Low-flow CO2 removal integrated into a renal-replacement circuit can reduce acidosis and decrease vasopressor requirements

Critical Care

Carsten Willam¹  Kai-Uwe Eckardt¹  Stefan John¹  Jens Schriewer¹  Christian Forster¹ 

[1] Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nuremberg, Ulmenweg 18, Erlangen, 91054, Germany

关键词: Renal-replacement therapy;    AKI;    ARDS;    Low-flow CO₂ removal;    Lung-protective ventilation;   

Others  :  817992
DOI  :  10.1186/cc12833

 received in 2013-03-22, accepted in 2013-07-09,  发布年份 2013

【 摘 要 】

Introduction

Lung-protective ventilation in patients with ARDS and multiorgan failure, including renal failure, is often paralleled with a combined respiratory and metabolic acidosis. We assessed the effectiveness of a hollow-fiber gas exchanger integrated into a conventional renal-replacement circuit on CO₂ removal, acidosis, and hemodynamics.

Methods

In ten ventilated critically ill patients with ARDS and AKI undergoing renal- and respiratory-replacement therapy, effects of low-flow CO₂ removal on respiratory acidosis compensation were tested by using a hollow-fiber gas exchanger added to the renal-replacement circuit. This was an observational study on safety, CO₂-removal capacity, effects on pH, ventilator settings, and hemodynamics.

Results

CO₂ elimination in the low-flow circuit was safe and was well tolerated by all patients. After 4 hours of treatment, a mean reduction of 17.3 mm Hg (−28.1%) pCO₂ was observed, in line with an increase in pH. In hemodynamically instable patients, low-flow CO₂ elimination was paralleled by hemodynamic improvement, with an average reduction of vasopressors of 65% in five of six catecholamine-dependent patients during the first 24 hours.

Conclusions

Because no further catheters are needed, besides those for renal replacement, the implementation of a hollow-fiber gas exchanger in a renal circuit could be an attractive therapeutic tool with only a little additional trauma for patients with mild to moderate ARDS undergoing invasive ventilation with concomitant respiratory acidosis, as long as no severe oxygenation defects indicate ECMO therapy.

