Abstract
BackgroundLung-protective strategies are the cornerstone of mechanical ventilation in critically ill patients with both ARDS and other disorders. Extracorporeal CO2 removal (ECCO2R) may enhance lung protection by allowing even further reductions in tidal volumes and is effective in low-flow settings commonly used for renal replacement therapy. In this study, we describe for the first time the effects of a labeled and certified system combining ECCO2R and renal replacement therapy on pulmonary stress and strain in hypercapnic patients with renal failure.MethodsTwenty patients were treated with the combined system which incorporates a membrane lung (0.32 m2) in a conventional renal replacement circuit. After changes in blood gases under ECCO2R were recorded, baseline hypercapnia was reestablished and the impact on ventilation parameters such as tidal volume and driving pressure was recorded.ResultsThe system delivered ECCO2R at rate of 43.4 ± 14.1 ml/min, PaCO2 decreased from 68.3 ± 11.8 to 61.8 ± 11.5 mmHg (p < 0.05) and pH increased from 7.18 ± 0.09 to 7.22 ± 0.08 (p < 0.05). There was a significant reduction in ventilation requirements with a decrease in tidal volume from 6.2 ± 0.9 to 5.4 ± 1.1 ml/kg PBW (p < 0.05) corresponding to a decrease in plateau pressure from 30.6 ± 4.6 to 27.7 ± 4.1 cmH2O (p < 0.05) and a decrease in driving pressure from 18.3 ± 4.3 to 15.6 ± 3.9 cmH2O (p < 0.05), indicating reduced pulmonary stress and strain. No complications related to the procedure were observed.ConclusionsThe investigated low-flow ECCO2R and renal replacement system can ameliorate respiratory acidosis and decrease ventilation requirements in hypercapnic patients with concomitant renal failure.Trial registration NCT02590575, registered 10/23/2015.
Highlights
Lung-protective strategies are the cornerstone of mechanical ventilation in critically ill patients with both acute respiratory distress syndrome (ARDS) and other disorders
We describe for the first time the effectiveness of a commercially available combination of extracorporeal CO2 removal (ECCO2R) and continuous renal replacement therapy (CRRT) regarding decarboxylation and ventilation as well as other clinical parameters
Using a standardized protocol of ventilation based on current ARDS Network recommendations, we were able to demonstrate that the investigated combination therapy was able to ameliorate respiratory acidosis and effectively reduce the invasiveness of mechanical ventilation in hypercapnic critically ill patients while providing efficient renal replacement therapy and exhibiting a positive effect on hemodynamics in terms of vasopressor requirements
Summary
Lung-protective strategies are the cornerstone of mechanical ventilation in critically ill patients with both ARDS and other disorders. Whereas low tidal volume ventilation has been shown to reduce pulmonary inflammation and mortality, it is often accompanied by hypercapnic acidosis, which will even be more pronounced under “ultra-protective” ventilation strategies. Many patients with ARDS present with multi-organ failure, e.g., due to septic shock, and exhibit massive metabolic acidosis in combination with severe cardiovascular instability. This may further limit the concept of permissive hypercapnia since an additional decrease in pH may be considered unsafe in such patients. This problem is even more pronounced when aiming for an additional reduction in the invasiveness of mechanical ventilation by further reducing tidal volumes
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