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dos Santos YDAP, Cardozo LCM, Mendes PV, Besen BAMP, Park M. Factors associated with carbon dioxide transfer in an experimental model of severe acute kidney injury and hypoventilation during high bicarbonate continuous renal replacement therapy and oxygenation membrane support. CRITICAL CARE SCIENCE 2024; 36:e20240005en. [PMID: 38985048 PMCID: PMC11208041 DOI: 10.62675/2965-2774.20240005-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/26/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE To investigate the factors influencing carbon dioxide transfer in a system that integrates an oxygenation membrane in series with high-bicarbonate continuous veno-venous hemodialysis in hypercapnic animals. METHODS In an experimental setting, we induced severe acute kidney injury and hypercapnia in five female Landrace pigs. Subsequently, we initiated high (40mEq/L) bicarbonate continuous veno-venous hemodialysis with an oxygenation membrane in series to maintain a pH above 7.25. At intervals of 1 hour, 6 hours, and 12 hours following the initiation of continuous veno-venous hemodialysis, we performed standardized sweep gas flow titration to quantify carbon dioxide transfer. We evaluated factors associated with carbon dioxide transfer through the membrane lung with a mixed linear model. RESULTS A total of 20 sweep gas flow titration procedures were conducted, yielding 84 measurements of carbon dioxide transfer. Multivariate analysis revealed associations among the following (coefficients ± standard errors): core temperature (+7.8 ± 1.6 °C, p < 0.001), premembrane partial pressure of carbon dioxide (+0.2 ± 0.1/mmHg, p < 0.001), hemoglobin level (+3.5 ± 0.6/g/dL, p < 0.001), sweep gas flow (+6.2 ± 0.2/L/minute, p < 0.001), and arterial oxygen saturation (-0.5 ± 0.2%, p = 0.019). Among these variables, and within the physiological ranges evaluated, sweep gas flow was the primary modifiable factor influencing the efficacy of low-blood-flow carbon dioxide removal. CONCLUSION Sweep gas flow is the main carbon dioxide removal-related variable during continuous veno-venous hemodialysis with a high bicarbonate level coupled with an oxygenator. Other carbon dioxide transfer modulating variables included the hemoglobin level, arterial oxygen saturation, partial pressure of carbon dioxide and core temperature. These results should be interpreted as exploratory to inform other well-designed experimental or clinical studies.
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Affiliation(s)
- Yuri de Albuquerque Pessoa dos Santos
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Luis Carlos Maia Cardozo
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Pedro Vitale Mendes
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Bruno Adler Maccagnan Pinheiro Besen
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Marcelo Park
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrazilMedical Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
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Müller MC, Wilke SK, Dobbermann A, Kirsten S, Ruß M, Weber-Carstens S, Wollersheim T. Dissolved Oxygen Relevantly Contributes to Systemic Oxygenation During Venovenous Extracorporeal Membrane Oxygenation Support. ASAIO J 2024:00002480-990000000-00430. [PMID: 38446867 DOI: 10.1097/mat.0000000000002171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
When determining extracorporeal oxygen transfer (V ML O 2 ) during venovenous extracorporeal membrane oxygenation (VV ECMO) dissolved oxygen is often considered to play a subordinate role due to its poor solubility in blood plasma. This study was designed to assess the impact of dissolved oxygen on systemic oxygenation in patients with acute respiratory distress syndrome (ARDS) on VV ECMO support by differentiating between dissolved and hemoglobin-bound extracorporeal oxygen transfer. We calculated both extracorporeal oxygen transfer based on blood gas analysis using the measuring energy expenditure in extracorporeal lung support patients (MEEP) protocol and measured oxygen uptake by the native lung with indirect calorimetry. Over 20% of V ML O 2 and over 10% of overall oxygen uptake (VO 2 total ) were realized as dissolved oxygen. The transfer of dissolved oxygen mainly depended on ECMO blood flow (BF ML ). In patients with severely impaired lung function dissolved oxygen accounted for up to 28% of VO 2 total . A clinically relevant amount of oxygen is transferred as physically dissolved fraction, which therefore needs to be considered when determining membrane lung function, manage ECMO settings or guiding the weaning procedure.
