P1111MULTI ORGAN SUPPORT WITH EXTRACORPOREAL CARBON DIOXIDE REMOVAL (ECCO2R) AND CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) WITH CITRATE ANTICOAGULATION IN THE CLINICAL SETTING OF DIFFICULT WEANING FROM MECHANICAL VENTILATION

Abstract

Abstract Background and Aims Prolonged mechanical ventilation is associated with the risk of difficult weaning due to the onset of muscle weakness. A disproportion occurs between the respiratory workload and the muscular force, which leads to failure of the ventilatory pump and hypercapnia. Some early experiences suggest that ECCO2R facilitates weaning from the ventilator in patients with a high risk of failure. Method Clinical case: a 49 year-old man with a) recent orthotopic liver transplantation (cryptogenic cirrhosis), b) acute renal injury (AKI) on continuous veno-venous hemofiltration (CVVH) and c) acute respiratory distress syndrome (ARDS) requiring prolonged mechanical ventilation. After unsuccessful attempts at weaning from the ventilator, a lung membrane was inserted in series, before the hemofilter, on the CRRT circuit in order to remove CO2 and so reduce the workload of the respiratory muscles (Fig. 1). The patient was then extubated. We used citrate anticoagulation due to the presence of contraindications to systemic heparin (high bleeding risk, thrombocytopenia). Results ECCO2R + CRRT treatment requires a relatively high blood flow (300-350 ml / min) in order to extract a significant amount of CO2, but, the more the blood flow increases, the more citrate must be infused, and the more the metabolic load increases. The patient developed mild alkalosis as an initial sign of citrate accumulation (Table 1), but it was self-limiting. During ECCO2R we actually obtained the desired decrease in respiratory muscle effort (decrease in respiratory rate from 24 to 18 per minute and a maximum negative value of esophageal pressure from -8 to -4 cmH2O) and the treatment was interrupted after 36 hours. Mechanical ventilation was restored due to a complication independent of ECCO2R (massive pneumothorax). The patient tolerated the treatment for 36 hours. Conclusion ECCO2R proved an efficient and relatively simple technology helping respiratory function recovery. Due to the very frequent association of AKI and ARDS, leading to a high mortality rate, nephrological care in intensive care units should include this new treatment. Moreover, reduction of the inflammatory pathway secondary to mechanical ventilation could also benefit the evolution of AKI.