Abstract
IntroductionLung-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.MethodsIn 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.ResultsCO2 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.ConclusionsBecause 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.
Highlights
Lung-protective ventilation in patients with ARDS and multiorgan failure, including renal failure, is often paralleled with a combined respiratory and metabolic acidosis
These ventilation specifications often lead to respiratory acidosis, the concept of permissive hypercapnia and concomitant acidosis is presently widely
Whereas evidence has been provided for immunologic, redox, and vasoactive protective effects, acidosis has been associated with higher hemodynamic instability [4,5,6,7]
Summary
Lung-protective ventilation in patients with ARDS and multiorgan failure, including renal failure, is often paralleled with a combined respiratory and metabolic acidosis. Ventilation itself, in particular with the use of high tidal volumes and high airway pressures, has been shown to be deleterious for patient outcomes [1,2], and protective ventilation strategies, including lower tidal volumes, have been implemented into clinical practice [1,3]. These ventilation specifications often lead to respiratory acidosis, the concept of permissive hypercapnia and concomitant acidosis is presently widely. In the recent Xtravent study by Bein et al [13], pumpless CO2 removal enabled efficient low-tidal ventilation (about 3 ml/kg PBW) without severe acidosis, which was associated with more ventilator-free days for patients having a severe oxygenation deficit
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