [76-87] mmHg, p = 0.005) and rSO2 (from 53 [52-54]% to 60 [59-64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67-73] to 72 [67-73] mmHg, p = 0.015) and rSO2 (from 53 [51-56]% to 57 [55-59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75-79] to 64 [60-70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56-65]% vs. 56 [53-62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001). CONCLUSIONS Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Denise Battaglini
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas, Austin, USA
| | - Emanuela Moncalvo
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Iole Brunetti
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa , Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Daniele R. Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa , Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicolò Patroniti
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Basil F. Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
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Kryvenko V, Vadász I. Molecular mechanisms of Na,K-ATPase dysregulation driving alveolar epithelial barrier failure in severe COVID-19. Am J Physiol Lung Cell Mol Physiol 2021; 320:L1186-L1193. [PMID: 33689516 PMCID: PMC8238442 DOI: 10.1152/ajplung.00056.2021] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A significant number of patients with coronavirus disease 2019 (COVID-19) develop acute respiratory distress syndrome (ARDS) that is associated with a poor outcome. The molecular mechanisms driving failure of the alveolar barrier upon severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remain incompletely understood. The Na,K-ATPase is an adhesion molecule and a plasma membrane transporter that is critically required for proper alveolar epithelial function by both promoting barrier integrity and resolution of excess alveolar fluid, thus enabling appropriate gas exchange. However, numerous SARS-CoV-2-mediated and COVID-19-related signals directly or indirectly impair the function of the Na,K-ATPase, thereby potentially contributing to disease progression. In this Perspective, we highlight some of the putative mechanisms of SARS-CoV-2-driven dysfunction of the Na,K-ATPase, focusing on expression, maturation, and trafficking of the transporter. A therapeutic mean to selectively inhibit the maladaptive signals that impair the Na,K-ATPase upon SARS-CoV-2 infection might be effective in reestablishing the alveolar epithelial barrier and promoting alveolar fluid clearance and thus advantageous in patients with COVID-19-associated ARDS.
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Affiliation(s)
- Vitalii Kryvenko
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.,The Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - István Vadász
- Department of Internal Medicine, Justus Liebig University, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.,The Cardio-Pulmonary Institute (CPI), Giessen, Germany
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