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Affiliation(s)
- Michael C Müller
- From the Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
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Melro LMG, dos Santos YDAP, Cardozo Júnior LCM, Besen BAMP, Zigaib R, Forte DN, Mendes PV, Park M. Exploring the association of two oxygenators in parallel or in series during respiratory support using extracorporeal membrane oxygenation. Rev Bras Ter Intensiva 2022; 34:402-409. [PMID: 36888819 PMCID: PMC9987005 DOI: 10.5935/0103-507x.20220299-en] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/10/2022] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVE To characterize the pressures, resistances, oxygenation, and decarboxylation efficacy of two oxygenators associated in series or in parallel during venous-venous extracorporeal membrane oxygenation support. METHODS Using the results of a swine severe respiratory failure associated with multiple organ dysfunction venous-venous extracorporeal membrane oxygenation support model and mathematical modeling, we explored the effects on oxygenation, decarboxylation and circuit pressures of in-parallel and in-series associations of oxygenators. RESULTS Five animals with a median weight of 80kg were tested. Both configurations increased the oxygen partial pressure after the oxygenators. The return cannula oxygen content was also slightly higher, but the impact on systemic oxygenation was minimal using oxygenators with a high rated flow (~ 7L/minute). Both configurations significantly reduced the systemic carbon dioxide partial pressure. As the extracorporeal membrane oxygenation blood flow increased, the oxygenator resistance decreased initially with a further increase with higher blood flows but with a small clinical impact. CONCLUSION Association of oxygenators in parallel or in series during venous-venous extracorporeal membrane oxygenation support provides a modest increase in carbon dioxide partial pressure removal with a slight improvement in oxygenation. The effect of oxygenator associations on extracorporeal circuit pressures is minimal.
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Affiliation(s)
| | - Yuri de Albuquerque Pessoa dos Santos
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Luis Carlos Maia Cardozo Júnior
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | | | - Rogério Zigaib
- Intensive Care Unit, Hospital Samaritano Paulista - São Paulo (SP),
Brazil
| | - Daniel Neves Forte
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Pedro Vitale Mendes
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Marcelo Park
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
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Melro LMG, dos Santos YDAP, Cardozo Júnior LCM, Besen BAMP, Zigaib R, Forte DN, Mendes PV, Park M. Exploring the association of two oxygenators in parallel or in series during respiratory support using extracorporeal membrane oxygenation. Rev Bras Ter Intensiva 2022; 34:402-409. [PMID: 36888819 PMCID: PMC9987005 DOI: 10.5935/0103-507x.20220299-pt] [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: 08/26/2022] [Accepted: 10/10/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To characterize the pressures, resistances, oxygenation, and decarboxylation efficacy of two oxygenators associated in series or in parallel during venous-venous extracorporeal membrane oxygenation support. METHODS Using the results of a swine severe respiratory failure associated with multiple organ dysfunction venous-venous extracorporeal membrane oxygenation support model and mathematical modeling, we explored the effects on oxygenation, decarboxylation and circuit pressures of in-parallel and in-series associations of oxygenators. RESULTS Five animals with a median weight of 80kg were tested. Both configurations increased the oxygen partial pressure after the oxygenators. The return cannula oxygen content was also slightly higher, but the impact on systemic oxygenation was minimal using oxygenators with a high rated flow (~ 7L/minute). Both configurations significantly reduced the systemic carbon dioxide partial pressure. As the extracorporeal membrane oxygenation blood flow increased, the oxygenator resistance decreased initially with a further increase with higher blood flows but with a small clinical impact. CONCLUSION Association of oxygenators in parallel or in series during venous-venous extracorporeal membrane oxygenation support provides a modest increase in carbon dioxide partial pressure removal with a slight improvement in oxygenation. The effect of oxygenator associations on extracorporeal circuit pressures is minimal.
