Abstract
Coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS) is associated with high mortality. Lung-protective ventilation is the current standard of care in patients with ARDS, but it might lead to hypercapnia, which is independently associated with worse outcomes. Extracorporeal carbon dioxide removal (ECCO2R) has been proposed as an adjuvant therapy to avoid progression of clinical severity and limit further ventilator-induced lung injury, but its use in COVID-19 has not been described yet. Acute kidney injury requiring renal replacement therapy (RRT) is common among critically ill COVID-19 patients. In centers with available dialysis, low-flow ECCO2R (<500 mL/min) using RRT platforms could be carried out by dialysis specialists and might be an option to efficiently allocate resources during the COVID-19 pandemic for patients with hypercapnia as the main indication. Here, we report the feasibility, safety, and efficacy of ECCO2R using an RRT platform to provide either standalone ECCO2R or ECCO2R combined with RRT in four hypercapnic patients with moderate ARDS. A randomized clinical trial is required to assess the overall benefit and harm.Clinical Trial Registration: ClinicalTrials.gov. Unique identifier: NCT04351906.
Highlights
The percentages of coronavirus disease 2019 (COVID-19) patients diagnosed with acute respiratory distress syndrome (ARDS) range between 20 and 67% of hospitalized patients [1, 2] and 100% of mechanically ventilated patients [3] and are associated with high mortality [2]
For extracorporeal CO2 removal (ECCO2R) + continuous RRT (CRRT), the multiFiltrate was set in continuous venovenous hemodialysis (CVVHD) mode, and the multiECCO2R was inserted in series after the hemofilter (Ultraflux AV 1000S, Fresenius Medical Care, Bad Homburg, Germany)
Patient 4 developed combined respiratory and metabolic acidosis secondary to hypercapnia and Acute kidney injury (AKI), and ECCO2R + CRRT was commenced with a blood-flow rate of 200 mL/min, leading to a decrease of PaCO2 from 58.7 to 46.5 mmHg within 1 h while pH and bicarbonate levels progressively increased
Summary
The percentages of coronavirus disease 2019 (COVID-19) patients diagnosed with acute respiratory distress syndrome (ARDS) range between 20 and 67% of hospitalized patients [1, 2] and 100% of mechanically ventilated patients [3] and are associated with high mortality [2]. Lung-protective ventilation is the current standard of care for ARDS [4], which limits ventilator-induced lung injury but may lead to elevated carbon dioxide (CO2) levels and respiratory acidosis, which are independently associated with worse outcomes in the setting of ARDS [5, 6]. In these patients, extracorporeal CO2 removal (ECCO2R) may help to avoid the progression of clinical severity [5]. The use of ECCO2R has not been described so far in COVID-19associated ARDS
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