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First positive experiences with low flow decapneization in Acute Respiratory Failure

veno-venous

SUCRE M.J., DONNARUMMA G., VITELLI G., CIRILLO A., COPPOLA A., DE NICOLA A.

Complex Structure of Anaesthesia and Reanimation - Hospital of Castellammare di Stabia (NA)- Italy

Recent studies have proposed new selective extracorporeal systems for CO2 removal characterized by low extracorporeal blood flow, by means of a veno-venous bypass (1,2). Those procedures are able to reduce the CO2 levels by 20-25% and allow to protect the lung of the patients with Acute Respiratory Failure by a further reduction of the tidal volume and the ventilation pressure, avoiding an excessive hypercapnia. In the system that we used the venous blood is drained through a double lumen catheter positioned in femoral vein for the removal and the reinfusion of the blood in order to reduce the invasivity of the technique, compared with artero-venous bypass. The oxygenation is obtained in the patient lungs thanks to the mechanic ventilation and by means of the arterealization of the blood circulating in the oxygenator. In our Reanimation Center the first 3 patients with severe forms of respiratory failure of type II (hypercapnic-hypoxia) of COPD, were treated with the extracorporeal CO2 removal technique. All studied patients were characterized by hypoxia (average pO2/FiO2 <150), hypercapnia (average pCO2 >70 mmHg) and low compliance. The lungs of these patients were very susceptible to damages induced by mechanic ventilation (barotrauma and biotrauma) thus requiring a low flow tidal volumes; those ventilatory settings resulted insufficient to guarantee an adequate CO2 clearance, so the extracorporeal decapneization was necessary (3). The technique has been carried out introducing an usual double lumen catheter in femoral vein, using the veno-venous approach. The anticoagulation has been done through a low dosage heparin, in continuous infusion. The measured plateau pressures were higher than 26 cmH2O, with pH <7,30 therefore the protective ventilation has been applied, reducing the tV in order to bring the Pplat =26 cmH2O and starting the decapneization. The decapneization system (Decapsmart, Medica), has been kept in function for at least 48 hours from the pH stabilization and however not less than 72 hours. The benefit of the Decap treatment has been fast in all cases with a maximum efficacy at 24 h, considerable in the decreasing of the average pCO2 of 17% of the pre-treatment value. The utility of the method has resulted constant for the whole period of the procedure. There hasnt been any side effects or complications related to the method itself, to the anticoagulation or to the use of extracorporeal circuit. The time of learning for the device by the hospital and nursery staff has been sufficiently brief. The positive effects obtained in the three cases has permitted to further reduce the volumes and the pressures applied by the ventilator in order to minimize the barotrauma risks without running into the effects of the respiratory hypercapnia. Two of the three patients has been dismissed in home assistance with a nightly non-invasive ventilation and one has died after 13 days from the end of the treatment due to cardiac complications.

It is our opinion that the results we achieved are very promising. This has to be seen as an important data since, beside the fact that the first applications confirm our results, this procedure may become the primary choice for the ECCO2R (ExtraCorporeal Carbon dioxide Removal) in patients with acute respiratory failure in intensive care. The extracorporeal techniques become more often a mandatory therapeutic option to support the various organs disfunctions. The different approaches in this context, like the continuous veno-venous ultrafiltration, together with the plasmapheresis and with the extracorporeal CO2 removal, may be carried out contemporarily in the so-called multiorgan support therapy.

BIBLIOGRAPHY
1. 2. 3. Livigni S et al. Efficacy and safety of a low-flow veno-venous carbon dioxide removal device: results of an experimental study in adult sheep. Critical Care 2006, 10:R151 Mielck F. and Quintel M. Extracorporeal membrane oxygenation. Cur Opin Crit Care 2005; 11:87-93. Morris AH, Wallace CJ, Menlove RL, et al: Randomized clinical trial of pressure-controlloed inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994, 149:295-305.

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CO2 Removal during CRRT

G. BUSCAGLIA, P. DE BELLIS, M. MESSINA San Martino Hospital, Genoa - Italy

Introduction The treatment chosen for the patients with ALI and ARDS is the mechanic ventilation which, in order to obtain values of paO2, paCO2 and pH, needs high inhalation pressures and high concentrations of inhaled O2. In reality the mechanic ventilation is harmful for the lungs causing injuries through various mechanisms: altering of the lung epithelium, inflammation by releasing cytokines, alveolar hemorrhage. The release of inflammatory mediators may increase the lung injury and cause injuries to other organs. The actual methods of ventilation try to reduce the barotrauma and volutrauma accepting paCO2 values higher than usual. Permissive hypercapnia is a term invented by Hickling to explain the aim to reduce the lung stress induced by ventilation with a CO2 increase that is tolerated but not a desired effect. The patients who need mechanical ventilation often develop a renal disfunction sometimes as a consequence of a pre-existing pathology; however there is also the proof of the damaging effects of the ventilation itself on the renal function. The positive pressure alters the venous return flow, the cardiac preload, the vascular resistances and the afterload with consequently alteration of the glomerular filtration flow and of the renal blood flow. The acute renal insufficiency in patients in intensive care is combined to a high mortality and morbidity. When also a lung pathology coexists (ALI-ARDS) the mortality exceeds 80%. Gattinoni and Kolobow introduced the concept of extracorporeal CO2 removal (ECCO2R) reducing the damages of mechanic ventilation. The technical progress and the use of a heart-lung device (ECMO) has suggested the use as a support therapy in patients with ARDS thus introducing the concept of extracorporeal life support (ECLS). From that moment other methods have been developed also on modified ultrafiltration systems.