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Affiliation(s)
| | - Yuri de Albuquerque Pessoa dos Santos
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Luis Carlos Maia Cardozo Júnior
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | | | - Rogério Zigaib
- Intensive Care Unit, Hospital Samaritano Paulista - São Paulo (SP),
Brazil
| | - Daniel Neves Forte
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Pedro Vitale Mendes
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Marcelo Park
- Intensive Care Unit, Discipline of Clinical Emergencies, Hospital
das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
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Andrei S, Nguyen M, Berthoud V, Durand B, Duclos V, Morgant MC, Bouchot O, Bouhemad B, Guinot PG. Determinants of Arterial Pressure of Oxygen and Carbon Dioxide in Patients Supported by Veno-Arterial ECMO. J Clin Med 2022; 11:jcm11175228. [PMID: 36079158 PMCID: PMC9457238 DOI: 10.3390/jcm11175228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The present study aimed to assess the determinants of arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2) in the early phase of veno-arterial extracorporeal membrane oxygenation (VA ECMO) support. Even though the guidelines considered both the risks of hypoxemia and hyperoxemia during ECMO support, there are a lack of data concerning the patients supported by VA ECMO. Methods: This is a retrospective, monocentric, observational cohort study in a university-affiliated cardiac intensive care unit. Hemodynamic parameters, ECMO parameters, ventilator settings, and blood gas analyses were collected at several time points during the first 48 h of VA ECMO support. For each timepoint, the blood samples were drawn simultaneously from the right radial artery catheter, VA ECMO venous line (before the oxygenator), and from VA ECMO arterial line (after the oxygenator). Univariate followed by multivariate mixed-model analyses were performed for longitudinal data analyses. Results: Forty-five patients with femoro-femoral peripheral VA ECMO were included. In multivariate analysis, the patients' PaO2 was independently associated with QEC, FDO2, and time of measurement. The patients' PaCO2 was associated with the sweep rate flow and the PpreCO2. Conclusions: During acute VA ECMO support, the main determinants of patient oxygenation are determined by VA ECMO parameters.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
- Correspondence: ; Tel.: +33-38-029-3031
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | - Bastian Durand
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | - Valerian Duclos
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | | | - Olivier Bouchot
- Cardiac Surgery Department, Dijon University Hospital, F-21000 Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
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Control for Carbon Dioxide Exchange Process in a Membrane Oxygenator Using Online Self-Tuning Fuzzy-PID Controller. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Veiga VC, Silva LMCJ, Sady ERR, Fernandes PV, Rojas SSO. Apnea test for the diagnosis of brain death in a patient undergoing extracorporeal membrane oxygenation. Rev Bras Ter Intensiva 2020; 32:468-473. [PMID: 33053038 PMCID: PMC7595728 DOI: 10.5935/0103-507x.20200077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/10/2020] [Indexed: 11/20/2022] Open
Abstract
Extracorporeal membrane oxygenation is used as extracirculatory support for the care of patients with severe and reversible cardiac and/or respiratory failure. Neurological complications may be related to the procedure. Given the unfavorable neurological evolution and the need to perform a brain death protocol, the performance of an apnea test in this context remains a challenge. We report the use of an apnea test for the diagnosis of brain death post-cardiac surgery in a patient receiving venoarterial extracorporeal membrane oxygenation.
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Affiliation(s)
- Viviane Cordeiro Veiga
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
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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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Romano TG, Mendes PV, Park M, Costa ELV. Extracorporeal respiratory support in adult patients. J Bras Pneumol 2017; 43:60-70. [PMID: 28380189 PMCID: PMC5790677 DOI: 10.1590/s1806-37562016000000299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/05/2017] [Indexed: 01/19/2023] Open
Abstract
In patients with severe respiratory failure, either hypoxemic or hypercapnic, life support with mechanical ventilation alone can be insufficient to meet their needs, especially if one tries to avoid ventilator settings that can cause injury to the lungs. In those patients, extracorporeal membrane oxygenation (ECMO), which is also very effective in removing carbon dioxide from the blood, can provide life support, allowing the application of protective lung ventilation. In this review article, we aim to explore some of the most relevant aspects of using ECMO for respiratory support. We discuss the history of respiratory support using ECMO in adults, as well as the clinical evidence; costs; indications; installation of the equipment; ventilator settings; daily care of the patient and the system; common troubleshooting; weaning; and discontinuation.
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Affiliation(s)
- Thiago Gomes Romano
- . Disciplina de Nefrologia, Faculdade de Medicina do ABC, Santo André (SP) Brasil.,. Hospital Sírio-Libanês, São Paulo (SP) Brasil
| | - Pedro Vitale Mendes
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.,. Hospital Sírio-Libanês, São Paulo (SP) Brasil
| | - Marcelo Park
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Eduardo Leite Vieira Costa
- . Hospital Sírio-Libanês, São Paulo (SP) Brasil.,. UTI Respiratória, Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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