【 授权许可】

   
2013 Forster et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Malhotra A: Low-tidal-volume ventilation in the acute respiratory distress syndrome. N Engl J Med 2007, 357:1113-1120.
• [2]Walkey AJ, Summer R, Ho V, Alkana P: Acute respiratory distress syndrome: epidemiology and management approaches. J Clin Epidemiol 2012, 4:159-169.
• [3]Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, Kairalla RA, Deheinzelin D, Munoz C, Oliveira R, Takagaki TY, Carvalho CR: Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998, 338(6):347-354.
• [4]O’Croinin D, Ni Chonghaile M, Higgins B, Laffey JG: Bench-to-bedside review: permissive hypercapnia. Crit Care 2005, 9:51-59.
• [5]Curley G, Contreras MM, Nichol AD, Higgins BD, Laffey JG: Hypercapnia and acidosis in sepsis: a double-edged sword? Anesthesiology 2010, 112:462-472.
• [6]Ijland MM, Heunks LM, van der Hoeven JG: Bench-to-bedside review: hypercapnic acidosis in lung injury–from “permissive” to”therapeutic. Crit Care 2010, 14:237.
• [7]Ismaiel NM, Henzler D: Effects of hypercapnia and hypercapnic acidosis on attenuation of ventilator-associated lung injury. Minerva Anestesiol 2011, 77:723-733.
• [8]Sidebotham D, McGeorge A, McGuinness S, Edwards M, Willcox T, Beca J: Extracorporeal membrane oxygenation for treating severe cardiac and respiratory failure in adults: part 2, technical considerations. J Cardiothorac Vasc Anesth 2010, 24:164-172.
• [9]Allen S, Holena D, McCunn M, Kohl B, Sarani B: A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ECMO) in critically ill adult patients. J Intensive Care Med 2011, 26:13-26.
• [10]Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, et al.: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009, 374:1351-1363.
• [11]Bein T, Zimmermann M, Hergeth K, Ramming M, Rupprecht L, Schlitt HJ, Slutsky AS: Pumpless extracorporeal removal of carbon dioxide combined with ventilation using low tidal volume and high positive end-expiratory pressure in a patient with severe acute respiratory distress syndrome. Anaesthesia 2009, 64:195-198.
• [12]Zimmermann M, Bein T, Arlt M, Philipp A, Rupprecht L, Mueller T, Lubnow M, Graf BM, Schlitt HJ: Pumpless extracorporeal interventional lung assist in patients with acute respiratory distress syndrome: a prospective pilot study. Crit Care 2009, 13:R10. BioMed Central Full Text
• [13]Bein T, Weber-Carstens S, Goldmann A, Muller T, Staudinger T, Brederlau J, Muellenbach R, Dembinski R, Graf BM, Wewalka M, et al.: Lower tidal volume strategy (approximately 3 ml/kg) combined with extracorporeal CO2 removal versus”conventional” protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent study. Intensive Care Med 2013, 39:847-856.
• [14]Esteban A, Alia I, Gordo F, de Pablo R, Suarez J, Gonzalez G, Blanco J: Prospective randomized trial comparing pressure-controlled ventilation and volume-controlled ventilation in ARDS, for the Spanish Lung Failure Collaborative Group. Chest 2000, 117:1690-1696.
• [15]Liu KD, Matthay MA: Advances in critical care for the nephrologist: acute lung injury/ARDS. Clin J Am Soc Nephrol 2008, 3:578-586.
• [16]Gattinoni L, Kolobow T, Tomlinson T, Iapichino G, Samaja M, White D, Pierce J: Low-frequency positive pressure ventilation with extracorporeal carbon dioxide removal (LFPPV-ECCO2R): an experimental study. Anesth Analg 1978, 57:470-477.
• [17]Young JD, Dorrington KL, Blake GJ, Ryder WA: Femoral arteriovenous extracorporeal carbon dioxide elimination using low blood flow. Crit Care Med 1992, 20:805-809.
• [18]Livigni S, Maio M, Ferretti E, Longobardo A, Potenza R, Rivalta L, Selvaggi P, Vergano M, Bertolini G: Efficacy and safety of a low-flow veno-venous carbon dioxide removal device: results of an experimental study in adult sheep. Crit Care 2006, 10:R151. BioMed Central Full Text
• [19]Batchinsky AI, Jordan BS, Regn D, Necsoiu C, Federspiel WJ, Morris MJ, Cancio LC: Respiratory dialysis: reduction in dependence on mechanical ventilation by venovenous extracorporeal CO2 removal. Crit Care Med 2011, 39:1382-1387.
• [20]Ruberto F, Pugliese F, D’Alio A, Perrella S, D’Auria B, Ianni S, Anile M, Venuta F, Coloni GF, Pietropaoli P: Extracorporeal removal CO2 using a venovenous, low-flow system (Decapsmart) in a lung transplanted patient: a case report. Transplant Proc 2009, 41:1412-1414.
• [21]Iacovazzi M, Oreste N, Sardelli P, Barrettara B, Grasso S: Extracorporeal carbon dioxide removal for additional pulmonary resection after pneumonectomy. Minerva Anestesiol 2012, 78:381-384.
• [22]Moscatelli A, Ottonello G, Nahum L, Lampugnani E, Puncuh F, Simonini A, Tumolo M, Tuo P: Noninvasive ventilation and low-flow veno-venous extracorporeal carbon dioxide removal as a bridge to lung transplantation in a child with refractory hypercapnic respiratory failure due to bronchiolitis obliterans. Pediatr Crit Care Med 2010, 11:e8-e12.
• [23]Gramaticopolo S, Chronopoulos A, Piccinni P, Nalesso F, Brendolan A, Zanella M, Cruz DN, Ronco C: Extracorporeal CO2 removal: a way to achieve ultraprotective mechanical ventilation and lung support: the missing piece of multiple organ support therapy. Contrib Nephrol 2010, 165:174-184.
• [24]Terragni PP, Del Sorbo L, Mascia L, Urbino R, Martin EL, Birocco A, Faggiano C, Quintel M, Gattinoni L, Ranieri VM: Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Anesthesiology 2009, 111:826-835.