Materials and methods We have considered 11 patients recovered in our intensive care cardiac surgery unit in the period of June 2003 till June 2004. All of them had the ALI/ARDS diagnoses due to septic causes non responsive to conventional therapies, paCO2 50 mmHg, significant radiological outline for lung infiltration, renal insufficiency or with three important criteria for the continuous renal replacement treatment as to actual indications.

Ventilation technique All patients were subject to mechanical ventilation with the Siemens Servo Ventilator 300 device, maintaining the lung pressure peak less than 30 cm H2O, PEEP less than 10, tidal volume of 6-8ml/kg. All patients were tracheostomized (transpharyngeal tracheotomy as to Fantoni modified De Bellis).

CRRT Technique For the renal replacement treatment we have used an EquaSmart 3P device, filter BLS 714G (Bellco). A CVVHDF was started with bicarbonate solutions. The patients received a 24 hours renal replacement treatment with a weight loss of 1-1,5 Kg/24h, blood flow 130-150 ml/min, predilution 3000 ml/h and dialyses 2000 ml/h with correction of potassium and phosphorus ions as needed. Measurements We have taken arterial samples for monitoring the paCO2 prior the treatment and after every 60 min for 48 hours during CVVHDF. Characteristics of the patients 11 adult patients, 7 males, 4 females, medium age 72, subjected to a 7 days mechanical ventilation + 3 prior to the beginning of the renal replacement treatment, subjected to cardiac surgery (bi-valvular replacements

n. 5, aorta-coronary bypasses n. 2, valvular replacements n.2, replacement of the ascendent aorta and aortic arch for aneurism n. 1 or for dissection n.1. Results The period of treatment was 10 days + 3. 6 patients died during the intensive care recovery; 5 patients were transferred in the wards, 2 of them needed a chronic dialytic treatment. The paCO2 progress is shown in the graphic (Fig. 1). Discussion Although the evolution of the ventilation techniques the mortality connected to ALI/ARDS remains high. If there is also a renal concern then the values of mortality reach 80%. Also the damages caused by ventilation have been proved and the concept of permissive hypercapnia has developed to reduce the barotrauma and the volutrauma. During the years concepts of extracorporeal life support (ECLS) have been developed which use the development of techniques deriving from cardiac-lung bypasses (oxygenators). These devices need high extracorporeal blood volumes (ECBV), vascular venous access of high diameters and high blood flows, highly invasive methods and with risk of complications. In order to reduce these complications low flow CO2 removal techniques have been introduced which have demonstrated to be efficient and well tolerated. The sepsis and the acute renal failure which are often present in complex intensive care patients, are treated with renal replacement systems which become now common in the experience of the intensive care staff and nursing staff. The CO2 reduction, during CRRT has often been desired and searched for as direct effect. It seems there is a relation with high flow renal replacements techniques and in relation to the increase of ultrafiltration. Certainly the determining effect is the reduction and resolution of the interstitial lung edema. In our experience the CVVHDF did not show a direct effect on the paCO2 reduction. Actually we are using a new device: a decap filter for the CO2 removal during the continuous renal replacement treatment. The technique uses a filter to simply implement in a CVVH-CVVHDF system, without particular managing difficulties in conducing the abovementioned therapies. Bibliography 1. Jayroe JB. Wang D.Deyo DJ. Alpard SK. Bidani A. Zwinschenberger JB. The effect of augmented hemodynamics on blood flow during arteriovenous carbon dioxide removal. ASAIO J. 2003:49:30-4. 2. Zwinschenberger JB. Conrad SA. Alpard SK. Grier LR. Bidani A. Percutaneus extracorporeal arteriovenous CO2 removal for severe respiratory failure. Ann Thora Surg. 1999:181-7 . 3. Deslauriers J. Awad JA. Is extracorporeal CO2 removal an option in the treatment of adul respiratory distress syndrome. Ann Thorac Surg. 1997 Dec: 64(6):1581-2. 4. Tao W. Brrunston RL Jr, Bidani A. Pirtle P. Dy J. Cardenas VJ Jr. Traber DL, Zwinschenberger JB. Significant reduction in minute ventilation and peak inspiratory pressures with arteriovenous CO2 removal during severe respiratory failure. Crit. Care Med. 1997; 25:689-95. 5. Habashi NM, Borg UR. Reynold HN. Low blood flow extracorporeal carbon dioxide removal (ECCO2R): a review of the concept and a case report. Intensive Care Med. 1995:21:594-7. 6. Mira JP. Brunet F. Belghith M. Soubrane O. Termignon JL. Renaud B. Hamy T. Monchi M. Deslande E. Ficrobe L. et al. Reduction of ventilatory settings allowed by intravenous oxygenator (IVOX) in ARDS patients. Intensive Care Med 1995:21:11-7. 7. Gattinoni L. Presenti A. Bombino M. Pelosi P. Brazzi L. Role of extracorporeal circulation in adult respiratory distress sindrome management. New Horiz. 1993; 1:603-12. 8. Liebold A. Philipp A. Kaiser M. Merk J. Schmid FX. Birnbaum DE. Pumpless Extracorporeal lung assist using an arteriovenous shunt. Applications and limitations. Minerva Anestesiol. 2002:68:38791. 9. Frenckner B. Palmer P. Linden V. Extracorporeal respiratory support and minimally invasive ventilation in severe ARDS. Minerva Anestesiol. 2002:68:381-6. 10. CC. Huang. YH, Tsai, MC, Lin. CT. Yang MJ. Hsieh, RS, Lan. Respiratory drive and pulmonary mechanics during haemodialysis with ultrafiltration in ventilated patients. Anaesth Intens Care 1997:25:404-70.