first positive experiences with low flow veno-venous

8/4/2019 First Positive Experiences With Low Flow Veno-Venous

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First positive experiences with low flow veno-venous

decapneization in Acute Respiratory Failure

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 thelung 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 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


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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 tosupport 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 multi-

organ support therapy.

BIBLIOGRAPHY

1. Livigni S et al. Efficacy and safety of a low-flow veno-venous carbon dioxide removal device: re-sults of an experimental study in adult sheep. Critical Care 2006, 10:R151

2. Mielck F. and Quintel M. Extracorporeal membrane oxygenation. Cur Opin Crit Care 2005;11:87-93.

3. Morris AH, Wallace CJ, Menlove RL, et al: Randomized clinical trial of pressure-controlloed in-verse 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 CRRTG. 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 June2003 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 priorto the beginning of the renal replacement treatment, subjected to cardiac surgery (bi-valvular replacements


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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 augmentedhemodynamics 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 extracorporealarteriovenous 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 adulrespiratory 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. 2002:68:387-

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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 pulmonarymechanics during haemodialysis with ultrafiltration in ventilated patients. Anaesth Intens Care

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first positive experiences with low flow veno-venous

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