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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Trepatchayakorn S, Chaijitraruch N, Chongsrisawat V, Chanakul A, Kongkiattikul L, Samransamruajkit R. Therapeutic Plasma Exchange with Continuous Renal Replacement Therapy for Pediatric Acute Liver Failure: A Case Series from Thailand. Indian J Crit Care Med 2021; 25:812-816. [PMID: 34316178 PMCID: PMC8286369 DOI: 10.5005/jp-journals-10071-23896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective Pediatric acute liver failure (PALF) is a life-threatening condition. Extracorporeal support has been applied for toxic metabolite clearance and serves as a bridging therapy to liver transplantation (LT) or to the regeneration of the liver, but evidence for treatment approaches is still lacking in the pediatric population. We aim to report our experience on therapeutic plasma exchange with high-volume continuous renal replacement therapy (TPE + HV-CRRT) as a promising supportive treatment for PALF. Materials and methods A total of eight PALF cases aged 9 months to 14 years, weighing 10–50 kg., who were admitted to PICU King Chulalongkorn Memorial Hospital, Thailand and treated with TPE + HV-CRRT from January 2016 to September 2019 were reviewed. Patient demographic data, indications, technical aspects, and clinical outcomes were recorded. Results All patients who underwent TPE + HV-CRRT showed clinical improvement regarding serum bilirubin levels and coagulation studies after the therapy. Complications from the therapy were hemodynamic instability, symptomatic fluid overload, and bleeding from catheter sites. Among these, 6 (75%) patients survived with 4 (50%) successful LTs and 2 (25%) spontaneous recovery. Two children (25%) died while on the transplantation list. Conclusion TPE + HV-CRRT can be used safely as a bridging therapy in children with PALF. As opposed to the adult population, higher volume of TPE or higher blood flow rate in pediatric patients might associate with hemodynamic instability during the procedure. How to cite this article Trepatchayakorn S, Chaijitraruch N, Chongsrisawat V, Chanakul A, Kongkiattikul L, Samransamruajkit R. Therapeutic Plasma Exchange with Continuous Renal Replacement Therapy for Pediatric Acute Liver Failure: A Case Series from Thailand. Indian J Crit Care Med 2021;25(7):812–816.
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Affiliation(s)
| | | | | | - Ankanee Chanakul
- Department of Pediatrics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Lalida Kongkiattikul
- Department of Pediatrics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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David S, Thamm K, Schmidt BMW, Falk CS, Kielstein JT. Effect of extracorporeal cytokine removal on vascular barrier function in a septic shock patient. J Intensive Care 2017; 5:12. [PMID: 28127437 PMCID: PMC5251288 DOI: 10.1186/s40560-017-0208-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sepsis and septic shock are major healthcare problems, affecting millions of individuals around the world each year. Pathophysiologically, septic multiple organ dysfunction (MOD) is a life-threatening condition caused by an overwhelming systemic inflammatory response of the host's organism to an infection. We experimentally tested if high circulating cytokine levels might increase vascular permeability-a critical hallmark of the disease-and if this phenomenon can be reversed by therapeutic cytokine removal (CytoSorb®) in an exemplary patient. CASE PRESENTATION A 32-year-old Caucasian female presented with septic shock and accompanying acute kidney injury (Sequential Organ Failure Assessment (SOFA) = 18) to our ICU. In spite of a broad anti-infective regimen, adequate fluid resuscitation, and high doses of inotropics and catecholamines, she remained refractory hypotensive. The extraordinary severity of septic shock suggested an immense overwhelming host response assumingly accompanied by a notable cytokine storm such as known from patients with toxic shock syndrome. Thus, a CytoSorb® filter was added to the dialysis circuit to remove excess shock-perpetuating cytokines. To analyze the endothelial phenotype in vitro before and after extracorporeal cytokine removal, we tested the septic shock patient's serum on human umbilical vein endothelial cells (HUVECs). The effect on endothelial integrity was assessed both on the morphological (fluorescent immunocytochemistry for VE-cadherin and F-actin) and functional (transendothelial electrical resistance (TER)) level that was recorded in real time with an "electric cell-substrate impedance sensing" (ECIS) system (ibidi). We found (1) severe alterations of cell-cell contacts and the cytoskeletal architecture and (2) profound functional permeability changes, the putative cellular correlate of the clinical vascular leakage syndrome. However, the endothelial barrier was protected from these profound adverse effects when HUVECs were challenged with septic shock serum that was collected after extracorporeal cytokine removal. CONCLUSIONS Beneficial observations of extracorporeal cytokine removal in septic shock patients might-at least in part-be promoted via protection of vascular barrier function.
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Affiliation(s)
- Sascha David
- Department of Medicine, Division of Nephrology & Hypertension, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Kristina Thamm
- Department of Medicine, Division of Nephrology & Hypertension, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Medicine, Division of Nephrology & Hypertension, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Christine S Falk
- Institute of Transplant Immunology, IFB-Tx, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Jan T Kielstein
- Department of Medicine, Division of Nephrology & Hypertension, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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