EXTRA-CORPOREAL CARBON DIOXIDE REMOVAL IN COVID-19 ARDS

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Management of Acute Respiratory Distress Syndrome (ARDS) involves lung-protective mechanical ventilation with an emphasis on low pressure and low tidal volume ventilation(LTVV). Permissive hypercapnia is a known consequence of LTVV, the progression of which can lead to hemodynamic instability and death. Management of hypercapnia in such cases may require ventilator settings which may exceed known lung protective strategies. The incidence of ARDS in SARS-coV-2 is approximately 30% which has increased emphasis on ventilator management. Extracorporeal carbon dioxide removal (ECCO2R) utilizes a gas exchange membrane to remove carbon dioxide from the blood and control hypercapnia while still allowing lung-protective mechanical ventilation. We report the first case of ECCO2R safely and successfully utilized to manage life-threatening hypercapnia in severe ARDS related to COVID-19. CASE PRESENTATION: A 57-year-old male with a history of hypertension presented to our hospital with severe ARDS secondary to COVID19. He was intubated at an outside institution 7 days prior and transferred for management of refractory hypercapnia. ABG revealed pH:6.9, CO2:188 mmHg,O2:93 on 100% FiO2. ECCO2R was emergently initiated using a 15.5 Fr catheter in the right internal jugular vein. The sweep was initially set at 3L/min, the blood flow at 500ml/min. Repeat ABG improved to a pH of 7.17 and CO2 of 80mmHg. Ventilator requirements were weaned to achieve acceptable pressures (Pressure control: pressure support:5, PEEP:18). His pH and pCO2 gradually normalized. On day 5, ABG showed a pH:7.27, CO2:55 sweep was turned to 0 and he was able to maintain a pCO2 of 52 for 24 hours, after which a decision was made to decannulate. His hospital course was prolonged due to hypoxemic respiratory failure, transient renal failure requiring dialysis, and difficulty with sedation. A tracheostomy was performed on day 31. The patient was successfully weaned off the ventilator on day 37 and discharged home after 41 days in the ICU. DISCUSSION: ECCO2R has been utilized in ARDS to facilitate “ultra-low” volume mechanical ventilation in cases with refractory respiratory acidosis and facilitate weaning from assisted mechanical ventilation. This case demonstrates the successful utilization of ECCO2R in a patient with COVID19. Despite significantly elevated d-dimer levels the patient did not experience complications related to circuit thrombosis or bleeding and was maintained on full-dose anticoagulation throughout his hospital stay. CONCLUSIONS: This case highlights the use of ECCO2R in severe ARDS and refractory hypercapnia related to COVID19. ECCO2R may be more advantageous and an acceptable alternative in comparison to other rescue modalities in this population. Future studies are required to further investigate its safety and efficacy. Reference #1: 19 Registry. COVID. https://sccmcovid19.org/. Published May 30, 2020. Accessed May 30, 2020 Reference #2: Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications [published online ahead of print, 2020 Mar 10]. Perfusion. 2020;267659120906048. doi:10.1177/0267659120906048 Reference #3: Jacobs JP, Stammers AH, St Louis J, et al. Extracorporeal Membrane Oxygenation in the Treatment of Severe Pulmonary and Cardiac Compromise in COVID-19: Experience with 32 patients [published online ahead of print, 2020 Apr 17]. ASAIO J. 2020;10.1097/MAT.0000000000001185. doi:10.1097/MAT.0000000000001185 DISCLOSURES: No relevant relationships by Sukhmani Boparai, source=Web Response Scientific Medical Advisor relationship with ALung Technologies, Inc. Please note: $5001 - $20000 Added 06/01/2020 by Steven Conrad, source=Web Response, value=Consulting fee No relevant relationships by Nasim Motayar, source=Web Response No relevant relationships by L. Keith Scott, source=Web Response